>> thank you. we're now firmly, obviously, into the post-war period. we've discussed before, some hours ago, the isg report. i really don't want to go back over that. i think we can agree it indicated that saddam had never lost his interest in wmd programs. but the headline for most people was that the actual stocks of wmd, the reconstituted facilities as discussed in the dossier, for example, had not been found. what was your, when did you realize that that was likely to be the case? ..

getting reports and trying to direct the armed forces and it was a major part of our operation after the 19th of march. obviously it became difficult to sustain. >> general frey cold us even as the troops were on the mission, frye told us that they became somewhat disillusioned that it wasn't there even during the course of 2003. we've gone into this campaign on one assumption. maybe in as things developed in the future, it still could have

turned out as badly as you always thought it was. but it meant that in effect that the quality of post-saddam iraq was now going to be the major test of what we were doing. i just want to briefly go back before the war. were you aware of the prewar assessment that the american army -- the general made that 500,000 troops were going to be needed to secure iraq? and it wasn't just him that was saying this. he was slapped down by paul wolfowitz for the comment. were you aware of that? >> i was there was a debate within the american system. did he use was the doctrine of overwhelming force on you did you have a smaller group of people? a smaller force. and i think the issue is really for the post-war period.

i mean, i think you can argue for the actual conflict itself there were sufficient troops. the question is, should you then have changed and had more or different troops later? now, i think again that is a difficult question to answer and there are people who take both sides of that. >> indeed, part of the debate within the united states was the determination of donald rumsfeld to demonstrate that it was possible to wage a campaign of this sort with comparatively few forces. it meant that he under-provided for the security situation that was going to arrive after the war, which was the general's point. and so in some senses the difficulties that were going to be face were predetermined. it was always going to be difficult after the war. there just weren't enough troops to be around? >> i think the key thing is this, and again this is a major

part how such operation would be done in the future. the force to reform remove a regime and change the government, if that's what happens, that's the only way you can secure your objectives. and this is the decision we'd come to. the only way we can prevent saddam being a threat was actually to remove him from office. the force that you require to do that is one function. and there are one set of arguments that go along that. you're probably much more expert in this than me. however, what we now know and in any of these situations should know from now on that you will be nation-building after that. and that may require a quite different type of force. and it may require more. it may require simply different forces. but it's a different task. >> and indeed they are different

requirements. we've heard evidence about the skill of british forces in being able to move quite quickly from a war-fighting role to this nation-building role. but it's fair to say the americans certainly now would disagree with this. that that was not the way that they looked at it. that from rumsfeld's point of view, it was the war-fighting row he was interested in. and they made very little provision both in training, doctrine and numbers for the follow-on forces that would provide for the security. so in the context also of the disbandment of the iraqi army, the risk of the vacuum in the security is very high indeed. >> the disbanding of the army, i think it was mr. slocum who was dealing with on behalf of the americans. and i think his view was in a

sense the army melted away and they tried to recruit. >> the principle point that you mentioned -- it was true it didn't exist as an organized force. but there was a basis to get them back together quickly again which was lost. >> right. i think a huge question here -- because security is what went wrong. i mean, people say you've done the reconstruction. quicker or got more underway or something it would have been a different situation. my view of this the very purpose of the people we ended up fighting was to stop the reconstruction. so every time we'd repair electricity they'd bomb it. anytime you'd get the oil production going they would try to sabotage it. the issue is a security issue. now, i think we moved beyond

what was the debate at the time, which really went something like this. and you probably recall this from 2003 and the early part of 2004. and that was the debate which said, look, the americans are going to do war fighting and the peacekeeping and the british can do both. i think if we are looking at our own capabilities now and what we will do in the future, i think it's not as simple as that, actually. and if you look at what general petraeus did in the end with the surge, it is correct that he had his political dimension reaching out to the sunnis and so on. but as the surge began, the american forces suffered even heavier casualties. i mean, they were doing fighting. >> yes. >> and one of the things that i think -- i'm afraid we have to learn from this situation 'cause we face exactly the same situation in afghanistan is that

in these circumstances it's not going to be easy. you know, it's not -- you don't move to peacekeeping because actually you're facing a situation where your enemy is trying to -- >> and it partly depends upon your ability to assert order and authority early on. and we don't need to go into all the details but that's clearly where things went badly and we can remember the looting and so on. and comments that were made at the time. let me fast forward to what seems to me a particularly significant month, which is april, 2004. a lot of things happened in that month. i won't -- one of them was spain left the coalition-building. we'll leave that to one side. fallujah. you have relations with the sunni community had deteriorated. they felt they were potentially

being disenfranchised. this was coming to head in fallujah where u.s. marines were going into the city to take out 2,000, i think, insurgents. how did you view that situation because it was potentially extremely dangerous? >> it certainly was, yes. and i was involved in discussions with the americans, with the president and also with -- with allawi as well. he took on the interim administration in iraq. i mean, i think -- at the time i was worried the americans were going in too hot and too heavy. they made certain changes as a result of the conversations that we were having. if i look back at it now, i'm

not sure i was right about it, though. you see, i think -- the truth is we were reaching out to the sunni. and indeed one of the reasons why i could see us having a more challenging situation in the south through into 2005 and it was something we were discussing in the government was that it would become at some point very clear that the purpose of what we were doing was not to replace a sunni dictatorship. minority dictatorship with a shia majority dictatorship. we wanted a genuinely inclusive government. at some point we must be able to persuade the sunni that we were actually their best chance in participating in the political process. the reality is there were people who were quite determined not to allow that reconciliation to happen. >> i mean, this illustrates the dilemma you now faced.

the coalition faced. because on the one hand you had people who clearly have no interest in any accommodation with the coalition, starting to cause serious casualties. developing their numbers and their skills. and not just external forces. these were indigenous. but if you came down too hard on them, the risk was of alienating further the scenes that would be out in algiers -- algeria could do. so if you look at the dilemmas we now found ourselves in, in iraq. either way it was going to be very tough. >> yeah. it was going to be very tough. and one of the central questions -- i mean, my view is

the way that these terrorists are trying to stop us doing what is right and right by the people of iraq shouldn't deter us. we should carrying on and beaten one tyranny as one iraqi told me. beating the tyranny of saddam we should now beat the tyranny of the terrorists. and i was certainly of the view that we had to carry on in that endeavor. but you're absolutely right. that was a huge problem. and it -- the interesting thing to me if you look around the world it's a problem for all nations dealing with this type of terrorism. if you take -- i spend a lot of time out there obviously in the middle east with the israel-palestine question. it's a constant problem for israel. they get attacked. they then use great force in retaliating. before you've gone two weeks they are the people who started it all. if you look at the difficulties that india has or russia and

chechnya -- >> it's undoubtedly true that the nature of the response to this sort of insurgency makes a difference, too. and we can talk about these other cases. the problem that you were in at the time is that the forces available to the coalition were insufficient to get a grip on it. and that the methods that they, therefore, would have to use in order to impose themselves militarily would be much more likely to cause civilian casualties than they would have done if you had had far more forces properly trained to start with? >> obviously, this wasn't the issue down south. >> but that's the other issue for april 2004. >> yeah. well, i think you've got to look at this question very carefully. because i think i would put it in a different way. and i think if you look at how

the surge actually worked in the end, it worked because you had a political -- in fact, it really worked for four reasons, the surge. >> i mean, i think -- the surge worked in very different political circumstances than those obtaining in 2003 -- >> yes, that's my point in a sense. if you analyze why it worked, then 2007 and in 2004 it wasn't working, then that's the question -- what is the difference? >> it worked because you had forces that were trained for the job. you had a doctrine that was appropriate. and the political conditions including -- you've indicated the aspiration of the iraqis with the violence helped. but in '2003/4 it was different. let me stay in april, 2004. you got sadrist uprising. we considered the shia areas to be more settled and you've given indication there.

and we're finding even there's violence starting to take root. >> absolutely. and what was very clear was that -- as i say this influence of iran and the situation was growing. and we debated a lot what to do with muqtada al-sadr. did we try and reach out to him? well, i think we tried to make certain approaches there. did we try and arrest him? there was an issue there. would that provoke more violence? this is why these things become really, really difficult. so i didn't mean to sort of take you out of your time zone -- >> no. >> the reason i think it's so important because it's a real lesson out of this is that -- you see, you are bound to take a certain amount of time to win this battle because essentially what happened in iraq -- i tried to explained this to people before. you had one conflict which was the removal of the saddam hussein regime. and that was over pretty quickly.

you had the aftermath which was very difficult. but then what started to happen in 2004 and 2005 and full on in 2006, half -- first half of 2007 is you had a metamorphosis of a different type of conflict where you were fighting yes a certain amount of indigenous insurgency with these external factors coming in. in the end we needed four things to defeat this. and two of them take time. one is we needed the political buy-in. the?oo second is we needed to bd up iraqi capability. the third is as you rightly say sir lawrence, the right troop configuration. and the fourth thing is we needed to be prepared to stick at it and to indicate clearly that we were going to stick it until it was done. >> and you've taken us again three, four years further on.

and you indicated what happened in those three years. the final aspects of this month, 2004, which was the revelations of what had happened at abu reaction when you q+ii[t76vq:j@ saw the photographs what was your reaction when you saw the photographs of the conditions inside the prison? >> well, i was shocked and angry as anyone would be. and shocked because it was wrong. and angry because of the damage i knew it would do. and, you know, you mentioned earlier the media part of this and al-jazeera. the truth is we had -- we were fighting a constant battle. against people utterly misrepresenting us, our motives, what we were trying to do. and obviously these pictures and the abuse of prisoners was going to be vital propaganda for our enemies. >> had you been given any advanced warning by the americans that these revolutions --

>> i think everyone was taken by surprise including in the white house. >> but there was knowledge from january that something awful had been going on there? >> i actually pointed and -- yeah, we made a real effort, in fact, to try and say, look, things are going to happen differently. so there's no excuse for it. it's completely wrong. the most important thing is that it did damage to our cause. on the other hand, and it is right to say this and i said this at the time, the activities of a few within the american forces and the british forces shouldn't take away the fact the majority of the american and british forces were doing an extraordinary job under difficult circumstances and we were doing that job for the iraqi people and protecting them and helping them. >> well, just consider how much there were. i mean, we've covered some of this let me just summarize where we seem to be. a year after the invasion, at

the moment, the coalition is unable to provide security for the iraqi people. and you've indicated without security life can't get better. >> uh-huh. >> infrastructure is blown up. life of people deer tear eighties. service isn't any good. you can't develop the economy. and that feeds in to an awful situation. now, for the iraqi people at this time, things are not getting better. is that fair to say? and if you look at the promises that have been made to them, it might have some grounds of disillusionment with the coalition. actually let me give you some figures because i find them tragic. we're in january 2010 now this

these are just monthly figures for documented civilian deaths from violence in iraq. 517 in january 2004. 10,000 -- 1, you 042 in january 2005, 2,807 in january 2007. these are monthly figures. these are the documented deaths. they're not the -- they're not the undocumented and the deaths of deterioration of services, poverty or health and so on. the striking thing is they're getting worse each year. what did you feel at the time that you could do about this? what could you say to the iraqi people that could explain what they must have felt a sense of letdown at what the coalition had been able to do for them? >> what we did with the iraqi people is to say, first of all,

we're going to carry on with the political process. because for the first time you're actually being able to elect your government and your officials. you're drawing up a constitution in a proper and decent way. the second thing was to say we're going to be with you and we're going to help you defeat this. and the third thing to say -- and this is immensely important to this whole argument. when people say there were people dying in iraq and, you know, the figures i think the most reliable figure of iraq of the body count off the of the brook, institute over 100,000 in this whole period the coalition forces weren't the ones doing the killing. the ones doing the killing were the terrorists, the sectarians, and they were doing it quite deliberately. to stop us making the progress we wanted to make. so my attitude -- and i took this line very, very strongly with people. when we say isn't it terrible that the death toll went to 2007, that high, yes, it is terrible.

but the first question to ask is, who was killing them. and this turned out to be precisely the same people that we were trying to fight everywhere. and our responsibility was to stick in there and see it through, which eventually happened with the surge, with the charge of the knights down in basra and today, of course, the situation in iraq is very, very different. and the people are better off. and have a decent chance of a proper future. >> let us hope so. >> well, i think that's the evidence that was given to you -- >> they're certainly better off than they were in 2007. >> or in 2003 or '2 or '1. >> i think -- i mean, just having some conversations with iraqis, i think that's something that has to be sure. but i don't want to get into that. we can agree and hope that the position for ordinary iraqis only improve. can i just go back to this question of responsibility. and there's no doubt that there

was not british troops killing iraqi civilians. that this was violence on a major scale. but isn't it to some extent to a considerable extent our responsibility if we've gone into a country initially as an occupying power and then unable to provide the basics of security? let me just -- this is evidence that we got from the general describing the situations he found in may of 2006. the single battalion commander responsible for a city of 1.3 million people told me he could put no more than 13 half platoons or multiples on the ground. less than 200 soldiers on the ground. you compare that with what as i recall as a young platoon commander in the late 1970s when

there's a brigade on the ground and he goes on to makes the points we've made before. so that was may 2006. and his basic description was that the militias had filled the gap that we had left. >> and by may, 2009, that is a different situation. and why? because we then built up the capacity of the iraqi forces themselves. actually, in the end the british, i think, were particularly with the iraqi 10th division. in the end we managed -- and if it hadn't been for the british forces down in basra making sure that we were acting and helping keep this at bay the entire time, the charge of the knights would never have worked. but it did in the end. and if you talk to people about basra today, there are real improvements there now. and it's a completely different situation in security. likewise, in the rest of iraq. in the end, we did stick with them. and i agree with you it's our responsibility.

but here's the point that i think we've got to get ourselves into in the western world, if i can put it like this or when we're doing these types of operations. yes, it is our responsibility. but let's be quite clear why we face the difficulty. we face the difficulty because these people were prepared to go and kill any number of completely innocent people in suicide bombings. 'cause as you know in the first half of 2004 i think we had 30. in the first half of 2005, that number got to 200. we should be prepared to take these people on. and the fact that they're prepared to act like this should not be a reason for our not being there or our fighting them. >> i want to conclude because there's other questions that need to be possessed to you. -- posed to you.

this is a very heavy price to pay, was it not, for the lack of preparation and the cavalier attitude to planning taken perhaps more in the united states than in the united kingdom in 2003? >> we certainly didn't take a cavalier attitude to planning in the u.k. what we planned for was what we thought was going to happen. but you will consider this and i just give you my view of this. because otherwise i think we'll make a mistake in future such situations. however much you plan and whatever forces you have, if you have these elements, you u.k. on one side. and iran on the other. the fact that these people in breach of not just the rules of international but humanity are prepared to do these terrible

things in order to frustrate the will of the iraqi people, should not mean we break away from confronting them. we should be there with the iraqi people alongside them as we did and were in the end in order to make sure that having been released from saddam they were then released from the reign of terror. i mean, i do speak to iraqis. and i spoke to one just a few days back. who said to me we have changed the certainty of repression for the uncertainty of democratic politics. he says it's difficult. and challenging. but the progress is extraordinary. and nobody would want to go back to the days when they had no freedom and no opportunity and no hope. so i understand what you're saying. and we do have to take our responsibility seriously in these situations. but we're in exactly the same situation now in afghanistan. and heaven knows where we'll be in the same situation again in the future. and the lesson out of it in my view you've got to be prepared

for the long haul. and you've got to be prepared to stick it through until the end. >> the long haul started in 2003? >> it did started in 2003. but i posed the 2010 question earlier and i would pose it again. >> i think at that point i better pass it over to the chairman. >> thank you. i think we'd like to ask just one or two questions about afghanistan and its influence as it were. from the side on the iraq situation. not to look at afghanistan in its own right. roderic? >> just one really. you've just mentioned it. in 2004, geoff hoon told us that he was against the idea of deploying into -- more troops into afghanistan until we reduced our commitments in iraq. in the following year, we decided to take responsibility for helmand province in afghanistan. and to deploy much larger troop contingent there and the effect was that by the end of 2006, at

its peak, we had over 7,000 troops still in iraq. and over 6,000 by then in afghanistan. weren't you concerned that this was stretching the resources both the human and the equipment resources of the army absolutely to their limits? >> well, i was certainly concerned that we were fighting in two different theaters of operation. but again, i think the decision actually to go down into helmand was taken -- or began to be taken in 2005. we were told that we were able to do this and it was right that we did it. and what was actually happening in iraq was that unlike what was happening in basra i would say in the south as opposed to the rest of the country is that the problem in a way was that people

were worried that we were the attacks were happening on us, on the coalition forces. and so our concern was that over time we should be building up the iraqi capability. and then that would allow us to draw down. but we were capable of doing the helmand mission and indeed we wouldn't have done it. >> and it was stretch and you were warned it would be a stretch? >> actually, the discussion that we did it came from the m.o.d. of course, they said it would be tough for us and they should we should do it and we did do it. in a sense it was difficult in iraq. we were prepared to make the additional commitment to afghanistan. >> we'd like, mr. blair, to ask a few questions about the strategic direction of government and how one does that in a cabinet system in situations like in iraq. and i think baroness prashar would like to start. >> some questions, mr. blair. just taking your meeting on the 23rd of july in 2002.

which you chaired and in which the chief of defense of staff forwarded some military actions. and according to mr. campbell you did not want any discussions at this stage and did not one any of this swimming around the system. why was the participation restricted to two cabinet ministers and not, for example, to the secretary of state for international development secretary? >> we were discussing then what was likely to happen in relation to the politics and the diplomacy particularly in relation to the military. now, at a later time as you know there were officials from dfid were involved in the planning meetings. >> my understanding it came at a very late stage and -- >> i think the officials were together. it's true it was at a later time that clare short herself joined the committee. however, having said that, i mean, we were in pretty regular correspondence. and as i say in the end dfid

equipped itself pretty well. it was not a problem that was capable of being cured by dfid. >> that's true. in the early stage of effective planning to go ahead you need cabinet involvement and why wasn't dfid involved in this? >> obviously, we were in close touch with the treasury and so on. and right at that moment the single most important areas were diplomacy and were the issues to do with military planning. and, look, i know much has been made these were ad hoc committee meetings with a small a and small h rather than a large a and a large h. the thing is to get the key players together so you could have a proper frank discussion and take the decisions necessary. and that's really what we did both before the invasion and afterwards. >> that's true. but i mean, lord turnbull said -- he said i think you

should include people even if they are going to be difficult because even if you're going to look at the aftermath, dfid and treasury had a -- >> as i said in response to the butler inquiry that, you know, in future there's a case for having an especially constituted committee. as i said we did have a key players and there was a constant interaction with the key players. insofar as what we were predicting what we would find, we made provision for it. the relationship between myself and jack straw, geoff hoon, the politicians but also the chief of defense staff were close. we were in close interaction the entire time. the main bulk of this was going to be done in the first instance by the military. now, it's correct that as we got into late 2002, early 2003 dfid became a bigger part of the picture. clare wanted to come to the meetings. that was fair enough and that

then happened. the issue, however, that dfid was focused on was on the humanitarian side we did it. >> i think the chairman has a question on that. >> i sat on the butler committee and i don't want to go over old ground. but just to be clear, the cabinet met frequently in the period 2002 and '3. it's not that they were not consulted. but rather that papers in general i think were not circulated the butler committee found on and we haven't found any. which has given rise to the question, was there sufficient information analysis both of the issues and about the background to enable your cabinet colleagues -- who would take full collective responsibility for the big decisions to understand and if necessary challenge within the cabinet discussion? >> we had -- i think it's -- i

think there was -- >> at least 25. >> yeah, 25 preinvasion discussions about iraq. and there was ad hoc ministerial discussions, i think 28 of those meetings. there was a constant interaction. and people would describe -- it wasn't just a sort of formal cabinet discussion. jack straw would take people through the information that we had. there was an immense amount going on inside the m.o.d. inside the foreign office. actually inside dfid as well. and i really don't think any of the members of the cabinet at the time felt they weren't involved or felt they couldn't challenge. indeed, robin cooke didn't. robin and i disagreed about it in the end. and so, you know, obviously there are these issues to do with the nature of the meetings that were held. but i was in an almost constant interaction for 2002 and 2003 with members of the cabinet.

>> you do have both from two very witnesses that we've taken testimony from, alastair campbell and lord turnbull. the same thought that you need to accommodate difference of view and respond to it within a collective -- within in this case the cabinet or some smaller grouping, the ad hoc committee, for example, with hindsight, do you think that there was sufficient space and opportunity for those differences to be accommodated and fed in to final judgment? >> i really do actually, yes. nobody in the cabinet was unaware of the -- of what the whole issue was about. it was running throughout the whole political mainstream at the time. and there were members of the cabinet who disagreed but most agreed that it was the same with parliament. i was in contact with constant

numbers of people you shouldn't do it this way and do it differently and so on. and in relation to the planning afterwards, i mean, whatever else -- whatever differences clare short and i may have had from time to time the one thing i would never accuse her of being is backward in coming forward. there was huge all the time interaction as i say between people on the very issues. >> thank you. i think we'd like to explore just one other aspect of this. and that's the interaction between major strategic policymaking at cabinet level, prime ministerial level. and there's a set of questions we'd just like to pursue and starting with you. >> thank you, mr. chairman. we discussed with lord goldsmith, you know, the process through which he was involved in this decision-making process.

and what became very clear that during the time, particularly, before july, 2002, ministers were making public statements. i think he had to write to mr. hoon and he saw a memo of the comments that mr. straw had made to colin powell. and he was having to constantly write and tell them, you know, they should be seeking his legal advice. do you think the fact that he had to respond to people making statements without being clear about what the legal situation was -- do you think that could have been voided if the attorney had been able to discuss issues in the cabinet? and that would have actually ensured that the formal advice of the attorney would have been preempted? >> i think the very first paper we got on this back in march or the collection of papers we got in march 2002, which were seen obviously by jack -- i mean, the legal paper was provided by jack straw's department.

and by geoff hoon as well was having fully aware of all this. i mean, people had the basic legal framework. and now i think it's perfectly good for peter goldsmith as the attorney general on his own volition if he thought someone was saying something that couldn't be justified or was unwise in legal terms. he got on the phone and said, don't do it and wrote them a note and said come back on line on this in which they did. i don't think it would have made a great deal of difference that made them there at cabinet. what he needed to be in a position feeling sufficiently confident which he -- >> he was constantly having to ask and want to write his opinion -- provide his opinion and he said it wasn't always welcomed. >> well, i think he said that about the particular opinion he gave at the end of july. it's not that i said it wasn't welcomed. i was dealing with another

difficult situation and now i had another difficult issue to take account of and i had to take account of rightly and he was completely right to do it because it made a big difference to the way we approached 1441. and the resolution there. but i don't think it would have made -- look, i'm very happy to talk about how, for example, you know, you might do some of these things differently now. but i honestly don't think having peter at the cabinet meeting would have made a difference. what did make a difference was his having the confidence to be able to say as he should as an independent attorney as it were for the government to pick up the phone and even to the prime minister, which he did, say this is what you can say and this is what you can't. >> but that doesn't allow for a collective decision-making where there's a proper consideration of different options and so on. >> well, i think in respect to the legal opinion, baroness, i think -- the key thing really was this.

the cabinet wasn't interested in becoming part of the legal debate. they just wanted to know is the attorney general saying it is lawful or it's not? i think with respect to these other issues, there were actual debates about this. i mean, there was a debate, for example, in january, 2003, if i recollected. it was not just about the diplomatic issues but specifically on the humanitarian and aftermath questions in cabinet. >> but going back to the legal advice, i mean, when the cabinet met on the 17th of march, i think lord goldsmith presented the draft parliamentary question answer. but there was no discussion on this legal advice. and we've seen the report of a discussion that he had with mr. straw on the 13th of march in which he was persuaded not to present a finely balanced paper of arguments but to actually, you know, present this paper which was going to be his parliamentary question. and i think clare short made it clear that she wanted to discuss it and know whether the attorney general had changed his mind.

but no such discussion took place. >> well, the whole purpose of having -- i think andrew turnbull explained this to you. the whole purpose of having the attorneyg3 there at the cabinet was so that he could answer anyone's questions about it. >> but the attorney general did say that no legal basis is essential but not sufficient. so in that sense the broader implications of invasion -- i mean, should that not have been discussed? >> the broader implications in terms of whether it was right or wrong to do it? >> yeah. >> i mean, that was in a sense the purpose of the cabinet discussion, i think. and, you know, it's perfectly -- the legal issues were one aspect of this. but i think once the members of members of cabinet were really focused on the politics. and indeed even robin cooke, his attitude is if you get a second resolution, then i'm with you. but if you can't, then politically i think this is too difficult.

so, you know, we were very focused on those political as well as legal questions. >> but would it not have allowed them to weigh up the risks for themselves, for the civil servants and so on? >> i think they were weighing the risks up for the country but i don't think with respect to the law as it were, i don't think members of the cabinet wanted to have a debate with -- i mean, peter was there and could have answered any questions they had. but their basic question to him was, is there a proper legal base for this or not? and his answer was yes. and he actually wed and this is the reason why we had peter there and i think in any future situation, it's sensible to have the attorney there. but we offered -- in a sense we offered him up. he was the lawyer there to talk about it. >> mr. blair, do you think there's a contrast of approach between what frequently happens in government at all levels including to the top. but in forming policy or engage it in legal advice because it made need expression at statute

or existing bodies of law you folded the legal advice through the policymaking process and that's one approach. the other is set very clearly what your policy objectives are and they may be in the iraq case high and strategic objectives. and then as it were work around through and with the constraints and opportunities that legal advice then gives? do you see a difference of approach there? >> i think that there could be. but i would say in this situation -- since in a way march 2002 was the time when you set thw first framework for this, the legal advice was one of the key things we asked for. and we got it. and that legal advice -- it's interesting to go back and look at it. it was legal advice that was saying you needed a fresh resolution. and one of the reasons why we went down the path was to give a fresh resolution. one of the things -- and this was part of the debate that

i felt well, we got the fresh resolution why is this still a legal problem and i was told it was the problem was. >> it seems from what we've heard today and from previous witnesses that there was a very clear strategic policy objective set for iraq, which was to bring about compliance between the united nations resolutions, disarmament and wmds and it meant regime military by military means that was the last resort but not ruled out. but there were moments very, very late in january, february, march, 2003 when that policy objective could have been blocked by a failure because of a legal constraint. is that unavoidable in situations like this? >> well, i think it's unavoidable in a situation where it's that controversial and divisive. and it's that -- you know, that open to challenge.

you see, there actually could have been been a major debate about kosovo and legality. there could have been. there wasn't because in the end most people went along with the action. they agreed with what we were doing. the truth is that the law and the politics follow each other quite closely. >> yes. >> and i think necessarily in this situation where we -- we were setting our strategic objectives, you know, we had this strong belief -- as i say this is my belief now, too, that this threat had to be dealt with a certain amount of urgency. and we had our alliance with the united states of america and so then and all the issues to do with saddam. and then obviously at the same time as you're proceeding in strategies evolving, diplomacy is evolving. you're looking at the issues having to deal with legality. >> i think we would just like to ask one or two questions before we come to the close.

>> my final question, mr. blair, is about the effective government. because there would be a long command chain because if you're looking at the top decision-makers in london working with soldiers and civilians who are to deliver locally in iraq, it's quite a complex operation. and many of these issues were cross-departmental and, therefore, quite a new operation had kind of come together. how did you hold your secretary of state account for delivery because delivery was your mantra at that stage. how did you make sure that what was to be delivered was being delivered effectively on the ground? >> in the prewar part we had the ad hoc group of -- on iraq of officials which met from september onwards and that included all the relevant departments. i was chairing the ad hoc ministerial discussions. as i say we had 28 of those meetings.

and afterwards we had the war cabinet and then the meetings and then jack straw became the effective chairman of the ministers and the officials driving forward policy from that front. there wasn't an issue really at any stage of this with people not feeling they were part of this -- apart from the one issue having to do with clare and the ad hoc committee which as i say was resolved in early 2003. >> but tim cross said to us there was no minister cabinet rank reporting back and because we were hearing from the ground. this is tim cross' comment to us. >> i think one of the questions that's been raised in some of the evidence is -- you know, again, if we knew then what we know now, would you want perhaps to put a specific cabinet minister in charge of this? i mean, all of these things are worth looking at.

the only thing i would say to you is we were partly through my own personal involvement but also because you had mike boyce in the chief of staff committee and you had the official meeting and you had david very close in this. i can't really think -- i think andrew turnbull said this to you in his evidence that there was a machinery of government problem in the sense if we had a different machinery we would have acted differently. i don't think that. that's a judgment. >> one thing i want to put to you because he emphasized structuring the decision-making so that you are simply not swept away along with the pace of events like military preparations. do you think we had the ability and the will to pause and look at our strategy? for example, in early 2003, inspectors had returned to iraq

and were expecting either saddam would grossly obstruct them or they would find evidence of wmd. in the event this did happen, did we actually think -- did we actually stop and reevaluate our strategy at that stage? >> we would have entirely reevaluated our strategy had as i say -- and i'm just using this as a short ham saddam said get out of here. i'm finished with all of this. i want to join the international community on proper terms. but he didn't. and what he did -- and this is whereas i say the iraq survey group, unfortunately, people have only looked at one part of their findings and not the other part of their findings. he never had any intention of complying because he had the intention once he got sanctions out of the way restarting it again. >> even later it became clear that post-war efforts were becoming strategic failure. did we think at that stage because the impression one gets we were responding to events on the ground.

were you doing any rethinking? >> absolutely. the reason why we were in a constant iteration very quickly after the conflict was because what we were finding. and then as i say there was than metamorphosis of this whole struggle really and battle. when, you know, the aq and iran elements became utter most then it really did change into a different type of fight. and one of the interesting things, for example -- i mean, kimberly kagan does this on your book on the surge and it's important because in the end that's what worked. what nobody foresaw was that iran would actually end up, in fact, supporting aq. i mean, the conventional wisdom was these two are completely different types of people. 'cause iran is shia. the al-qaeda people are sunni. and, therefore, you know, the two would never mix. what happened in the end is that

they did. because they both had a common interest in destabilizing the country. and for iran, i think the reason they were interested in destabilizing iraq was because they worried about having a functioning majority shia country with a democracy on their doorstep. and for al-qaeda -- they knew perfectly well their whole mission was to try and say the west was oppressing islam. it's hard to do that if you replace tyrannical governments with functioning democracies. >> so from your point of view, you think the machinery of government worked? >> well, i can't think -- i mean, i don't doubt you could have different machineries. but we did have a machinery of government that worked and worked effectively in order to analyze the problems we were look likely to face and how we would deal with them. and as i say, i think no doubt there are other ways that it can be done. >> and on reflection there's nothing you would do differently? >> look, i think when you look

back now -- and i had just said to you earlier, if you want to look at maybe putting a specific cabinet minister in charge of this, there are all sorts of things that if you knew then what you know now you would do differently. i've been through the whole reconstruction piece but in terms of what we knew at that time we had a machinery of government that was perfectly adequate for it. there were as i say 25 separate cabinet meetings. 24 ad hoc -- or 28 ad hoc committee meetings, regular weekly meetings of the officials. now you could put them with a capital a and a capital h rather than a small a and a small h in the decision-making. >> we're coming to the end, mr. blair. i've got a couple of questions i'd like to raise. i think the first is to look at the perspective of the whole enterprise from the standpoint of the people of iraq. the coalition went in as liberators.

rather soon they began to be resented by the population and then attacked as occupiers by some. by the time, for example, british forces withdrew from basra city to the airport, 90% of the attacks there were against them. as against between members of the shia factions. so do you think looking back from 2010 with the people in iraq thought that the enterprise was worthwhile? and just as one piece, not of evidence but as a bit of  anecdote, a very senior constitutional iraqi said clearly it was good that saddam is gone. but the inept nature of some of the things that the coalition did -- the coalition not british, specifically, has caused great suffering. so the price was high. >> it's too early to say right

now whether the iraqi democracy will take root and will function effectively. as, i think, john jenkins and frank baker said to you, and there are really hopeful signs. andome the things that i think are taking place in iraq today. if you look, for example, at the electricity, you look at income which was several over than saddam and you look at the money that's being spent on infrastructure, i think, yes, it was a very, very difficult fight indeed. it was always going to be difficult. once these external factors came into play. of aq and iran. but sure, in the nation-building situation in the future, i think we will be far better prepared and better educated than we were then.

i would just give one -- if we're talking about, you know, was it worth it in terms of the iraqis themselves, if you look at the latest information from the brookings institute and the polls that they're doing about the right direction, wrong direction for their country, they're actually upbeat about the future. if you look at whether they believed that security and services are getting better, a majority of them think they are. despite all the trouble. despite the fact these terrorists carry on. let me just give you one example. of where i think you can see both the nature since we're talking about how is it for iraqis because the iraqis themselves were less interested about the issues dealing with the united nations and so then. they were worried about their country and the oppression. just focus for a moment on what the saddam regime was like. in 2000 and 2001 and 2002, they had a child mortality rate of

130 per 1,000 children under the age of 5 worse than the congo. that was despite the fact that saddam had as much money as he wanted for immunization programs and medicines for those children. that equates to roughly about 90,000 deaths under the age of 5 a year. the figure today is not 130. it's 40. that equates to about 50,000 young people, children, who as a result of a different regime that cares about its people. that's the result that getting rid of saddam makes. and you can talk to iraqis, of course, who will say some of them particularly those from the sunni side still worried about whether they'll be able to come in the politics. and some of them may say well, i don't believe it was worth it.

but i think if you ask the majority of iraqis today, would you really prefer with all the challenges that lie ahead to be back under saddam, i think you'd get a pretty overwhelming answer to that question. >> the other perspective clearly -- and you will appreciate this better than anyone can probably, our participation in the iraq conflict has been very divisive here and abroad. has caused deep anguish to people who lost people who they loved, some of whom are in this room. there is great gratitude to our armed forces for the sacrifices they made and the bravery and their sorrows of their losses and we experienced firsthand the angle which is felt by many people in this country and we have been asking, therefore, the question why. and so as we conclude today, can i ask what broad lessons you've

drawn -- you've drawn some already in the course of your testimony and if you have any regrets about key aspects of the iraq conflict? >> i mean, i've said some of the things that i think are lessons that could be learned. about nation-building, i think you've got to look very carefully at what type of forces you require because this will be a security situation. that you face a challenging security situation. i think you've also really got to look at the issue to do with the nature of this threat from al-qaeda on the one hand. iran on the other. and the impact that that will have not just on iraq but potentially in different arenas right around the middle east region and beyond. and i feel -- of course, i had to take this decision as prime minister. and it was a huge responsibility then and there's not a single

day that passes by that i don't reflect and think about that responsibility and so i should. but i genuinely believe that if we had left saddam in power, even with what we know now, we would still have had to have dealt with him, possibility in circumstances where the threat was worse. and possibility in circumstances where it was hard to mobilize any support for dealing with that threat. and i think we live in a completely new insecurity environment today. i think that then and i think that now. i take a very hard, tough line on iran today. ts apply. in the end it was divisive. and i'm sorry about that. and i tried my level best to bring people back together again. but if i'm asked whether i believe we are safer, more secure, that iraq is better but our own security is better, with saddam and his two sons out of

power and out of office than in office, i believe indeed that we are. and i think in time to come, if iraq becomes, as i hope and believe that it will, the country that its people want to see, then we can look back and in particular our armed forces can look back with an immense sense of pride and achievement back with pride and achievement in what they did. wd no regrets. responsibility for saddam >>ssein -- >> be quiet please. >> he was a monster. i believe he threatened not just the region but the world. in the circumstances that we faced then, even if you look back now, it was better to deal with this threat, to deal with it and remove him from office and i do genuinely believe the world is safer as a result.

this happens in the region. people will say to me saddam hussein was a break on iran. let's be clear. there is another view of foreign policy in this instance which is if we left saddam hussein in place he would have controlled iran better. i really think it is time we learned it is a matter of sensible foreign policy that the way to deal with one dictatorial threat is not to back another. the best answer to what is happening in iran is to allow the iraqi people the freedom and democratic choice that we enjoy in countries like ours. >> this brings us to the end of today's hearing is. 85 no comment beyond those you already made? in that case can i say two

things? clearly there are considerable limits to what we can cover in one day. a number of dimensions have risen out of iran. i thank our witness for a long day of testimony and i thank those of you who have been here as witnesses to this session as opposed to those present in the morning session. thank you very much indeed. we will resume hearings next week at 11:00 in the morning and in late february or early march we will be taking testimony from gordon brown and other senior ministers. with that we close this session. thank you all again.

>> president obama and vice-president biden begin their monthly bi-partisan meetings with congressional leaders. nancy pelosi and republican leader john mainer along with the senate majority leader harry reid and minority leader mitch mcconnell are expected to discuss the economy and jobs. that gets underway in about an hour. president obama said the white house is introducing a plan to fight child the obesity that would include cabinet secretaries and the private sector. michele obama rolls out the plan and now in eastern on c-span2. health and human services secretary kathleen sebelius will sit in on the childhood obesity task force. she helped all the analysts and researchers about the president's plan for health-care registration. we will show her comments and margaret hamburg at the same

conference. it is about 90 minutes. [applause] >> good morning. thank you for having me here this morning and organizing this conference for the tenth year. i think that there is a lot in common between working and planning for months and having a clear agenda knowing exactly what you are going to do and having 30 inches of snow interrupt that brilliant planning. it feels like the day after the massachusetts election. but here we are. i am delighted to have a chance to visit with all of you. time was struck looking at the

agenda about how much there is in common with the topics you're going to talk about for the next couple days and what we deal with in the office each and every day. you have a terrific lineup of speakers and panelists. i am really pleased you are going to hear from dr. hamburg. she is one of our great leaders. i get to hang out with some of the most brilliant scientists and health policy advocates in the country and you have assembled a lot of them here today. issues like how to use the new technology to empower consumers and how to create incentives for providers to deliver better care, how to invest effectively in prevention, those are the challenges we are dealing with within the department each and every day. the same questions we are

asking. sorry i can't blame you for the full presentation but anxious. i am sure david will share with me all the good strategies and ideas that you come up with. i want to start by just giving you the administration's view on health reform as it stands now and where we see things heading. let me tell you from the outset that the president and the administration are as committed to delivering on comprehensive health reform now as they have ever been. the president is very determined that not only does this need to happen for the citizens of this country but it is essential for the economy of this country. every day that goes by and every

report that comes out reinforces his notion of how intimately what is going on in the health-care system is tied to our economic survival and economic progress. this isn't about a legislative victory or proving a point. as he said eloquently in the state of the union address, clearly it isn't about his political standing or he would have chosen something else to start with. he feels strongly and i feel strongly that this is one of the determining issues about the future of our country and how prosperous we will be in a global marketplace and frankly how healthy our citizens will be in this competitive world in which we live. we know a lot about the human stories, imams who are paying for hospital bills because of

pre-existing condition and they can't get the insurance they need or a steel worker who every year sees his pay go down because more and more of the salary is diverted to trying to pay for a health care plan or seniors who are going to the hospital to get treatment for a urinary tract infection only to end up dying from a staff infection that they get in the hospital, 1 of the 100,000 people year who still dying in this country or the younger people who are continuing to worry about whether or not the promise of medicare may now ever be there for their future. there are lots of individuals around this country who are worried about the system and don't know what the answers or solutions are.

we had our own interesting moment, a glitch in the health-care market where the mother of two, 20 something sons and when both of them graduated from college, neither was in a job situation which provided health care. they are healthy and they had not a lot of trouble finding affordable insurance and we had resources to help them pay for that but i watch their friends, in number of kids who had a previous football injury. another one had treatment early on in high school for ec's of challenges he was facing with drugs and alcohol. neither of them could get insurance in the marketplace and really had to spend some time struggling and trying to figure out what their options were and hoping to not be in a situation

where they ran into an accident or disease they couldn't cope with. that is a very tenuous situation that they are in. we know that the process over the past year has been confusing to a lot of folks. when you talk to people when i have a chance to travel around the country and visit people about what are the elements in the house and senate bills there is overwhelming support for those measures to be enacted. when people watch up close and personal the activity of congress they tend to not only be confused but sometimes disgusted with the whole process and they don't want anything to

do with it and are too afraid that whatever is going on can't possibly be good for them or their families. we know from beyond the personal stories about what this is doing to our economy, i deal a lot with people in the small business market and my friend karen milne, the new small business administrator tells me this conversation goes on all over this country that small-business owners who are in the real crunch of a marketplace want to do things. how do they drop coverage altogether? they simply cannot afford the dramatic increases that they are seeing or they lose employees to people who can afford much better coverage. they can't say competitive in this marketplace and their choices often between keeping employees and keeping health coverage.

they can't do both. we know that our entitlement programs of medicaid and medicare are on track to be broke and medicaid budgets are crushing states all over this country and medicare is due to run out of money in the next seven years. we are also at a point in this country where we spend almost double what any nation on earth spends on health care. we are now, according to the report last week, spending over 17% of our gdp on health care, largest 1-year increase in the last 40 years is the jump in health-care costs compared to what is going on with the rest of the economy. yet we live sicker and die younger than many countries on earth. i was with the danish ministers of the other day.

they were coming to the united states to look at our it systems to look up the work we are starting on prevention. i was struck by the fact that in denmark their per-capita health care costs are $3,300 a year and we are over $7,200 a year and their health measures and virtually any area you can choose, are significantly better than ours, from life expectancy to low birth weight babies and on and on. i know some of that can be explained with a relatively homogeneous culture and not nearly as many issues or problems that we may have with the diversity of health experiences, they are too large and we are spending too much money and getting worse results. both congress -- both houses of

congress have worked on this issue for more than a year and there are numerous good ideas in the house and senate and they really have much in common. when the push for reform started a lot of people said we can't do it now. we can't take up this much time but once again, it is so intimately tied to our opportunity for economic recovery, we have to do it. we have to do it in a way that not only are the bills paid for and don't add to the deficit which is very different than most recent health reform that was passed by the previous administration, the drug benefit which was not paid for and was part of our growing deficit, the president is committed to having it paid for but look at ways

that the system is transformed into a much more cost-effective, higher-quality system in the long run because if we pay for what we are doing and continue to do it into the future and add forty-five million people into the system we haven't made any progress. we haven't changed the trajectory which is now indicating that we will not be able to afford this system long into the future. we have to have as part of the system had different way of delivering medical care, change in not only payment practices but delivery system and a way to tackle these underlying causes of our extraordinary cost. those are all key elements in the reform system. the president, as you probably

saw, has invited key members of congress to join him on the twenty-fifth of february. he is very hopeful that this won't be just one more conversation about the various components of a plan but really hopes the republicans are willing to come forward with their own plan. not just criticism but a plan. how do you plan to address a way to reduce costs in the system. cbo scored the senate bill most recently as over the next two decades taking $1 trillion off of the deficit. that is a significant step forward from where we are now. covering all americans, having a delivery system that begins to focus on wellness and prevention and not just wait until we deal with acute care, come together

and move forward. a lot of people said this is starting over and the answer is absolutely not. there are comprehensive proposals on the table that he is ready, willing and able to add the various elements that may be missing but we have to -- frankly, republican members of house and senate to read engage in this process. it is not acceptable that half of the legislative body is pushed away when this conversation began months ago and basically say we don't want to participate in this process. if you remember for a long time the discussion was we don't want to participate in anything that has a public option. we can't talk about any insurance strategy. as far as i can determine the public option is no longer part

of the plan and yet no one has come back to the table and said we will now talk about how to move forward with a private market strategy. we hope to have it in february. we will continue to work the house and senate leadership, continuing to discuss with each other what are the best ways forward but the president remains committed to the notion that we have to have a comprehensive approach because the pieces of the puzzle too closely tied to one another. it is disingenuous to say we are for insurance reforms and yet don't support a notion that everyone would have to come into the marketplace. if you have to have a private market system without rules that allow them to frankly cherry pick the system, and don't require those who are well to buy insurance you have effectively destroyed the

insurance market because quickly will have an adverse selected pool and only sick people and the costs will skyrocket. i don't think it is a genuine step forward to say we want to provide coverage for all americans and yet not recognize that there are lots of working americans who cannot bear the full cost of providing their own coverage and are not in a job situation where there is an employee -- employer contribution. without some subsidized assistance we will have an offering of coverage which we do now but not the affordability of coverage. pieces of the puzzle are necessarily tied together if you have a comprehensive approach and cost containment has to be part of that comprehensive approach and i think the house and senate have gone a long way to making sure there are a whole

series of ideas on the table which we feel will not jeopardize benefits but actually move us in the direction where hospitals and providers will be helped to a standard of providing higher-quality care and eventually will face financial disincentives for not following opprobrium protocol. the cause for reform and the case for reform is still fundamentally before us. it is a conversation that we have had in this country for 70 years. i was not part of those original conversation although i feel like i was. we need to sit -- step up and deal with a comprehensive health

reform in america because our economy can't afford us to do anything less. our health system is fundamentally broken in many parts and needs some transforming live in fusion of assistance and there is no question that millions of americans are desperate for some sort of health security we don't have now. reform itself, comprehensive look at the health-insurance system and changes in delivering the prevention system doesn't magically transform all the issues facing us in our health system. it would be a huge step forward. it would be the biggest step we have made in 40 years. our health system didn't begin an end with health reform and was never going to stop when the

bill passed which is why for the last year we have been working on some underlying features of the system and we will continue to work in all kinds of strategies with the proposals that are contained in the 2011 budget which fits as companion pieces to the comprehensive health reform bill moving forward. one of the first bills the president signed into law last year was the expansion of the children's health insurance program which has been enormously popular and the enormously successful in ensuring children across america. we put in a report last week which looked at the baseline numbers and in spite of the economic downturn experienced by every state in the country, 2-1/2 million children have insurance today who did not a year ago or are enrolled in medicaid or programs, states

have worked to expand their coverage options for kids. in spite of tough budget times angeles's, they understand that that is a fundamental step forward if you want to have a prosperous state and want kids to do well in school, they need to be healthy at the outset. children's health-insurance continues to be expanded but we have a challenge. we think there are approximately five million american children who qualify for medicaid who are not yet enrolled. for the first time with the passage of the legislation last year congress appropriated some out reach money and we are working diligently with partners not only across my cabinet colleagues and government looking at the various programs people enrolled in, we might make it more and auto enrollment in children's health insurance if you qualify for a variety of

things that we would alert parents but conceivably actually enroll folks. working with states with our faith based partnerships with outreach organizations, high am asking all of you when you return to your home areas, if there are ideas or strategies you have about enrollment opportunities. some parents have no idea that they may be eligible. others have listened to the discussion. about health reform. they have to wait until health reform is passed in order for their children to qualify. they don't understand the bill was passed and written into law. some may have been enrolled and because they moved work because they did not fill out the proper forms are disenroll and we need to reach out to them. we are looking for great

partnerships to make sure that at this tenuous time and when families needed more than ever that we actually have an aggressive and non-traditional outreach effort to try to get the word out to folks that they are indeed available for coverage. another huge investment in the public health infrastructure which is essential moving forward and continues to play a major role is continued expansion and investment in community health centers. during the recovery act there was a major new investment not only updated, centers that are currently in place but a major new footprint in areas underserved by health centers. what we know after a number of years is high quality, lower-cost primary care delivered very effectively neighborhood centers and health

becomes a component of what is available and offered to families and offers everything from child care services and job counseling and mental health services become a component of it. in the president's budget for 2010 and again the proposals for 2011 that footprint will continue to expand and strengthening our primary care delivery and again, what i have seen in the creative strategies going on around the country is community health centers working in close partnership with community hospitals have developed some really strategic health plans. patients in the emergency room are referred to a health center.

it reduces the strain, in gauging the family with a home health providers and primary care provider and delivers care in cost-effective and culturally sensitive base. started in the recovery act and continued in the budgets, there is no question of health care providers. more doctors and nurses. that investment has continued and it is not only traditional providers but increased emphasis on nontraditional providers. men and women will serve in underserved areas but a great

deal of effort in of reach for minority providers or spanish-speaking providers or multiple language providers recognizing the health barrier deals with cultural competency and unless we make an enhanced efforts to have a diverse help work force we will have lots of barriers to health care delivery. the president has made it abundantly clear to members of his cabinet that he takes very seriously the stewardship of taxpayer dollars and one of the areas that we know has great potential, recovering tax dollars with fraud and abuse. there are all sorts of estimates about what kinds of fraud may take place in the medicare

system. groups estimate that in any enterprise, small business for large corporations, 3% of business is likely to be fraudulent. if it were accurate, medicare is a system, million dollars of claims every day, accused target for fraudulent activities. the activity used to be pretty unsophisticated kind of mom-and-pop operations that it now is the target for a much more serious organized criminal activities. ..

activities to prosecute and prevent fraud. thiwe have been asked to convena multi agency operation, the task force we put together and part of the goal was to use data to analyze ever and billing practices. some of you have probably had situations where you will get a call from visa or american express saying did you make a charge i am but a cerus -- buenos aires? were you in boca raton in this date? they have analyzed what are the

billing practices and want to get ahead of what may be fraudulent activity. we're doing a similar operation where we now have an opportunity to share real time data with those at the justice department. we have analysts who are looking at various patterns to try and have boots on the ground to we have analysts who are looking at various patterns to try and then have boots on the ground to go and very quickly check out what in the world is happening. the strategies are already paying off. later today you have a panel dealing with geographic variation in healthcare. but let me just give you an example of how we're using our current tools. miami-dade county is home to 2% of the medicare beneficiaries

who are receiving home health benefits. but in recent months they have 90% of the home health patients receiving more than $100,000 of care every year. now, you don't need a ph.d. in statistics to see that something is going on. and, in fact, we moved one of the strike forces into the miami area. it was one of the first places that we targeted within a very short period of time. literally billions of dollars in home health billings dropped in miami county having people on the ground verifying. unfortunately they moved someplace else. so this has to be -- we now have seven strike forces throughout the country. we've asked in the new budget to have resources for up to 17 cities. but more than that, i think the

data-sharing, the verification we started doing, new prescreenings and verifications for providers coming in. we need to do a better job actually making sure that somebody isn't just hanging out a shingle and holding themselves out to be a medicare provider. that there actually is a service being delivered. and there's always a tension between wanting to pay promptly not hold up provider claims, not hold up services delivered and making sure that these activities are legitimate. but it's something that we are taking very, very seriously. no question in this country that we are behind a lot of the rest of the world in our use of technology in the health system. it's still fairly stunning to me that in the vast majority of hospital systems and doctors offices we are still using paper records. and i can't imagine any small

operation in the manufacturing sector who still would be ordering inventory with a written list hand-mailing it to someone in hopes that that delivery would take place. but that's the kind of technology that is in most providers' offices today. again, congress and the president made a significant investment in developing a national electronic health records platform in the recovery act. and what we're hoping is that we can provide enough incentives to actually have the tipping point that the market will take over. this is not -- you know, that the government will provide the technology. but what we know is without a platform, without some assurance that these systems at the end of the day will be interoperable and without some, frankly, incentives and assistance

particularly for smaller providers or community hospitals we will stay in our papered world. so the technology move is underway. we've already seen systems in place in pockets of the country where very positive patient outcomes are achieved because of, you know, the use of technology and health systems. one health system was using electronic health records to identify older women who weren't receiving osteoporosis screenings on a regular basis. but they went through the patient list. looked at the screening. matched them. mailed letters and the screenings went out the following year, 300%. and i identified some folks with real problems. and another system, about a third of the diabetes patients

were actually receiving regular eye and foot exams as is necessary in a diabetic. and again the tracking of patients, monitoring with electronic records and following up carefully in terms of who got exams doubled the amount so that 2 out of every 3 of those patients is now receiving the appropriate follow-up care. so the recovery act investments, the ability to put extension systems on the ground to do outreach to providers in underserved areas to be the tech center helpers and to be led by dr. david bloomen thal who is not a great leader in this area but comes from this perspective from a practicing physician who used electronic records. he frequently describes himself

when he deals with providers as, you know, i'm not the technology geek. we've got those folks in the system. but i can tell you how as a doctor this informed my practice and actually made me a better healthcare provider to the point that i would never go back to practicing any other way. it's a way to really virtually intergrate a lot of healthcare practices. so that doctors and hospitals don't necessarily need to be in the same system. not even in the same city. but the kind of opportunity for coordinated care and bundled care and follow-up. and monitoring. we know can have enormous success. -- successes. and when used appropriately, the opportunity to lower medical costs and increase high quality care delivery is extraordinary. so that also is underway.

we continue to understand looking at the data that again we have a huge problem in this country with chronic disease. and chronic disease driven by some very clearly identifiable underlying causes. smoking, obesity are two where there is a huge opportunity to change our healthcare cost estimates into the future if we can deal with some of those underlying causes. i'm pleased to be joining the first lady tomorrow in her kickoff of her childhood obesity initiative, which she sees as a multiyear effort to really tackle what is a true health crisis in this country where we now have 1 out of every 3 american children are overweight or obese.

and that is double the number of 40 years ago. and it's getting no better. there's enough childhood type 2 diabetes that it's no longer called adult onset diabetes. we just call it type 2 because many more children are presenting with diabetes. and, in fact, if these health stats can't be changed, we have the first generation of american children who will have shorter life spans than their parents alive right now. so it is a very serious issue. we know that smoking dropped dramatically in the united states over the years but has, unfortunately, leveled off at about 20%. and isn't dropping. it hasn't dropped in a number of years. so not only is there a new aggressive effort at the fda which i'm sure dr. hamburg will talk to you about.

dealing with the opportunities presented with tobacco regulation finally being signed into law. but a whole host of strategies being looked at to really see what is it that can influence people -- smokers to stop and hopefully influence our younger americans never to start in the first place. congress made a major investment in prevention and wellness as part of the recovery act. a portion of those grants go to states and programs will be in place around the country mainly aimed at tobacco cessation and obesity and community grants will be announced later this month. we'll have 37 communities, urban and rural, some tribal communities who will be looking at strategies both dealing with obesity and tobacco cessation. so we'll really be able to figure out what works.

and be able to drive it to scale. and again, when 75 cents out of every health dollar is spent dealing with chronic diseases, the more we can have early intervention, the more we can change that pattern on into the future, the more we can make sure that 50 years old don't end up with diabetes but deal with it when they're 12 and 13. not only the lower costs will be but the healthier our nation will be. those are important steps already underway to make us healthier and more prosperous country. and we're going to keep in our department working on this in a host of other strategies dealing with health disparities, continuing to look at innovative medical counter-measures. trying to make sure that we're on the forefront initiatives

around the world. there's no question that comprehensive healthcare reform is an important and intrical of this strategy moving forward. if we did all those other initiatives and we did them very well we still would have a huge gap in our healthcare system in our country and we would be in many cases just moving money around the system where those with insurance are paying extra costs for those who don't have coverage where we still have millions of americans who can't adequate care on a regular basis and don't seek care until they are often too ill to be treated appropriately or dealt with very adequately. we will still cease to be

competitive with a economy in developed countries with the kind of major health gaps that we have here in the united states. these pieces of the puzzle are tied together. we take them all very seriously. i am confident as dr. helms that we will have a comprehensive health reform measure passed and signed into law this year and i'm also confident that we have an opportunity with that piece as well as these initiatives in technology and prevention and wellness and a new way to look at health in america to make some really transformative changes that will yield a more prosperous, healthier nation over the next decade. now, another new course that we have in the department is our effort to build a 21st century food and drug safety system.

and it is again a charge that the president has given to us. and we take very seriously given the fact that our marketplace looks very different than it did 25 years ago. we need a regulatory structure that looks very different than it did 25 years ago. and i'm just delighted that you're going to hear from another of our great new leaders at hhs dr. peggy hemberg whom we were able to steal from new york and convince to be here with us. but thank you all for being here today. thank you for braving the weather conditions. i don't know, dr. helms, your meeting is going to go on. but i understand we have another 6 to 10 inches -- well, you'll love washington, you know. we love having you here. we can use your expertise on a regular basis. we got lots of challenges to deal with on into the spring and summer. so we're happy to have you join us here.

thank you all very much. [applause] >> well, thank you very much. and it's really a pleasure to be here. and i must say i'm additionally glad that i simply made it here. i have a prius so in addition to having to deal with the snow, i was worried about the brakes. but i am really delighted to be here and very pleased to be able to follow our secretary, secretary sebelius, who is a remarkable woman. i thank her for her strong leadership. and her support of fda which has been really unwavering in her short tenure. she's already been out to the

fda twice which i think could be a record. i also have to say she probably has made another record in terms of how quickly she came on the job and immediately had to face major public health challenges first with the global pandemic of h1n1 and also as our nation has struggled to deal with the important issue of healthcare reform. i also want to thank the organizers of this conference for the invitation to be here today. i deeply appreciate the work that all of you in this room are doing. to sort out difficult and complex problems as our healthcare system and with the health of our nation. and to help us to be able to provide higher quality care to patients and to be able to improve the overall health and well-being of our nation. i really was not at all sure that this meeting would go forward.

i admire the determination of the leadership. i thought snow would probably do us in. and at a mini thought that i'd be addressing a rather empty room. so when i look out at all of you, i'm really impressed by your dedication. and i must say that i'm happy to get a warm welcome here. when i took this job back last spring, i was a little worried about the kind of response, weather or not, that i would received when i was introduced as fda commissioner. certainly, too many people offered me condolences along with congratulations when i was first appointed. many wondered why i would want to take off a position like this. as the head of an agency that

was always appearing to get clobbered. but, in fact, i've been amazed by the support that i've received from so many quarters. almost everyone that i've spoken to and met with in the last eight months since i was appointed has shown real commitment and deep interest in the success of the fda. a real desire to help support me in this task. and i think it's clear why. all of us eat. all of us need medicines from time to time. we all have families whom we want to keep safe. each and every one of us needs an fda that can do its job and do it well. yet, the challenges are daunting. consider that the fda regulates about 20% of every dollar consumers spend in this country. drugs, medical devices, vaccines and biologics, cosmetics,

tobacco products now as the secretary mentioned, animal drugs and feed and even certain products that emit radiation. to add to the challenge, an increasing percentage of these products comes from overseas creating new challenges in assuring the safety and quality of our food, drugs and medical devices. what i'd like to do today is to describe some of the priorities and perspectives that i bring to this job and how they're being addressed. the late senator kennedy, one of our nation's great champions of healthcare, once said that the fda is the most important health agency in the united states. this is a surprising statement to some. but the more deeply i'm involved, i learn every day about the complex and important work of the fda, the more emphatically i understand and share his view.

congress has given fda strong regulatory powers. the public expects us to take action to make sure that the products we regulate are safe and of high quality. but we're also the gatekeepers with a major role in getting new products into stores, pharmacies and hospitals. in both areas, preventing and encountering threats to health and furthering the development of innovative products we have a unique role and responsibility. if we cannot do our job and hopefully do it well, there is no one else, no one in government, in the private sector, in the not-for-profit world or in academia that can step in and back-stop behind us. ironically, when we succeed we're often invisible. the outbreak that did not occur, the dangerous drug that never made it to market. but when we struggle, our

mistakes are usually glaringly visible. moreover, if we miss a signal that indicates problems with a drug's safety or conversely if we unnecessarily delay an application for an important new drug, patients certainly can suffer. throughout our history, the fda has often been the target of critics who claim that we're too slow to approve important products and too quick to jump at the sign of a safety problem. that's one side. the other critics tend to say that we're too industry-friendly and allow too many dangerous products on the market. this is a hard job. and the challenge for fda leadership is how to steer the ship in often choppy waters. my approach has been to use as a compass what is, in fact, fda's historic mission. the promotion and protection of public health.

this public health perspective is perhaps not surprising as i've worked in public health most of my career. though i actually trained originally to be an academic researcher. but what does the public health perspective really mean? the institute of medicine has defined the mission of public health as, quote, fulfilling society's interest in assuring the conditions in which people can be healthy. to be healthy surely people need access to a safe and nutritious food supply and to the safest most effective medical products possible. the fda's role is to support this access and in doing so, to promote health, prevent illness and prolong life. as i said most of my career has been in public health. it began nearly two decades ago when i accepted the position of new york city's health commissioner and that occurred actually rather to my surprise.

and at the time my great aunt winnie who was sort of like a grandmother to me was actually very upset by my decision. she complained to my father that she just couldn't understand why i didn't want to be a real doctor. why was i taking on this strange government role? and my father tried to offer her some consolation by telling her that i would, in fact, still be a real doctor. but that now i'd have 8 million patients. and now i guess i have about 300 million. and so what are the key challenges? in my view, as a public health agency, fda must work to prevent problems. to balance risk and benefit. and to monitor outcomes. my goals are to modernize fda's work in all these areas and to strengthen the agency's credibility in doing so. these goals are intimately linked. and it's linked not just to strengthening the fda and the

important work that we do. but also to fda's role in the u.s. healthcare system and in a globalized economy. so i want to discuss each of these key areas in turn. first, fda must try to identify and prevent problems before they occur. one good example comes from how we address food safety. late 2008 there was an outbreak of salmonella related to contaminated peanuts. i suspect most of you probably recall this outbreak. i know it had a powerful effect on the president who was just coming into office as this outbreak was hitting its high point. in this case, the fda learned about the contamination of peanut paste produced by the peanut corporation of america but the agency did not take aggressive enforcement action until after there were confirmed cases of illness. in the end, eight people lost

their lives and thousands were made sick. by contrast, last april, a number of months after the peanut corporation of america had peaked of the problem, we learned that a california company pistachios were contaminated with salmonella. this time the fda immediately warned consumers not to eat pistachios while we investigated the extent of the problem. we soon found the source of the contamination. identified the shipments. and the products involved. the companies issued recalls. and there were no sickness or deaths. from the beginning of the investigation, we worked with the pistachio industry closely to identify products. both the products that were at risk and the products that were safe. within a short period of time, people could start eating pistachios again. the situations were admittedly different but between peanuts

and pistachios, fda had begun a shift towards more prevention. we now also have a reportedly full registry which requires companies to let us know of any safety problems with their ingredients before anyone becomes ill. and we're waiting for the senate to pass a major food safety bill. the bill which has received bipartisan support has already passed the full house and passed through senate committee. this bill is really important because it will provide important new authorities and resources to the fda for food safety. it will give us the ability to do mandatory recalls of tainted food. give us routine access to food safety records at factories and farms. and make sure that facilities develop and adhere to safe manufacturing processes. these are things that are vital for us especially if we want to

prevent major problems rather than simply to react. most businesses agree and support these measures as well. they understand that when an outbreak of food-borne illness occurs, it's deeply damaging to the food company that is responsible and can hurt the entire industry. the salmonella outbreak from the peanut corporation of america not only killed and sickened people. but it shut down plants threw workers out of their jobs and led to recalls that cost the food industry about a billion dollars. preventing problems also applies to medical product regulation. that's the reason for the agency's quality by design program which aims to build quality and to each stage of the production process. and other measures to address safety across the lifecycle of products. across all of our regulated areas, we're asking not just how

to fix problems but how they can actually be prevented. we're reorienting our inspectors to focus on key measures for prevention not just evidence of current or existing problems. but when we see problems, we cannot be afraid to take the actions necessary to stop them in their tracks. too often the agency has found itself engaging in back and forths with companies and with lawyers while serious health and safety problems remain in limbo. my view is that when the health of the public is jeopardized we have a duty to warn and to act. for example, shortly after i took office, i learned about a growing body of evidence that a zinc compound in certain nasal products for cold symptoms was damaging the sense of smell of consumers. there were well over 130 cases of people that appeared to have permanently lost their sense of smell from using these products. so we took action.

we warned consumers not to use these products. and the manufacturer removed them from the shelves a week later. this was a good outcome. and we'll always act when public health is clearly at risk. but enforcement is only one of the tools fda uses for public health. a second critical task for fda that i want to mention is to fairly balance benefits and risks. where there is much risk and little benefit, fda should step in to prevent products from reaching the market or pull products from the shelves. where there is much benefit and little risk, we should step up the efficiency of our approval process or actively urge people to receive the benefit as we're currently doing with vaccination against the h1n1 flu. of course, there's that gray area in between where products have both serious risks and important benefits.

in this case, fda must use all of its tools at its disposable to maximize the benefits and minimize the risks. to maximize the benefits we can help direct a product to those who can use it most. to minimize risk we can investigate predictors of problems. today including even such things as genetic markers and educate caregivers and patients about who should or should not use a product. all the while we should be monitoring the impact of our actions and using this information to decide how much more or less we should do to protect the public. indeed, a third key area of focus for fda is the assessment of outcomes. we can't measure success only by the number of facilities we inspect or drugs we approve. or whether we're following the regulatory guidelines to the letter. the true measure of our success is the health of the american people.

for food, we must keep a close eye on rates of food-borne illness including hospitalizations and deaths. for medical products we must have an idea of the key health needs of the population and whether we're creating regulatory pathways necessary to meet them. we've shown in the past year that fda can clear red tape to get needed products to consumers in emergency situations. for example, as a result of pandemic preparedness planning that actually has taken place over many years now, fda was ready when h1n1 flu pandemic began to take extraordinary steps to protect human life. we immediately authorized the emergency use of newly developed diagnostics for h1n1 so that people could be tested for the disease as a guide for treatment and for tracking the epidemic. in addition, on an emergency-use basis we made antiviral drugs available in circumstances for

which they hadn't been licensed but where they might save lives. we based our decisions on careful review of available data and risk benefit analyses that came from scientific evidence developed for these products. we must also be aware of where patients can be suffering adverse consequences of regulated products. last fall fda launched a safe use initiative to encourage medications to be used safely. meaning in part not accidentally ingested or overdosed not given to patients who will not tolerate them. not prescribed in inappropriate ways. and not used inappropriately by patients at home. some thought that this was going to a bit beyond fda's traditional role but we thought it was a vital part of our role. and through this effort we're partnering with a wide range of allies from hospitals to health plans to pharmacies and we'll

monitor our progress closely to make sure we are on the right track. we have a lot of important tasks before us. unfortunately, though, over a period of many years, fda has not gotten the resources and other support necessary to fulfill our important mission. but i do hope and believe that we are turning a corner. there's growing appreciation that is in everyone's best interest to have a strong, fully functional fda. and we're embarking on a new era of public health protection with the support of the white house and of congress. last week president obama released his fiscal year 2011 proposed budget which contains significant enhancements in some key areas for fda. there's a long way to go. but these are exciting times. recently as the secretary mentioned we've been entrusted with the unprecedented task of

regulating tobacco products the number one cause of prevent till illness in our nation. we're strengthening our safeguards of our food supply while looking forward to the legislation that will give us significant new authorities and some resources to support this area of work. we're implementing new strategies to enhance consumer and patient safety while supporting innovation. and we're working hard to bring the fda fully into the 21st century with respect to two key areas of activity. science and globalization. and before i close, i want to say a little bit about each of these key areas of activity. first, with respect to science, we're moving forward to strengthen and streamline the science of our current regulatory procedures and implement new strategies to guide our work. as you may know, a number of reports and advisory boards have warned about the dire state of

science funding at fda. and how the scientific and regulatory demands are outstripping fda's capacity to respond. clearly this cannot be allowed to continue. in everything we do, a fundamental priority must be strengthening science. in everything we do, fda must demonstrate that there's a science-based science-driven agency. we must ensure that we always use the best possible science and data to guide our decision-making and our thinking. we must get advice from the best possible experts. and always be prepared to change our mind in the face of emerging science. it's obvious that the agency charged with the responsibility of judging the safety and efficacy of drugs and medical products and monitoring the safety of those products and other products including foods and cosmetics needs to post scientific capability equal to that task.

but while that statement may seem logical, the fact is that in terms of investing in the kind of science we need to advance as a nation, we are somewhat off-kilter. fda clearly needs more resources for science. and the president's budget reflects that but it's more than that. just as biomedical and life sciences research has evolved in the past decades, regulatory science, the science and tools we use to assess and evaluate a product's safety, effectiveness, potency of science must also evolve. i often use the metaphor of a row around the potomic with one muscular arm and one scrawny arm. it's inevitable that the boat will not go on a straight trajectory forward. so it goes with u.s. biomedical advances over the past several decades. basic science, spearheaded by

nih is pulling hard. but it also takes muscle to create innovative tools, standards and approaches for the efficient assessment of product safety, efficacy and quality. without these complementary advances in regulatory science, promising therapies may be discarded during the development process simply for the lack of tools to recognize their potential. and outmoded review methods can unnecessarily delay approval of critical treatments. conversely, both significant dollars and many years may be wasted assessing a novel therapy that with better tools might be shown to be unsafe or ineffective at an earlier stage. strengthening regulatory science is a vital and urgent challenge for the brightest minds in academia, industry, and government. a robust state-of-the-art field of regulatory science is essential to fda's work.

there is no doubt. yet it also represents an important driver of our nation's health, our healthcare system, and our economy. and it's a goal that we all must embrace. i feel confident that if we do so, we'll be able to speed the movement of new discoveries to practical applications. and we've seen examples in the recent past where concerted scientific investment led to the development and approval of new drugs in remarkably little time. this has a very personal resonance with me because when i trained in medicine, i watch the emergence of the aids epidemic and when i was doing my residency in internal medicine in new york city during the mid-1980s, i was taking care of a lot of aids patients. at that time we had virtually nothing to offer these patients besides supportive care. we had patients with devastating illness and yet there was so little that we could do.

shortly thereafter, i went to work with tony at the national institute of allergy and infectious diseases first as his special assistant and then director of the institute. by that point in the aids epidemic there were few emerging potential drugs and there was a huge push to get as many people as possible into clinical trials of the new antiretroviral videos. -- antire trovirals and -- there was a scientific regulatory pathway for companies to follow and also approved an entire new class of drugs to treat aids, inhibitors as well as with the antire trovirals. we had drugs that were keeping hundreds of thousands of aids patients alive. the early years of the aids epidemic were my early years in

medicine and they gave me a deep appreciation of the fundamental importance of innovative research but also what scientists, pharmaceutical companies, advocates and the fda can do when working together. more recently, several partnerships with industry and universities to advance regulatory science are starting to bear fruit. one example concerns new tests for kidney toxicity. fda worked with european regulators, industry, and the nonprofit critical path initiative to identify and evaluate biomarker proteins that could indicate kidney damage from a drug. the idea was to determine whether these biomarkers might signal that a drug is toxic early in the development process before lots of time and money was spent developing the drug and bringing it into clinical trials. as a result of this effort, fda

now admits new data from seven different kidney toxicity areas. if we could develop a consensus on more such biomarkers we could make additional progress towards reducing the development, time and costs of drug approval and hopefully provide more improved products for those who need them. similarly, we're working in partnership with others to try to develop new clinical trial analytics to provide better answers with more patients and short time frames and with genomics we hope we can target treatments in new ways that will be more meaningful with benefits to the patient and to the healthcare system in the form of more successes and fewer adverse events. and lowered costs and time required to develop new drugs. we'd like to encourage others to join us in such efforts. and i'm happy to report that the fiscal year 2011 budget includes

for the first time a proposal for a new effort for regulatory science at fda. such an initiative will help us prevent problems, better balance risk and benefit. and create better health outcomes for the american people. and as we begin this new year and a new decade, one of our top priorities must also be to update our approach to import safety in a globalized world. the model for fda's current control system was established in a much, much simpler time when the modern fda was created back in 1938, only a tiny percentage of our goods were imported. today we receive imports from more than 150 countries and about 300,000 foreign facilities. these are fda-regulated products. this year more than 20 million shipments of such fda-regulated products are expected to arrive in the united states. just one decade ago, that number was about 6 million and a decade

before that, it was a much, much smaller fraction. so the problem is growing rapidly and enormously. consider that some 15 to 20% of the food we eat comes from other countries. in fact, about 75% of the seafood we eat here comes from foreign waters and around 35% of fruits and vegetables come from beyond our borders. and these are some of the foodstuffs that are, in fact, most vulnerable to contamination. and somewhere around 40% of the drugs americans take are imported with up to 80% of the active pharmaceutical ingredients in drugs that we take here coming from foreign sources. so the numbers really are extraordinary. this flood of new imports represents a wealth of new products now available to americans. and many, many benefits. yet it creates a whole host of additional challenges.

it is clearly impossible to screen out all bad goods at the borders. fewer than 500 fda investigators are responsible for monitoring this flow of goods. and that represents sadly an almost insignificant increase from two decades ago despite the fact that the volume of imports has been growing enormously. as a result, we inspect less than 1% of these products before they enter the united states. ...

>> and not rely on the fda to show up and find a problem in the plant. it means building up a network of oversight, working with national organization and other national governments, harm monoizing standards, helping to build regulatory capacity in other countries that have less mature regulatory systems, developing third party certification systems and sharing the responsibility of inspections and the information that comes from them. this is a supreme priority for the fda. we are in the midst of many

different initiatives to make it happen. we're setting up permanent offices around the world. we signed more than 30 agreements that enable us to share information and other important safety information with other countries that have mature regulatory systems like ours. and we're training regulators in countries with less sophisticated systems and helping them to try to build capacity. by doing so we're not only improving the safety of products coming from our shores, we're also helping other countries make healthy improvements in the goods being offered to their own citizens. this is a form of health diplomacy. and it makes sense in a globalizing economy where we are all more connected touche other then we sometimes realize. my first big job in public health was serving as new york city health commissioner for six years during the 1990s. during that time, my two children were born. and it made an impact on me.

on my children's birth certificates, my name appears twice. both as their mother and as the health commissioner. both roles gave me a duty to protect them. at home, but also by preventing illness and promoting health for them and the world around them. this second role wasn't just a duty to my children, but to all children and to everyone in the city. my job is bigger now and the approach is different, but the mission is the same. protect the public health. it's the goal and guide in all we do. thank you for your attention and hopefully for your support. [applause] i talked longer than plans. but i think we still have time for some -- yeah.

>> i think they are on. and there are out there. if you'll get to the microphone. thank you. >> brad, why don't you begin? >> good morning, i'm brad brad -- is this on? i'll talk loud. okay. hey, could you talk a little bit more about your responsibility with regard to the tobacco and how it compares with your authorities with regard to food and drug and sort of what you're doing to carry it out? >> okay. this is obviously a very important new mission for fda and it's a historic advance. i believe it will make a huge difference in the ability to reduce smoking in this country and hopefully prevent the onset of new smoking. it in many ways draws on existing strategies for regulation. but in many ways, it's also quite different and we're

developing a whole new approach. the legislation was signed into law in the summer, the last summer by the president. and it laid out a number of very explicit requirements for us in terms of actions we must take. and we have been moving forward rapidly, setting up a new center, recruiting a terrific center, director dr. lawrence deton and hiring up at the same time we are starting to implement important programs. the law focuses on several key areas. one is really deepening our understanding of the science of tobacco and tobacco products, understanding the components of tobacco products which now the companies are required to report to us and really being able to address with much, much better information and specifics the

health hazards contained therein. we also have very explicit authorities to try to reduce the onset of smoking, particularly in youth and to address strategies for getting people who are already smoking to quit. we've already moved forward, as you may know, in banning candy and spice-flavored cigarettes which is something that has been linked to enticing young smokers into taking up the habit. we also are moving forward with making more explicit warning labels for cigarette and tobacco products and addressing issues of advertising. we have a big job in some arenas, we are really charting new ground.

we're also working with regulators from other country who's are already engaged in doing some aspects of tobacco regulation in order to learn from them where we can working closely with states and local authorities as well to implement aspects of this law. and we've already been sued three times. which hasn't surprised us. but we are up and going, moving forward, beginning to see the fruits of some of our labor and really have an ambitious agenda going forward. >> what do you think is the biggest single challenge there, peggy? >> you know, it's such an important area. and, you know, many ask the question at time of whether this was too big of a challenge for fda to take on given all of the other important tasks that it

already was juggling. for me, it's very appropriate for fda as a science-based, science-driven regulatory authority with the public health mission. i can't think of any other place that it can be. the legislation came with a source of funding. which is very, very important, user fees from the industry. so we really feel very comfortable that we are getting the systems in place and the requirements of the law as i said are very explicit. so i think the great challenge was really to hit the ground running, because we simply had no other choice if we were going to achieve the goals of the law. and i believe that we are well on our way. but it will obviously require continuing effort, lots of

attention, real dedication, because what we're doing is not always well received. but what we are doing will make a difference for health, i'm sure. >> back to the comments, fda, no deed goes unpunished by people who think you're either moving too switchly, or not swiftly enough. the vaccines, it was brought out in record time, and in the other perspective, it was late. if the virus has been more deadly than it was, we could have had a major problem on your hands. what learnings does fda take away from the entire experience? >> well, we have learnings at fda, there are also overall lessons to be learned for public health preparedness. i think that one is planning

matters. had we not been investing in public health preparedness and pandemic flu planning over a period of many years, we would have been in much more desperate shape when h1n1 emerged. ironically, i was working in leading the department of health and human services effort at pandemic preparedness planning back in the clinton administration. but at that time, we could bearly get anyone outside of hhs to take it seriously. when i approached fema about working with us in our planning effort, they said epidemic disease, we don't do that. we do floods and hurricanes, we do natural disasters. well, they did agree to do a tabletop exercise where we unfolded a scenario with their participation. they realized it was a natural disaster on a major scale. they engaged with us, similarly

other critical components and levels of government, the private sector and others have been engaged in pandemic preparedness and other biological threats, public health preparedness planning. much more intensively, i think that made a difference. it certainly underscores the importance of not becoming complacent. right now i think it's critical that just because h1n1 turned out not to be as severe of a disease as we had initially thought it might be, we cannot take comfort and think, well, you know, pandemic flu isn't really the big problem that everyone hyped it up to be. now is the time to really look back at specifics of the lessons learned and put in place the changes to our systems that will make a difference going forward and we need to keep investing in critical research to leverage advances in science and technology to make us safer and

more nimble in addressing the threat of the next flu pandemic or the next unknown. we do not have to be relying on out moded vaccine technologies that even under the best of circumstances, and we did produce this vaccine which was a licensed product and has proven to be very safe, we nonetheless were relying on a vaccine technology that reflected yesterday's science not today's. we need to continue to invest in new diagnostics, new vaccine platforms, and new antiviral drugs. and fda plays a critical role in helping to support that innovation and translation into real world products. >> great. thank you. i think we have another question over here.

>> science tiskly progressive, in the area of clinical trials, analytics, about the fda about comparative effortiveness and the methodology for that going forward. >> well, i think, you know, the whole way that we address clinical trials and our tools for analysis and our strategies for clinical trial design is very, very key i think for both a more effective and efficient regulatory pathway for new medical products. we are working hard in that area. i mentioned that we have some working partnerships to try to enhance our scientific understanding and we want to expand that work and implement it in practice. we also see population-based

approaches as very, very key to strengthening our ability to monitor safety throughout the life cycle of a product. we are putting a lot more attention now on postmarketting survey lens strategies and farm coo epidemiology approaches that will enable us to identify safety concerns once a drug or medical product is out in the marketplace now being used by many, many more individuals than during the clinical trial process. we can use these population-based approaches and the postmarketting arena, also bringing information technology to bear so that we can do data mining and access large and often diverse database in an integrated way so that we can really identify and respond quickly to emerging safety issues.

so that's another important area and, i think, very exciting work. comparative effectiveness research obviously is very, very important to deepening our understanding about the relative value of certain products and the role of different products under different circumstances. fdas statutory responsibility is really to review and approach or disapprove products that come before us. not so much many a directly comparative way. we certainly use comparative information in terms of how we might recommend certain drugs, for example, but there are many opportunities for fda to engage more deeply with broader efforts in comparative effectiveness research. and we actually have received

some resources through the stimulus moneys to help us build that capacity. and it really comes by opening up some of our data bases and resources so that people asking questions in the comparative effectiveness research to use the information to deepen our understanding and ultimately to better serve people who need access to the best possible drugs for their conditions or concerns. so it's a very important area. and i think that obviously there's a lot of work within the department going forward and, of course, within the broader world of health services research. take a question over here please. >> hi, can you hear me?

julie lynch, university of massachusetts boston. i was glad you mentioned biomarker, my area is drug development and health policies. i'm concerned about the new drugs being developed based on biomarker with the percentage of ethnic minority enrolling in clinical trials. our lot was approved with less than 4% african-american enrolling in the clinical trials. and it appears that drug is not at all effective in patient with african-american ancestry. >> well, i think your question speaks to the point that we need very much to examine medical products in a range of different subpopulations and recognize that there may be difference in response both in terms of benefit and risks. and i think as we learn more about both underlying mechanisms

of disease and the potential role of genetic markers and biomarkers, we need to start to really target therapies in new ways for the subpopulations that will benefit. it's -- it's more demanding in terms of the research needed in some ways. but i think it also obviously will bring human benefits and it will help us better understand both people subpopulations that should not be receiving a given drug because we know that they may be more acceptable to risk or it may not work for them. but it will also, i think, enable us to not discard potentially useful drugs for

certain subpopulations because if you just look at the broad numbers, there are risks that might jeopardize the approval and use of the drug overall. so it's a tie trading effort that has to go on, looking at risks and benefits, it depends on both deepening our understanding of the science and how we use these emerging tools appropriately. and making sure that we collect data from all of the appropriate populations in appropriate ways and that we're examining the use of medical products through the whole life cycle from the time of initial discovery through the approval progress into the marketplace through i was just discussing some of the most

information can be gleaned. but we want to be able to glean it in a timely way. so that we can protect health and minimize risk. >> well, we want to thank you so much. we know you have to get back and protect all 300 million of us. we wish you god speed and thank you for being with us this morning. >> thank you. [applause] >> president obama signed a white house memo on childhood obesity. michelle was among those, she'll discuss it more today here on c-span 2. here's a look at the signing earlier today. >> everybody, i am so proud of the work that the first lady, along with the cabinet secretaries behind me have done in trying to tackle one of the

most urgent health issues that we face in this country. that is the increase of childhood obesity. because of the outstanding planning that we've done, they are going to be rolling out a terrific plan of action that involves the private sector as well as government agencies coordinating much more effectively. a lot of public information out there to help parents make good decisions about allowing their children to be active and eating healthier and what the executive order i'm going to be signing today does is to create a 90-day plan as moving forward in addition to the coordination that we are doing with private sector companies and non-for profits and other organizations that are interested in the issue. we think this has enormous promise in improving the health of our children, in giving support to parents to make the kinds of healthy choices that often times are very difficult

in this kind of an environment. and so i just want to say how proud i am of the first lay -- for her outstanding work. i will now sign this order. there you go. >> thanks. >> all right. >> now they get to work. thank you, guys. >> and we'll have live coverage when first lady michelle obama discussing the plan in about 20 moons at noon eastern here on c-span two. meanwhe the discussion on the health care legislation from today's washington journal. >> on our republican line, in charlotte, north carolina, your first phone call. what are your expectations for the health care summit. >> caller: yes, ma'am. thank you for having me. i like the idea of transparency in government. unfortunately, the transparency

that we're going to see out of this summit is phony transparency. i took away from the republican retreat in baltimore where they interact with the president that the president always has a better answer for everything. and they are painting the republican party as a party of note. well, that's a strategy. republican party is the party of alternatives which they have been shut out. 50 plus bills have been not considered, backroom deals, the list goes on. it'll be with a great, i guess, show for the democrats and president obama to try to make the republican party look like they are not cooperating. but i don't have a great expectations. i think they are going to go ahead and do the reconciliation. the american people are watching this. they know exactly what's going on. they see it. they are not as student as they

might think. so it's not going to be very good on them in november. because the american people see exactly what's happening. >> all right. next phone call comes from lawrie on the democrat line in california. good morning. >> caller: good morning. am i on? >> host: you are. >> caller: okay. well, i basically -- it's the president listens to the democrats, i think that we poor people in middle class will be taken care of. but if we doesn't listen, then i don't think we'll be taken care of. >> host: okay. kansas city, dawn on the independent line. what do you think? >> caller: well, i think basically the republicans have been following a plan that was written by reagan a long time ago. and it's been proven heavily in this last -- before obama with george bush, they want to break the government. they want to defund the government entirely.

what, with with starting a war, after 9/11, starting a war, not paying for it, putting in the medicare thing and not paying for it and then cutting taxes to boot. you know, if obama doesn't stick with his base, that's what -- that's the lesson from george bush. either you stick with with your base, or you lose it all. >> host: all right. victor on the republican line from maryland. >> caller: good morning. i don't think there's going to be a summit. and i'll tell you why. if i were the republicans, i would stay away from this as far as i could. let them own this. when you have nancy pelosi making remarks about if we can't get through the door or over the wall, we'll parachute in. let them own the mess that they created in the first place. >> host: all right.

chicago. mark on the democrat line. what do you think? >> caller: i don't see one way another the president getting anything accomplished with the republican party. they've never done anything since day 1. they've always said no. they've always been against everything. so as far as i'm concerned, there's absolutely no need, no need to even include the republicans. they are not going to be involved in anything. all of their plans have no numbers. all they have is talking points. >> host: all right. here's a little bit about where the democrats and republicans degree and differ in a couple of stories this morning.

>> host: we'll read more of these article that outline where they agree or differ. katie of florida on the

independent line. >> caller: yes, good morning. this is going to be a dog and pony show by the president to show you how he can out legalese the republicans. 85% of the people have access to health care. if you take that number, what's left? 15%. whichs to about 45, 48 million. and half of those 48 million can afford health care, however, they elect -- choose not to have health care because they want to save their money like i did the time when i was 20 to 25. maybe i went to the doctor in 25 years, maybe four or five times. i didn't have the need. i didn't have the need for health care. and when you widdle that number down even more, it comes to about the same amount of people who are in the country illegally. what does health care plan will do is like the congressional budget office said three things it won't do, it will not improve

the quality of health care, it will not make health care more assessable, and it will not, i can't think of the third thing. but anyway. it's a bad plan. president obama doesn't have a plan. this game from harry reid and nancy pelosi. >> host: all right. ron on the republican line. go ahead. >> caller: good morning. if i were republicans, i wouldn't meet with the shady street organization. you know why insurance went up in california, obama wants to put them out of business. why is obama on tv all day long? i think obama is going to take over the tv. thank you. >> host: this is the "baltimore sun." in this peace they have a statistic here.

>> host: that is an area where republicans and democrat agree. >> host: next phone call. robert in alexandria. >> caller: can you hear me? >> host: we can. go ahead. >> caller: one dollar out of every six is used for health care in the country. and it's doing to get worse. can you believe your eyes? that's the question. can you believe what's happening to us? i mean the republicans gave us

this bankruptcy bill, the health care bill, i mean the prescription bill, no money allocated for it. they don't believe in government. they want to destroy the government. they are doing everything possible to destroy the government. i'm not saying all republicans, but the people in the tea parties are basically people who voted against obama and they are democrats and republican. they are not always republican. these are people who voted against obama. they are upset because the situation is such now where we have to depend on each other and they are not willing to become homogeneous society the. >> host: go ahead. independent line. >> caller: yes, when -- what i feel as independent, i don't think either party as pointed out to the american people that the health care system will symbolize a two-tiered health

care system in the country. one private market-based system which nancy pelosi says cannot work, which is the federal employee health benefits program is which is basically a private system. and the other, a government controlled system which will eventually morph into socialized medicine. now the premier of newfoundland is coming to this country to get a surgery that is not available in canada. that is a statement for the failure rate of socialized medicine that obama is trying to put on the county. >> host: another area of possible agreement.

>> host: some areas of agreement. bob, on the republican line. >> caller: good morning. you know, i think the republicans should stay away from this. especially if they don't start from scratch. because i don't want them to join hand in hand and bring us into socialized medicine. and you put on -- you put on a guy from political left wing organization and you don't have a counterbalance to that. that's just amazing. it's -- i would suggest that c-span sit down and listen to their daily rep tar. it upsets me my payment to

comcast is going to this. >> host: i did read from health care -- >> >> caller: well, you read something. you bring on the msnbc to give a unbiased opinion on what's going on. >> host: okay. you don't think -- i guess we lost bob. norm on the democrat line. good morning. oh, sorry, norm are you there? >> caller: i think politico is pretty far to the right myself. [laughter] >> caller: anyway. yeah, i don't have very good expectations for this health care summit. because i don't believe either party is trying to solve the problem. the democrats, i'm a democrat, and have been all my life, democrats have really sold us out on this. people are not understanding what single payer health care is or what socialized medicine is,

which is the same thing. it means simply this. based on what we are saying now, we have to cut our health care payments in half, everybody payment will be cut in half, every health care worker will get a 25% raise and everybody will be able to go to any hospital or doctors office without an appointment. that's what single health care payer is, and that's what they are trying to block. >> host: ann on the republican line. >> caller: good morning. i think you are doing a great job. as the republican and physician, i think, you know, i don't really think much is going to come out of the summit. i don't like the democrats plan. but at the same time, the think i republicans plan is worse. last week, a couple of days ago, they had the piece on people with no insurance. without anything being done, 39% -- i mean an increase in premiums in california. if nothing is done, it's all going to get worse. i think single payer is the way to go.

but it's never going to happen. without doing anything, things are going to get worse. people need to wake up and see that. where should there be some compromise? >> caller: yeah, i think there should be compromise on both sides. we'll come up with something. both sides do need to compromise. >> host: all right. here's what republicans want to see.

>> caller: thank you for getting me on. i wanted to say the health care plan is ridiculous. we should abolish this. i'm thinking about all of these young kids, 22/24 years old. they have to pay $100, $125 a month. they don't want to pay this. they want to put this in the savings account. the republicans, i was a democrat, changed the independent, and i voted for obama. i'm 55 years old, i'm unemployed, i was making more

money in 1989 than i am today. and it's getting worse. i'll get me a job in sales. i'm a salesperson. but let's take care of our senior citizens. let's take care of the people that need the help. let's get a plan together? my social security may not even be there in seven years. i would like to have my money that i paid in hundreds of thousands of dollars in social security. what is it going to go? if i'm 64 and have a health problem, thank god i'm healthy now, where is my money going to go that i've put into the system? >> host: the latest college survey found that president obama is losing independents. a poll shows that 44% say they approve of job performance.

>> caller: i am a democrat. i wanted to. yes, hi. i am a democrat. i just wanted to say that i am just to sad about the republicans and the democrats. you know if we were with on our job, we acted like this, we would be fired. we could not be on our jobs and acted like this. i think both the democrats and republicans need to just tone everything down just a little bit. i also need to say that we need to come to the center.

and not go forward to the right. because we better be very aware of the right is just trying to bring government down. you bring government down or you senior citizens, the republicans do want to cut medicare. they do want to cut social security. i also want to really know if they are going to start trying to farmtize government. [blank

>> host: jeff on the republican line. we're talking about expectations for this upcoming health care summit later this month at the blair house here in washington between republicans/democrats on capitol hill. >> caller: my thoughts my expectations are really low for this thing. i believe it's nothing but smoke in mirrors. they won't got much accomplished. 80% of the country would rather focus on the economy rather than the health care. i don't think it'll reduce cost of health insurance. i don't think it will provide more coverage. frankly, i believe i have to start from scratch. so i'd rather see them focus on the economy.

>> host: pat on the independent line. >> caller: yeah, i'm about the same way. i don't expect anything out of them. i think that hit it right, with the smoking mirrors. they just want to sell us on something that try to make it look good. you never get anything done. the one thing i don't understand is how come we don't talk about prescriptions? i mean -- we're getting robbed on those. the one place will charge you $17 and the other place will take $90 something. nobody talks about that. is c-span going to be in there when they have the meet thing? i'd love to see that. i'd love to see across statelines, single payer, and if you remember, george bush told you that you had to get the consumer involved. and that's what you have to do. everybody has a prescription

card. charge what you will. i don't put much faith into it. thank you. >> host: the first lady, michelle obama unvealed her new obesity initiative and some proposals which would have to be approved by congress are $400 millions in tax credit thes. [blank >> host: roger on the

democrat line, good morning. >> caller: how are you doing, thank you c-span. one the things i want to get out of the way is politico was unbias. now my next point is february 25 is supposed to be the next meeting that obama will have. >> and we're going to leave this recorded program and take you this event. michelle obama is talking about childhood obesity, she has been meeting with secretaries. live coverage from the white