in -- [inaudible] [laughter] it will happen. even with this scenario, you still get the same number of imports of oil by 2035 as we have today. all this depends on this transformation on other forms of energy and these new technologies because they don't pay for themselves. you have to subsidize them. here you see under jimmy carter at the top of the line how much we were spending on r&d. we dropped it, and we were no longer the leaders in solar, we were no longer the leaders in windmills. so all those new technologies are controlled by others. you see the stimulus program, finished. that's not going to be the same growth in the renewables and new forms of energy.

and when we have a new congress coming in november, these are the areas where they're really going to cut. so forget about these massive increases in that sector. i just have to go very quickly to the conclusions, but the conclusions, basically, are that the demand for oil is stagnating, and it will continue to grow rapidly outside of the oecd particularly outside of asia. this comes from the likes of the head of -- [inaudible] gym schlessinger, my former boss, so don't dismiss it lightly. so that means the growth of additional fuels, additional oil in the future will come again from the middle east and our -- the transformation is going to take a lot of time, and as a

result of it we're going to see more dependence on the middle east in the decades and decades ahead until we succeed in this transformation process, and we are going to have major rivals in china and india and others for access to that oil in the middle east. .. >> we have not been as heard in previous panel. we have serious, seriously upset

the balance of power in the region by the invasion of iraq. it's amazing to see that maliki had to go to iran to form an alliance with the person who is -- in the quiet and diplomacy of ahmadinejad, so he owes mr. ahmadinejad in having a cheetah that for him. instead of coming to washington, he went to ironic. what a difference. and my final note is on the other alliance we have, which has made us, let us say, last loved by the people in the region. let us just use one sentence that peace market used when he was the prime minister of prussia. he said then, he said what we and prussia have alliances, have

any alliance has a rider and horse. and prussia will always be the writer but, unfortunately, the allies we have is what other ally in the region come we have always been the horse. a belgian doors, big. but moving in the direction of ever the writer wants us to go. [laughter] we want to have continued access to oil in the future we need a stable middle east. if we want a stable middle east, in part, let's listen to him. thank you very much. [applause] >> thank you, for the very comprehensive presentation. next where going to hear from rayola dougher, and rayola is a senior economic adviser for the american petroleum institute's media relations department. i know all of us here in america greatly appreciate the work of the american petroleum institute in educating the american public

about petroleum markets. in this capacity, rayola serves as the principal spokesperson in the media, and she's also often found testifying in front of congress on these issues, which is not an easy thing. prior to the american petroleum institute, rayola was with the institute for energy and now says, and she also very involved in the oil and gas industry in working in cohort with them in the american petroleum institute on educational issues. so rayola, thank you so much. >> i'm hoping when i get a. my slides will magically appear. they haven't yet. so just bear with me one moment. well, i'm going to wing it then. it's very nice to be here. it's an honor for me, and that some of you may know, the

american petroleum institute is a national trade association for u.s. oil and natural gas companies. and we have about 400 member companies, and they represent all aspects of the business. the u.s. oil and gas industry support over 9 million jobs in the united states. we account for over 60% of our nation's energy needs. we pay hundreds of billions of dollars in taxes that goes to the federal, state governments. and since the year 2000 with invested almost $2 trillion in u.s. energy projects. so what happens to our investment, what happens to our resources are critical to united states energy supply. and when we look to securing that supply, it's within the context and the framework of the world energy market. and -- they are here. i will go ahead because i have a nice picture of the world. here we go.

and i really like this because i think it helps underscore the importance of energy, to the quality of our lives. most of us taking for granted. we come home and i reflect if we flipped on the switch, it is there. magic force. but it especially% of the population of the world don't have basic access to electricity. and there are women in africa today that spent several hours a day just collecting firewood. so it's clear that energy really is the energy of our economic growth. it creates more jobs, higher income, but a better quality of life for all of us. and when we look to the global energy consumption outlook, we are going to be challenged to be able to sustain this economic growth. but it does look somewhat optimistic to me, going from $63 trillion in the world, to 104 trillion. almost doubling going from 500

quads of energy to 739 in just another 25 years or so. that's going to take a lot, and it's going to be a challenge for all of us. and i think the formula is pretty simple for the united states. it's really the implementation that's been a challenge. and that is to consume less, provide more, supplied more come and invest in these new technologies. when we look to how much energy countries use, it's really a function of a lot of things. our wells, our weather, and a lot of other variables that the united states uses less energy on average per capita than the rest of the world, which kind of surprised me a little bit. japan, of course we are way ahead of japan. we are way behind china. in terms of consumption per dollar of gdp. and we've been -- improved a lot over the past 20 or 30 years or so. we use about 42% less energy for

every dollar we produce. and moving forward we are fairly, at least the department of energy, is looking to our gdp doubling in almost 25 years. our population increasing by about a third, and yet we're on a path to consume about 60% of the energy we do today. and that's what the good news in the sense that our biggest source of supply living to the future is going to be saving energy. it's going to be consuming less. and without it we would be on a path of almost doubling our energy consumption in 25 years. and instead, we're going to increase may be another 15% or so, 14, 15%. if you look at this chart you will see that most of the energy we use today, and even most of the energy we use in 25 years, is going to come from fossil fuels. over half of it from all and natural gas. and the picture for the world is really no different.

except that slope of the curve is, it's a little awesome and it is kind of exciting if it really plays out this way in terms of the economic growth happening and taking off in the rest of the world. it's going to be a terrific challenge. and there are some -- you can hardly see the world, but it is behind there. and there are some who propose that one way to enhance america's energy security is energy independence, which is really code for just getting off of oil. and i think a lot of support for this notion comes from the mistaken idea that somehow we can isolate ourselves from the world oil market. and, in fact, our securities lies exactly in that marketplace. it lies in our mutual interdependence. it lies in supporting and encouraging our relationships, rather than trying to separate

them. and it lies, too, we have a variety of options in terms of diversifying our sources. most americans are pretty shocked to know that we get most of our supplies from canada. we do have opportunities with the development of oil sands in canada to move forward with them, and displaced other imports if we so choose to do so. we have a lot of resources in the united states, and we are very rare among countries in the world in terms of keeping a lot of these resources off limits to development. and we have options in that regard. but we will never be totally energy independent. in terms of the global oil trade challenges ahead, we're going to need about at least according to the department of energy, about 26 million barrels a day more oil in 25 years from now than we have today. that's the equivalent of replacing all of the oil in north america.

interestingly, they show an uptick a little bit in the united states supplied, and i love this will hinge on development off shore areas and the rest of the country. but the biggest developing in this country has been in the developing of unlocking shale gas. it has been over the past four or five years, has really been a big game changer in terms of our vision of our energy future. in the barnett shale in the texas area right now, it's providing about 6% of the energy we use. and forecast very conservative forecast looking at the marcellus shale in pennsylvania, new york and west virginia, shows that it could actually provide about 15% of the natural gas our nation needs. so it's enormous and very exciting for us. and for our energy future. and again in terms of natural gas use, add to the growth in natural gas will be even faster than the growth in oil, worldwide.

again, you can see a lot of the growth coming out of asia, but the united states is still poised to add more to the supply than we are to our demands. and investing of course is the third year. investing in new sources of energy, new technologies, the oil and gas industry invested that all other industries combined in new low carbon emitting fuels and technology. , biofuels to algae, to wind, solar, geothermal, we have invested about $58 billion this year in 2000. out of a total of $133 billion. one out of every $5 spent and deny states are non-hydrocarbon fuels is being spent by and natural gas companies. we had an awful lot about green jobs and green jobs and let's get off oil so we can have green jobs. well, we are the biggest invest in green jobs in america today. so we are all for them. this chart is from exxon mobil,

but i like it. it shows the united states share of our fuel, how we have to do this country since 1859 with forecast going out to, oh, i think 20, 235. and if you think about 100 years ago or so, coal was king. the turn of the last century, and there were articles at the time they were worried about running out of coal. and just as today many people are worried about running out of oil. and just think, the changes, if you are at the start of a century ago, and you were looking out to the future, just think, all the changes that happen in that century. the car, the on the bill, the man on the moon, our communication system, the is a communication with one another. they had no idea what was coming. and i think if anything, that change is now accelerating on our lives. we have no idea either. that leaves me very optimistic

asked about the future because i think we have a lot of possibilities. will have technologies. we have an invasion. that are going to change our lives. but in the meantime we are in the present, and transitions do take some time, and we do need elected and appointed officials who understand the challenges we face as a nation. the challenges we face in the world to fuel that future. and we would like to see them focus on increasing production from all sources of fuel. and encouraging the production, encouraging energy efficiency, encouraging investment in new and renewable sources of fuel and technologies, allow the markets to work. they are much better than government at doing this efficiently. refrain from new tactics because if you have more taxes you have less investment and give you a supply. we as an industry want to grow that taxpayers. we want to grow those jobs. and we want to grow that energy. and, finally, recognize and

support our need to produce the in the global marketplace. because at the end of the data we are really all in this together. thank you very much. [applause] >> thank you, rail. where are not going to have the question and answer period. we had some factors questions from the august that i think will only have time for want of peace, it looks like. is that right? so i'm going to start with the fun question since this is such a fun panel. dr. franssen, this question is for you. the obama administration is presently having heart palpitations that the presidency of opec will be assumed by the concern treat of iran. if you were advising the u.s. administration, what would you tell them to do? and if you were advising opec, what would you tell them to do? >> advising the u.s. administration is of no consequence, so don't do

anything. it really doesn't mean anything. opec is really like nato. what is nato? is an organization which includes luxembourg and it includes the united states. are the equal? yes, in some ways. opec, who is opec? opec, the one with a cloud, with the spare capacity, who can enforce but opec wants to do with saudi arabia. and saudi arabia usually gets the concerns from gcc partners, united emirates. so taking that into consideration i am not worried because the real power is with the gcc and the saudi arabia. saudi a reagan has been extras and responsible manager of the global oil markets. many times when disruptions of supplied, the saudis had the spare capacity, they have used this time and again to reduce

the impact on prices. they did not succeed in 2007, 2008 because it had grown so rapidly that the demand was passing so -- supply. we didn't have the defining capacity to define it. so the speculation that came into the market, financial institution, which spiked $50 a barrel. but the world of opec is still one basically invited -- divided gcc. and i've also confidence to make sure that prices will remain moderate, reasonable, for as long as they can, reasonable, why? $60 to date is a marginal cost of developing and finding and producing new oil, and that is oil from deep water. so the current price range is just slightly above the marginal cost of finding and producing. and it is very closely observed by our friends of the gcc. >> thank you.

so the obama administration has nothing to worry about. rayola, this question is for you. and utah globe about the impact of the bp oil spill on the american petroleum industry, and any legislation that congress either has passed or intense to pass during this lame duck session, regarding the addressing of this particular problem? >> well, it's had an enormous impact on the oil industry. first and foremost is a came as a big shock to all of the people who work in this industry that it ever could it even happened. in our years, decades in the gulf of mexico we have drilled over 40,000 wells successfully, over 2000 in the deep water. so the fact of this, this incident, really took everyone by surprise. and what we've done as an in michigan we've gone back with four different task forces, and

look at offshore safety again, looked at the well control, looked at the blowout preventer, you name it. and gave recommendations back to the government in terms of tightening up, were there any gaps in the system, how can we make this stuff safer, how can we make it better? so we've been working very closely with the government on this. this is something the american between institute has done since 1990. we have over 500 recommended practices, and we are constantly revising them as the technology evolves. but our concern now is that this moratorium -- although the moratorium has been lifted, it's really a de facto moratoria on the industry because the permitting process, we are very concerned that it's not going to be done in a manner that will allow us to get back to work sooner than later. when we look at the shallow-water drilling is, they didn't have a moratorium. get their permitting process has really been slow down. in the past six months they have

had permits approved -- a federally about 12, a dozen or so permits approved. nobody would have that many done in a month. so there is concerned about that. and is concerned about legislation moving forward. what this is going to be, especially liability limits. if there is no liability limit, and some in congress have proposed, what this could mean is if you put a lot of drillers out of business in the gulf of mexico. so we have to have a better formula than that, but at the end of the day i think we will end up with a safer industry. and we're hopeful we can move ahead sooner than later in getting back to work, back to bring the energy this nation needs your thank you. >> gray. thank you, rayola. and jay, we have one last question for you. and i were reading from the questioner. it is well-known that the future stability of iraq depends upon the ability of the international oil companies to rejuvenate iraq's oil ministry. however, 20 years of embargoes

and sanctions means there's very little experience in iraq with the iraqi people within the ioc. what is the ioc doing or need to do to ensure that efforts are coordinated complementary and putting iraq back to its rightful place, both as an oil producer and as a powerful ally in the middle east? >> well, very thoughtful question. i think it touches on a lot of dimensions of our industry that are probably misunderstood to a certain degree. many of the ioc's, international oil company's and resource holders, when you think about importance, generally a lot of technical people, not a lot military strategists or security people employed in these companies. and i think what is important to understand its long-term stability is very important to energy development. so its price stability, its

capital into the market. its security. it's the ability to create transport sectors and infrastructure sectors to support anything from roads, bridges, pipelines, power, you name it. that all takes people. people is the common denominator of our industry. we begin training iraqi people right after the bullets stopped flying the first time. and we've trained over 1000 iraqis outside of iraq into new technologies directly applicable to oil and gas production, not some of the other industrial thanks, but very much. what you have to do in any circumstance, is you have to employ the local people and bring up their standard of living, the standard of education, their ability to help in the whole process. no ioc is going to come in and do this. it's not possible to do it that way. that's an old fashion amp realistic way of looking at things. as i talked earlier, partnership is the key to work together with

the iraqi people, to work with their neighbors, he knows he's in the region are going to be very helpful in this process, i believe. the iocs have a role to play, but it's a long-term process. don't expect miracles overnight. but i probably made 10 trips into iraq in the last three years personally. and feel like there's a lot of progress being made. and if we are allowed to be in the right of i'm in the region that you will see develop in of that resource over the next 10 or 20 years. it won't happen by next week or next month. but over the next 10 or 20 years that industry will be back to its normal place i'll say in the region. >> terrific. well, thank you. thank you very much to the panel for the terrific overview. [applause] >> of all the issues. and other we have the audience educated on this issue, let's go out and educate the american public. thank you. >> thank you, madam chairman.

a word of thanks to c-span, which has filled all of yesterday's proceedings, and today's. while we have more than a thousand people who registered for this conference, an all time record high, c-span alone has enabled millions more to do these proceedings. so we are fortunate and appreciate that. now is networking time. i'm sorry. sorry, sorry. thanks for the conversation interruptus. we will transition now to ambassador james smith. sorry for that slip up. >> in a few moments a couple of segments from the "daily beast" innovators summit focusing on india.

>> now discussion of technological innovation in india. from the recent innovators summit hosted by the website a "daily beast," this is a little as than half an hour. >> okay, we're going to get started on the next session if you all will take your seats. very good. thank you very much. i want to start with an announcement. neither sam know i are running for the presidency, so if there is anybody out there who is

really screaming with rage, don't direct it at us, okay? sam pitroda, we are very privileged to have him here. the characteristic innovation that i think is wrapped up in the story of sam and what is done with his life. the first part is that so much innovation really only happens when a truly innovative person gets the idea and follows through on it. and in the second chapter of innovation is that it is facts whole groups of people, and that's kind of the sam pitroda story come if you a. he grew up in a small village in india. he ended up as an adviser to gandhi when he was prime minister. and literally wired the indian nation. and that is sort of chapter one. chapter two is what he is now in the midst of doing. in fact, he's leaving for new

delhi again, i think it's a monday, isn't it? so sam, why don't we start by just telling them the 1980s chapter of this remarkable story of wiring a whole nation, and i want the technical part, which is the wiring, but what it does for a country and its people? >> welcome in 1980, i had sold a company that i had in chicago to rockwell international, and i decided to go visit india after having made a little bit of money. i had never been to delhi. went to delhi, try to find my wife from a five star hotel, and couldn't make it to chicago. so little bit of arrogance, and a lot of ignorance said i'm going to fix this damn thing. so then i decided to commute back and forth for several years, trying to convince the

government that we need to focus on i.t. and telecom for nationbuilding. i was convinced that informati information, communication technology brings about openness, accessibility, connectivity, networking, democratization, decentralization, and social transformation. based on my own background i was also convinced that technology is a great social level of second only to death. i believe technology can be an entry point to bring about generational change. so i got a chance to meet mrs. gandhi then, she was prime minister. and i told her that we need to focus on i.t., because we have a lot of young talent. you've got to worry about rural india, access, sustainability,

development, your own design of digital switch, not a lot of multinationals. and at the end, she says what do you want? so i said give me 500 -- in three years. that i got 500 engineers at the age of 23, and we build all the products that india would need, why are. rural india. so we build fiber optics, factories, we build switches, software, and trained almost 30,000 people. that started the whole new revolution to end and mrs. gandhi died, rajiv gandhi became a prime ministers, and ultimately i decided to go back to india, change my nationality back from u.s. to india. and then spent about a decade working on all aspects of

telecom, i.t., software. i remember jack welch coming to india. he wanted to meet prime minister, prime minister was busy so prime minister said to meet with jack. said jack and i had a breakfast. we had never met before. and jack said look, i'm here to serve any. and i said jack up on not buying india. i want to sell you software. so he said i'm not buying software. so then he said what do we do? i said, let's go have breakfast i guess. finally, he let me tell him a little bit about software, and he said what you want? i said give me a 10 million-dollar honor -- order. this was the time that -- [inaudible] jack give us 10 million-dollar order. i picked up phone and called ibm

and that's how software industry got started in india. all kinds of interesting stories, that we had great time in '80s. i was convinced that i.t. will change india. that democratization of information is the key to strengthening india's democracy. >> give the audience a sense of the scale of what we're talking about. when you started they were how many phones when the you got -- >> interesting. in 1981, we had 2 million telephones for 800 million people. roughly. it used to take 15 years to get a telephone connection. if you got a connection, half of the time you got dialed wrong. half the time you have to wait. it used to take great deal of

pride, connections, to get a telephone connection. i had a friend who went from u.s. to india, want to get married and he decided he was going to marry a girl who had a telephone connection. [laughter] today, we have 700 million mobile phones. we are adding 10 to 15 million a month after month. the next way for months we will probably have 900 million mobile phones. for the first time, a country of a billion people is connected. we are a nation of connected people, so we need to think carefully. 10 years ago we were a nation of a billion unconnected. so how do you strategize for the

future with this connectivity? so my job now is really look at public information. >> let me come back to that. that is chapter two. i first want to wrap up chapter one. there is a first glance when listening to you, it sounds a, this is not so difficult to wire up 900 million people, and so on. they were all sorts of obstacles that you had to overcome, some of which is osha logical, some of which -- social logical, some our infrastructure and so. go over some of the things you have to do to get to where india now is. >> first of all, i had to decide that i want to build a nation, and not build a business. so i had to give up everything. i took one rupee salary for 11 years. i spend lots of money going back

and forth. i had to take approach. sacrifice, love for everybody, simplicity, openness, transparency, there were stories in india that cia -- a man in a prime ministers office, that was me. you have to be very careful that you're working with a system that doesn't expect outside information, change it overnight. i had to give up my nationality. it was pretty painful, but it had to be done. i have young children, born and raised in chicago. i had parents in chicago so i had to move my family where my parents there, the personal level, pretty tough.

at political level, i had all the support from the prime minister. so i believe political will was very important. without political will, i would have done what i could do. and then the real support, as you know any we have 550 million young below age of 25. we essentially need to build their future, their prosperity, jobs, education. that's the main challenge today. so it was tough. >> and there were systemic problems. the federated nature of government, the level of corruption, and lots of people benefited from the system the way it was and you have to get over all of that. now, chapter two which is what you are engaged in now is even

more pervasive and impressive than chapter one. explained, -- explain why recounting for all information at the use of clouds to generating mechanism. >> well, for last five years i've been working on knowledge commission as the chairman of india's knowledge commission, along with about seven of my colleagues. we looked at five aspects of knowledge. access to knowledge, which include lineages, translation, libraries, broadband, quotas. all concepts, school education, higher education, distance learning, vocational education. we also looked at creation of knowledge, patents, trademarks, entrepreneurship. use of knowledge in agriculture,

health, industries and the government. about 27 different subjects, spent five years preparing a roadmap for next 20 years. it's all on the web that if you go to www.knowledge commissio commission.gov you will see hundreds and hundreds of pages of documents on recommendations. for the last year, i am focused on building six different for this predominant connected country, how to build a broadband platform on 100 bandwidth, all libraries, all higher institutions. it's going to cost at least two to 5 billion, government already approved. it's underway. 1500 points will be wired.

then we want to create i.t. platforms. universal id. where all billion people will have id we face, fingerprint. and we want to put security in place, gis, applications, payment. these are the six platforms that we need to create. to do this we need to connect 250,000, which are local governments, 200 megabit with. we have 800,000 miles of fiber already underground. it is all fiber, most of the. so we are using that fiber which

with telephone copies, to wire up all the local government. to improve education. like last night, there was a discussion on education. what we are really missing is the role of technology. we don't learn the same way i learned 50 years ago. teacher does not need to create content. teacher does not need to deliver content. today, most of the time, 90% of the time, teacher creates content and delivers content. so the role of the teacher will change to that of a mentor. so how do you define new teacher? so we are looking at a lot of these things in light of what technology can do. without technology, we cannot get our aspirations. we don't have enough teachers, don't have enough buildings,

enough doctors, everything that we plan to do in the next 10, 20 years is going to be based on i.t. >> you mentioned the session yesterday on education. one of the points made during that session was that within the crap the profession, what you want color, there's a built-in resistance to change, and can be overcome to some extent. which are proposing is a more radical movement, we're talking about for america. what is the situation in terms of both public government and educational establishment, as far as change of that dimension and how you would educate? >> like your, we also have -- we also have a lot of lobbies, and we also get lots and lots. our job is to go out to public, talk because it is to a democracy. openly promote our ideas, and

kerry young people with us. in many of these areas, we really have territory. we have greenfield. we don't have a lot of investor interest that i give you one example. in u.s., we have 1200 -- for cover. everybody and his brother. in india, we try to build for. because we are starting in 2010 as opposed to 1980. so we have sort of an advantage to leapfrog to because we are doing it now. so we are counting on that, and we keep fighting the battle every day. >> the session we have coming up after this is on india and china. now, you obviously are taking some radically different approaches to the use of technology, the use of

information. because such different political systems. how would you characterize, if i can put this way, the competition between these two great and very large countries and the roads there on, and what your prospects within our? >> well, i don't see it as a competition. you know, they have a billion people deserve. we have billion people to serve. we have a democracy. so we are going to focus on democratizing information. we are going to focus on open government. we are going to focus on technology to deliver public services, education, health. we have very strict problems of our own. disparity, disparity between rich and poor, urban, rural, educated and uneducated. 550 million young below age of 25. development, we are doing everything but we are not doing fast enough.

we need more of all of that. so our pattern is going to be different. will be slow compared to china. back and shine had they wanted to build road going from airport to the city. somebody probably to a line and says that's the road. in india you can't do that. you have to go through like this. but that's the price you pay for democracy, and we're happy to do that. >> we described a bit to the scale of transformation that comes when you wire a whole country for mobile telephones. what we didn't do, and we can do just an example so people can get an idea, of how does it actually change the life in rural india today, what is primarily fundamentally different now that jeff telefunken indication where you didn't have any come of any kind before speak was interesting.

first of all, people can pick up phone and call member of parliament. and they think that is great. wake them up at midnight. you know? ask for help to take someone to hospital. get permission for my kids, you know. ask for all kinds of things. they get a lot of information about their jobs. weather forecasting, informati information, pricing for the goods and services, by lots of tomatoes to sell, i make a lot of calls and find out where to sell. so i think communication has opened their horizon. we still have 19th century mindset, 20 century processes, and 21st century needs. but when little kid in the village gets in front of the

screen and go visit guggenheim museum, it changes his perception. compared to when i came to america in 1964, i had never made a telephone call in my life. i have a masters in physics. i had never seen television. i knew how to design one, but i had never seen one. compared to that, kids today see the world day in and day out, so their aspirations are very different. their reflexes are very different. so i think technology has given us a new roadmap with the nation. we ought all excited about it. we think next 25 years are going to be very critical for india. we have a window of opportunity for the next five, seven years to put all of these things in

place. so someone like me and my age can do. >> this is a little off the subject we've been discussing right now, but we have sort of a unique situation here. you are an indian and also went a long american heritage. we have a president about to go to india on what is a more consequential trip than usual we tend to think. what are some of your thoughts about what i to happen on this trip, and particularly in your area of modernization development? what would you like to see come of? >> well, there are a lot of expectations about this trip. everyone believes that the oldest and the biggest democracies coming together would mean a lot to the rest of the world. we have signed a nuclear treaty. we need lots of energy. we believe in open government. and i believe this visit to

present obama is being watched by the rest of the leaders in the world as an important event. and i hope we can send the right signals to the world that we want to build a different kind of the world. together. i think u.s. needs india, and india needs u.s. more so than ever before. earlier u.s. looked down on india. for longtime. there are all kinds of stories about how mrs. gandhi and reagan got along. i think it's about time to look in your eyes at the same level of respect, and begin to hold new chapter. lot of hope is going to be spending two days in mumbai i'm told, and a day in delhi. trying to see if we can work out some programs on open governme

government, and send signals to the world that we want to democratize information together. >> sam, that is a very good note in which to transfer speed is giving one minute. i forgot to talk about innovation. we have set up in india a national innovation process to look at five innovations. one, innovation as a platform. so it's not about product and services and technology and high-tech, and laboratories. it's more about innovation in government, social sector, families, and to look at innovation. two, innovations to improve road. we believe, especially i believe, best plans in the world have been solving the problems

of the rich who really don't have problems. as a result, problems of the poor don't get the right kind of talent. we want to get the best brains solving problems of the world. because we have lots of poor, and workers looking to us with our talent to solve the problems of the poor in the world. three, we want to create new ecosystem for innovation. we want to define new dryer, for example, disposable and durable. we want to create this on innovation. so we are really putting a lot of interesting things to make sure that innovation comes out of the lab. . .

[inaudible conversations] >> hello again. this is session two this morning. or three, actually. and the subject is india and china. but i'm going to throw in a third nation because it is so consequential to both those and really the whole east asian region, and that's us, the united states. particularly since there's quite a bit coming up. there's the g20, our own election and what's going to happen in congress afterwards. so i think a little bit of u.s. and how it relates to india and

china is very much in order. now, we have on our panel today starting on my far left is robert hormats, he's had a long and distinguished career both in public life and in the investment community of new york. he is currently u.s. undersecretary of state for economic, business and agricultural affairs. and next to him is tarun tejpal, and he is a journalist and author of great distinction and great courage. he's the publisher of, the ehelka magazine that is known for brave reporting. and on my right is yasheng huang, and on my far right is dambisa moyo, economist and author formerly with goldman sachs, and she has written a very provocative book, "how the

west was lost." so let's get started. and, bob, let me start, first, with just a few, very few statistics to give people a sense of this tale of what we're dealing with and the change. china has a gross national product of about $5 trillion. compared to that, the u.s. has a gross national product of $15 trillion. but the chinese figure is growing at a rather dramatic rate, and they're closing the gap all the time. the third player here, india. india is only about a fourth the size of china in terms of gnp. but the growth rates in the all of these cases except our own are really on a very fast scale. china is expected to grow this next year at a 9.5% rate, india at an 8.5% rate and comparing us to the two of them, we're expected to grow at about the rate of 2.5%.

bob, what do we expect from the trip that obama is taking, and how special do we think this one is versus normal international presidential travel? >> well, i think this trip is special in a number of ways -- >> let's just check to make sure everybody can hear. >> is it coming across? >> good. excellent. >> if not, just shout, and we'll pass this back and forth. >> i think this trip is very interesting. first of all, it's the longest period of time president obama will be outside the united states. second, if you look at the path of this trip, there is an important signal here. he's going from india to indonesia, then he's going up to korea and japan. these are the four biggest democracies in that area, and if you look at this trip, it's really to underscore several things. first of all, india. the growing importance of india

in the u.s. political, security and economic relationship. second, indonesia, a democracy that has really been growing very rapidly and has become a vibrant democracy really over the last 10, 15 years. then south korea which went from a very authoritarian kind of system to a democracy and is now a very prosperous country. not a brick, but it is very close to the bricks many terms of its growth -- in terms of its dynamism. and, of course, our old ally in the region, japan. so working with these countries is extremely important to demonstrate that we do support democracies in the region. when you look at india in particular, there's a tendency to look at india versus china. it's not really india versus china, it's india and china. the united states has to have a relationship with both. but we have a particularly compelling relationship with india. as sam pointed out, india has

demonstrated very balanced growth over the last several years. it does not depend as heavily on exports as china. the democratization in india does not make it a more interesting society. therefore, one of the points the president's going to emphasize in india is how we can work with this democracy to work with respect to open government, democratization of information, increase trade, increase cooperation with india and the security of the indian ocean and support for the politicians in the india who have been reforming the country at a very rapid rate. and the other point is when you go -- the other two meetings in japan and korea, the meeting in korea is a meeting of the g20, so india's a very important part of the g20. it's a very unwieldy group, it's quite large. you need to cooperate on certain

items. we're going to work with india very closely in the g20 on a whole range of things. then he's going to japan for an apec summit which, again, is supposed to emphasize cooperation in the asian region. and the last point i make is that the particular element of the trip that's worth noting and worth noting in the region is that the united states has not opinion playing over the last seven or eight years as proactive a role in east asia as many countries in the region would like, but the fact that the president is making this trip, visiting these countries, he's going to demonstrate that the united states must play and will play and is going to play a much more proactive, more energetic role in the asian region, and this trip is really designed to do that. not just because of the rise of china, but that's a very important part. the other is that these countries want a strong american presence in the region whether china was there or not. this is --

>> let me get you to address that point for a moment. we've had a policy, really, for quite some time publicly of engagement with china and not so public of containment is too strong, but constrainment through this archipelago of countries starting with india going all the way around korea. this is now surfacing that in, that archipelago more than we have done many this the past. and i wonder, bob, if one of the reasons for that is that china has at least recently gotten far more belligerent in the number of ways against us in particular and the rules that we set, norms for international behavior, and then against its neighbors. >> well, i think, i think without trying to categorize china's position, i do think that the chinese have been asserting interests in the region in the particular areas of the region where the united states also has interests. and secretary clinton made it very clear when he was in hanoi

a few months ago that matters, territorial dispute issues in the south china sea and elsewhere were not just issues that could be resolved by china, that the united states had a very strong interest in this region as well. and i think that the neighbors of china want to make sure that the seventh fleet remains there, that american troops, marines remain in okinawa particularly with what's going on between japan and china, the role of okinawa becomes even more important. so asserting that the, that the south china sea is not china's lake is a demonstration not that the united states is trying to exercise a strong military role in terms of countering china, but to demonstrate the united states has strong interests there, that other countries in the region have strong interests there, and we intend through our presence in the region to underscore those interests. but the other point is economic. the other point is that if we're

going to grow -- and we heard the first panel yesterday talk about weak growth in this country. if we're going to grow this economy and create jobs, one with of the major ways of doing it is to work with these countries to expand markets in the asian region. that is an important part of domestic recovery now and domestic prosperity for the next several decades to come, and we want to assert our economic interests particularly in areas such as protection of intellectual property, making sure that our trade rights are protected in the region. and by going there and participating in the g20, the apec conversations that will take place in japan, we're trying to say we have a strong economic role to pray in the region -- play in the region by demonstrating that we work with countries and allies, we want to strengthen political cooperation with these other democracies. the chinese have what they call

string of pearls where they've developed commercial relations throughout the region from china all the way through to sri lanka, but we have a string of very strong democracies that we want to work with in our own interests not so much against china, but to demonstrate that we have a sustained and continuing role in this region. >> well, bob, this is a new phenomenon to a certain extent, isn't it, in that there is less activity to america playing a very aggressive role is up among china's neighbors and precisely payoff china's behavior. >> i think, i think that our neighbors feel more reassured by america being there than america receding in terms of its economic, political and security role in the region. the interesting thing is that the united states has been encouraged by virtually every country in the region, including vietnam. our old adversary, vietnam, is one of the strongest advocates of the united states continuing

to play an active economic, political and security role in the region, and virtually every country in the region wants it. the old notion of balance of power is not a conventionally-used word, but i do think there is a feeling that a strong american presence in the region is very comfortable. we do not have territorial objectives in the region, but we do play and have for a long time played a strong and balancing security role in the region, and that is what others want to see us do, to do more proactively and secretary clinton has been doing this with her trips, president obama's going to make this point very clearly. we support democracies in the region, we want more trade with the region, and our own interests and in theirs, and we have an abiding, long-term security role. these sea lanes are important to us, the strength and the stability of our friends in the region is important to us, and you can do this with a security role, but you also need to keep a lot of economic engagement up, and we're going to emphasize that also. >> okay.

let's go inside china for a moment, yasheng. reevaluation of currency is a hot topic right now, and it's likely to come up at the g20. i'd like to hear a little bit more on just how important a factor this is in china's success story versus a number of other factors. >> that's a very good question. if you look at the chinese growth in the last 30 years, in the first 15 years or so it was mostly domestically driven. domestic consumption was rising extremely fast in the 1980s, early part of the 1990s. one of the reasons was that you cited the figure about gdp growth. gdp growth has been very fast, 8%, 9% consistently for the last 30 years. but if you look at the household income growth, personal income, that growth has been extremely uneven in the last 30 years.

in the first 15 years, that growth was very fast. perm income growth -- personal income growth that powered personal consumption, and that made china, basically, like a typical growth story with gdp growing and consumption growing. what has happened in the last ten years and maybe last 15 years is that the household income is just a little bit like the united states if you look at median income growth in this country, it has been virtually flat. china's not flat, but relative to gdp growth, the personal income growth has not nearly been as fast. the personal consumption has suffered. so i would view the currency issue more as a result of those factors that have inhibited the growth of the personal income rather than as a deliberate policy, that kind of mentality or that kind of philosophy. rather than as a result of that,

one of the consequences of the relatively slower pace of the personal income growth is that lot of the jobs have been created in the export sector. and that becomes a political issue. leadership is absolutely right when they say that the currency issue is not a technical issue, it is a political issue. but one of the reasons why it is a political issue is that so many of the -- so much of the jobs is concentrated in the export sector. you look at the service sector of the chinese economy is 40% of the gdp, much lower as compared with india. service sector is one of the most labor-intensive sectors, and i would argue that the way to go forward is not so much the focus on the currency issue on the chinese side, but the focus on further liberalization that will create more jobs. >> you mentioned the human situation in china. for the last three decades,

china's had one massive five-year program after another. >> yeah. >> primarily focused on, and very successfully so, the buildup of infrastructure. we've just had an announcement of the next five-year plan starting in the 2011. >> yes. >> massive investments again, but of a quite different nature this time. >> that's right, yes. it's a very interesting shift in the -- it's a subtle but very important -- >> not so subtle. >> not so subtle. they look at five-year plan and think it's homogeneous, but this one is precisely a result of the recognition that the personal income growth in the last 15 years has lagged gdp growth. so this time around for the first time as i remember the phrase inclusive -- [inaudible] which made in india and other countries, but for the first time it made it into the official documents about the

economic development and economic growth. inclusive, basically -- china has a higher or comparable level of income equality as compared with the united states. it's very, very high, and one of the things that many people don't know is that china is the first -- in the first 15 years of the reforms had a improvement in the income distribution. it was actually going down. it was really in the last 15 years the income inequality becomes a huge issue. it has massive implications for politics, for society, things like that. so i am very happy that for the first time at that level they recognize the problem and began to address it. >> well, to kind of summarize it, it looks as if they're going to invest -- if they follow through -- massively in education, social services and

in knowledge-based job creation. now, if they follow through on the scale they're suggesting, we may not notice it that much right away, but within a few years we will notice a tremendous change. >> well, i mean, i think in terms of the science and technology they have made massive investments all along. >> yeah. >> the r&d share of the gdp is about maybe not 1.8% of the gdp. typically you have 2%, that range among developed countries. so for a developing country to have such a high ratio of r&d to gdp is a very, very dramatic. i have done research with my colleagues. if you look at the publications, i mean, the number is rising. >> the number of patents are way up too. >> the number of patents and all these things. we can, you know, quibble about the quality of some of these things, but overall china is, there's no question the chinese science and technology

capabilities are rising significantly. i think the issue more now is not about that. it's not about the top tier science and top tier education. it's more about the bottom tier. surprisingly to many people, they don't know that china has in the last 15 years has invested less in basic education as compared with many other developing country. countries. public investments. the shortage of the public investments was more than made up by private investments, by households, by the peasants. but the problem there is that if you ask the households to invest a high percentage of their income in basic education, then don't ask them to consume tvs and electronics and bicycles, all these other thicks that your -- things that your economy is producing. >> right. >> so this is a social contract. now they recognize that the lack of public spending on education is hindering -- in china if you

talk about economics, everybody listens. if you talk about social stuff, people think, oh, this is soft. we don't need to listen to you. but if you link the lack of social investment to economics, they listen, right? so the reason why people are not spending is because they have to spend so much on their basic education, they don't have the money to spend on other things. >> let's turn to india for a second. it has followed in the wake of china, several decades later, with sustained, large growth increases. and today it's an economic middle -- miracle of a sort. however, you have been very forthright in pointing out some of the holes in the pizza, so to speak, and the thing that either are not being addressed or willfully not being addressed. tell us a little bit your own picture of the current economic

situation and sociology, if you will, in many india and where you think it's headed. >> vastly more complex than america. the difference really is is is that while i've been hearing since yesterday morning everyone obsesses about the idea of the american dream, in india what we talk about is the idea of india. the founding is what we call the ideal thing, and the ideal thing is very unlike the american dream, a kind of obsession with the idea of equality, liberty, compassion. these are the kind of deep ideas that were determined by the founding fathers, an outstanding group of men. the thing that resonated so strongly is sam said he had to become a ghandian to actually do his work which is to understand the idea of self-application, reduction of personal needs and, thereby, go and do his work. in india today you have a situation where you have a very large number of people, i'd say

200 million, maybe 300 million, who are part of a very strong narrative of economic growth and -- [inaudible] but you also have incredible -- [inaudible] of 7-800 million people who still don't have a story to their lives. you're talking about almost 5-600 million people, probably the size of africa that lives in sub-saharan poverty. so i agree with sam it's terrific that we all have mobile phones, the truth is there are many million people, 500 million people in india who still barely get sustainable food. so you, so a lot of the conversation -- [inaudible] what you've got to ask us is what would work for india. what would work for america in our port of the world -- part of of the world doesn't work for us. we actually have a lot of

problems with official america. what excites india is americans. we react strongly to the ideas of liberty and democracy in america, but we do not like at all american foreign policy. i heard them say we pursue the idea of aligning with democracies, but that's historically not true. even in many asia for very many decades america's actually backed a very, very undemocratic series of regimes -- >> it's a new administration. >> it's a new administration, it's a new day, and we look at it in a new way now. [laughter] >> let me ask a question between the two of you, are you less optimistic than bob about the results of what the u.s./india relationships are likely to be from this trip? >> i'm genuinely less optimistic about the -- [inaudible] at the official level. i'm hugely optimistic about the people at the people level because i have thousands of

friends, indian friends who live in america and absolutely are very much part of american culture today. when i meet my american friends, i resonate to them very strongly. but when we look at american foreign policy, there's a lot to hold back on. what is our concern, i think -- i don't even think, and i think sam would say that very well towards the end of his talk, i don't think we're obsessing about china. if china's obsessing about us, i think america's more obsessed about china than india is. it's exactly what sam said in the morning. we have 800 million people who we need to feed and educate, and it's a huge ask. india's best and brightest, i can tell you, are not trying to make great corporations and great wealth. india's best and brightest are working very hard, and i know hundreds of these guys, to somehow crack the conundrum of profound poverty that afflicts india. and so for me when i look at it, and i've been hearing this conversation since yesterday morning, i'm a little amused that i would imagine that if you

lacked economic well being, you would be neurotic about it. but i find that a lot of the conversation here has been an incredibly economically powerful country, a lot of the ideas of world economic well being. without a single inflection of moral principles in that conversation. it's always been about the money china has. it's never been about what china doesn't do right, you know? you'd imagine that liberty would be the founding principle in a conversation that the west -- [inaudible] with anybody in the world since they viewed that as a founding principle for themselves. but we don't see that when it comes to a conversation about china. we don't get any really tick marks in india for practicing a democracy which is very complicated, very difficult. and i would actually say that we do a better job of managing our complex democracy than -- i was being reminded again and again of the 30-year-old novel, "the quiet american," you know?

there's a kind of innocence at large, you know, which can get a little worrying. we are a complex country, we are trying to deal with things in a complex way, and i don't think it's either china or america that most people in india would obsess about. what they would obsess about is -- hugely imperfect as a society. we're ridden by costs, we're ridden by religion, we're ridden by problems that we need to negotiate. but i think the idea that what we use to try and negotiate that is fairly sound. we are a work in progress, but i think we feel we are doing it the right way. >> you have provided quite a bit of coverage on corruption as an issue. how serious is it? is us growing? >> you know -- >> will the -- >> [inaudible] >> -- economic growth rate continue? >> for some reason, the work that telhelka has done has been linked to corruption issues, but i think it's a symptom. i don't think it's the cause. if you have inequality of the skill that we have in india,

corruption is inevitable. you look at any society in the world and see the inequality, you know there will be corruption. so i don't think that is the problem. our problem is inequality, potential religious trouble, our problem is gas trouble. we have the second largest population of muslims in the world, we have more muslims in indian that we have in pakistan. so there's lots of issues. there's the right-wing hindu stream against which we have done more work than corruption. so these are great battles in the india. >> you even have some very vigilant maoists up to the north. >> well, again, to be honest, we have fought again and again and sought a government policy that's more humane. it was the whole idea of the society of the maoists because, actually, there is a very strong core of ideologically-driven maoists. and those should be -- maybe should be hunted out. but most of the people who align around them are really the poorest of the poor.

and these are people who have been driven pretty much to the gun because the state policies have failed them for decades now. so our argument has been consistently that you need to adopt a more humane approach to this them. you need to provide development. you need to provide food. you need to provide education. and you need to stop going into the forests and can dumping these guys out because you figured out therest crap loads of -- there's crap loads of -- [inaudible] and that lies at the bottom of the problem. everyone wants a slice of the forest because under the forests lies craploads of oxide. >> very good. we're going to turn to you all in a second, put your hand up -- i'm getting to you. i said in a few minutes we're going to go to you for questions, but first i want to hear from -- and i know you all want to hear from dambisa who has, to get back to the third country that's in the mix with

this panel, united states. you have one of the more dramatic views. there is a debate going on about whether the decline that we're suffering in the united states now is kind of a bad patch for a while, or are we on some historical incline -- decline that's going to go on and on? you have some rather dramatic figures that suggest the latter. >> so i guess i am glad i'm speaking after tarun, because i think it's important, this discussion about whether america's going to rise or decline, i think, should be set in a broader context. there's a very interesting article that came out last week about restoring the american dream. and in it it talks, initially starts talking about how he was raised in the india watching "dallas" and how he was completely obsessed with the big hair, the cars and shiny america. the thing that struck me the most is that growing up in africa i had exactly the same

experience. and we have in africa a billion people who, of which 60% are living, are under the age of 24, living in dire poverty, and all the issues that have been discussed here with respect to the need and te sire to have economic -- desire to have economic growth, issues of poverty, all of that applies to africa tenfold. when it comes to the united states specifically and just going back to economics 101, economists look at three things as drivers of economic growth, capital, labor and total effect of productivity. and the point here is that if you look at the quality and quantity around capital labor and productivity, it's very clearly a story that is leaning towards the emerging world, and i would say in many ways because of the structural issues that we've been discussing around the united states the last couple of days, it's sort of leaning against the united states. i don't think that the united states is the sort of -- it's all oversaid and done, but i do think there's still a lot of

policy issues not just around the united states specifically, but also on how they engage with bigger regions such as a billion people in africa and even closer to home, you know, brazil and chile which now are, you know, have china as their leading trading partners. so much for the monroe doctrine. we have to start to have a bigger engagement and bigger discussion around what america's role is going to be, particularly given that in places like africa in particular the united states' policy and approach has been one which has been -- [inaudible] but now africans and the african leadership has decided that that hasn't worked for 60 years. africans are demanding more, and they're very simple people. we want what you want, we want education, we want health care, and the reality is there are now other potential sources of finance, potential opportunities to build alliances with the chinese, with the indians. and so i hope that, you know, next time we're sitting up here

there will be discussions about the obama presidency going to africa with a new lens, not just to hand out money which, by the way, the united states is just borrowing from china to hand to africa. [laughter] so i think there are a lot of issues that need to be discussed about the policies that have driven to misallocation of capital labor in the united states, but the issues are much bigger than that. >> they are. but there's a very big one for us that you tend to focus in on, and that is that we made such a mess of things that at least for a period of time we need to close our economy some. we cannot continue as an open economy to the extent we are now and build jobs and take care of our own people. in other words, that hairy word, protectionism, may be more current than we think if we want to do things right. you want to explain? >> yeah. my next book basically argues that the united states faces what i call a hobson's choice.

either you stay hope to the rest of the world, or you close up and try to figure out how to deal with what i believe are structural issues. i mean, i think the united states is going to be facing structural unemployment which is something that no one in this room has really experienced unless you come from outside. now, i know that in the united states people get, you know, because it's always, you know, left or right or democrat, republicans, black or white, people don't want to have a discussion around protectionism. however, given the fact that you do have a large number of jobs that are not coming back which hutchens talked about yesterday, and also if you look at the fact of what globalization has done in terms of income and equality in this country and also the income growth as talked about moments ago in this country and not just in the united states, but also in europe, there should be space to have a clear discussion around what the possibilities around, of having protectionism at least until you can fix some of the structural

problems in this country. i know people don't like that discussion because they view, they point to smoot-holly, they claim because we're so integrated now it wouldn't be possible to have some kind of more aggressive, protectionist policies. but the reality is it has to be on the table and not just from the fringe as a discussion, but it has to come back into the mainstream. >> why don't we get that discussion started here, but it'll have to be brief given time. bob, do you want to respond? >> with all due respect, i think that would be the worst possible way of looking at the problem and the worst possible answer to it. it's not an either/or question of whether we're protectionist or not protectionist. many countries, many countries are far more open to the global economy and have much less income disparity than the united states does. scandinavia, they're smaller countries but nonetheless, they're far more open to the global economy. the problem with the united states in terms of dealing with the problems would not be

resolved by protectionism or restricting the inflow of immigrants, particularly talented immigrants or restricting the inflow of capital. i think that the question is asked, are we going to be the number one economy or a leading economy over the next 20 or 30 years? exactly the wrong way to do it is to cut ourselveses off from global competition. the right way to do it is to go back to the first panel that was discussed yesterday and deal with our own internal issues in a more purposeful way. education. we're not dealing with education. we're not going to be a world class economy 20 years from now unless we have a world class education system today. infrastructure. we need to build out the infrastructure. we don't need protectionism to do that, we need a purposeful approach internally to deal with that. we need to deal with energy, reduced energy dependence. we need to do that, and we have the capability of doing that. we need to get our country, our act together to address this. we need to address a number of

internal structural issues on our own looking a to the rest of the world as sort of the boogeyman and saying, well, the rest of the world's responsible for our problems diverts our attention to the problems we have at home. we have to deal with those, we can't blame the rest of the world. cutting us off from competition is exactly the wrong answer, and countries that have done that in the past have not succeeded, they have failed. and in this global economy it would be so disruptive to the average american consumer and the average american producer. american companies need the global market in order to expand jobs and expand profits. so they can invest more in innovation in the united states. an innovation economy is a competitive economy. sam made the point earlier -- >> got to stop you -- >> you need to have flee flow of information. >> we can go with you the rest -- >> i'd like to. [laughter] >> we're going to have to stop. >> i would agree with you on

that. >> we need a few questions from the floor before we close out in the about five minutes. can i see some hands? over here. way other there. way over there. >> hi. my name is ryan, i'm with "the daily beast." for the past 40 or 50 years, the pla, for the most part, has been cooperative with the u.s. military. however, in the last decade the new guard of the pla has been inculcated with a paradigm that the united states and specifically the u.s. military is the enemy of china. what does this ramify for the u.s./china relationship especially in a closed society where the ccp stokes nationalism in order to balance against enemies? >> [inaudible] [laughter] >> any discussions on pla is -- i'm not a expert on the military, but i -- let me say

this. you're right that china is not a democracy, we know that. but i have to say, you know, the internet technology, this is an innovation summit, the internet technology has dramatically, is dramatically affecting the political discourse and the discussions in china. there is a rising level of transparency in china on the internet. the official channels are trying to suppress the information, but they are succeeding, but they are not doing it completely. so there is more transparency now. about the pla, the kind of claims that china has been making about south china sea and others, they have been remarkably consistent in terms of their rhetoric. i think what changed, obviously, is is the power that china has

today. >> right. >> to make similar claims in 1972 was not going to have the same impact as you do now with the second largest economy in the world. and when president obama visited china in the joint communique, there was a reference to south asia. a lot of my asian friends feel very, very angry, how can the two country, america and china, get together and discuss issues related to south asia? and a communique from nixon making making exactly the same points. so the reference point has changed. and so i'm not sure how much the rhetoric has changed or is it the perception of the power and the power itself, obviously, have changed. and i think this was a new reality, t a new reality that both sides -- it's a new reality that both sides have to come to some sort of a consensus about how to deal with. it is, it is tough. >> it is. we're virtually out of time, but

i want to give tarun, and i want to give dambisa a chance for a very quick final comment in case we said some things that you think need to be responded to. why don't we start with you. >> yes, coming your way. >> i just want to underscore the fact that everything has to be on the table. i don't think we can outright dismiss certain things because we have, it's an emotional attachment to the status quo. i do agree that having an open society where capital and trade, you know, moves freely is something that we all should aspire to and we should all want, but the fact of the matter is that the united states does have a history of preaching, saying do as i say and not as i do. we know there are foreign subsidies, the government in the united states has intervened in a number of sectors. so this is just another way of saying it's important for us to have this discussion about what the implications are. i do believe that there are gains, cleary, for the united states -- clearly, for the

united states in terms of trade, but i think we should, be open-mind today the fact that you could see an increase in genie coefficient as people who are educated are the ones that are going to be the most competitive on the global scale. we should at least have the space to have that discussion. it's not crazy, and i do think that's the most important thing to remember. >> very good. tarun? >> largely, i just think india's success or failure is going to weigh very heavily on the world. i think we are, in some sense, a template of whether the u.s. will succeed in the way it's shaming, market failures, ethnic, i mean, there's all that. and it's also very poor. and if india succeeds, then i think a new kind of ideal, a subtler idea of economics might come into play. gandhi said many things about everything. he did, there are 100 volumes of

gandhi's writings. he truly wrote about everything, including self-depp pri case. i think the one thing he spoke about very intelligently which is now coming home to us today is the idea of sustainable life. the idea of sustainable lives. and i think that ghandian idea is going to come back in the coming decades to haunt us in this a huge way. there is a question of productivity, and there's a question of growth, but there's also a question of contained consumption. and i think that ghandian idea will come to play and maybe, maybe -- i'm not too sure because india's quite whacked out itself -- it might find roots in india and take flower, and we will see then, you know? >> just a footnote before we quit, dambisa mentioned fareed zakaria's article which i think is in the time magazine that came out on friday. it's a very long and striking

cover story in which fareed took a position i hadn't heard him take before. he does say we need to rethink who we're going to be and what kind of initiatives are we going to launch now to kind of close the gap which, in his opinion, is growing between us and some of the state capitalist countries of the moment. help me thank this very fine panel for this discussion. [applause] >> thank you. [inaudible conversations] >> looking, now, at the i who gee ma memorial -- iwo jima memorial just outside of washington on this veterans' day. a lot of events around the city and country marking the holiday, and here's some of what we are covering today. vice president joe biden will be at arlington national cemetery. he'll be laying a wreath at the

tomb of the unknowns before taking part in a remembrance ceremony at 11 a.m. eastern. a little bit later the focus shifts to the vietnam veterans memorial. scheduled speakers include interior secretary ken salazar at 12:50 eastern. >> as the country marks veterans' day, learn more about the holiday and the men and women who have served in the military with the c-span video library. oral histories, authors on the nation's wars and veterans' day commemorations through the years. all searchable, all free on your computer anytime. >> and now older driver safety. the national transportation safety board hosted a two-day conference on in this week here in washington. the final day of the meeting the focus was on a screening and assessment of the physical and mental abilities of aging drivers as well as what measures state and local governments have

in place to address such issues. speakers including transportation safety researchers as well as federal and state traffic safety officials. this portion is about two hours. >> welcome to our second day of the public forum. yesterday our three panels discussed the safety risks posed by aging drivers, and we established that with the exception of the very old, there was not really a disproportionate crash risk associated with aging drivers. however, when the elderly are involved in a crash, they're more likely to be fatally injured because of their frailty and low tolerance for injuries. we looked at what vehicle occupant protection systems could do to improve crash outcomes for the elderly, and we also looked at what technology and highway designs could do to improve the performance of aging drivers and all drivers in if general. so today we're going to turn to our last two panels, and the first panel looks at enhancing driver performance. this panel will be discussing the ways that we assess driver

capability both in terms of mental and physical abilities. the initial question will be how do we assess performance. an assortment of tests and evaluation approaches will be covered in the panel today. road tests, vision tests, occupational therapy abilities for driving testing, medical assessments, medical review boards and self-evaluations. a great deal of public interest has been focused on driver screening methods, and the panel will open with the survey of that work. once a limitation or a performance deck riment is identified, the focus shifts to a second important question, what could be done to remediate the driver? dr. deb bra bruce -- deb bra bruce have prepared questions for the panel. will you, please, introduce the panelists. >> good morning.

lisa is a member of the behavioral sciences group. she joined in 1986 and her primary areas of interest are traffic safety and driver behavior. she holds a ba in sociology from michigan state and public health policy and administration from the university of michigan. she's co-author of a recent book, "maintaining safe mobility in an aging society." dr. richard maratoli is an associate professor of medicine at the yale university school of medicine. he's also a medical directer of the alder geriatric assessment center at yale new haven hospital, and she is a staff physician at the veterans' administration connecticut health care system. he received his undergraduate and public health degrees from yale university. among many things, he's the former chair of the trb committee on the safe mobility of older persons and a member of the connecticut department of motor vehicle medical advisory board. dr. art kramer is the directer

of the beckman institute for advanced science and technology at the swanland chair and professor of psychology and neuroscience at the university of illinois. professor kramer served as an associate editor of perception in psychophysics and is currently a member of seven editorial boards. he is a recent recipient of the nih tenure merit award, receiving this degree from the university of illinois. davis has coordinated the american occupational therapy association's older driver initiative since 2003. she is a registered, licensed occupational therapist and a certified driving rehabilitation specialist. she holds a bs in if occupational therapy from the university of minnesota and has been an occupational therapist for 30 years. thank you all for coming. i'd like to start with lisa. i often see screening and

assessment as sort of paired in the same seasons. ?rsh -- sentence. would you give us a general description of driver screening and maybe distinguish it from assessment. >> madam chair. well, just by way of background, you know, as we heard during many of the sessions yesterday, driving is a complex task that requires visual, cognitive and motor abilities, and as we age most people experience some loss in these abilities due to medical conditions that become more prevalent with aging and also the medications used to treat them. and we know that this process has a lot of variability from individual to individual. people are very unique, and the older driver population is very heterogeneous. so making informed decisions about driving really requires meaningful information about

drivers' functional abilities. and the issue of -- okay, excuse me. so the issue of evaluating driver fitness which is what we really want to talk about today is really complex, and can it's often controversial for a number of reasons. and one that you just mentioned is that often there's a lack of clarity about the difference between screening and assessment, and i'll, and i'll be talking about that. so in the work that we've done at the university of michigan -- and i think that among many other researchers, policymakers and practitioners this is becoming, also, the case -- there needs to be a clear distinction between what we mean when we talk about screening and what we mean when we talk about assessment. so screening and assessment

really represent different and distinct domains of driver evaluation, and screening is really the first step in a multi-tiered process. it's not something that in and of itself should be used for making licensing decisions. on the other hand, assessment provides a basis for identifying reasons for functional deficits, determining the extent of driving impairment and making recommendations about licensing actions. and also identifying options for for driving compensation or remediation which i know we'll be talking about later on in the panel. so when we think about driver screening, we're talking again, as i said, about the first step in a multi-tiered process. screening is something that we use to identify very obvious impairments in functional abilities, in vision, cognition, psychomotor skills. it's intended to lead to more

in-depth evaluation if gross impairments are identified, but it should not be used to make final licensing decisions. and, again, driver assessment provides the basis for identifying the reasons for the functional deficits that might be observed and the extent of driving impairment. it's used to identify options for driving, compensation or remediation recommendations and licensing actions. and so as we conceptualize driver screening, we think about it really as part of a more multifaceted, multidisciplinary approach to driver evaluation. it's something that can occur in a variety of settings and at various levels of complexity. yesterday we heard dr. dobbs talk about a process of identification of drivers, assessment and then options at

the end for maintaining mobility. and screening is really that part of the identification process. it involves a number of players from the community, it's done in licensing agencies, it's done in physician offices and other clinical settings by occupational therapists. it's something that can be done by law enforcement who are making traffic stops of older drivers. it's something that's also done in the community by friends and family members of older drivers who might be experiencing problems, and it's done by older drivers themselves. so it is part of a comprehensive, multifaceted, multidisciplinary approach to drivers who may be at risk. that being said, i think it's important as was said many times yesterday that when we talk about identifying drivers who may be at risk, we're focusing on the safety aspects of

transportation. we can't lose sight of the fact that although it's important as researchers, policymakers and practitioners to find ways to identify drivers who may be at risk, we need to also think about how we can provide community support to drivers who are not able to drive or who choose not to continue driving so that they can maintain their independence and well being and quality of life. >> thank you. so i'm hearing you say that we need to do screening on medical providers, social services providers, law enforcement, licensing, older drivers, caregivers? those are a lot of different players, and i would assume that the screening tools differ, so would you give us some discussion about the type of tools, self-assessment tools and the value of each of those? this. >> yes, i'd be happy to.

so as i mentioned, screening can be done in a variety of settings , and in the licensing agency, for example, there are a number of forms that screening can take. observations can be made of people as they come into the counter to renew their license or take care of licensing issues. oh, i'll get to -- there's also review of medical history that can occur in the licensing agency, and there are a variety of tests that can do be done in the licensing setting to screen for deficits in vision, cognition and psychomotor skills. within the physician's office, there are also a number of tools that are available for physicians. physicians have a unique opportunity to screen as part of

regular medical care and treatment. one of the challenges has been that many physicians feel that they don't have the tools to really make fitness to drive decisions. and also there are issues of not wanting to really disrupt the patient/physician relationship. and so screening, i think, really, you know, offers an opportunity to intervene early, to identify red flags and, if necessary, refer patients on for more in-depth assessment. some of the work that's been done in the physician area has included developing guides for physicians like the ama guide for assessing and counseling older drivers that offers information about the kinds of red flags that might alert a physician to something that might be problematic with driving. the physician' guide also contains a screening battery

called the address which has a series of tests that can be administered. and similarly in the licensing area, there's been a lot of work on developing some protocols for doing observations at the counter as well as developing batteries that look at the kinds of limb takes -- limitations in physical funking that we know are -- functioning that we know are associated with problems with driving. having said all of that, i guess, now, if you could go to the state of the research. [inaudible] so having said that, i think that, you know, in general although there's been a lot of research to develop screening tools that are valid, reliable, low cost and easily administered, these are particular constraints faced by physicians and licensing

agencies. to date there are really no tools that have been developed that satisfy all of these components. we've been doing the research for a long time. that research continues on ways to improve the sensitivity which is maximizing the correct digs that an individual has a high, you know, crash risk. and the specificity which is minimizing the incorrect decisions that an individual is a high crash risk. so that research continues and, hopefully, i'll have an opportunity to talk more about some of that. but in the meantime, i think there's widespread consensus as came out of yesterday' discussion that -- yesterday's discussion that screening tools really need to focus on looking at these functionaldeclines as opposed to focusing on age per se or even looking at the complex array of medical conditions that people might be experiencing. and then in addition to, i think, the licensing agencies

and physician settings i mentioned, law enforcement has an opportunity to do screening at the roadside, and there have been a number of efforts over the last several years to develop curriculums and training materials for law enforcement so that they have a standardized way of using cues to look at drivers who they may have stopped during a traffic stop and make a determination of whether there seems to be some impairment. a lot of these cues have to do with cognitive functioning. so, for example, they might include something like, you know, assessing whether the person is oriented in time and space, you know, where they -- if they're getting lost and they don't know where they are or where they're going, those kinds of cues that can then lead to referrals for more in-depth assessment. >> right. thank you. i recently went to my dmv to turn in my motor scooter license, so i've got some questions about how the practicality of that might work. but i'm going to -- in the

interest of time -- proceed on through the panels and go through the questions by the parties, and then if there are any at the end, i'll reserve my time for then. so with that, i'm going to turn it over to ivan chung and dr. marottoli. >> good morning. dr. richard marottoli is an associate professor of medicine at the yale university of medicine. and we're going to talk -- we're going to ask dr. morottoli and talk about some of the cognitive assessments, and please, give us your introduction. >> thank you, dr. chung. i'd like to start just by talking, giving an overview from the medical perspective, and then i think we can get into some of the individual aspects.

i also didn't bring any slides, but if there are specific things people want, i can get you slides -- >> just send them to me, and i'll put them in the docket. >> will do. i'd just like to cover thinking from the clinician's end of the process, sort of what is realistic to expect and why do people need to get involved. so why should we evaluate, what do we evaluate, how, who does it and what do we do with the information, and then e i think from there a lot of the other questions will come. we heard about sort of the demographic imperative which is a large part of the why, but also there is the issue that was raised earlier about the clinician's role in concern about the safety and health and quality of life of their patients as well which is another reason to get involved. in terms of what to assess, i would argue that actually there is a benefit to looking at diseases and conditions. in addition to functional abilities and impairments, in apartment because we're looking, also, for interventions. we're looking for things we can

improve. in this patient population, this age group, oftentimes our ability to intervene is limited in terms of the extent to which we can make a big difference. so if we can have several different avenues and make smaller improvements in each of those, hopefully cumulatively there'll be an additional benefit. so i think the disease's process and also functional impairments that result either from the disease or from the aging process alone are both avenues for both assessment and intervention. the third arm of possible, i think s to look at and intervene upon is medications, and this was touched on briefly yesterday, but there are many different categories of medications that can have beneficial and potentially negative effects on either the conditions they're being used to treat, but also on abilities relevant to the driving task. in terms of how we assess that, there are a variety of ranges, and it was covered a bit in terms of the specific aspects of visions, of visual acuity,

visual field, contrast sensitivity, cognitive abilities, there are a variety of global measures that can potentially be used by clinicians as well as individual cognitive domains. the ones that come up most be often are things like information processing speed, attention in a variety of forms, spatial ability and executive function. and lastly, physical ability, particularly range of motion and speed of movement, are the two areas. one area that tends not to get looked at a lot but that comes back and is rell slam to everything -- relevant to everything is the issue of awareness or insight deficits. and we're thinking about how to change their awareness of their insight into their deficits is critical in the recognizing the need for change. we also clinically also like to have some measure of driving performance. so it's nice to have all these assessments of different capabilities, but in terms of convincing people of the need for change, it's helpful to

relate those to how people actually drive. we had the advantage of often having families in their clinic visit, we'll recommend families ride with them and get a sense of that. it's helpful in affecting that change, ultimately, often times particularly for cognitively-impaired patients, it's the family that ends up to having to do the dirty work, so it's helpful to have them onboard with that. and there are also formal assessments that can be done, and i believe we'll talk more about those. then we get to the question of who does the screening, assessment, etc. the issue is sort of the assessment, the driver themselves, office staff or, lastly, licensing agency. and there are pros and cons of each of those. then the last segment of issues is what to do with that information, and ultimately, the goal is gathering that information and to convince the clinician of the need for change and then, ultimately, to convince the patient or driver and the family that, indeed,

change is necessary and what that change should be. so that's the ultimate purpose of driving, of gathering that information and then transmitting it. and also to identify interventions or adaptive strategies that may help ameal yore rate these problems and allow people to continue driving for a longer period of time, more safely. and lastly, then, the issue of reporting to licensing agencies and how that process goes on. i think there have been from a get stat perspective, there have been two major areas of development over the course of the last 10-15 years in this, and one that's been touched on by a number of speakers, and that's the appreciation of a more holistic approach to this rather than just dealing specifically with the issue of driving or not driving, licensing or not licensing, but looking at the broader perspective of a person's mobility and their ability to fill in that void if they're not able to drive or choose not to drive. and then secondly is increasing evidence where the effectiveness of a number of interventions particularly relating to those functional abilities i outlined

which, hopefully, over time will allow us to really sort of change the tenor of a lot of that discussion from one that's very negative to something that's slightly more positive in the process. and there are also a variety of education interventions that can work more broadly rather than focusing on specific individual functional abilities but take the actual driving task and look at that in more detail. >> thank you, dr. marottoli, and thank you for giverring us a very -- giving us a very good, succinct definition. and i'm wondering if you can comment on some of this distinctly different professional training that our medical care professions need in order to deal with those very different aspects of driving performances. >> so that's a difficult question because there's many different levels at which one could answer that.

first is getting people, clinicians to recognize that it's something they should do in the first place, and i think that that's an initial barrier that needs to be overcome. and partly that's because there's the negative perception of the issue and the negative effects it has on the clinician/patient relationship. and secondly, is the broader issue of not knowing what to actually do, and the third is want to that -- what happens to that information after the clinician gathers it. so potentially each of those are areas to look into. i think from the first perspective is convincing them of the need from a clinical perspective that it's the safety and mobility of their patients that is of interest, and this is part of that as well as their obligation to society in terms of public health and public safety and working on that aspect. and i think most people will recognize that and weigh that against potential negative effects on their patient. the second is the issue of what, specifically, to address, and that, again, depends on i think

what we realistically want people to do as well as what they will do or can do. and i think focusing on sort of the medical aspects, both in this conditions and impairments related to that is realistic. a lot of people have the trouble making that next step to safety implications. so i think to the extent that one can focus the physician's or clip in addition's task -- clinician's task on the functional impairment, i think there's a greater likelihood of getting people to do it. and then there are also the issue of specific tools or things that they can do fairly readily in the clinician's office, and there are a lot of different tools out there, a lot of different things that have been looked at, many this of which are impractical in that setting, and it's become increasingly difficult because time is of the essence. there's a limited number of things people can do in that setting, and i think everything we look at has to be considered in terms of its potential burden

in displacing something else from that interaction. and so those are trade-offs that we need to think about. and lastly is the issue of what happens to that information afterwards. partly, it's sort of dealing in discussions with patients and families about affecting a change and then separately and perhaps the subject of a much longer discourse the issue of reporting and providing that information to a licensing agency. i think i won't go into detail on that, but we can deal with specific questions. i think, again, keeping that process as transparent as possible, making sure everyone understands their responsibilities, the drive as well as the clinician knows what their obligations and responsibilities are in that jurisdiction and then having a process that is as straightforward and simple as possible and that also provides some communication back and forth. it tends not to be a two-way street in most areas, so we're asking clinicians to provide that information to a licensing agency, but very often there's no information that comes back

unless there's an irate patient or family that then comes back, and is very angry about the nature of that. the clinician's often clueless as to what happened or transpired. some way of feeding that information back akin to the medical consultation where you ask someone to provide input, they then send a letter or note back saying that is what my impression or, and i think that would facilitate some of that interaction as well. ..

and really sort of create a media flurry. we tend to hear very little or know very little in fact about appropriate cessation and premature cessation. i suspect it does occur a lot. and but there are a number of studies looking cognitively in the populations by the time they reach a assessment septemberter or geriatric center most people have already stopped driving. in fact they're regulating in some way on our own or family or private physician's input so they made that determination. a relatively small proportion go beyond that. fortunately an infinitesimal portion that refuses under

any circumstance. but i think it is worth understanding what contributes to people stopping and this question of prematurely stopping. is it outside influence that force them to do that? other people's impressions of their driving capability? or do they have some innate sense they're uncomfortable with that? they're better at figuring that out than we are. therefore it is not really premature but appropriate for that person. i don't think we have a really good way of measuring that precisely and identifying that information at present. >> thank you very much. dr. kramer would you please give us your remarks. >> sure. thank you for inviting me. i appreciate being here. my task was to talk about driver enhancement through cognitive training so i will be a bit more focused than the last two presenters. what i wanted to start by saying that most cognitive training programs are still in the experimental stage. think of it as a phase two drug trial i suppose if we

want to apply it to drugs but there are an increasing number of commercial products that purport to improve driver training. in fact some of them even advertise that if you go through this training program you can reduce accident rates by 50%. and i think it's worth evaluating them with the same level of scrutiny that we evaluate drugs in drug trials because i think they can have the same benefit and or harm, depending upon what the assessment is. my bottom line, to start with a bottom line, there is some interesting and potentially promising results from these cognitive training programs. but if i was to evaluate them by virtue of the same, information that is used in national institute of health consensus statements, to evaluate research in a particular field, and i did participate in one of these within the last year on alzheimer's and aging, i would say at present, given the present state of referee journal articles, the evidence is weak at best and let me tell you why i say

that. even the gold standards, and by gold standard, i mean the randomized control trials that randomly put people in one training group, another training group and perhaps a control groups and control groups are always tough because no contact controls have their disadvantages. it is a control group that often gets used but perhaps isn't the optimal one. when we look at those randomized control groups, control studies, there aren't many, number one. they tend to be underpowered quite substantially, number two. number three the effect size tends to be rather small. what i mean by that small in a statistical sense in terms of effect size but also small in terms of the number of variables that are relevant to driving that show changes. that is beneficial effects from various cognitive training programs. i'm not going to mention any particular studies unless you decide you want me to do that but perhaps one of the gold standard studies compared one cognitive

training program that looks promising by the way in terms of on the road driving and driving simulation. those were the outcome variables subsequent prior to and subsequent to the training program. and found a benefit for one out of 19 variables. simulator training, which has been around for a long time both in aviation and as well as driving in many fields actually showed two beneficial effects for two different variables. so i'm not suggesting that cognitive training programs aren't efficacious. i'm suggesting we need to collect the kind of data we collect for drug trials and other kinds of trials. that is, set the same high bar and standard for these trials. i think it is also the case that we maybe as a scientists, and i am a scientist as well as a research administrator, haven't been creative enough in terms of the kinds of cognitive training programs we've pursued. as we have already heard from our two speakers, this is really a multivariant

problem. it is not a univariant problem or one aspect of cognition or one aspect of perception or physical function or disease or poly pharmacy but truly a multivariant problem. in terms of cognitive training we don't focus on the complete or richness of the problem. the multivariant sense, we tend to focus on particular areas. i think this is true with respect to cognition. some programs focus on what is called speed of processing which is probably much more than that when you look at the specifics of the training programs but there are many other aspects of sensory function, whether it is vision or hearing, motor function and cognition in terms of visual spacial memory, executive control and speed of processing that may be important. so i think we need to look, we really need to look at the breadth of the cognitive changes that take place and of course with respect to the assessments how they relate to driving performance to use them in a theoretically principled way

to target in terms of our training interventions. i think in addition to the randomized control trials which really are the gold standard we need more observational studies. think of it as epidemiology for drive driving which we track different driver populations based on choices they make in life to give us hints what randomized control trials we might perform in the future. again there are precious few of those observational studies that would provide information and enhance us to what kinds of training interventions we might pursue. i think just like drug trials we need broader replication of the promising results we've seen. we need independent validation. these studies tend to be done at a very small set of laboratories, again for to us have some assurance they really are broadly applicable. we need to go beyond single laboratories or groups of researchers. i think more importantly we need to understand mechanism. i think for many training

approaches that are pursued today, there are almost black box engineering approaches. and i don't say that pejoratively because i taught in engineering for 15 years at the university of illinois but they work in some cases. they give you small positive benefits. of course we need replication but why they work just like why drugs have particular actions knowing the molecular pathways tend to be very important in understanding the process and more specifically may be more iaea text tiffly targeting the intervention. we need more detail about mechanism and studies that focus on mechanisms so we understand what's going on. i think stratfied sampling is very important. many of the stu dishave been done have focused on individuals that are older and individuals that have very specific problems whether in vision or visual attention or what have you. so we really don't know if we look at these studies how these training interventions and these successes even with small effects apply to the broader community of older and middle-aged.

in fact middle-aged people are pretty much ignored in many of these studies. i think we need to move on with that. accidents are certainly the bottom line gold standard in terms of the outcome variables but it takes a large study to get enough accidents to make much sense ever the data. i think there are a number of studies in the literature now if you look at them the data doesn't make a whole lot of sense perhaps the because the sample size is so small. so i think we need to come up with better proxies, better proxy measures just as we do in terms of drug target effects for accidents that we can have some faith in both valid and reliable in being related to accidents so we use them in simulator studies or on the road studies or randomized control trials. that is my statement. >> thank you, dr. kramer. i guess the message there is some positive sign but at the same time there needs to be, you know, concerns and

be cautionary taking the process. i, i'm wondering if you can give us a, sort of like a high-level okay vision? can we -- observation. can we actually say some of these positive, positive evidence of the effectiveness of this cognitive training, perhaps they were maybe, you know, some of these people would take these all these cognitive trainings a safer subsets of the older driver? therefore we really don't know a lot about the driving history of them in comparison to those who actually don't take all these cognitive training? >> sure. i think this is a problem we have in any study be it a drug study or a driving study. certain people volunteer for studies and we always have to worry about those, not volunteering who might need it the most. but it has been the case with a number of these, not all, but with a number of these cognitive training studies that the researchers

have specifically selected individuals who did poorly on some screening tests. often a screening test of visual attention or processing speed or what have you. probably both of the above. i think population is very important. volunteers tend not to be representative of the whole population. we need to be careful about that but at least in some of the studies they have targeted people who had deficiencies in certain functions that have been related to driving. >> great. thank you. i did have one more question before we move onto the next panelist. yesterday we, we heard a lot about the newer technologies, the newer vehicles that actually perhaps collecting a lot of data about our own driving. do you think that's the advancement of this kind of technology may perhaps help us out with, you know, what you have just described to us about the lack of observational data that perhaps can view a better

case for cognitive training? >> i think that's certainly the case. i mean it seems very similar to the whole research domain of bio informatic and genewide screens. we collect a health data, genetic date and question is what can we do about it. we can take a brute force approach. there are many modeling techniques to use that data to outcome. accident rates, mortality, what have you. or we can take a more principled approach and need to take both and theoretically driven approach based on some of the information we heard from the first two speakers about the kinds of problems that older adults have and how those problems in terms of physical function, disease, polypharmacy, cognition, sensory function, motor function relate to driving. so i think there are a number of ways to use the kind of data that the sensors that now exist and are possible in automobiles might be iced to build

models for large populations and really stratify the population. of course there is always the issue of confidentiality here too. >> thank you. so we're actually marching down this multitier process that we first introduced with the panel. we start with screening, trying to identify candidates who need to be evaluated. we look at cognitive testing as one aspect, one type of that evaluation. we presented the question to dr. kramer, once we've identified that what do they think about cognitive training. and we've gotten to the end of the table. elin davis is the occupational therapist to take what we decided is driver problem and see what can be done to rather further assess it or remediate it. so my first sort of general question to you is,

occupational therapy is a broad field i like for you to describe aspects of it, what you actually do. more specifically there is a driver rehabilitation specialist component of it that i want some description of. thank you. >> thank you. thank you and thank you for inviting me and including me in this esteemed panel. so i appreciate the opportunity to speak on driver rehabilitation. yeah, occupational therapy is a very broad field and we address activities of daily living and instrumental activities of daily living which are really core to people's functioning, their abilities to do the things they want to do. when we look at driving, occupational therapists look at driving as an instrumental activity of daily living and what dr. evi said yesterday being last on the panel because a lot of things have been said. so i will go through some of these very quickly but to set the stage. again we look at driving

concerns as an issue of function, not an issue of age. we have issues with driving across all age spans but certainly when we're looking at the older driver issues we want to be looking at the minimum skillset that's required for the task of driving. so all occupational therapists in their evaluation process for a person that find themselves in the rehabilitation setting or the hospital setting will look at this minimum skillset in the domains of vision, physical ability and cognition. then we want to think about would those impairments challenge one's role as a driver? would those impairments challenge their critical roles of transporting other people, driving grandchildren? so we find seniors equally as concerned being making sure they're safe to do these roles, participate in these roles that they are responsible for as well as doing these activities. and so we want to be able to provide an evaluation that looks at that driver as an individual. as we've gone down the table and dr. molnar was talking

about screening, we're looking at more population-based criteria, cut points that help us recognize flags and when there is a concern. the driver rehab specialist is really there to look at the individual. so we're part of the team and part of the process. not everybody needs a comprehensive driving evaluation, if it were you, being told by the results after screening tool that you need to stop driving you would want the opportunity to be having your individual situation looked at, your individual skills and abilities measured so you have that opportunity to see if there is anything that can be done. when i think of any diagnosis as catastrophic as a cancer diagnosis might be the first question is, what can i do about it? is there anything i can to do restore this ability? and i think that is where the driver rehabilitation comes in to assist with that. driver rehab dates back to the beginning really of the vehicle. franklin roosevelt drove with hand controls. it originated looking at people with disabilities and assisting them with driving.

it is important to keep in mind when we see some of the variability and programs around the country, part of it is related to the fact that the issue of older drivers, the issue of aging with medical conditions, really issue of deciding when a person should stop, is somewhat new. it's new and being placed upon this field and it's really requiring a different skillset. helping anyone be able to drive is a different skillset than deciding when they need to stop. so, thinking about the purposes for our evaluation and our intervention, it is really to see if we can ready somebody to drive. this could be the occupational therapy, the driver rehab or the medical setting and then we can look, in looking at what are the key signs if somebody is in declining condition, such as a dementia, when they should stop. who administers the driving eval? we had discussion along with the different panel members but i just want to make the point there are different domains of where people

enter this system and different places. unfortunately we have a language problem i think driving evaluation is a one name for many different services. these are very good services but they have different personnel, different training and different outcomes. at the driver licensing level, you have a performance-based test that is pass fail. at a physician level you have a medical, you know, looking at the medical condition. at a driving school their mission is to teach people to drive. comprehensive driving evaluation by an ot is looking at a mixture of the assessments that lisa molnar talked about, pulling them together to form a comprehensive evaluation. we look at their history. we look at physical assessments. looking at concerns about their arthritis how that might affect their driving. looking getting in and out of vehicle, loading equipment with visual perception. we look at cognition. we also add for a comprehensive driving evaluation, the performance

base behind the wheel. assessments so we can see how these impairments play out in the context on the road. in many models you need to qualify to go on the road. sometimes you don't need that part if there's enough impairment or lack of impairment to not need that specific on-road piece but it's part of the package. there are several possible interventions because, in occupational therapy, occupational therapy if we do an evaluation it's followed by treatment. when we try to figure out what a person problem is our mission is then figure out what we can do about it. so our goal is to remediate. i think it is important that a lot of times when we think about driving evaluations and older drivers and the high-profile media cases might be represented by a group that may fall into the dementia category in a group that is declining and isn't a candidate for restoring these subskills but there's a bunch of people that are. we need to make sure we not forget them and that we have

the services so if they have a remeadable problem that we can develop intervention tosses a sis them, whether putting happened controls in their vehicle, extending their pedals for driving. making sure they not only have a scooter so can get it in their car so they're not homebound because they can't get anywhere with their mobility device because they can't get it in their car. so they can be doing the things they want to do and their mobility is getting them to the places they want to be. there are several possible interventions but we also as occupational therapists have the intervention if a person needs to stop and we have to provide mobility counseling and assist people. if you have an impairment that says, that leads you to not being able to drive, it likely puts you at risk to just go take public transportation. go hopping on a bus, if you fail the driving evaluation, probably puts you at risk. so the mission of the our work is a spectrum in trying to help get people to continue to driving if we possibly can or helping them

to safely transition from driving. thank you. >> thank you. we are delightfully on time and i thank you for your remarks. they are very pointed. it's a treat. i do have one last question for you and that is, who is a driving rehab special activity? how -- specialist. how do i get to be one? i wait to see if party questions don't cover any aspects of questions i queued up for you but briefly describe for me how that varies state by state. >> a driving rehabilitation specialist, there is a, is a little bit difficult to answer unfortunately for the clarity for the panel. part of it has been the evolution of the field. driver rehabilitation is a professional that has been trained how to evaluate and treat driving. there is an association called, the association for driver rehabilitation specialists which is a

multidisciplinary field. the field addressing driving involves occupational therapists the majority of the professionals are occupational therapists but involves driving school. education drivering instructors. it also includes rehab engineers and vehicle modifiers. just as in other areas of medicine there is constellation of professionals involved in this area. >> am i tested and certified? >> there are, those, the association for driving rehab specialists have a test that gives the credentialals of certified driving rehabilitation specialist. this makes sure that that person has a basic understanding of driver rehabilitation but it is not specific to any professional field. the american occupational therapy association has a certification in driving and community mobility. it's a performance-based certification that makes sure that the occupational therapist working in that area understands the evaluation, the intervention

and the mobility counseling side to transition somebody from driving to nondriving, which is more in keeping with the occupational therapy frame of reference for living life to its fullest and being able to address getting people off the road as well as keeping them on the road. >> thank you. >> good morning. we'll move to the panels and we'll begin with the first table and nhtsa will be asking the questions. if you could for the camera identify yourself by name and organization, thank you. >> thank you. for the opportunity. my name is jeff michael. i'm with the national highway safety traffic administration. question for dr. marotolli. are there, are there validated protocols available for physician screening of patient driving ability that thenalgy i'm

thinking of here and screening and intervention for alcohol abuse problems. a number of validated tools are available for physicians and the availability of these tools has, i think, fostered the growth of the screening and for options for treatment. are there similar validated tools available for clinician use for evaluating driving ability? >> yes and no. so there are many tools that are available. many of which have been validated. although usually those are for individual components or has been validated in a relatively small sample. there are number of composite measures so that the ama, adrs composite measure that was mentioned before is based on

individual elements some of which looked at and validated specifically for their driving ref vans. others of which a amalgam of things so the entire grouping has not necessarily been looked at but some of the individual components have. and that is i think the limitation that often comes up is that there are individual elements that have been done but not necessarily a composite, sort of multidimensional one that has. >> thank you. keep going. >> are there other questions from your table? >> yes. i apologize. another question for dr. marotolli. could you say something about the incentives and disincentives for physician reporting to licensing authorities? >> the incentives are easy, there are none. there are many disincentives.

so that, you would actually, did a study a long time ago where we specifically asked, we pulled clinicians in connecticut with 2,000 respondents and asked them specifically about this issue. the positive, the one positive, being a bit glib, the one positive a sense of obligation to societal safety and public health. and that is a very real one and people who do participate in it do that as well as the issue of protecting, if they truly feel that their patient is increased risk and they feel the need to intervene to protect that person as well as those around them. so there are some positives to that. those are unfortunately often outweighed by the many negatives of that. one is the opaque process that often is in place. two is the very real negative effect on the doctor-patient relationship or the clinician-patient relationship. this is something that most,

if not all physicians and clinicians hold very dear dear. the nature of reporting typically changes that from one being advocate to being more of an adversary. many clinicians are very reluctant to sort of make that transition. third is sort of the practical aspects of what they assess and how they actually gather that information and the timing of that and the cost of that but those don't necessarily affect the reporting aspect as much. >> thank you. question for miss molnar. are there screening tools available for family use and have these been validated? >> there are number of, there are a number of materials available for families to help them think about changes that an older driver might be undergoing and how to initiate conversations about driving

concerns. there are also several self-screening tools that have been developed over the last few years and, although it hasn't been, tested actually about the effects on family members, one idea is that these tools can be used by older drivers and their families to initiate these conversations. what the research has shown, with with regard to self-screening tools is that they really represent, i think a special case of screening in that their best strength is for increasing self-awareness among older drivers and generating, general knowledge about declines that people might be experiencing, the impact of these declines on driving. and, recommendations for further evaluation. so unlike other, kind of more rigorous, i think screening tools, self-screening at it best

really focuses more on increasing self-awareness and some of the studies that have been done looking at how well the outcomes of various self-screening tools and predict real problems on the road or problems with declining abilities kind of find no statistically significant but modest correlations between the outcomes of the tools and actual driving. some self-screening tools haven't been evaluated at all in this way but, i think there's enough that's positive that shows that these kinds of screening tools do have promise for increasing self-awareness and might be used to facilitate those kinds of family discussions. >> thank you. another question for miss davis. it seems that changes in driving ability might be better assessed over a

period of time rather than a single point in time. would it be feasible or cost baseline for drivers to assess against over a period of time? >> sorry. that's an excellent question and if we had our wish i think many of us would wish that we could get the discussions about driving to happen earlier. if they can happen earlier it gives us time to plan. it gives us time to think about transitioning from driving. so certainly what we are working on in the occupational therapy association really increasing occupational therapists role at the clinical level or the practice level to be identifying driving as a concern. having red flags that show concern about it, addressing strengthening those concerns that we could but also starting the discussion that just as we do for financial

planning we do for housing planning, we should be thinking about driving planning. and so at the medical level we can start screening and helping people understand how changes may be heading them that way. people are living longer with medical conditions that they didn't drive with so long. mass parkinson's disease as examples. if we intervene earlier have strategies earlier we believe they might be on the road longer and safer and enhance their ability to be self-aware and be the leader in helping decide when the time is right to make that change. >> thank you. one more testing, one more question about evaluation. it seems that aging-related driving deficits may appear under stress rather than in less stressful driving. do the driving evaluations

conducted by therapists typically involve any stressful situations such as heavier traffic, faster decision times, darkness, glare, et cetera? >> that's an excellent question and it is certainly something being debated and studied right now. as many areas in medicine are working toward having a more evidence-based criteria for how decisions are made, the same is true with driving and there is work going on trying to look at some of these factors. i think that as the practice stands right now, the experienced driving rehabilitation specialist would like to take people on the road to give them real life experience with merging, with traffic conditions, and try to challenge them in planning, go back and find where you last were. doing some navigation. there is certainly some look at simulators and being able

to give more challenge. but then we have the, we aren't sure if people are really reacting in those simulated situations in a realistic enough way to make a decision about their driving competence. so we do have driving rehab specialists try to add the appropriate challenge we think is safe for both the driver and the tester. >> thank you. finally a question for dr. kramer. the cognitive training is very interesting. could you give us specific example of sort of the theory of the relevance of cognitive training for older drivers? that is, what is a, an example of a driving deficit that could be addressed by a type of cognitive training and then what would be the desired out come? >> sure. i think there could be a number of examples. one would be as we get older we're slower to respond. slower to extract the

information from the visual environment which is a large part of the environment in driving. so there have been training programs that have specifically looked at whether we can broaden the amount of visual field from which we can extract information per unit time. and these programs have often tried to force attention, further and further out into the periphery as i was forcing the microphone. there is certainly some evidence that you can train these aspects of visual attention and visual attention we know decline as you age. of course there are many other aspects of cognition. the decline as we age, not just visual sensory function or per september wall function but decision-making ability. various aspects of memory and so forth. these other aspects of cognition show age-related cognitive decline have been addressed less frequently in terms of driving-related training. >> thank you. that concludes our questions.

we thank the panel for their interesting presentations and for the answers to the questions. >> thank you. and we'll move to the second >> good morning. my name is julie lee. i'm from aarp and with me is rodney peale from the american opt at this metric association. thank you very much for all the information you shared so far this morning. we have a couple questions for you. you talked a little bit assessments and cognitive training and brain training. and for the panel would like to know what you're opinion is on the benefit of older drivers taking a defensive or refresher driver safety course? >> i'll take a shot at that one. so i think, i think they are very valuable and they're useful. they have a lot of faith validity in terms of the content of those programs. if you look at the studies of their actual demonstrated

benefit there, there are somewhat variable from perhaps slightly worse to slightly better. there have been a couple studies now that have added on-road training to that sort of fairly succinct on-road training in the classroom setting and those have shown consistently positive benefit in terms of that. i don't think that the, sort of mixed data on the classroom alone, sort of is a detriment necessarily because i think there is useful information that can be provided and certainly recommend people do and also just raises the awareness and getting back to the issue some other panelists raised making people aware what they need to attend to. i think there is lot of information provided in there they're fairly easy to do. they're inexpensive and there is also often an insurance discount goes with that. there is actually an incentive for the person to take that. i think there are many potential benefits for that and i think they can possibly be tweaked to make them even more beneficial.

>> okay. i'd like to respond also. yesterday, we heard a great deal yesterday about self-regulation or self-restriction of driving is a way to compensate for declining abilities and extend over the period in which people can safely drive, and two, self-regulate appropriately, people need information to become more self-aware. so i also see the driver training courses as a forum for providing that information, generating discussions among people. >> i think dr. marotolli was being humble because one of the excellent studies was his that he published in 2007 in which he combined both classroom training with on the road training and in looking across the literature to prepare for this panel, i did notice that the studies that combined both the instructional training, classroom training with some on the road or simulator training tend to fair better in terms of out come

variables. if we look for programs useful for older adults knowledge is important but so too is feedback and actual practice to provide that feedback whether it is a driving instructor or what not. >> if i may add one more comment, the strategies and interventions are not a one-size-fits-all with this population. i think insight-based programs are excellent for the majority of senior drivers or older drivers but we need to help families and persons with certain conditions where they are not a good match or we can't be expecting of people coming away with the insight. that in particular is probably the group with dementia or cognitive impairment. and we can't expect families to be using an insight-driven approach to be expecting the change that they're looking for. so it is important that families understand that what can be good for many might not be the right thing for their situation.

>> thank you. since vision screening is low sensitivity and does not insure treatment, what do you recommend to the mtsb for vision assessment and improved vision function for the aging driver? >> we're missing our vision person today so, default -- i'm sorry. i think, so it is a bit tricky because i would say the associations for the most common measures, static visual acuity are relatively weak in terms of their association. in terms of face validity it has an obvious relevance to the driving task and there is an association that's there. people are very familiar with it. licensing agencies are familiar with it. i think it is reasonable to still have a general standard on that. the question what to supplement this to perhaps enhance the benefit of that? visual fields and

sensitivity would be two moist likely candidates and sort of ease of meshment and also familiarity to the general audience. it depends a little bit on where you do those because not everywhere can do them relatively accurately. they're a little bit trickier. visual acuity can be done anywhere simply and cheaply and everybody knows how to interpret it. it is trickier when you quantitativelily measure visual fields in horizontal film. and contrast sensitivity you have need a chart which most people don't have. you could make those more readily available and have more widespread use of them. as mentioned in yesterday combination of those have been shown to be beneficial in terms of identifying people who are at risk for driving related difficulties and also in terms of contrast sensitivity, flaw risk as well. another added benefit if you want to implement its usage giving sort of another angle where this would be potentially beneficial. >> and if i may add, just to respond to the questions earlier about overrestricting, certainly

there is vision screening is a health screen as well for the health of the eye and getting, getting into new glasses prescription, the prompt to get in and maybe get cataracts treated is certainly often times, for some people, that's where they get the trigger they need to get that assistance. i also want to make a plug. there is a specialized field called low-vision driving and in some states the visual acute and the vision guidelines allow for an exception when people have training in low-vision driving. find i quite find a fascinating specialty area. it is only licensed in certain states and sometimes people with low vision want to know what states they can go to so they're able to meet the criteria to be able to drive. >> thank you. couple more questions. doctors are reluctant to tell patients they should no longer drive but occupational therapists are trained to do so. can you, how can we get more

doctors to work with occupational therapists to help us with this? >> so i, one is to make people aware, like the first question on, you know, what is a drs and how do they get licensed and who are they? i think one, many physicians are not necessarily aware of the different therapy professionals and what the distinctions are and what they do. so many people can not distinguish specifically what a physical therapist does and what an occupational therapist does. within the spectrum what occupational therapists do the niche of driving rehab specialists is also not recognized. one making people aware of what they do and what the benefit is to their patients and to themselves. the second issue and one that elin and i talked about many times in the past, the dearth of people who are actually available and trained to be able to do

that. and there are many reasons for that. the main one from my perspective being economic. even in our area, many programs have closed and have used, sort of transitioned occupational therapists to doing more traditional occupational therapy as opposed to driving assessment simply because of the costs of the program and renumber race so it is easier for them to get paid and make more money doing it that way. so they closed the programs and moved them to different things. so access to the people is much more limited. so partly broader recognition and enhancing the way those are compensated. >> is it fair to say when you say these programs are closing it is not based on no need? it has been based, they have been closed despite having the need. so we certainly are, one of the things we've been doing for at american occupational therapy association is working on educating all occupational therapists about driver rehabilitation because we can be our own

triage. we can't always expect physicians to understand the difference between our subspecialties but we need to be identifying driving by all practitioners. if you put this slide back up i forgot to mention it when i asked you to put it up before and i didn't comment on it. it is just the idea, we're working very hard that all occupational therapists are addressing drives as an instrumental activity of daily living. if concerns are flagged within the medical setting they will be finding and refering to a specialist. we have a chicken and egg problem getting more driver rehabilitation programs because we need people requesting them or referring people to them so that we can get more programs to grow. certainly using the more, the beginning with the medical model, the screening for driving is certainly part of our typical occupational therapy evaluation and that is reimbursed. it is as you get into the

subspecialty area we have variability across the country for reimbursement. and this is just describing all of these are different things, all occupational therapists can do. only in the green triangle where you need the subspecialty not unlike oncology or other areas of medicine where many things are handled by a number of people and you send people to the specialist when they're, when we've identified that's the right place for them to go. i do believe if, as we get more efficient getting the right people to these specialists it also helps make it more financially appropriate. >> and as follow-onto that, do insurance companies pay for the ot evaluation and if so, how do we get more insurance companies to buy into this evaluation? >> reimbursement is variable. it's, answer that doesn't please people but it's just true. it varies by state and it varies by interpretation of the statutes.

some areas have reimbursement for occupational therapists performing the complete comprehensive driving evaluation, particularly when they really describe it by its functional components which it is. and in other areas it's, sometimes for convenience, they have actually pulled the whole program out of the reimbursement system. and they asked people to pay for it privately. i think what can help is demand of trying to make sure that we are getting reimbursement for the areas at least fit well within our practice. >> thank you very much. >> go to the third table and it looks like the alliance of automobile manufacturers will be questioning from the third table. >> yes. i'm joined by kelly bright man with ihs and kelly grabowski with aaa.

first question is three-parter. the panel stated that there is no one accepted screening tool. what does the panel recommend as elements of a model screening assessment system? then what elements are known to be ineffective and will the public view screening as profiling especially in minority communities? and how can this impression possibly be mitigated? >> i'll take a stab starting. i think in terms of what would be the optimal screening tool, i think the challenge is that the science really right now lags behind the need by practitioners for tools and instruments and procedures that they can use right away. we, we know that, we've talked about the various functional abilities that are important in driving and

if you could put up, i think there's, i have a slide on the pod study which is some of the early work that came out on screen tools for licensing agencies and that study, that study identified a number of functional abilities that are associated with crash risk and it also identified a battery that had a number of tests for those abilities. so i think that's one kind of starting point that we know that we have to look at the kinds of abilities that relate to driving. part of the challenge in implementing something in a licensing agency like this, as has been discussed there are a lot of other considerations in terms of constraints on time, constraints on costs. constraints on the resources that are available, trained personnel to do these kind

of tests. but we do need to think about, which abilities are related to safe driving and start there. i think similar to what dr. kramer spoke about in terms of evaluating cognitive training programs, in thinking about coming up with a good screen, we really need to think about the kind of research that's necessary. unfortunately that research is often time-consuming and very expensive. we need more longitudinal studies. we need studies that have sufficient samples so that we can reach meaningful conclusions about the impact on crash risk for example. and we haven't really been able to do those kind of studies although i think it is very promising that there's been a lot more collaboration in recent years and there are actually are some research efforts underway to try to get at what would be the best kind

of screening tool, particularly that could be done in physician offices. that research is being carried out by a consortium of canadian researchers. it is called can drive. they have funding for five years. they're using a sample that is recruited from seven sites across canada as well as one site in australia and one site in new zealand now. they will have sufficient numbers of drivers they can test a screen that they're identifying and look at, and look at crash risk. they will have about 1250 drivers. so i think that's really exciting and hopefully in the next few years we might have some more definitive results on that. >> if i may comment, i think one of the best protections is making sure that screening is screening and not, doesn't become an evaluation. i think that we have to recognize the context where

these different screens occur. the purpose of them, and the scope of them. if we develop screening tools at a dmv level, they should be referring somebody for the next level of expertise. i certainly understand population-based screening. i think it is very important. i don't support screening everybody for things. you know, i think that is too costly and it's not probably warranted. however, we need some kind of, at different entry points whether it is at dmv level. obviously you have a different skillset and a different tool than you have at a physician's office. then you will have at a senior center. then you have in different contexts. these all might be entree points. these might be places screening tools may be used but we need to insure that we're getting people to the right service so their needs will be met. they won't be overrestricted and won't be missed, ideally. >> i just follow up very

quickly. i wanted to add too i think these issues of sensitivity and specificity are really key. we have a lot of screening tools and the research can really on inform about what are the effects of different cut points, those kinds of things but ultimately i think policymakers have to weigh in and decide what's acceptable in terms of sensitivity and specificity. so, for example, if a screening tool can identify old drivers who would have failed a road test, but they also identify a considerable number of people who actually passed the road test, and passed those people on as well, those are considerations that policy-makers need it think about and weigh in on kind of what's the tradeoff between the potential for losing mobility? or forcing people to incur considerable costs for further evaluation that may not be necessary.

those kinds of issues that go well beyond the state of the research. >> i think one of the difficulties is it is inherently a multifactorial issue so it is hard to come up with a narrow set of tests that will sort of cover the full range of that which is ideally what you're trying to do with a screening test and maximizing its sensitivity. getting to your last point which i think is the tricky evident of that, the issue of profiling. i don't think from the perspective that we usually think of that in terms of, in terms of racial or ethnic or socioeconomic one but i think age is the equivalent here in terms of a visually identifiable, or perhaps physical frailty or other things that are visibly identifiable in terms of singling out individuals who would subsequently undergo screening as opposed to other individuals. and that becomes a trickier aspect. i think one that needs to be

guarded against. but the question is, how do you identify who is at increased risk as an initial step? then move that person through the system into more detailed assessment. >> okay. the next question is, when drivers are presented with information or evaluations suggesting that they may not be safe to drive, what resources are then available to transition them from drivers to nondrivers? >> okay. i'll go. so i think the difficulty is it varies from location to location. so there's no set answer. in some places there are none or very few. in others there are more. and so, part of the difficulty is that it is very hard to generalize and also one needs to figure out what those resources are in a given community and what the possibilities are based on that person's own sort of social network family and

other resources. the question is who does that and where does that get done or does anybody do that and that's part of the problem is there is no readily identifiable individual or group of individuals who that responsibility falls and that is perhaps the biggest gap. if you figure out who is going to work on that then the question is can you muster those resources and in many places you can even with informal ones but it would help to have more systemized approach and standardized way of dealing with it. >> i would just add i think from a research perspective it's been gratifying to see over the past several years there's more emphasis on research to help facilitate the transition from driving to nondriving. for example, dr. dobbs talked yesterday about the work she's done on putting together support groups for drivers with dementia to help them move toward driving retirement. so i think there's kind of two east pa -- pieces.

first we need to have more evidence-based practices about what are effective ways to help drivers transition. we need to have something for drivers to transition to when they're no longer able or they can't drive. there was a lot of talk yesterday about really a focus on providing alternative transportation. maybe not in the traditional way we think about it but in new ways that are acceptable to people and available in the areas which they live. and then, also, making that information available to people. i think there's a lot of discussion about, who should be responsibility -- responsible for doing that i know we had a licensing workshop a couple years ago sponsored by aaa foundation. we brought together about 40 experts from around the country in older driver issues and the consensus was that licensing agencies, given all of their other responsibilities, do need to think about how they can

also participate in making resources available. so i think it is a really community-based approach. >> and speaking for the occupational therapists in the rehab setting which is probably a net where we're capturing a lot of people that are facing medical conditions, we're certainly working with our therapists to be moving from identifying that a person should be stopping driving to how else they're going to get around. there is a number of tools that have been created that we have been distributing to the ots and that, like for example, the beverly foundation has come up with a dementia friendly calculator to assist determining what public transit options would be appropriate and what kind of safeguards would need to be in place for a person using those. there's a field that's been gaining strength called mobility management at transit side trying to help match people with the public, with the support services they need. and travel training has been

gaining, there's a gaining interest in gaining training and support through easter seals. they have a travel training program to try to bridge, if a person should be using alternative transportation. they might need to learn how and we're trying to increase the number of professionals that know about this and so they can employ it. i think the upshot is we find ourselves saying it sort of take as village. we need a number of, a number of groups and professionals in different areas. it may differ in different communities but if each community works on trying to have a network of services, we're hopeful that will be an important way toward a solution. >> thank you. >> okay we'll go to the last table and ivan will asking questions. >> i'm tom emanuel. american association of automobile administrators and with me is barbara