and we're not generating jobs fast enough really to get down to meet that 2017 level. and we've just picked an artificial 5% there. you know, but the path is about the same. what's really disturbing, though, is we've had some of our economists and be our aaba's economic advisory committee are not convinced that's going to hold. for example, paul -- who i love, because he's one of the outsiders who says, jeez, i just don't believe my of this stuff -- has the unemployment rate next year at 9.5%. he is not confident we are going to follow any of this path. and, again, it takes 200,000 jobs -- i mean, 200,000, yeah, jobs on average each month and a strong gdp to drive that rate down. we're not there yet, and we'll show you a few other things that

will convince you of that, i think. housing starts is another enormous issue. this is, again, i showed you this before. i think this is my all-time favorite chart partly because you can just visually see the contrast with other recessions across that period. you can see how sharply other recessions rebounded because housing is such an important part of the u.s. economy. and look where, look what's happening here. we're barely treading water under here. this is the average rate across that period, 1.5 million housing units, housing starts. typically, the 1.5 is enough to handle the increase in population, the, you know, the destruction and rebuilding of houses that have deteriorated. we are nowhere close to that at all. and the obvious reason of course, is we have a huge overhang of existing properties that are outstanding. there's no reason to build new houses.

the other thing that's disturbing, now, the housing starts includes multifamily and singles, so this is a little -- you've got to kind of keep that in mind. but you may have noticed this week new home sale was 295,000. so we're producing, and it includes multi-family here, we're producing at 571, and we don't have -- in my opinion -- enough demand to absorb the record low levels of housing production that we are having today. and it's still low. and it's because there's a huge overhang of existing houses. in fact, there's 1.7 million houses in that shadow inventory, the ones that are in the process of being sold whether they're in foreclosure or they're serious delinquent. there's one in ten properties that are nonperforming.

it is still a huge overhang, and that alone is going to take 30 months to wind down at current sale rates. now, the shadow inventory's lower than it was before, lower than a year ago. that's a good thing. it's down about 18%, in fact. but we still have this enormous overhang, we still have this pipeline of housing that are in the process of being sold. that is going to be a drag on this economy. so, again, if your time frame is one to two years, you've got to push it out. it is way too short. it still is way too short. what's remarkable is a year ago, you know, if you looked at this picture and the one a year ago, you'd say, gee, there's no difference because nothing has happened. we have not made any significant improvements on this. well, all of this if you wrap all this up, is what one of our economists on our economic advisory committee termed it a

confidence recession. there is no confidence. there's no business confidence, consumers are losing confidence, you can see that in these pictures, particularly on the consumers' side. consumers are really depressed. businesses are kind of hang anything there, you know? they're kind of wondering what's going on, and they're building their balance sheets, so that isn't quite as bad. but it is a recession based on the lack of confidence that we are in this country. well, the next theme is it's a small world. and i know some of you are now singing the song, as painful as that is for you. [laughter] but it did kind of capture what happens with the rest of the world. so the first thing is looking at a comparison for what the other countries in the world are doing. and one way to think about this is, you know, one other positive thing is when you look at

states, states in the united states, and say which states are in recession? the only state that is officially still in a recession is nevada which is kind of interesting. a couple years ago, of course, every state was in a recession. but one of the things that we do in the united states, of course, you think more globally. you think, okay, what is the nation's unemployment rate, what is the nation's gdp? and we know that some states perform better than other states, and it all kind of blends together, and you have movements of population, and all kinds of things balance that out. so take that view that we often have of the united states and blow it up to the world and ask yourself, jeez, is 4% world gdp all that bad? and you might say, well, you know, no, it's not really. that there are parts of the world that are doing better than others, and that's what happens in economies. and resources flow to those places that are doing better. the interesting thing is emerging countries, the developing countries used to

absorb back in the '90s, i think, 20% of direct foreign investments. they're now up to 40, 45%. money is flowing into developing countries. that's where the, where it hooks like the big change -- where it looks like the big changes are taking place. and look, this is the bricks for bric in case you didn't know that, and these are some -- you know, and they're not too great even for 2012, but look at the strong performance in these countries. now, there's worries, of course, about those countries and about those economies. but those countries are driving resources. china is absorbing half of the cement in the world, that the world produces, and almost half of the iron ore and steel produced in the world. it is the biggest purchaser of aluminum and copper and other materials, often for things that get exported back to us, and this is great.

china consumes half of the pigs produced in the world and a third of the eggs produced in the world. it is a very quickly-growing economy that is sucking a lot of resources, ask it's not far behind -- and it's not far behind with india and other countries. look at, of course, the united states and europe. oddly enough, with all the problems in europe it is still projected to be doing better than united states, so we should be a little careful not to be too critical. japan, of course, is still struggling, and they had the tsunami and the other problems which have add today that. so for the united states, let's look at some of the risks of what makes thicks worse. -- things worse. and we've been thinking about this for nine months or so when our economic advisory committee looked at the risks of what would make the u.s. economy go slower. and they were doing this back in january before we met with the federal reserve. and when you go through all these things, look at all these things, decline in equity

values, yes; state municipal financing, yes; weaker external demand, yes, because those countries are slowing down. downturn in confidence, oil prices, you just go down on that list. everything bad that could happen that would drive the economy slower has happened this year. we had some momentum coming into 2011, the tsunami, other shocks slowed that down, and we had the self-inflicted head wounds which we haven't talked about yet. all these things are pressures that are keeping things slow. one of the things, again, back to kind of thinking about china, and one of the things that sort of struck me as we're always looking at tons of data and charts, this is commodity prices index. so they all start at the same level back in 2003. so you get a sense of how quickly they are growing and growing relative to one another. right? and look at all of these changes that are occurring. you have doubling and tripling.

i think the whole index if you take that all together is doubled or tripled with all of those things. so, again, think about what that means for the u.s. economy. you've had a strong increase in all these commodity prices. it's because of those developing countries absorbing a lot of those resources increasing that demand. well, what does that mean for the u.s.? well, here's what's happened to the price of a gallon of gasoline. it's back up toward levels that we've seen. and to put this in perspective here for the u.s. economy, a one cent increase in gasoline is a billion dollars worth of added expenses. it is a huge impact on what happens with the u.s. economy. so when you get high ones or you get low ones, you know you free up a lot of money when gas prices fall. we're back up at levels where

it's absorbing a lot of, you know, spending that consumers otherwise would have. let's talk a little bit about what's happening in europe. this is a more complicated slide. we always try to keep it simple. but what we're trying to show you is the different countries and focus really on this light blue line all the way across here. that's the 2010 increase in debt that's occurred in every case, debt has been rising across europe and in the united states. no surprise. the only country, you may notice, where that line is down is sweden. now, good things, of course, often happen in sweden, i'm sure. but sweden ten years ago put in

place changes to bring their debt levels back in place. and i had the pleasure of listening to one of their, one of the elected officials that happened to be making a presentation at aei, and he said the attitude of sweden was we know what the right thing to do is -- as a politician -- we just don't know how to get reelected after we do it. [laughter] and that feels the same in this country. but he said, you know, the interesting thing that they learned is that, in fact, when they did the right thing, they did, in fact, get reelected. because they took the hard decisions, they cut it back, and in fact, of all the countries that are out there, they have the best fiscal position now among all the countries that you see there because they took the hard things fast. and we'll come back to some of the factors that build, that build upon that and what makes a credible plan. and some is based on the sweden experience. but we'll leave that for a

little bit. this is a measure, the pigs of portugal, ireland, greece, italy, i guess, would be another one that you often add with a second i in there. you can see the relative risk of what happened, and you can see just how dramatic the problem is. and some of this is because we continue to let this thing continue to grow. greece is way up here. two-year greek bonds are trading at 70%. that's the interest rate, 70% interest rate on it. which has got to kind of frighten you on this. there was a little -- one thing we were looking at, of course, is, you know, there was an agreement on july 21st to try to move and reduce some of the debt, help fill the hole with a stabilization fund that they have, and that would involve a 20% reduction in the outstanding debt, what's kind of a tet swap

or a -- debt swap or a rolling over of debt in interest rates. and that had a tiny effect, perhaps. this little downturn may have been responsible for that. but in the meantime, greece's debt because the economy is so weak is almost up to 200% of gdp. because it really is entering into a depression here, and part of it is because things continue to go on. it's less true of ireland and portugal because at least what i'm told is that portugal and ireland have at least implemented systems that seem to be credible, seem to be working because they had the political will to be able to do that, and there doesn't seem to be the political will in greece. and the system has gotten worse and worse as that debt has built up. there are losses there. my opinion now, there are losses there that have to be written down. and, again, that july 21st said 20% haircut on those losses, that hasn't been adopted by any of the 17 countries.

there are some people now saying the losses really, you know, that reduction, the haircut on that should be 50%. now. but the key thing is there are losses there that have to be recognized, ask we haven't recognized them -- and we haven't recognized them yet. you've got to get debt levels down to sustainable levels, and the issue is someone has to pay for that. a 20% reduction would be a severe hit particularly to greek banks and others, and we'll show some things on that. but and that may be doable. a 50% haircut, then you have solvency and capital problems at all the major banks. um, this is a chart that i asked rob morgan on my staff to put together was when the united states got downgraded said, well, wait, what's happening with credit default swaps, what's happening with the pricing of risks. and you can see even with a aa-plus s&p rating, we still

have the lowest credit risk of all the other countries, even the aaa countries. so that was just sort of for my own amusement because it was driving me crazy. [laughter] you know, that s&p did that, not realizing the overall strength of the u.s. all right. let's talk specifically, one of the questions that we've been trying to answer which we thought may be of interest to you is, what is the direct exposure on greece's debt? so we looked at the bank exposure, and we also looked at not only the sovereign debt exposure which is the yellow, but we also looked at the bank and private sector debt to get a feel for if bad things are happening in greece, what does that mean for the rest of the country? and you can see what the political issues are. france and germany, obviously, have big exposures to greece. so they're worried about it. that gives them incentives to do

things. look at the u.s., though, very low, um, levels particularly to the sovereign debt. and even if you add up the bank and private sector debt, low exposure. there's exposure there, but it's nowhere compared to what happens in other europeans. and if you take this, this is the dollar level. if you take this and look at as a share of gdp the impact on that, you can see that the u.s. is very low here. so the direct consequence from greek debt to u.s. is small, and even on the interbank transactions, that is declining as banks are positioning themselves to deal with that counterparty risk. so low exposure directly to greece. and this gives you kind of -- we were trying to say, well, what is a good relative measure to capture that direct exposure to greece, both the public and be, i think, both the banks and the

private side. and so we said, all right, let's just compare the industry in 2010, sort of stunningly, i guess, charged off over $200 billion. now, that was a shocking year, of course. this year it looks, if we project forward, it looks like it's going to be about 140 billion. so still a lot of losses. the banking industry is still working through that. you know, the exposure to greece is tiny relative to what the industry has charged off in the past. in fact, if you look at the gap between the two, there's plenty there of capacity if you assume there's, you know, the capacity to be able to charge this off to absorb much more than what the greek debt is on direct exposure. so, again, the point is here the banking industry's direct exposure to greece is very, very small, very manageable, not really an issue. well, the exposure changes

though as we look to what happens with other countries and other countries' exposure. so we have greece along the bottom here, and then we have the exposure for other countries. and you can see france and germany, again, very large exposures particularly when you hear talks of italy, particular particularly on italy, the issue of spain are big issues for those countries. and there's derivative effects, obviously, as those translate and move through the system. the u.s., yes, there's expose your, but it's more on the indirect nature of what happens. well, there is spillover that occurs as well. this was in a recent imf report that just talks about, you know, if you narrow down the greek debt, well, that's one thing. but then it expands to portugal, and you get this exposure that spreads across europe as you include all the exposures, the counterparty exposures between them.

so the imf's conclusion is you've got about 200 billion euro exposure just in the main countries that are at risk and be up to 300 billion if you really spread that out across those high-risk countries across most of europe. so it gives you a feel for the magnitude. it is not small. and it, obviously, has implications for the u.s. because 20% of our exports go to europe. so if europe has problems that create a recession in europe, it directly comes back and be effects u.s. exports. and i will remind you u.s. exports have been the shining star throughout the recession that has kept gdp moving forward. that has been a huge benefit to the u.s. and, again, think about the exports across the rest of the country, rest of the world including china and india. all of that is tied together. the point is, this has a big impact because of the secondary effects. that occur. not necessarily the direct effects.

all right.ú< self-inflicted head wounds. here's a picture of our congress. they continue to do this -- [laughter] now, winston churchill purportedly said something like this, and i've been unable to confirm it, but i like it. so i'll say it anyway. [laughter] winston churchill purportedly said americans can always be counted on to do the right thing after exhausting all other options. [laughter] and that seems to be our congress, right? we lived through the biggest self-inflicted head wound which was the debt ceiling debate. we're living back through the continuing resolution. god help us when the supercommittee comes up. it is just a horrible situation. and in my opinion, and i think this is shared more broadly, again, it's back to that confidence recession. we have no confidence that our government can take the steps to

do the right things to get us back on a reasonable track. because it'll be all this in if-fighting, all at the last minute which creates business uncertainty and freezes those markets. and we're going to continue to do that. well, let's talk a little bit about -- i don't know how i'm doing with time. let's talk a little bit about what this means. i think i showed you something like this, the federal deficit last year, and as i recall -- and i may, i may not have done this, but i think i asked you all to get out our checkbooks. did i ask you to do this? and write a check for $4,000 for you and every person in your family. and how many of you did that? [laughter] show of hands? and you wonder why we have a problem. [laughter] just again, to put a fine point on that it takes about 4,000 per person in this country to eliminate that debt for one year. okay? so you've not, obviously, stepped up and met your obligations here. all right. well, let's talk about what happens here. this is cbo's baseline estimate

under what they think is reasonable assumptions if the government does certain things. now, this includes things like continuing the tax breaks for everybody except those over, couples over 250,000, individuals over 200. so that includes that. it also includes the continuation of the amt fix, it also includes the doc fix on medicare. and you can see, you know, i mean, this is not pretty. this is really not very good at all. and this is a better forecast than others like the concord coalition which is the bipartisan group that thinks about these things who believes it won't be 1.4 trillion deficit, yearly deficit, it could be as much as 2 trillion at the end of this period. so this is just their baseline of things that might happen. so what we want to do is now

contrast this between what the administration has proposed to give you a sense of the impact of what's being proposed. so here's the obama jobs plan, and you can see the components there. and you can see where, you know, it's front loaded, you know? >> you need spending. so you've got tax cuts for small businesses which includes a payroll tax for small businesses, so that's extended not only to individuals, but to businesses' incentives to hire, so that's a big portion of that. we're continuing some long-term unemployment relief which we can probably debate about and, you know, tax breaks for families, includes the payroll deduction. so we're continuing that. so, in fact, some of these, like the tax breaks, are a continuation of what we had, and that's probably not a bad thing if you think without that, you have a contraction in spending. so, you know, it would have the impact of increasing tacks. and you can see -- taxes. and you can see then it fades,

and some things are paid back as it goes on. here is the obama's deficit plan, and so you can see the components. and you get savings if you change things, you get savings every year, and it tends to compound. that, so you can see the different elements of what's involved. the tax revenue, of course, again, coming from some redefining of things and the cost on the higher income on that. some of the war spending was built in. so let's combine these two things to give you a feel for the jobs plan and the deficit reduction. all right? because they've got to work together if you're going to do a stimulus to try to keep the economy going in the reduction. and it's an interesting pattern. one of the things, just to kind of focus, look at the deficit reduction under the plan for 2012. i mean, it's tiny. right? it gets back to are we taking action quick enough to encourage investors around or the world to

put capital in the u.s.? so all these are back-loaded things. well, you know, remember, congress can do anything they want at any point in time, so this doesn't lock them into these changes even with that. all right. so if you wrap all that together, you get this blue line here. all right? so it improves the picture. notice how the deficit gets worse because you're doing all that spending to begin with. then you get the savings as it starts to kick in, and then things kind of go back on track. here. again, look at the position here at the end. you're still adding to the overall debt. you haven't totally changed that curve. so understand what that means. well, to give you a better sense of the context here, this is what omb's baseline adds up to

across that period, 2012 to 2021. this is what the president has proposed. you can see it doesn't come close to closing the gap that's been created, and this is what the supercommittee has to come up with, otherwise you get the sequestration, you get 1.5 trillion in spending cuts. so as good as those changes are, it still doesn't change the fact the debt is rising. well, the issue is dealing with the entitlements. now, what we've done here is you can see the path of the entitlements here. this is the cbo eastern scenario. cbo eastern she square know. there is a general assumption that revenue if you even take it back in history, doesn't change much even with tax rates. it stays at a fairly consistent

about an 18% level. so it's hard to influence tax revenue. now, if you go to a simplification of the tax system which i think is a good idea, maybe you can improve some of that, but look at this point right here which is about 2024. sorry, on this side. you know, 2024. if revenue stays about the same there, we would only have enough money to pay for social security, medicare and the interest on our debt. we have no money left over for any other spending; defense, social programs, things like that. no money left over. you've got to deal with medicare and social security. and what was really depressing, social security as you can see, that's not growing very fast. that's one of the easier ones to deal with particularly if you deal with it in the sense that it only applies to people under 40 or, you know, some level like

that. but it wasn't included. and here's the issue with social security. look at the workers to beneficiaries. you know? the path is that we have less than, what is it now, almost less than two people working for every retired person that's out there. you've got to deal with this. and you've got to deal with medicare and medicaid. all right. states, just to kind of conclude this and, you know, we'll tie things up in a bow here in a second. states also have an issue. this is the state cumulative budget deficit, um, and there's two interesting things to think about. if you look at the total bars here, okay? the state deficits are closing, and they're doing a better job of closing that deficit, okay? so that's a good thing. still there's a deficit there. but the yellow component here is the part that was filled by the stimulus package. and you can see the stimulus

package is going away. that's why in the president's proposal you got more money back to states because the burden, this red burden now even though the total deficit is declining, the portion that has to be handled by the states alone is bigger than it was in previous years because you don't have that federal contribution. so a lot of pressure back on states to close that gap, a lot of the states, of course, thinking about the obama plan, you know, spending for teachers, spending for, you know, police, first responders, that sort of thing. that's, that is the issue that he is trying to address in here, is this decrease in the stimulus that states are provided. ..֖ stimuluses

that didn't have much money for infrastructure spending. which are investments in things that make a difference and you can employ people. but, you know, we're having the same argument today when they

say infrastructure spending, the response is there's no shovel-ready programs. well, you know, we're three years into this. if you'd done infrastructure spending we would be three years in. you would start to be getting the benefit of that spending now and you can do things like education and research and development that preserves growth and puts spending in places that gives you a positive return so that's kind of the high level principles that i've thought of. well, again we have some things that we hope you're looking at. one is the dodd-frank tracker for the website on it. and every day we produce the banks and the economy so we're updating things including things that happened today. there's a lot of economic news coming out today. so i don't know if i totally exhausted my time but i'm certainly happy to entertain your comments and questions.

i do have this effect of stunning audiences into silence. thank you so much. i've done that once again. [laughter] >> yes. >> yeah, the question was, would i choose to say which will congress wake up and do the right thing? there was an interesting comment recently -- i was at the iif, the international institute of finance meetings this past weekend. and it was a european -- i can't remember who that said, you know, you have to get the pain threshold high enough for congress to take action. and it obviously isn't there. we went through that whole thing and it isn't there. one of the interesting things -- there was the turkish finance minister who was there. and they actually have taken a lot of steps to do things.

they put in place 6.5% surplus target. and his comment was if you asked anybody on the street what is the target for the surplus, they knew it. they would say 6.5%. and his comment was you walk out on the street and you say what's the target, deficit? no one knows. so having a consistent message that everybody understands. i don't have a lot of faith that the super committee is going to come up with something great. i wish they would. it gives them an opportunity to back out all the politics so there is some hope there. but i don't know. the past history is everything goes down to, you know, the brinksmanship. so i don't have a lot of confidence that our congress is going to do it and everything is being pushed to be, you know, a debate after the election next year. so i think we'll struggle through most likely we'll get

the sequestration results, although i may be surprised by that which punts everything to after the election, the sequestration doesn't come in to effect till after the election. and then we'll deal with it and then i think it's partisan politics. i don't think -- i don't think congress believes that there's an issue that they have to come together and i don't think the general public believes there's an issue that really is worth coming together. and some of the advice, you know, back to getting the media to focus on that, you have to make a convincing argument that people are going to totally lose some things, whether it's social security, medicare, or medicaid and that's real. and that's in your face. you're going to lose this unless we take some change and then you change the public sentiment. i don't have great hope that we're going to do anything over the next year. it's back to we know what the right thing to do we just don't know how to get re-elected and i

think that's the attitude. [inaudible] >> the question is, what's the likelihood of another credit downgrade by one of the agencies? you know, i think that was a possibility. i was disappointed that s&p did it because they did it because of the political -- lack of political will and i appreciate that. i understand that. but when you made a $2 trillion mistake, too, it's a little odd to see, gezz, it isn't that stuff. it's the political will so i think others are being more cautious. the one thing that's interesting when you do a downgrade typically the banks also get downgraded and we started to see that both in the united states and in europe. so there are implications to just even that first -- that first downgrade. yes. [inaudible] >> yeah, the question is what is the odds of slipping back into

another recession? you know, the odds -- i had a few months ago, the odds being better than 30%. i think the odds have gone up to about 50% now. so it's sort of a toss-up. i think we're in this very painful slow growth period here. i think there will be growth. i think it will feel like it's a recession. it's not 2008 but it feels that way. so i think we're kind of in a 50/50. i think the worry is that what economists call sort of that stall seed, you know, with the plane analogy, you know, that you can climb but if you don't have enough forward momentum, you end up stalling and declining and i think that's where the fear now is coming in. but to me, it's all about uncertainty. it's not about, you know, again coming back to some of the themes that i described. banks are better. businesses are stronger. the ones that have survived are doing things. consumers are doing better in

this country. there's the right kind of base for that. there's plenty of money to be lent. there's just not a desire to borrow the money as there had been before because there's uncertainty about what the prospects are. and think about it. you know, most businesses and individuals are now worried about what is my tax burden is going to be? is it going to be higher? what am i going to do with the business? are there more regulations, you know, what is my health care costs going to be if you're a business or an individual? all these things are adding up and people are saying, i'm stopping. i'm not going to do anything 'cause i don't have the -- i don't have the certainty that things will change. so i would say it's probably 50/50 now that we would get that. but i think again we're just -- you know, it's going to be an ever so slow increase so maybe it's not a technical recession but it's going to feel painful. all right. well, it's a pleasure to be back here before you. [applause]

>> join us tonight for more to the road to the white house at 8:00 pm eastern we'll feature two of the candidates wives starting with anita perry, wife of texas governor rick perry. then ann romney, mitt romney's wife will offer comments and later a speech from earlier today from minnesota republican michele bachmann. we'll continue our coverage tomorrow night with an event featuring former house speaker newt gingrich. he was in des moines, iowa, recently and you can watch this speech thursday at 8:00 pm eastern. and friday, it's remarks from texas governor rick perry from a town hall meeting in dairy, new hampshire. watch all of this campaign 2012 coverage each night at 8:00 pm eastern on our companion network, c-span. >> now get ready updates of what's on the c-span networks with c-span now on twitter. get tweets once an hour with

quick program information including which events are live. and links to help you watch. it's easy to sign up. just go to twitter.com/c-spannow and then hit follow, the latest most instant information of what to watch on c-span, c-span2 and c-span3 now on twitter. >> returning iraq and afghanistan war veterans and veterans health officials took part in a discussion monday on the challenges war veterans face when reintegrating back into civilian society. the u.s. naval institute and military officers association hosted this 40-minute discussion in washington, d.c. this is the fifth annual defense form on providing services to severely injured service member members. >> okay, ladies and gentlemen, we'll go ahead and get started. i hope everyone had a chance to get some coffee and juice. it's now my time for our first panel discussion, community

reintegration the challenges back home. directing this panel is our moderator, national security analyst kt mcfarland. mrs. mcfarland appears frequently on fox news, fox business news and numerous radio programs. she's also the host of fox news.com step com 3 one of the internet's most popular national security shows. she has served on national security posts for several presidential administrations to include president nixon, president ford and president reagan and received the defense department's highest civilian award for her work in the reagan administration. she's a graduate of george washington university, oxford university, and the massachusetts institute of technology. concentrating on nuclear weapons, china and the soviet union. equal significance, she is the mother of five, proud of all of them but i understand that one of her daughters is a recent graduate, 2008, of the naval academy in the surface warfare business on the west coast.

ladies and gentlemen, my distinct honor and pleasure to introduce ms. kt mcfarland. [applause] >> thank you all for being here. you may not recognize me but i'm the brunette at fox news. [laughter] >> this year's defense forum focuses on the journey back and helping the wounded warriors and their families transition. and the panel this morning is going to take a look at the issues of community integration. the challenges our veterans and their families face and especially our wounded warriors and their particular needs. you know, i'm of the vietnam war generation. i just want to ask is anybody as old as i am. is anyone here of the vietnam era. wow, more than you think. after the vietnam war we treated our veterans shamefully. it was an unpopular war, as the

secretary just pointed out and it didn't end well and instead of blaming ourselves we blamed the military. when they came home in the 1970s, we did not honor them for their service. we did not adequately care for their families and we did not give them the support and medical attention they needed. it was a war we wanted to forget and so we forgot about them as well. in the 1970s, the programs were few and far between. when i went in the pentagon with the reagan administration in the 1980s, not only had we hollowed out our military force we had ships that couldn't sail, we had planes that couldn't fly, we were cannibalizing parts, we had pilots who weren't certified to train because they didn't have training hours but the most shameful thing of all was when we went around the country and we met our veterans and saw men who had lost limbs and their

prosthesis didn't fit, people who couldn't get to veteran hospitals because they were too far away, people who had medical and psychological injuries which we pretended just weren't there and it was a sign of weakness. and the most shameful thing was when cap weinberger met some of our junior enlisted. they were paid so little that they qualified for food stamps. but we promised ourselves as a nation we would never let that happen again. so here we are today. and we got returning veterans from afghanistan and iraq, many of whom who have seen three, four, five tours of duty. we have been at war for 10 years and many of our returning warriors have serious injuries and disabilities. they'll need help not only integrating the society but they will need significant medical care for the rest of their lives. so have we learned from our past mistakes? well, the good news is as we do wind down our wars, our national leaders of both parties have pledged to care for our returning warriors. there's a new and general recognition in the country that some of our vets are coming back

with injuries on the outside as well as on the inside. it will be with them for the rest of their lives. our military culture which is often as i don't have to tell you suffer in silence is now more up front, our military culture is more up front about the psychological injuries or troops suffer and offered treatment that was never available after previous wars. there's a focus on medical attention and there are programs now to help the transition reintegration civilian employment for our veterans when there were none before. and we're going to talk about some of these today. this morning's panel and then this afternoon's panel focusing on employment. but in a lot of ways, the integration tasks that we face after these wars are going to be more difficult. our active forces as well as our reserves have done more combat tours, more frequently, than they were designed to do. our guard and reserves have not been used as militia but have been used as rotational forces. many of our military families,

husband and wife are both in the service. and that family is double burdened. our women particularly as they return -- half of our women are mothers, who have left their children behind to fight. that's an integration issue. our all-volunteer force means that the service men and women we have on duty -- they want to be there. they've signed up. but what it means is they're isolated from the rest of society. only 1% of our citizens serve in the military and less than 10% of our citizens even know a family or know anyone who's in the military. that's a small minority. and in politics the worry is out of sight, out of mind. and so with the pressures that we're all facing with government cutting. many service men and women worry probably rightfully that this time the budget ax is going to fall on them as it did in the 1970s but with greater intensity

and immediacy. so this morning's session is one of those rare events where everybody -- that means you, me, them -- we learn from each other. our panelists have been carefully chosen to cover the range of challenges and opportunities our returning vets and wounded warriors and their families face. and the programs that are available to them. we have a wounded warrior family, tom marcum and his wife april marcum who are sitting in the middle of that panel and they're going to talk about the unique and difficult journey they've had from a perspective of the inside, of what a family goes through. now, you're all going to have an opportunity to ask questions but the way this is going to work is i'm going to introduce the panel, they're going to talk about the programs that they represent, that their communities offer, and i'm going to grill them, fox news style, and then we're going to let you grill them and i think that by the end of this, what we want to do is go over a couple of things. what are the roles and

responsibilities of the government? not just the defense department and the veterans administration but the other agencies. what is the demobilization process and the disability evaluation system? where do the programs that we have fall short? where are the gaps in the care and the services whether they're from bureaucratic red tape, budget shortfalls or their poorly designed mramz we want to talk about the pearl program that will be an issue that comes up. and finally, how do our wounded warriors and their communities react to each other? you know, they come back, it's not world war ii. they're not coming back to the parades. but they are coming back into their communities and what are the expectations that they and their communities have and what's the reality? what i'd like to do now is introduce the panelists so you know who i am. the only brunette at fox news. and i want to introduce -- let's see general todd -- okay.

we've all switched around because we wanted the marcums to sit in the middle of all this. let me first introduce major general james adkins he's the 28th adjutant general of maryland. he oversees 7,200 soldiers, airmen and civilian employees and volunteers of the maryland military department. he's also very interesting because he's a dual-hatted guy or at least has been. he was the secretary of veterans affairs in maryland as well as the adjutant general so he knows both sides of the equation. we also want to introduce todd by the way -- bowyers. he was part of the fiercest combat in the iraq war, the battle for fallujah in november, 2004, when he was hit by a sniper and has lost 80% of the hearing in his left ear. he was formerly with the

iraq/afghanistan veterans association which is the largest veterans association from that war. with over 200,000 members and he is now working in new york for jp morgan as part of their community outreach and philanthropic programs. so although he has lost 80% of the hearing in his left ear, he has enough left to hear what those bankers have to say. david brown, yeah, david brown used to be a brunette. [laughter] >> so he tells me that he thinks that's good enough reason that he should ultimately end up at fox news. [laughter] >> but he is with the office of the secretary of defense where he's a clinical psychologist and an expert on recovery and reintegration. a former army sergeant dr. brown is deployed with the u.s. army and the former yugoslavia to work with survivors of ethnic cleansing and genocide and he is now with the office of the secretary of defense but before that he was a defense

department's lead for recovery, care and support centers for excellence. lieutenant colonel rod lewis, the guy on the end, not wearing his uniform, works at the white house. and he is a former air force -- well, he is a current air force c-17a pilot, a former commander of the forest airlift squadron which handles the country's most sensitive cargo which is the prime nuclear air force and he's the part of the first lady's staff for the joining forces initiative. that's the national program to mobilize all sectors of society to support our service members and their families. that's the mother ship. we have nicole keesee who's from little rock, arkansas, and ms. keesee is a colonel in the army reserves and served as a army combat medic. today she's a behavioral health officer in the little rock, arkansas, veterans center dealing with soldiers dealing with post-traumatic stress syndrome and finally we have the

marcums, sergeant tom and april marcum. they're our wounded warrior family. we thought it was important to meet up front close and personal people who have dealt with these issues. the marcums have had a long and difficult journey through the bureaucracy. sergeant marcum was injured, he had brain, hearing, and cognitive deficits, conic mygames and short-term memory loss his wife and caregiver is going to speak with the family and she's going to talk about their experiences getting snarled in red tape and finally getting adequate red tape for tom and how his injuries have impacted not just him and their marriage but their entire family and their children. so i'd like to get started by going first to rank and we'll ask general adkins if he would like to talk programs what he's in charge of in maryland and what they're offering and then we're going to go to everybody, as i said, we're going to go to everybody. they're going to talk and i'm

going to ask some questions and you get to ask some questions so i'm going to sit down and introduce general adkins. >> the rank doesn't work at my house and i want to thank moaa and the naval institute for hosting this great event. i happened to be life members of both the organizations and let me say what's an army guy being part of the naval institute. i'm in maryland. the naval academy is there and four naval academy congratulations have held my job at one point in maryland's history. so a little bit of information there. i come to the position of adjutant general out of rhythm and after having served as the secretary of veterans affairs from 2003 to 2009 and i tell you it brings a great perspective of dealing with the veterans of our nation's greatest generation, korea, vietnam, desert storm and to see the young men and women and some not so young that serve

today. i was recently in iraq. you know, we have 6500 troops in maryland and i tell you that the generation of service members today stands as tall as any generation that has ever gone before. so our nation should be extremely proud of their service to this nation. you know, we've been at war for a decade using the guard and reserve at a level not seen since world war ii. tens of thousands of marylanders have served in combat and continue to do that. there are a lot of lessons learned from our past that i think we maybe have not used. we need to capture the lessons we are learning now as we build systems for the future and i would recommend the greatest generation comes home, this book, that i read as a secretary of veterans affairs to identify issues faced by returning veterans. some of you may know that general omar bradley was the

first director of the va and he was quoted right after world war ii saying it's a vast dehumanized bureaucracy meshed in red tape and how far have we come after the 60 some years after world war ii. another interesting quote from general bradley was, you know, looking at the va system after world war ii was that it was a world war ii load on a world war i chassis. in other words, the systems supporting the va, the veterans was not sufficient for those world war ii veterans coming home. and i think as late as last week, in a senior army meeting i heard an army four star make the comment that we are operating now on that world war ii system. and we've been kind over the last 10 years trying to build a system like working on a car,

building a car, maintaining a car and repairing a car as it goes down the road at 65 miles an hour. so i think that there are lots of lessons learned. and one last quote from general bradley, as we look out at our nation, is that the problems of our veterans cannot be solved by washington alone. those problems are solved as they rub shoulders with their neighbors and where the friction occurs in the communities as they return home. there is a tremendous cost of war and as we apply military power we must never lose sight of that cost and it's not just fuel, bullets, those who make the ultimate sacrifice. those who can continue on for decades to bear the wounds of war. and i think these wars that we're in now for the next five, seven decades our nation will be dealing with issues related to

these wars. and i tell you that because when the war came out, the ken burns film, i was in a room with a bunch of world war ii veterans at the premier of that film, and post-traumatic stress that came out in those veterans after decades of not having issues, and i've seen it with individuals that i've served with. came out of vietnam, extremely strong individuals and as they get older, that post-traumatic stress comes to be. so, you know, we need -- our focus is that the war is not over as it was in world war i where they got out and got discharged and were given $30 and a train ticket to go home. the war is not over until the individuals are fully integrated with their family and friends in their communities, back at work or on the college campuses. so i think that -- i guess we need to prepare for the next

war. we need to look at our systems now to identify those lessons learned and work on building that system that's going to support the needs of the nation for our veterans in the future. thank you. [applause] >> thank you, general adkins. i would like to turn to tom bowers who's in new york listening to those bankers. >> can you hear me okay. i would like to point out the general is using the ipad and we're switching to the marine using a pad of paper with crayon and definitely there will be different things that we discuss. on a good note, as was set i've always been in the marine corps reserves. it's something i'm very proud of. i will always consider myself a marine and it wasn't until just may that i completely dropped off. i have about a year to decide if

i want to go back so on day 364, they're probably going to be getting a phone call from me. but during that time i did four tours. i had the honor of serving with multiple battalions and most recently returned from afghanistan. it was in between my tours that i was serving as a veterans advocate for the iraq and afghanistan veterans of america. what better job for someone serving in the military? we are seeing the resources that are available. you're seeing the benefits that are provided. you're understanding what the issues are at hand and making sure to focus on yourself. but i was not. it was something that i did not handle correctly looking back on it. and i'm trying to pinpoint the reason why. if i knew all these resources were available, why did it take me until last month to finally step foot into the va and say, wow, it's time to start taking care of todd? it took a very long time for me to really soak these things in and to understand while i'm so

busy doing what the military did a great job of teaching me which is taking care of others, i wasn't taking care of myself. it's something that was noble in the military but also something that is a detriment to the individuals themselves. so even though now i wear a tie and i do all this other stuff, i'm still a veteran reintegrating. as i went through the four different levels of it. a.p.s., i saw transition assistance program change over the years. sometimes for better, sometimes for worse and it was made very clear, hey, you just got home from war. you are different. it's time to start taking care of yourselves. and what did all of us do? we took the death by pamphlets, we put it in a bag and we stepped away and we don't focused on it and the general is exactly correct and it takes years for these things to start manifesting and you're questioning why you're not sleeping correctly and why am i having a tough time getting along with my friends? it was literally two months ago where sort of all these things came together at just the right time. i look back on it as a blessing

but social issues combined with work issues combined with marine corps issues -- they all sort of piled up onto me and it wasn't until i made that call and called the vet center which i'm very excited that we're going to hear from someone from a vet center here today that i said, i really need some help, can you help me out and the va was there in a heartbeat and they were providing outstanding services and they took me under their wing and got me all squared away and i convey this now publicly to a lot of the service members i deployed with because that simple step, that small piece of communication, on the battlefield we learn that communication is the key. you've got to communicate as well. if you're on the radio and you're just hearing message traffic and you don't ever respond, then you're not accomplishing your mission. and that's very hard for some folks to step up and do, myself included. and having made those changes now, i realized that life turned around. all of a sudden i got a big fancy banker job now. i have to wear these things. they're called ties. i thought they were fabric belts of some sort for a while. and when i look at these things

and the capacity that i'm in now working on philanthropic giving specifically for -- i don't know, jpmorgan chase is apparently a big company of some sort. focusing on their philanthropic giving, something that has been said to me by many folks is that, you know, we need to focus -- and you mentioned it, too, general, that the sea of good will that is out there is what we're going to rely on for service members as they come back. this is not a job that dod and the va can handle on their own and we're going to be looking into the future at that outreach. what are the tools that we can use to get to these folks to say, hey, it's time to make sure you're taking care of yourselves. it's the community level organizations that are able to reach out to these folks as they reintegrate and become civilians. they're the ones who will be able to communicate and say are you stepping into the va? are you having difficulties with housing? va has programs for that. that communication is going to be critical to move forward. and i have to applaud the va right now because they made some amazing steps in doing their outreach for the younger generation of service members.

they're on facebook. they're on twitter. they're on multiple levels of social media really doing the best that they can from the mother ship here in washington, d.c. to reach out to these vets and the places where they are which is online. i was revoked about the crayon and the ipads but in all honesty i have a smart phone in my pocket right now where i know if i need to go through some counseling or something of that nature, it's a couple buttons away. and it's just making sure that i know it's available to be able to step into that. so going forward, you know, one of the things that i think we're really going to have to focus on is that every service member is different. everybody reacts differently when they come home. we can't just do a blanket powerpoint presentation to deal with these folks when they come back. i'm a young, single, somewhat stupid, you know, combat marine. i'm very different than some of my other friends, you know? and so understanding how to communicate with these folks is really going to be critical and i look forward to seeing how it goes forward. thank you very much. mraus mra[applause]

>> thank you, todd. and now we're going to turn to nicole keesee who is somebody who is familiar with all those programs at the local level. nicole is a colonel in the reserves and she's head of the va and vet centers in little rock, arkansas. nicole. >> good morning. i want to thank the doctor of the va for letting me be here today and my boss lou ann engel who's also actually a retired social worker in the army reserves -- or actually, army, i'm sorry. it's something to come be prepared to talk about something and you find you're going to talk about another. but all the ladies in the audience who heard single, that are single, he's your guy, right? [laughter] >> and i just want to interject and i'm married to a banker. they have good jobs. he's not only cute and eligible but he's probably a good catch.

>> my number is on the back of the pamphlet. [laughter] >> he said he used crayons, i used pen and a pad. that's army. in order to understand the context of the situation we're dealing with regarding our returning or transitioning service members, we got to remember the differences between the military and the civilian culture. and i just want to point some of those out. in the military it's a faster pace although anybody in the military would dispute that if you spent in a line for any length of time but in the civilian life it's a much slower, natural kind of pace on day-to-day. there's hypervigilance. in the army or in the military, there's a fostering of aggression and paranoia. you have to be aggressive, you have to be paranoid in order to survive on a battlefield. now, hypervigilance doesn't work so well in the civilian sector.

it will get you fired. it will get you reprimanded. it will get you booted out of your house. in the military you have use of targeted aggression. well, that creates kind of a hostile environment in the home and in your workplace as well. in the military, you give and receive orders. it's an environment of obedience. it's also one of a maturity level that is somewhat different than in the military and it's more inclusive. in the civilian serb, though, you make decisions. you have to engage in critical thinking all the time. in the military you foster teamwork and interdependence. and if you could understand -- those of you who aren't been in the military will have a hard time understanding this but there's a symbiosis that happens to people who enter the military. we go from being an i to a we. and when we transition back to

the civilian sector going from that we to an i has incredible psychological ramifications. interdependence in the military, independence and self-sufficiency in the civilian sector. we answer to a chain of command. there's no chain of command in the civilian side except you include your spouse. that might be your chain of command. in the military, it's a very closed system. and that's very evident if anybody's tried to find or access an army reserve unit. where are they? how in the hell can you get into them? in the civilian, it's a very open system. and lastly, that i want to point out, in the military there's -- they foster emotional stoicism, okay? you have to be tough. you have to put your best face forward. whereas, in the civilian sector you require -- it requires emotional investment, emotional

relationships. so what are the challenges we face? it's difficult for the military to provide community support. especially if you're outside of a military installation. there's fewer, clearer pathways to assistance and information. when a person goes from the military to the civilian world, there may be an increase or a decrease in respect one is given. you know, think of being a 21-year-old squad leader who get out of the military and does not have a job. that's a real shift -- it's a real shift in the mindset that's really hard to get your head around. there's a lack of knowledge of benefits to the reserve component. a lot of people hear, well, i don't know what the reserve has. i only know what the active component has. and there's a big difference between reserve component

benefits and active duty benefits. and there's constantly changing military and veteran policies and benefits. i know that every veteran that i see that walks through the vet center doors, i have to know them individually. i have to know when they served, where they served. i mean, there's so much i have to know about them on an individual basis to even begin to understand what their benefits are. not everyone has the same transition challenges or at the same time as it was pointed out. there are changes in significant relationships. i mean, how many people do you know on the civilian side undergo the tremendous relationship stresses that our military members go through? there's feelings of being left behind when you transition out of the military. and also we forget that in the

civilian sector, people have a limited capacity to listen. it's hard for others to listen to another person's story because they're all caught up in their own life. reserve components they have family readiness groups but they're geographically dispersed and many of them don't have the same understanding of the military culture and command structure. you have to understand before -- before this war started, you can have reserve folks that were in the military for 20 years and retire and they would tell their spouses that they didn't even get a paycheck for going to reserve duty. it was one of those guy things, you know? websites are hard to navigate and they give the impression that they don't care. there's difficulty getting benefits because you don't know where to go. you don't know what to do. again, this death by powerpoint, the death by brochure, nobody

listens. their minds are elsewhere. and they won't -- it's hard to really reach out. we can have a discussion about that but there's probably a lot of factors that lend to that. there's a variance of policies and procedures among active duty components and the services and with veterans. one big example is for a reserve component at least in the army reserves you have to have a line of duty in order to get your military health care needs taken care of, if they're related to the military. if you don't have that line of duty, you got to pay for it out-of-pocket. whereas, the active component does not need a line of duty. and believe me, not everybody knows how to fill out a line of duty. what works for the rc during peacetime does not work during wartime. soldiers that transition, service members face feelings of

isolation, disconnection, confusion, frustration, anger. isolation is a killer. fort hood is a really good example of how the installation really rallied around a very traumatic event that occurred. but ask the reserve components that were stationed there. ask the family members of the reserve components that were stationed there and how much rallying was around them? health care skipping, when you go from active -- when you go from reserve to civilian to reserve to active duty back to -- i mean, it gets really confusing on who do i go to for what? and who's going to cover what? now, the va has a wonderful 5-year health care program but not everybody wants to go to the va. and there's also the challenge of being dual statused. am i a reserve member? am i a veteran?

and actually you're both. and outreach, outreach is a big issue. more later about that, i guess. in order to successfully transition, service members have to have a strong sense of community. they have to have meaningful employment. they have to have a strong healthy sense of self and they have to have support. i'll say it again. isolation is a killer. solutions, everybody needs a readjustment plan. why aren't we providing transitioning service members readjustment planning? we have t.a.p.s. we have some other things but who sits down and just sits, you know, ask people face-to-face, where are you going? what are you doing? what are your plans? do you know about your benefits? all too often, service members are told go to the va. well, where is the va in my

community? and when you get to the va, where do i go? as good as it is, we still need to do better regarding navigation of these systems. it's best to help those of us who are veterans, we are, i think, are the ones that are best to help our veterans. one thing about the vet center staff over 72% of the vet center staff are veterans. 47% are combat veterans. 31% are g-wat veterans. 42% are women. big brother-type programs might help out, too. i know -- i know canada has a wonderful veteran program, a kind of peer-to-peer where they actually train their older veterans, give them two weeks training that they can mentor

young veterans that are coming off military service. we need to expand the concept of team concept. we need to expand support systems. and we need to foster relationships with veteran-owned businesses. mental health services for service members and veterans and not family members is not effective. we have to try more to provide services to family members. we need to make our systems and processes easier. most of all, we need to make sure that every service member, whether in the service or as a veteran are welcomed, respected, and are given the respect of privacy and our continued gratitude for their sacrifices. the programs are very unknown. we get a lot of calls asking about how to care for dogs and cats and at least several times

during the day. but i am one of a staff of six little rock vet center we provide counseling services to most of the state of arkansas and anybody who's from arkansas realizes that it's a very rural state. we have areas in arkansas that are very underserviced and we do have veterans in these underserviced areas. vet centers were established in 1979 thanks to max klingon and we were specifically established to provide readjustment counseling to veterans thanks to our vietnam veterans. they really spearheaded this program because they stopped going to the va because of the treatment they were getting. we're community-based. we're safe. we've grown from 187 to 232. we have 50 mobile vet centers out there that will go where they're needed. and i got to wrap it up and we have -- anyways, i'll be happy to talk more about vet center

services. thank you. [applause] >> thank you, nicole. and now we're going to turn to dr. david brown, who is with the office of the secretary of defense where he's an expert on suicide prevention, recovery, and reintegration but before that, he was the lead in the department of defense for recovery care in the support centers of excellence. dr. brown? >> thank you, kt. i'm going to -- i'm former army and i'm going to lean into the general here. i feel comfortable doing it if you don't mind, sir. we offered up our seats and we didn't think about the mics. i'd like just to take a minute or two to speak about help-seeking centers and have conversation in that direction. prior to coming to dc i was overseas for 15 years. i was lead psychologist in bavaria, over seven bases there treating people, you know, the whole slew of when you have a from being in the military. part of that grass is green on the other side issue has come

in. all of my career was very active duty-centric and what we would hear with the guard and reserves things work much better because once they deploy they go home and they're back with their families and all of their support. whereas, when you're overseas active duty you don't have a lot of those support networks that we have set in place here. since shifting over, i'm now in a nonclinical role i learned that is not the case for many individuals so i'll highlight a couple of areas with regards to care for caregiver, well-being and employment. before doing that, what i want to do is speak briefly on a program we created in europe called soldier 360. and what this was about to help -- help-seeking behavior and trying to bring treatment to individuals who were let's say maybe resistant to seeking that out. when i was active duty and was deployed, i was in a tent sleeping 12 inches from, you know, the next individual. and you knew who got letters

from home, who didn't, who was sleeping, who was eating. when you go back from deployment, many times they stick behavior health in the back corner of a base and no one can really find us. so with that said what we decide was at soldier 360 let's create this program where it's invite-only. the best and the brightest and you're hand-selected from your company commander or battalion commander. we had these individuals who were screened who did not meet any criteria for treatment and lo and behold we start to realized that this was somewhat about a trojan horse that four hours of sleep is not sufficient contrary to what their first sergeant told them. we had folks who would eat -- i kid you not would eat skittles or mountain dew for a week or two in the striker because it was a funny thing to do and then they realized, i'm kind of impulsive and irritable. [laughter] >> so the course that they went through you received three college credits for this course

by the way and we had a lot of great success with this. this encouraged us then with reaching out in bavaria now for the army they embed providers in primary care. they embed providers in the units. they embed providers in the school systems and we're seeing great benefit in that. with regards to the help-seeking behavior i recalled there was a time over at the wtu and we were encouraging folks with this help seek behavior and using a component that we used in soldier 360 which was humor. we went off to the herbie benson medical center and we learned the benefit of having a one hour instruction in humor. and i go to wtu and try using humor with the wtu folks and there was one gentleman, i recall, who lost a portion of his foot and after we really got going, this guy was cracking us all up and he said it's been almost nine months and i forgot how to laugh and i forgot the

things i used i used to do. you remember the dean martin roast. you were talking vietnam and i'm trying to relate here. [laughter] >> so do you remember the dean martin roast? this guy had us going, and he says, you know, doc, he says i may have lost a portion of my foot but i still have my hair. and he says, you know, you can go seek help for that. and he just had us going. and, you know, taking some of this -- these insights and opportunities i've had to learn from others and coming here in a nonclinical position, it's interesting. i was presenting on polytrauma at the national institutes of health and we really were focusing quite a bit on care for the caregiver. and the fact that, you know, we're just hearing here many times we focus on the other and we don't focus on ourselves. this is a focus from polytrauma, i think it's important for all of us to really take time and look at ourselves. we're taught not to. we're taught about selfless

service, loyalty, duty and i think it's a big challenge that we're now going counter to our culture with that. well-being, we've been focusing quite a bit on well-being. those of you who aren't familiar with the gallup studies there's a lot of studies on well-being but gallup when you look at national guard and reserves, the active duty folks -- when they return they still have a job. guard and reserves, when they come home, they might not. and to show you how important well-being is and employment -- employment that is, the gallup studies focused on employment and have noted that your well-being recovers faster from death of a loved one over a course of a year than it does from prolonged unemployment and it's something to really think about and what's wonderful for moya and unsi and today is a special day but they bring employers, they bring the businesses. they bring all those other components in which is rather important.

lastly, i wanted to just shift to one more lesson learned. if you're not familiar with the work of thomas joiner the psychologist. he speaks about suicide and he speaks about two components in particular. a sense of belonging and a sense of burdensome. and i had a soldier who was released from a suicide attempt and i sat down with him and i went over the paperwork and i had an idea what he was going to today. with we release you from the hospital we screen you to make sure you're okay before we reintegrate you into your unit and i want can you please give me a heads up, you know, on what brings you here. and he said, i killed a soldier. and i'm thinking oh, my goodness is this going to be a sanity board? i wasn't prepared for him when he said that and i thought perhaps there's a mishap with the paperwork. so i said can you tell me more? and he said everyone had a chance to take a break during the deployment. when the first sergeant came to me and he said i'm pulling you from the mission and i'm putting

in a substitute, that substitute died as a result of an ied. and i killed the soldier so he's carrying this guilt from him. this is from his first deployment. he's now returned from his third deployment at this time and it's still eating at him. and he had a new spouse. and before he left, the primary concern was family planning. and she said, you know, when you come back, we'll work on a family. well, that wasn't working. not to change the topic here too much but i've shared this story. she could see in the morning it looks like in the morning but when she tries to engage it's not working. he's still down range. and yeah, i brought this information to the soldier 360 program and said any of you guys experiencing this? these are guys in their 20s, you know, upper 20s young 30s and 7% of the soldiers had reported, yeah, i thought that was kind of normal. i didn't ask them a show of hands just to write on a piece

of paper yes or no if you're experiencing this. so the gentleman shared with me back to the suicide attempt i failed my team down range and now i failed my wife i'm a burden and i don't belonged and that's when he attempted suicide. not to leave you on a somber tone here. there is a positive side here to the story. after going through treatment, doing rather well, they are now -- well, they are stationed locally and they have three children so he's going well. i swear the wife looked at me like i'm going to kill you. [laughter] >> so, yeah, with regards to help-seeking behavior i think it's rather important. i think it's good that we focus on that. and what we do when we reintegrate back to society. so thank you for your time. [applause] >> thank you, doctor. i'd like to now turn to the white house and lieutenant colonel rod lewis, rodney lewis.

this administration has seem to come in and they have a particular interest in not forgetting our military families. would you like to talk to us about the joining families program that you have at the white house? >> absolutely, kt. first of all, for the u.s. and i and moya thank you very much for having me here today. it's a privilege and an honor to be here on this panel and to speak to you and have a conversation. i'd be remiss if i didn't say the executive director of joining forces, captain brad cooper would love to be here. unfortunately, his schedule didn't allow. so you get the second team. as you get to know me a little bit better i think -- i think that's me. i'm an active duty air force officer. lieutenant colonel graduated commander and in the spirit of best practices, i do have my crayon, my pad and paper and my ipad. [laughter] >> so, you know, us air force guys, we're always prepared. but in all seriousness, i've

been in this job and i've seen some amazing things in terms of watching not only our government but the private industry all galvanized to come behind what we all know that's a force that's been fighting over a decade. and the first lady recognizes that as well. as kt had mentioned earlier, you know, 1% of the individuals are out there serving our country. and i think the stat that she put up that only 10% know of a service member. well, the first lady is trying reach the other 90%. that's what joining forces is. it is an awareness campaign. traditionally the east wing is not the policy side of the white house. that falls within the west wing and it falls within all of those agencies that the va, the dod and it's a unique privilege for me to be on the east wing to

watch the first lady really try to bring a nation up to speed in terms of awareness. so that's what joining forces is. after many conversations, the first lady had traveled around and seen many military members and specifically talking to spouses. you heard a recurring theme. these are places and areas where we need help. these are places where you can help us as a first lady. and the pinnacle point of that really rested up on three pillars, the employment piece. you know, as transitioning members meet at jobs, that was something that the first lady and dr. biden heard a tremendous amount. so that is one of the pillars. the second pillar, education. and to kind of go back briefly to the employment piece. what she heard was the fact that military members were ecsing,

changing locations so much that the spouses were being left out. now, a personal story, i've had five different assignments in seven years. so my spouse who is a college graduate, has a master's degree. the last location we left she had a wonderful job but when she transitioned to the next location she couldn't take that job with her, those are issues that the first lady had heard. and those are issues that dr. biden had heard. and that's where, you know, the employment piece really came in. not only for spouses but, obviously, for veterans transitioning out of the military as well. so it's been nice to watch this come together with agencies really focused on a specific task. education. there are issues that can be there when military families pcs. you know, using my example i don't have high school children

but imagine if you will five different locations in seven years, the transportability of records, the transportability of just having a consistent education base. my parents, when i grow up my dad had a job and he was really proud to have his 35 years in working for the state of oklahoma. i lived in one house. i had the same friends. i had the same teachers. i knew the school that i was going to before i went to them. so it's a different environment. so education in terms of military families, that's an important piece that we are working towards trying to improvement with great agencies like the national math and science initiatives with the initiative of military families who do advanced placement courses for specifically military schools or schools that support military members. and then finally the third piece was wellness. that was an area where the first lady and dr. biden really saw a

need when they were talking to the spouses, military members -- so the way i like to think of it is a tripod. employment, education, and wellness. and like any good tripod, if one of those legs is broken, it's not going to stand. so joining forces is a program and you can go to that joiningforce.gov to learn a little bit more about that. ..

>> challenges that our military and their families face. but there's one family i really think we should spend time listening to, and that's the marcos. sergeant tom marcum and his wife april marcum are sitting in the middle. april will speak on behalf of the family, and i spoke to her, have spoken to her several times and i was particularly moved by, first of all what an amazing the courageous lady she is. and by her husband who i think is not atypical of the military man and women who have injuries and their reluctance to admit they have a problem. and then finally, the difficulties they had in navigating the system.

april, you have a statement. i would love for you to read it. >> as i look around i see it as, i have mine typed up, double spaced because i am a teacher. [laughter] tom and i came here today to share our story with you not necessary to bring attention to us but to help the men and women who are in the road right now where we were two or three years ago. so this is our story. my husband deploy for iraq in january 2008. i had the usual worries of any spouse. how long is he going to be gone this time? how will i keep up with working full-time, parenting our children and the demands of running a household? this was not our first deployment so i did what thousands of military spouses do every day, i dug in, i did what i had to do. so when i received the phone

call from my husband saying he had been working on a mobile armory when a mortar exploded 35 yards away from him, my first thoughts were oh, my god, are you okay? he downplayed the extent of his interest to me and told me he was fine, i'm fine. he said he had a bad headache and his ears were ringing but the medics told him to take it easy for a few days and rest and he would be fine. when he came home a few weeks later after spending nine months in iraq, it was easy to see that not everything was fine. he still had the same headache. he was confused at simple things. he had short-term memory loss. the last straw for me was the day he called me on his way home from work, a base we have been stationed at for three years at that point, six miles from her home, and said i care in her how to get home. i major we call the doctor. the local medical community including the air force medical clinic doctor seemed to be reluctant to help.

tom's primary care doctor thought tom was trying to get out of work. this felt like a slap in the face to both of us because he served for almost 15 years active duty with never complaining of multiple deployments, or shin splints or anything. then the doctor made this statement, i'll write you a prescription for motrin but you really need to suck it up and go back to work. after that we both felt like there should be somewhere for us to go to get the medical help that tom needed so we made an appointment with a medical group commander, and in his primary doctor asked about an appointment decided time should probably go to a medical evaluation. this process was long and overwhelming. but my husband finally ended up at a polytrauma unit in tampa, florida, at a va medical center. where he received outstanding medical treatment. the medical team found that tom had a traumatic brain injury caused by an orbital blowout fracture behind his right eye. his right shoulder need to be

surgically repaired. he was diagnosed with hearing loss and vision deficit. they also suggested he be further evaluated for ptsd. at the time has been went to this hospital, the polytrauma unit, it had been over a year since he had been home from ir iraq. in may 2010 the air force placed on temporary disability retirement list status, which is also called tdrl. and told us he would be reevaluated every six months to find out what you're going to be with him. over a year later, in 2011, tom and i had to travel to san antonio, texas, from our home in south georgia. we paid for the entire trip, out of her own pocket and had to wait for the air force to reimburse us. the total for that trip was over $750, more than our mortgage payment. we have yet to hear the

determination of what they're ultimately going to do with tom. as of now we traveled over two hours one way to get to a va medical center that has the right sort of medical personnel to treat tom's injuries. we do have an amazing, caring team of professionals that we work with at the va. i would love to name them all by name, but i will just say that his primary care doctor is amazing. his urologist has been instrumental in his care. he has a psychologist that understands him and does not take his crap. [laughter] we have an oif nurse case manager who has been helpful in getting us the appointment we need and not making us travel more than the two and half hours we already travel. in this we are truly blessed. the challenges over the last three years have been many, and not only have we had to get used to renew normal in our own, because of tom's cognitive and emotional deficit, but our

family has shouldered the burden in other ways. by waiting for his va rating, because tom was placed into tdrl status with no joint rating when he left the air force, we were in a financial crisis. not only to have to quit my job to care for tom, get a significant pay cut as well and were forced to dip into our life savings. i made 2011 it was gone. our youngest son was diagnosed with secondary ptsd. he began to act out at school and at home and had to have -- had terrible nightmares. i myself felt oppressed. it seemed like the weight of the world was on my shoulders and i had no one there to help. i had to take care of my husband and my children, and try to figure out how i was going to pay the mortgage all at the same time. but not everything that has happened to us during this time has been negative. we have grown closer as a family and my children have matured under stress and are going --

going into finding. we have met some amazing people and made lifelong friends that we have never would've met otherwise, and some of them are in this room today. it may seem strange that i am thankful for the trials in life. and am i saying i am glad this happened to my husband? i would rather not have the old compaq? no. that we have accepted this, i have accepted this. and as a family we have accepted it. we are proud that my husband served his country well. i want to say god bless america and god bless the men and women who suffer. [applause] [applause]

>> i thank everybody in this room, everybody in this country feels that none of our veterans should ever have to go through anything like that again. and so i'm hoping to sell to anyone on the panel, you all represent various aspects of the reintegration and care community. why did this happen? what can we do to make sure it never happens again? and i'll open it up to anybody. and if nobody volunteers i will start calling on people. general, how about you? you have seen both sides of this. not only active duty and reserves but through the veterans administration and as an adjutant general of maryland. >> i wish that was the only story like that, but it's not. and i think he gets back to the system under the burden of dealing with the nation at war

for 10 years, not prepared to handle the tbi, or the post-traumatic stress. and i think it's critical as wickedly point of a point of coming out of the conflict of any violent of reduced resources that we build the system to be prepared to handle future cases like this, and to ensure that it doesn't happen again. there's a lot of work to be done. we've got to get beyond the turf battles. we've got to identify what's important in that reduced resources environment. and making sure that whatever we do, works to prevent this case, this type of situation happening again. >> anybody else? doctor, i want to ask you, you know, one of the things i think that is so upsetting is the first place they went for their primary care physician fell on deaf ears. is this white again with this

happening, is this something unusual? and how do we prevent that from happening again? >> to reiterate what the general said, unfortunately this, not to say -- you hear of this occurring, we have, when i showed up in germany they have transitioned the stryker unit out there. and i was one of the first resources to show up on my first thursday i had 17 people who were walk-ins, who were either suicide -- this was 2007 and i can't say how me other people were there to be seen. within the year i think we hired 42 new providers. of those 42, five of us were veterans. doctor guys from health affairs, principal deputy for health affairs had shared that the va did a wonderful dvd on military culture because many of these providers who come in don't understand military culture.

it's analogous to someone who has never drank alcohol in their life treating an alcoholic. because it is a different culture, to learn some of those nuances is rather important. the concern i have is i had the misfortune, or the benefit of going through eight joint commission accreditation inspection for hospitals, and it seemed with all the work that goes through to prepare a hospital for joint commission inspection, and in many of those people transition out. the next joint commission inspection happened yet the people and they said what all these documents, what are all these forms? and the disk garden. you get hit. you're not passing inspection. my concern is that we don't forget these lessons learned. as these conflicts dissipate, as we wrap things up, that we keep our infrastructure in place and we never forget.

>> one of the things, i ran for the united states in 2006 in new york and i would campaign around upstate new york where fort drum is, and i found that women would come up to me, mothers, sometimes younger women, and they would say, you know, who do i talk to? my daughter-in-law, or my son-in-law has just come back from deployment and he never used to drink and now he drinks all the time and won't get out of bed. other women would come up to me and say, you know, my daughter has come home because her husband has come back and he has anger management issues and is hitting her. and they have said to me, where should we go? i had no idea what to tell them. and i think todd, when you said you came back, you had all the pamphlets that you just tossed aside, you didn't want to read anymore stuff. once the first that somebody does when they come back? how does their family helped him to take that first step? i will throw it out to anybody. >> i'd like to add to that question. one of the things they can do is

find the nearest fed center. the reason i say that is because it's free. it's free to combat veterans. it's free to families of servicemembers that have been killed on active duty and it's free to veterans who are sexually traumatized while on active duty. we are community based, very informal. you can walking. if a counselor can't see you immediately, we will make sure you have an appointment scheduled within three days. we, we are kind of their on the front line. we are separate from the va hospital. our records are kept separately, so we have more of, we have more of a ability to be private. but we have, it's peer to peer. you know, we have a lot of veterans on staff that can relate to folks coming through the doors. we welcome veterans as they come through the door. give them a cup of coffee or something to drink, and we just make them feel at home. and it's good for style because then we can refer them to other

resources that are not only available to the va but throughout the community. >> i'd like to ask you, doctor, one of the things that seemed to come up time and time again is the idea that if you're in the military, you are the kind of person who'd does suck it up, doesn't complain and particularly if there our psychological issues. is there any way to convince people are convinced their families, you know, what should families look for when someone comes home? how do you change that mentality of somebody who, as the general said, somebody who fights and has the certain characteristics and then comes back to the united states and needs to have different characteristics to reintegrate? >> as a clinician, i got a lot of mileage out of asking people to bring their spouses and. many times were not the best keeper of her own records. i brought this up last year at the defense forum. and i can't say how may times i had a spouse can mean, i'm asking the service member, have

you experience this, have you expressed that? know, everything is fine. then the wife recall you can't recall your mother's phone number or your having not mothers. -- you are having nightmares. a large concentration of world war ii and korean war veterans in vietnam, and i mentioned this about people coming back and wanted to return where they were and he changed. our society is much different nowadays, even to those world war ii vets work greeted with praise they were not necessary greeted with treatment. one lady came up to me and said every fourth of july my husband doesn't engage in fourth of july. he used to drink too much on fourth of july and he would have nightmares and mumble in german. we are from des moines, you know? and you can start to see that there are cultures that really met criteria for these diagnoses. and they didn't have the

opportunity. so i think a community outreach peer-to-peer programs. we've got tremendous programs out there. last count i heard there was over, at the peak, 500 different resilient programs. i think we are learning lessons and doing well, doing better, but there's still a ways to go. >> top, why don't you add to that as a former marine? >> creativity for the spouses pay for them to understand these issues that are going on, one example of a friend who works at events in who came up with an idea when these families were returning because they didn't know what the signs were and they did nothing to contact. simple concept of a piece of paper he put on the fridge that said is he not sleeping well? is he drinking too much? is he having an overall hard time? don't think twice, call us. plain and simple. for the whole family to see. for them to understand like these are the issues, and just one single line, one single

number and that was the vet center that he was employed at. it's genius. just thinking of ways around and sort of communication, how to layout for these folks like it's all right. this is normal. this is normal behavior. if i go to combat with someone and they come on the exact same person they were before combat, then there something wrong, all right? these are extreme circumstances that individuals are dealing with that it's difficult to readjust. and making it very clear for family members is really going to be key. >> i want to turn down to lieutenant -- sorry. >> one of the things that i think is important and we have hit on as well is that aspect of not only should it be the members family that understand that, but a wider context in terms of the community. to raising that awareness with first responders. they may come in contact with an individual, and they need to know what to do. do we send into the va?

what services are available? so that's something that is being looked at and it's extremely important as well. on the policy side. in january the president signed it psds strengthen our military families, meeting america's commitment. and for me i think being an active duty air force member is a watershed event because every single service cabinet member signed that document. every cabinet member that i was going to look into his or her department, agencies, determine how are we doing this to go straight to it the general said. are we utilizing our resources effectively? so that was signed in january, and if you haven't read that, i think it's a document that is well worth the read on the policy side. so it's a part of government, a part of private industry as well, the community, and is deathly an education piece that

goes along with that. >> general, since you've got two stars on your shoulder, i want, and you know what it takes to a successful career in the military, is someone who comes even as active duty or former, if they admit to having any kind of psychological problems you can see like a broken arm, is that something that would be detrimental to their career, either as they integrate into the civilian world or if they stay in the military? >> no. and i think that you have to understand that we've been part of a journey for the last decade. and i have to tell you that, from experience within my own family, and i had an uncle who committed suicide after world war ii. and it did not come to me to understand the issue until i visited the behavioral health, mental health ward at walter before the doctors explain to me that the real challenges is to get them to sleep so the mind gets an opportunity to rest.

and that uncle, and we all probably have those uncles in our families, after world war ii who went to the vfw or the american legion, and a self medicated down there with that -- fellow veterans. and if that did work they get to the point of suicide. so that's the challenge we see now. and i think we are changing, we have change the culture. we have senior officers in our army come out and admit that they have issues. that's what we need to go in the future. and i think that, for example, our lieutenant governor, anthony brown, iraq war veteran came back and put a focus on making sure that we have the behavioral safety net in maryland for our returning veterans, for our guard and reserve. and the focus on families to get them to come forward and identify the issues is critical. they see them first, and to make sure that they understand that there's a place that they can

call that we are there to help. we all have to understand that there's tremendous costs to work. as i said earlier. and these are natural responses to the unnatural environment of combat. >> i think at this point it's time to open up to the audience come any questions that you might have. we have microphones set up here and here. and if you would like to ask a question, we would ask first you identify yourself, where you're from, and then if you have a specific number of the penalty would like to address, please do that as well. and i want to warn you, i'm from the world of television. we believe in sound bites, not speeches. and so if anybody -- if anybody's question is too long, it won't be for long. yes, sir, over here. >> i work for tricare. and i had a question for the colonel about the vet centers.

how often to prospective employers actually come to a vet center, or your vet center, and say they're interested in hiring a veteran? >> well, by my size i guess it you can deduce not very often. but that doesn't mean we are not working within the state and within the state employment division. and they have veteran representatives who work specifically to work with veterans. as far as employers coming to the vet center, they don't. >> i see this as an challenge to hire disabled veterans. on one of 16 veterans on my fathers side, and my wife's side of the family. and i work for the department of defense, and i reached out to hire veterans. i wish more people would. i know we have veterans to use the va bill endicott college and

university. i wonder if that would be a gateway. i think we need a gateway to help these veterans, unemployment is what, 15% and the rest of the country is nine, twice -- >> even higher when they go back to rural areas. >> and just a challenge for all of us to try to help these veterans. using the g.i. bill we can get the person to go there to the college and university career counseled office and say i'm looking to hire of that. there's a lot of national resource directory, all these things out. i hear a lot of what. i don't hear a lot of how. i guess i'm a little frustrated because i don't like veterans being unemployed. >> i think the afternoon panel will specifically address the issue that you're talking about him and we've got representatives from industry. we are talking about -- >> thank you. >> so ask it again this afternoon. >> let me just say in maryland, for example, something a simple as identifying in our job bank when a company puts a need in

there to put in their a little minuteman think i am interested in hiring a veteran. and if resumes of veterans and guard and reserve, putting another little minuteman on the resume so an employer can see that a military person, i would like to have their skills working in my organization. >> in the center, the lady in the center with the mic. >> can anybody hear me? >> let's go to the far end. yes, ma'am. at the far end. >> first of all let me say thank you for serving your country and continuing your service to our nation better stick my name is jennifer hunt, i'm a staff sergeant in the army reserve and i have to deployment under my belt so far. my question, i also work for an opposition called national resource directory, the gentleman before and he mentioned it. we have to try to connect veterans, their families and service members to over 14,000 resources nationally, and

community base to help connect veterans with the help that they need, making the reintegration and healing. so that's out there as well if anyone wants to look into that. but my specific question is that you say are often protects veterans our servicemembers when they come home, and to get their jobs back. but it seems like it would need an update to protect student veterans who might be called up in the middle of the semester, or maybe even family members who have to move several times with their service member and make jobs more affordable for the family members. i know my caa is out there but that's not always available for the spouses. can any of you speak to that, please? >> i guess let me just address a couple of those things. in maryland we had to establish an employment office within the

national guard to focus on giving individuals coming back from their tours of duty, deployment. as many of you know as adjutant general i had to sign off on the readiness of the unit before he deployed. and i get a briefing on that unit. we also have now started giving briefings on returning units in a by name listing of individuals who need employment when they get back. so we are looking, you know, 90 days out in identifying the needs and working, bringing them home is just, more important as anything or just as important. so i think that you've got a good point, there's lots of different resources that are critical. in maryland, for example, many of you serve in the military, your spouse, you got orders to move, your spouse had to quit their job. maryland change the law a few years ago to allow that spouse to get unemployment insurance. up until that point they could not get unemployment insurance

because they said it was not related to losing their job. so maryland recognized that change. and we're also looking at changing licensing in the state of maryland to make sure that those licenses are reflected, accepted as they go from state to state. that's a few examples of how we are working on that process. spent if i could just add any real quick. i've known jennifer hunt for years and she's actually a purple heart recipient, and the recently new mother of probably the cutest baby in the entire country, and she's probably one of the strongest in the advocates for service them censored in iraq and afghanistan. so if we could. [applause] >> so cal emulator for embarrassing her, but we love you. >> a nice shout out. >> i will add context to that real quickly as well. credentialing, reciprocity, those are all things that are being talked about right now. so that these key.

employment in the afternoon, but with the joint forces campaign, the first lady has been able to leverage her position with many private companies to provide job opportunities. we've teamed up with the u.s. chamber of commerce, and they decided to put on over 100 job fairs. and that's moving, you know, quite well. so there are some opportunities out there. there are places to go. i would encourage you to go to joiningforces.gov. >> okay, just? >> i'm the army wife military family advocate and executive director. i'm going to tag his -- tagteam this question because i have a feel we are going to asking about the same thing. april, you talked about your son having secondary ptsd, and your own challenges with mental health. one of the biggest concerns that i have both as a military wife

and an advocate is we are just not addressing effectively the mental health challenges facing the military families themselves. right now we really have no standing operating procedures on what happens if a family member of tens or commits suicide. with a working model that we use for the military member, but that does not, that does not apply to the family member. and another a lot of challenges around with hip and all the kind of thing but it's a huge issue out of don't think we really understand at this point with all due respect to the general, i do think that there is a stigma for reason. it's not just perception-based stigma in regards to if it's going to affect your career. we have seen it affect our husband's career, and us going to get services has had some negative blowback. so i do think there's a big perception issue that would help with education. but i also think that until that never happens people will air on the side of caution. so karen, did you want to bring

up jessica may be? >> actually mine was also to april. >> get a little closer to the mic spent mine is also to april. i was talking to young lady the other day. her husband is also tbi, 100% disabled. she went to a caregivers group at the va hospital in jacksonville and said i need help. i need to talk to somebody. and she was told, we are full up. we can't take you. we can't help you. now, i've never been so mad in my life. except with jessica and with a couple of other instances of active duty spouses who have committed suicide and were completely ignored. but what, what can we do and how do we make sure that there is enough help for the caregivers? because if you are told, we don't have room, when you are

the sole caregiver for your husband and three kids, there is something severely wrong. and i, i'm wondering, april, did you find that also or are you still sucking it up and pulled after a big girl panties and all the rest of that? >> well, it was really difficult to find the health care for my family at first in the mental health care. one, because our base that we were assigned to was very small, and the mental health unit there was allocated mostly for active duty people who have problems and needed to be seen right away. that didn't leave a whole lot of appointments for the rest of us. so i had been following with an off base provider on my own. for a while. the difficulty that came with that is because we do live in a rural area is because there's not anybody has specialized in

trained indian with family members who have gone through, not only did my husband have an injury, but the things, even if they come home with no injury, the things that they see and do and hear and smell stay with them forever. so, they are not trained to deal with what i live with on a daily basis with outbursts, or, you know, refusing to take his medication because he up and demand he's a man and he doesn't have to take his medication if he doesn't want to, you know, that sort of thing. the biggest problem i live in a rural area is not having adequate where i can fashion adequate care to providers. when it came to my sons problems, they were significant and abortion industry because they are very private. but he was behaving in a way that no little boy should behave. and there are only two mental

health providers in the town where we live that are capable of dealing with children. and when i called they told me it was a four month waiting list to be seen. i beg and i cried on the phone, and i called back the next day and the next day and the next day, and bade and told them, this is what's going on in my house every single day. and they were able to put us on a cancellation list. and luckily we didn't have to wait afford once. i think we waited about three weeks. but it was a long three weeks. so we definitely need more mental health people who are trained in dealing with ptsd, and the people that deal with the people have ptsd. because i may have ptsd from the way he acts sometimes, you know? >> speak our language. >> yes. >> i think also even if everything india the and that he

was working perfectly, and we all know it's not that we are all working to make those internal changes, i get all that. but even if is working perfectly, and we do not have the resources and the culture for that matter a lot of times. david, which you talked about, april, he said they never come home the same. that means no family is ever the same. and so what regulations do we need to change internally whether their joint ethic laws are whatever to let those organizations like some of these nonprofits that can step in and fill the gaps? i did not know about that organization until after i wrote an op-ed to the "washington post" and are sitting in the white house. that was the first time i heard about it. but we dashed what do we need to do internally, but we just need to get, they got away to connect those dots? >> doctor, is this just, we don't have enough resources to do this or is it an attitude in culture? >> it's complicated.

with that said, there are a great many resources. unfortunate a great many resources haven't been vetted. and trying to coordinate this is daunting. now, with that said as well, we are working a bit. and christy, i appreciate you bringing this up. and i've been many a conversation with general chiarelli, you will have approach of hearing him speak. he gets it. he's a phenomenal men. he really gets it. we are reaching out to all the respective services and then also the ngos and the civilian organizations, you know, to do what we have to do to bring that in. that said, i really don't have a clear answer for you on that. we are doing it. i have taken your drum and i'm beating it, in the pentagon the same as your. and the wonderful thing is there are people out there who really

understand, really care. their heart is in a. their mind is in it. their intellects matches their passion. and is just a a lot of work and i think people wash their hands and give up. so stay tuned, please. >> you to have been waiting very patiently. >> i'm going to concede to my colonel here. >> colonel jim mutter, retired between. i have first of all, i want to concur that it experienced the same thing, although my plate is nowhere near yours of the va saying the problem you have is beyond our capability to take care of, with the number of visits that you're going to have to have and the time you're going to take. you ought to go back and civilian world. you're going to have to go out in the civilian world and pay for it yourself if you don't want to have this thing going on for eight or 10 years.

but the big reason i came up here was to suggest one of the problems i think va hospitals all have, at least three that i have attended, and go into, is that i see people like my two brothers, one who served in the navy and one who served in air force, and a very good friend of mine who had two years in the marine corps, none of whom ever had an injury or scratch or anything else, all of whom served over 40 years ago. and all of whom it on, get right in front of anybody else. they get an appointment to the va listing for service, just as though they were 100% or 90% disabled. and i know the va has regulations and a prioritization

scheme of one through six or seven, as i recall. but it's not being enforced in where in the country. you know, people walk in, it least it's not being enforced in salt lake city, it's not being enforced in d.c. and it's not being enforced in indianapolis, those are the three hospitals that i have attended. free va's i have attended. so there's got to be, i know, you know, we say certainly on active duty, your sickness can't be any greater than mine, your health is no more important than mind. and as an officer, we always, it anyway, always would stand at the end of the line and just wait, or comeback after sick bay was almost over before i went back and. that you don't have that opportunity in the va hospitals. your clinician sees you and say i need to see you in another two weeks. you go out to get an appointment. well, they're filled up for the

next four months because there's all these people that are in there that have had probably little to, they're probably class five, six or seven and are taking the same spaces. they're taking all the spaces of just in chronological order. >> i want, we'll have a few minutes left. so colonel, i want to ask him is there anyone else who's waiting to ask a question, has a related question to that? >> no, but i would like -- >> well then, all right, go ahead. >> thank you. my name is sonia buschmann and i'm from san diego. from 2006-2009, we had a free reiki program for the wendy ward. i'm hearing speak explain to people what reiki is. >> it is energy work that research shows it includes heating 40-60%. it's very effective to post of extras. we are very successful. we did that for almost three years. over 500. and what i saw was before they

even got out of the military, what they got out of their bed in the hospital, we could see, i'm not a psychologist or i'm not a doctor, but we can see all the problems. and the problems with many of them, wouldn't go to see a therapist because they didn't want it into record. >> right, and we just address that and i think -- >> but what's even more, as much as we try to encourage a therapist to work with us, there was absolutely no interest on the part of the medical group. after walter reed hospital, they close down the program, fixed up the place, and then we haven't been able to get back in. >> maybe that's something that you can address, because -- >> but we are talking about the problem. the problem is before they get out of military. because we understand the problems of the va, but as a community support, how can we do it?

we are constantly told no, not -- >> we do have a solution in place. >> let's hear it. >> we do have a solution in place, and it is, in fact, the law of the land. and it was created by all the military services about two years ago, and if it is implemented with leadership oversight and accountability and data to back it up, the recovery coordination plan, and federal recovery coordination plan, and the screen to identify every series in severely injured service member, and a plan that addresses the needs of the family members also, and integrates the community assets, where the people live, we prevent that kind of thing that april our andrea or pam, or the other spouses and families, and the kids have to go through. we know how to do this.

and there is a statement that is still out there. and it is unacceptable that it takes leadership, and it takes accountability. the legislation is in place. the instructions are in place. the tools are in place, and they should not be happening anymore. >> all right. anybody want to address? >> may i piggyback on that for a second, and i knew you guys are probably saying the brain-dead guy is not talking up their son going to go ahead and talk. [laughter] i'm not quite completely brain-dead. [applause] but i think one of the big issues that i hear, and i just, i want to piggyback is, you're exactly right, ma'am. everything is put in place. i have heard from, from people in the navy, from people in the army, from the marines, from the

air force, every branch of the unit has something put in place. the problem is, they are not talking with each other. [applause] that's the problem. if the air force would talk to the army, and the army would talk to the marines, the marines would talk to the navy, the navy would talk to the air force, and if everyone would talk to each other and say, you know what, this is what everybody has, and make one big huge collaboration, this is the perfect plan. then we wouldn't have this. that's what i think. [applause] >> time, you probably said about the smartest thing anybody has said all day, thank you. [laughter] i think we have time for one more question. i will go over here. >> i was just wondering, my understanding, i served two tours in the non.

and i've got ptsd. one thing i would like to see the va do is, called the wounded platoon. you can google it and pick it up. they would show everyone working for the va, not only with their trying to help, trying to help people with ptsd but have no idea what the ptsd is. if they would show them mandatory that video, i think that would be a big help to make them understand what the guys dealing with who comes to see them. because pbs stayed about a year and it shows what happens to people who have ptsd, and who comes home with it. without care. >> well, i think we afford to have probably gotten to the end of our program. i know there are other people want to ask questions. you've all waited very patiently. can i ask the people on the panel, would you be available for a few minutes afterwards if any of you want to come and talk

to these people. you know, this is the 18 here. so if you have any questions i would say come right out afterwards. but we do have to break. if i could you summarize. i think they're a number of things that people have said. medco health is a bigger problem. we are addressing it. we've never recognized in previous conflicts whether it's in world war ii or vietnam, but we're at least identifying it but we have every long way to go. secondly, is the stigma attached to it? third would be the whole issue of families. is there support for families? people, as abel said, the caregivers are getting the care often have a lot of problems as well as a result of their wounded warriors coming home. and then tom, you probably said it best, we do have the programs out there but everybody needs to talk to each other. so thank you all very much for participating in this panel. i think we've learned a lot. i sure learned a lot. and i want to thank everyone here. doctor bowers, general atkins,

the cute single guy for anybody -- >> am i a dr. no? >> dr. brown. sorry. and the markings and lieutenant colonel from the white house. thank you so much for participating. >> tonight on road to the white house the wives of two republican presidential candidates and candidate michele bachmann. >> when a politician or sco is saying something, they're not telling you the truth. now, they may be telling you the truth but the burden should be

on them to prove it. >> he is an eagle scout, held a brief stint as editor of "mother jones" magazine, directed and produced three of the top 10 grossing documentaries of all time. and also a best selling author. his latest, is here comes trouble. sunday on in depth. your chance to call michael moore live at noon eastern on booktv on c-span2. >> now the vice chief of staff of the u.s. army, general chiarelli, talks about continue to brain research and quality health care for servicemembers. his remarks were part of a daylong discussion on the challenges were veterans face when we integrating back into civilian society. this is about 40 minutes. >> feels like i just joined yesterday. well, good afternoon.

thank you, sir. for that kind introduction. i am truly grateful for the opportunity to join you all. congressman edwards, i know you are here someplace, sir. it's great to see you, sir. this is truly a terrific for the iphone gotten some feedback. it has focused on a very important issue. and that is the reintegration of america's servicemen and servicewomen. and in particular those serving in the reserve components. as my chief of staff of the army, i deal with a wide array of programs and problems, simply stated, i'm the guy who's supposed to worry about everything. and i worry about it. and as you might imagine, i worry about a lot of different stuff. that said, there is no question that my number one priority is the health and well being of the force. the rest is important. the network, improvements made to a fleet of combat vehicles,

and other equipment, cost saving initiatives for sure, however, unlike the navy and air force, which are platform center, and i'm not in any way knocking the navy or air force. but i'm just saying they are more platform centric. the united states army is, in fact, people centric. we are a people centric force. and the rest simply won't matter if our people are not cared for properly. what i'd like to do this afternoon is to discuss a couple of challenges related to the health and well being of our soldiers, army civilians and family members there and then i will open it up for questions. i'd like to hear from you, what issues do you see from your perspective, what ideas do you have that might help us all. it is like to start the discussion by showing you a slide with three pictures. if i ask you which of these soldiers suffered an injury while serving in iraq or

afghanistan, how would you answer? the female in the middle left lost a leg, which has since been replaced with a prosthesis. the young man on the left is nate burns passionate sustained burns to more than 40% of his body and his undergone several reconstruction surgery. what about the soldier on the right? most will probably conclude he is one of the lucky ones, came home -- came home unscathed but that's not the case. the reality is this individual represents many, like him, who are suffering from the invisible wounds of posttraumatic stress and traumatic brain injury. these injuries are effecting a significant portion of our population. in fact, as of one september, 66% of our most seriously wounded soldiers were suffering from posttraumatic stress or traumatic brain injury.

i frequently refer to them as the signature wound of this war. and the fact is there are many, many others affected who are not enrolled in our army wounded warrior pro ram, or have yet to be diagnosed. we must get a handle on this. the reality is, as we continue to draw down in iraq and eventually in afghanistan, we are going to see more and more individuals return home. and stay home for more than 12-14 months. many of them dealing with physical and behavioral health injuries, including depression, anxiety, traumatic brain injury and posttraumatic stress. of course, it must also consider the possibility of the current wars will and but a requirement will still exist for large ground forces deployed to other locations around the world. i carry a chart around with me called failed assumptions chart.

it shows them numerous times over the past 10 years when you have made its options, either the war or projected, and been wrong. and i'm here to tell you we have been wrong 100% of the time. as the saying goes, expect the unexpected. we must also be prepared for a scenario where, due to an unperceived contingency requiring ground forces, demand remains high and our soldiers, many of them dealing with physical and behavioral health issues, don't have the time they desperately need to rest and recover. we need to find ways to help them as well. now, take a look at this next chart. as i mentioned, the vast majority of our wounded warriors, or wounded soldiers are suffering post of extras or traumatic brain injury. and yet, most of us don't recognize these injuries when we look at the pictures i showed you. in fact, the injuries we believe are most common, namely

amputations and burns, only represent 10%, and 2% of the population respectively. the truth is, because we cannot see these injuries affecting the brain, they don't receive the same level of focus and attention as amputations, burns, shrapnel injuries and other readily visible wounds. there is simply a bias, and i really mean that, there is a bias either conscious or subconscious where visible wounds and injuries versus those that are not visible. and i would be careful in qualifying that bias. it exists everywhere, including in the medical community. part of it i believe is lack of understanding of the theology behind these injuries. and they are, in fact, real, no getting injuries. no different than bullet wound, indication for severe burns. that is why nearly everywhere i go i give a tinker's explanation

of these injuries. i will spare you that today. [laughter] a big part of the challenge is the comorbidity of symptoms. both posttraumatic stress and traumatic brain injury, may display for example, since and including concentration problems, irritability, personality changes and memory impairment. we need to better understand how to differentiate between them and most effectively treat them. recognizing that it may be, that it may very well make matters worse if an individual is misdiagnosed. certainly, the lack of improvement or in some cases the worsening of symptoms can be incredibly frustrating for the patient and for his family members. and underline family members. another challenge we are seeing with respect to injuries of the brain is the latency of symptoms. unlike a broken leg or a shrapnel wound that is immediately apparent, and in most instances may be treated

and healed and a relatively short period of time, the latency of symptoms that is common to brain injuries often results in diagnosis and treatment. unfortunately, the period between when the injury is occurred and when it is actually diagnosed and treated properly can be fraught with related symptoms such as irritability, problems concentrating, anxiety and depression. nimh will take from the onset from whatever the element, what ever the incident is that causes post from extras here in these estates, it's 12 years until someone seeks their first treatment. 12 years. and a bunch of bad stuff happens in that 12 year interval. fortunately, many of our nation's very best and brightest men and women from academia, industry, and the medical community, nonprofit organizations, dod and government as a whole, are working tirelessly in this

important area. together over the past decade we have made tremendous progress in what has been largely uncharted territory, with the development of effective protocols that can be put in place downrange, new treatment and imaging methods, therapies, technologies and protective devices. we've also made great strides with our own ranks. among our many endeavors in recent years we've established a pain management task force and campaign plan to adopt the best practices army wide. we've issued much-needed guidance in critical areas such as all the pharmacy management and in pain management, medco, recently changed several policies regarding the number of prescription, medications and the duration from which a prescription may be considered valid or legitimate. these important changes have led to a decrease use of prescription medications,

specifically narcotics and psychotropic medicines across all. at walter reed for example, warrior transition unit your narcotic usage has decreased from over 80% to 8.5% in the last year and a half, among our wounded warriors. now, this is a good news story and we're doing our best to replicate it at other army installations. the problem is having people who are trained in alternative pain management who can work these productions. this type of challenge will help us to decrease the number of accidental overdoses, medication diversion and drug abuse. these are important elements of the army medical department's holistic pain management campaign plan. over all we've made great progress. and although i could talk for hours about the tremendous efforts by individuals and organizations, that's not to say that are areas where there are

still significant room for improvement. the reality is, we as a department and as a nation will be dealing with the symptoms and effects of these injuries for decades to come. and make no mistake, this is where your money will be spent. if you're one of those people that that's the only thing that turns you on, okay. this is where it's going to be spent. you look at those numbers, you look at 66% of my most severely wounded soldiers, traumatic brain injury and posttraumatic stress, that is where we will be spending your money. now, this should be familiar to you. we've learned many lessons coming out of vietnam. we've all seen images of veterans, penniless, homeless, living under bridges. that was sent is unacceptable. the reality is, these are not new injuries or injuries unique

to this war. they have been around since before the civil war. and we know this from research that's been done on the topic of posttraumatic stress. those of you who have not seen it, i highly encourage you to watch the hbo documentary war torn. 1861-2010. it provides an amazing account of the impact of these injuries on individuals in past wars. ..

americans have trouble facing the truth, said the event that kind of soft language to protect themselves from it and it gets worse with every generation. for some worse and it keeps getting worse. it's a condition in combat most people know about it. it's when a fighting person's nervous system has been stressed to its absolute eat-in maximum, can't take anymore input. the nervous system has snapper is about to snap. in the first world war, that condition was called shell shock simple, honest, direct language. two syllables, shellshocked. almost sounds like the guns themselves. that was 70 years ago. then the whole generation went right and the second world war came along and the very same

combat condition was called battle fatigue. for syllables now. takes a little longer to say. doesn't seem to hurt us much. fatigue is a nicer word than shock. shell shock, battle fatigue. then we have the war in korea, 1950. madison avenue is riding high by that time in the very same combat condition was called operational exhaustion. we're up to eight syllables now and that humanity has spread squeezed. operational in shawshank. sounds like something that might happen to your car. [laughter] then of course came the war in vietnam, which is only been over for about 16 or 17 years for thanks to the last of the seats around the work on i guess it's no surprise that the very same condition was called posttraumatic stress disorder. still expendables, but we've added a hyphen.

[laughter] and that pain is completely buried under chair again. posttraumatic stress disorder. i bet you if we were still calling at shellshocked, some of those vietnam veterans might've gotten the attention they needed at the time. [cheers and applause] >> you know, the person who try to educate america about battle fatigue after world war ii was none other then oddie murphy. audie murphy got hooked on a sleeping pill called pocatello and locked himself in a hotel room in texas for over a week until he could get himself off of it. he went around to veterans groups talking about what was called battle fatigue back then. he did not have a lot of success in raising awareness. not to overcome the statement that exists related to these invisible one thing to avoid the same outcome on the other side

of this work, we must continue to study and learn about raising awareness of programs to support services to ensure that men and women who selflessly serve our country are cared for properly in the event they are injured or in need of help. as the focus of this forum highlights, this is particularly important as it pertains to our reserve component soldiers. the reality is we are able to more effectively influence soldiers serving on active duty and help to mitigate the stressors affect demand. conversely if much what difficult to do so in the case of individuals not serving on active duty because as you well know, they are often geographically removed from a support network provided by military installations. they lack a ready camaraderie of fellow soldiers and oversights and hands-on assistance and chain of command insurance while serving on active duty and in many cases, these soldiers have understood or reduced access to care and services.

meanwhile, they are more vulnerable to the challenges of an adverse economy and a troubled labor market, especially for our young people. we are continuing to work this issue very, very hard and we are not going to rest until we figure out how to bridge the divide in the reserve component. we are looking for further ways to expand and reach sensibility programs and services that are positively impacting the lives of soldiers serving on active duty and their families. this is an absolute priority. that said, we recognize that the best long-term solutions are at the local level. but the citizens of our nations communities, towns and cities can support networks, colleges and universities, foundations, industry and health care groups, they are private, public faith-based civic, governmental and nongovernmental organizations whose sole desire

is to care for veterans and their families. numbers of the military to include senior leaders like me are limited by bob and what we can and cannot do with respect to supporting are promoting these organizations. we rely on others to help spread the word and rally around our soldiers, sailors, airmen, marines and coast guardsmen so when a young man or woman leaves the military and returns home to duluth, minnesota or des moines, iowa, we can be certain they will be embraced by the community and given the support needed to reintegrate back into the lives of those they left behind. i will quickly mention one final topic and i know that it up for questions or discussion. as i mentioned, after nearly a decade of war, our soldiers are feeling the effects and many will be dealing with injuries they sustained for decades to come. this clearly represents a readiness issue.

consider since january 2008 a number of soldiers in the army's disability evaluation system or des has increased 159% 250,000. the number is actually probably closer to doublecheck that or if you figure the number of soldiers who are not yet enrolled in des, but are nonetheless not deployable whether they are temporary or medical profiles. some will be giving ip four. they will get a permanent profile. they will have the profile for up to six months. they will keel and they will enter back into that portion of the service and redeployed. others will remain in the population of finite entry to des. you take 40,000 soldiers out of the act of strength in the united states army, data is one of the effects of 10 years of war. that is what happens.

1% of the population has to fight a 10 year glory. meanwhile, the average time it takes to get an active-duty soldier through the disability evaluation system is 373 days. needless to say, this is too long in the system is complex, disjointed and confusing. dod is continuing to work closely with the department of veterans affairs. along with the military services to meet needed improvements, i will tell you that i am pleased and encouraged to see the level of a location in collaboration today on a new integrated disability evaluation system for i des is not perfect but it does represent a step in the right to action as we work together to address these issues. all of them affect our readiness and we must address them accordingly, not simply as an

army or department, but i, the definition. certainly we recognize there'll be a requirement to reduce the size of our force in coming days as a worker forecasted budget cuts at the drawdown of forces in iraq and eventually in afghanistan. that said, we must make these reductions might say. whatever the size of the army, and must remain highly trained and ready. we cannot accept anything less. as i said in the start of my remarks, history has shown us to expect the unexpected. he must always be ready and prepared when called upon to meet our obligation to the american people and that is deciding when our nation worse. i appreciate the opportunity to join you. thanks to all of you for what you do each and every day and now i'll be happy to answer any questions you might have. [applause] >> thank you. questions?

carol minor, retired marine. in the penalty for lunch, we had a wanted warrior tell us he thought one of the things that needed to be done was for the services medical systems to talk to one another. they don't do that today and i know there's been a lot of dod talking to the da. that's still got some ways to go. what about services talking to each other? is there any work happening in that arena? >> well, general amos is who i started on this journey with three years ago at work in the protocols we put in place downrange. those particles affect all services. general dunford, the new act not as my partner today. i don't think the relationship between the crown forces has ever been integrated. i will tell you the air force and the navy are in fact asking us and they have participated fully in the development and implementation of the protocol

is downrange. like anything, it takes time to do those things, but i think that we are a lot further down the road in ensuring as a joint force we recognize post-roddick stressed the dramatic brain injury. but the problem, you know, like to put ourselves in beat up on ourselves. the stigma associated with these things is in civilian life. i mean, it's real. okay? and i am talking to 500 people in this room today. 400 of you get it and really believe it. another 100 sajak, but not really. some of these folks are just plain assistant. they are just plain assistant. i know that's true because a brief every formation at least in the united states army and i always know there's about 10% of the folks. it's like when he talked to reserve components. noah matter how wonderful the army is, there always be 10% who believe they are not getting what the active component guys do.

on the other side, the reserve had the problem of the component guys. it's just the way human works. and the stigma associated when you can't see that entry. you can see which techniques use the printer radek injury. we are starting -- at least i hear to be able to image changes in the rate of posttraumatic stress. but the comorbidity issues are huge. but back to your original question, i really think we've come a long way in the last three to four years and all the looking at these, but that does not say there are still folks out there who just don't believe they are real. sorry country and serve. >> retired marine. one of the things that i am

wondering is there any thought of for us coming up with some special line items to cover these costs that you're going to incur because they were going to be enormous relative to what they have been in past wars. and you still have to maintain a ready force and hardware. because that line item, no one is going to insist you reduce i wouldn't think. >> you're exactly right. i mean, we're just beginning to understand the second and third order effects of ten-year conflict. we are just beginning to understand the second and third order effects of fighting you for 10 years with the first all volunteer force we've ever fought with. there's always been volunteers in our forces, but we've never done it with all volunteers and be done with all volunteers and asked folks to do it two, three, four, five, six, even a soldier

yesterday said seven deployments. so, these are really no kidding costs that we incur. i think the absolute thing we ask this group to do is if you see anybody coming back on brain research, you raise up like a phoenix and attack them. because that is really the problem, okay? get on google and find me an article where the services are criticized for not taking proper care of folks who lost an arm or leg or land. you cannot find an article. all you find is what a wonderful job we are doing with prosthetic innovation. but every week there's an article about how we are in carrying when it comes to the treatment of posttraumatic stress and brain injury. i submit to you, we don't have a bunch of doctors saying i'm only going to take care of people who lustily chinned.

the problem is the science is still in the chair. there is no biomarker for a compassionate. i think what about a year and a half away from having a biomarker that we can get using a device not unlike what a diabetic looks at to check blood sugar to administer between two hours or 24 hours after an explosion. it'll say definitively that this individual has a concussion. do you know how huge that will be? that they have a concussion or do not have a concussion? what we need to do is to continue to push forward the research in this area and understand the brain. i believe will start doing a lot of further problems. if you are familiar with what in the key is doing in boston, i mean, she is looking at accumulation of partition in the brain and people that go through

significant concussive events like football players and boxers. that also has a tie, i think she thinks, i do want to put words in her mouth, but it could have, let's say to the dock directing and conducting research in this world, it could have a direct connection to alzheimer's. and what happens to folks with alzheimer's? so we need to be forcing everybody to continue all the research and good stuff that's been done to understand the brain. positron emission tomography and what that allows us to do in looking at concussions. i mean, put up by sligo court. the first one about brains. this is a picture using positron emission photography, rain sulfur and three in different individuals. this is part of my cantankerous explanation, but this is a no kidding injury. the brain as you look to this and i'm really getting old here, on your right is a normal brain.

20% of the energy created by your body. that's what it looks like when it's normal. okay, 15% to 25% of the energy by the body is in that brain. the brain in the center is an individual who has been comatose for five days, five days in a car accident and that is what their brain looks like. we are not missing those folks. the soldieris comatose on the battlefield. we get them to medical care. when a leftist ucla football player hurt for two minutes and 42 seconds to go in the first half on a field 100 yards long. someone told me the other day it's not 55 yards. it's 55.79. but let's just go with 55. 55-yard line with cameras and angles and everybody can luckenbach is an everybody rush out and bring him in at half-time. if he agreed to pay the second half. as a stressing out that night,

somebody comes up and says, if you have any display injuries in the morning, that was a pretty nasty hurt you to. guess what, he went in. he goes to the doctor come explains his systems. they took a picture using positron topography is up walking around and explain to not put his brain looks like. that's the problem. if that individual posts and receives his second concussion before that brain has returned to normal, the chances for cognitive impairment growing exponentially. we need to continue this kind of research so we understand more. and i would ask you well to force that point home. i guess i have time for one more question i guess. you guys have to get back to the real good food that's out there.

>> my name is andrea sawyer and i am the wife of a radically retired soldier. he was medically retired at 70% permanent nissan hundred% permanent with the va. my question to you, is there any system which will financially protect us when we are forced to be medically retired. for a lot of the, april lewis on the first panel this morning, we are put out of the military with our husbands unable to work and we have to leave our jobs and take care of them and our financial future is threatened. i mean, my husband was put out 70% permanent, which the $1300 check after four years april's husband whispered out at the same rate with a few more years in and we are having to leave our jobs, too. while we wait for the rating, we are burning through a lifetime's worth of savings, waiting for something that parody band decided on one side of the

house. what are -- we don't have any financial protections in that situation and we are at the mercy of a year system that says wait for us. is there a look at reforming that retirement wage for people who are going to be permanently, medically disabled and are going back into the workforce? >> the whole idea of ids reformed or ds reformed or evaluation reform is one that is very, very difficult for people to tackle. it is a huge issue. and i could go on for a long time, but you know, when you get a chance, but mask the congressman about des reform. [laughter] there are so many antibodies out there that believe in any form of reform is trying to take away from soldiers, the rights that they have. and somehow after tenure support the country has decided it's too expensive to do the kinds of

things we are doing. we also have a system that really rewards those individuals who don't want to get better. i mean, i have run into soldiers, okay, i will miss the soldiers who were at the military advanced training facility who said why should i rehabilitate now before i've gone through the va system? all i'm going to do is lower by disability rate. pat to me is a flawed system. it was a system in my opinion defined for world war ii army, a totally different army. not an all volunteer force and went to holistically, i think, blow the whole thing up and start all over again. that it is probably one of the most -- that is pete chiarelli speaking. boy, that one's going to get me in trouble. [laughter] i really believe it's a system that is needed to be reformed. >> right, and that i know was before the house veterans affairs committee within mental

reform. >> i do want to say, we have never worked closely with the va to try to get away from the kinds of situations that you are describing. the partnership has never been better than it is today. i am doing a video teleconference once a month with the va, my mission commander said on said on my post on my medical commanders to ensure that we are all over this. but it's a big problem. the problem is huge and there's always going to be stories like your story that need to be brought to our attention so we can see if we can't do something about it. >> and if i can piggyback on that, with the medical benefits, when we are leaving active duty because we are medically retired under military treatment facility, which then become way down the list. but then we had to transition into a va system until we have a rating we are at level six. you know, while there is

supposed to be some transitional help, we are saying that it's available to service members. is there a bigger push -- i understand the active-duty component should have priority, that when one day we are perverting one imac to duty and never get a medical retirement papers we are pushed right out and were bottom level priority -- >> i'd really like to talk to you about that. but they wondered where disability you follow my with all the other retirees? >> yes. >> let me take that one back. >> would you? great, thank you. idea back [inaudible] >> i have a few things. there's a doctorate neurologist at the university of florida and the va medical center in

gainesville is currently connect in a study on tbi and soldiers. you can google it. it is dr. david fitzgerald, anybody out there if you suspect tbi, and they are doing a study right now and really trying to work hard to make sure that these cases are brought to light. i wanted to say earlier we talked about how the military branches are not talking. my husband was placed in fort gordon. he's actually air force, but because nobody near for skin care, we didn't have any place for him to go. so he went to fort gordon and was there for three months. when he left there, he was given a form from the army has said he was medically unfit for duty. so we took it to our home base in georgia, gave it to our pcf commander and they looked at us and said, this is an army form. they wouldn't accept it.

we had to go through the whole evaluation process to the air force again air force again that we dirty done with the army. so obviously, the people talking is not happening. i would really like work to be done on that because their people down down the line whose husbands have been injured or working and they need to not go through those hospitals. >> you're right. but if there was an air force doctor if a soldier for the same thing can you take it to a soldier space and the soldier doctor would look at it and say that's an air force form. >> i agree. >> thirdly, i'd also point to point out to affirm that we talk about the wars in vietnam and korea and how we only hear about tbi and traumatic brain injury and ptsd with this war, but i'd like to remind everyone that our military has the state state aligned most effective body armor and weapons systems available. and that is why more of our

factions and family members are surviving these types of horrible incident is is because the army, the air force, marines are trying to take good care of them on the battlefield and we appreciate that. i'm so thankful my husband is alive. but when he comes back home and has these moments, i need him to be taken care of at home as well. >> well, i appreciate that. i am sorry for which you fight to go through. but i hear these stories time after time after time again and i honestly believe it relates back to the state issue. the medical issues is much stigmatized by these issues as anybody. i won't even say pts because to me worsening things. when you say that it thinks it sounds like someone really has this affliction before. and i don't believe that.

i believe posttraumatic stress is a no kidding injury. but if you were to get 10 psychiatrists and psychologists in here come the attack have maybe six or seven with me and the other 40 states general, you're nuts. and how dare you even say that when you studied as long and hard as we have. the stigma is everywhere. this throughout the service. we still have a problem. it's the rest of alien planets throughout the medical community. and that is why unlocking secrets of the brain so with no kidding empirical evidence we can point to and really understand these things is so absolutely critical. that will change so much of how this is handled today and stop folks like you from having to go through the pain you've had to go through. >> thank you, general. >> thank you. thank you, all. [applause]

>> on the road to the white house tonight, two candidates wives, and nita perry, waco texas governor, rick perry and mitt romney's wife >> "washington journal"

continues. maook, thoe back >> we are back with the two co-authors of a nedmw vote.t us thomas friedman and michael." mandelbaum. "that used to be us" call. you address the wake-up call. guest: we argue that the reason this book has a backward- looking title but a four-looking book, we had a formula for success in this country and it has gotten away from the senate fundamental way. it was to educate our people, up to whatever the level of technology is, the cotton gin or the steam shot or the computer. second was infrastructure, road, helicopters. we had the world's most open

immigration policy to attract energetic individuals. we had the most government- funded research. entrepreneurs could fall -- plucked off the flowers. that was our formula for success. it was backed hamilton and lincoln. but at the last decade, a decade that we call the terrible twos, you see the arrows pointing down on all five cylinders of tarp formula. host: you decided to write a book and a pep talk. michael mandelbaum. guest: we are on a slow decline so this is a wake-up call. we got into this but it is also, and this is where we come to the pep talk, it also offers

suggestions for how we get out of it. as tom said, we get out of it by going back to our traditions, how our values, our policies, things that we abandon or have forgotten of the last two decades. they hold the key to success in the future as they did in the past. we are optimistic, although frustrated optimist. we outlined the reason for our frustrations, but the country is doing wrong, but also the reason for our optimism. host: let me go back to this success that the united states said. the first two things you talked about sound about -- sounded like a government stimulus, that the government has to get them up and off the ground. guest: yes and no. let's start with the broad view. we did not become the world's

richest company or most powerful country by accident. we had the greatest public/private partnership in the world. we are capitalists. we believe in markets and innovation, but that is best exploited when you have the proper balance with the public's sight. when each is doing its part. i thought i was one lonely guy and did this all my own. you did not do anything at all. did you build that train station of a subway on your run? did you create that market on your room? you want to have a balance between the two. that is what we are calling for. it has gotten out of balance. we talk about education or infrastructure. we haven't $2.2 trillion deficit in and for sure to spending. we could build better schools but we do not think that education is a government

problem. we think it is of parenting problem. we think it is a teacher problem. we think it is a student problem. this actually requires collective action. does not like world war ii or pearl harbor. it is happening. pearl harbor is happening but you cannot see it. host: you start a book out carping about china. -- talking about china. they have trillions of investment compared to our deficit, and they invest in their country. some of their industries are heavily subsidized by the government. why is it so different?

guest: we compared it briefly to china for two reasons. a few of the things that china is doing are things that we ought to be doing. china is very good on infrastructure and we're not. by some estimates, we are $2.1 trillion in arrears in investing in infrastructure, and china has the can-do spirit that we used to have in the united states. but we are clear that the key to american renewal is not to imitate china. china has plenty of problems. china will not have a smooth path upward. we need to not imitate china's economic or political system but get back to our own basic values in the best features of our own system. -- and the best features of our own system. we respect what china has done but we think that that china in the uc in the united states is

really a comment on ourselves, looking at the mirror and not liking what we see. one of the themes of this book is to look in the mirror and not like everything that we say. we do need to change but not more like china. we need to be more like our own best selves. host: thomas friedman, let me get your response to this headline. their currency manipulation bill, what do you make of that? guest: i am all for taking on china whether stealing american intellectual property or manipulating its currency. remember, when they overvalue their -- when they undervalue their currency, excuse me, they are subsidizing everything that they sell to us. for 10 issues are cheaper, your computer is cheaper. we do need to keep that in mind, but they are also taking

american jobs. i just not think that is the only thing that will solve the problem. host: a lot of people calling in to you. a democratic collar in portland, oregon. -- caller in portland, oregon. caller: i heard him on another new show blaming baby boomers for being an obstacle for the american dream. i wanted to say debt i'll live with and economists -- i live with an economist to as good a forecasting things like the housing boom and what that would cause. how that would affect our economy. when you said baby boomers were a problem today, i wanted to say that i get very angry and everyone -- every time someone

blames me, a baby boomer, for causing this terrible thing. guest: let me defend, and myself. we're both baby boomers and we are very hard on ourselves, on our generation, because we have let things slide. we are the generation that has not squarely addressed the four major challenges that we see facing the country and that really forms the spine of "that used to be us." we need the boomer is what we dominate the society and economy is and we have the responsibility to face up to these challenges. things at this live on our watch but we have it within our power to deal with these challenges and we can leave a better chance at -- country for the next generation. it is up to us to deal with the consequences of globalization is and the information technology revolution. it is up to us to deal with

deficits and debt. it is up to us to deal with our pattern of energy consumption and its affect on the climate. but s a boomer, speaking as one who is just as guilty as anyone else, we cannot avoid responsibility for this slow decline. if you do not recognize our responsibility, we will not be of a change things or reverse the decline. host: that is one of the four major challenges for america in your book. adapting did globalization, adjusting to his permission technology, coping with budget deficits, and climate threats as well. guest: what they all have in common is that they all unfold gradually. they are all products of our success. we invented the i.t. revolution, we had all this consumption which created all the debt, we created of world of such fast growth. they are products of our

success. but we have faced them before. we have fixed social security, we got the deficit down, we had energy taxes. we have actually done all this before. that used to be us. the problem is that we are not doing it all. host: 8 tweet. guest: very good question. if you look at growth in china since the 2008 crisis, you see a huge spurt in this kind of debt- driven growth. one enormous here and suddenly you see this happening, you have to ask a question, how efficient you think all of that money was spent in china? i think there is real reason to be concerned that the bubble there, of which we know is in real estate and could be in

other things, but china has one advantage -- they have $3 trillion in the bank. we are driving around the world without a bumper. they have a bumper and a spare tire. they can avoid to be a little more like that and we are. guest: one of the major themes of our book is the hyper connectivity of the world. we are all much more connected than ever before, even than five years ago when he wrote "of the world is flat." if and when china is in trouble, and there is a real danger of a real estate basel, that would be bad for china but we will not escape the effect. we should not be routine for a chinese collapse. oting for chinese collapse. caller: i watch thomas friedman

on bloomberg and i kind of understand what he is saying. please do not cut me off. when it comes to the lending, the the last 30 years with the great divergence, and you depreciate the value of american citizens and property. when it comes to innovation, you have not allow people from all sectors to comment. with all of the major funds cutting people off, there's no way that anyone can bring new ideas. finally, as a millennial, 25 years old, some of you need to hold fashion retire. this is in congress and in the nectar sector. we cannot keep on living off the old ideas. it is not the 1950's and 1970's. you guys need to get over the cold war.

germany is about to save america and you're talking about what happened with hitler. guest: i am not sure that germany is about to save america but i welcome anyone who believes -- and we argue this in the book -- there is a new generation out there full of spirit and ideas, and the more they bring to the marketplace, the better. steve jobs is also a baby boomer. he still has a few good ideas. host: michael mandelbaum, another tweet. guest: a very good question and we devote a lot of attention to that in the bow. there two things that we sing aloud, and one is the political system. it is broken. the two parties are more polarized than ever before, for reasons deeply rooted for decades and cannot be fixed

easily. that means that they barely even speak to each other, let alone cooperate on the big things that we need to move the country forward. there's been a serious degradation of the political system and we do have ideas in the book for fixing it. second, our values have changed. what we emphasize is that there has been a shift from all we call the sustainable values, values for the long term, to situational values, which said basically do whatever you can get away with at the moment. that is what led to the financial crisis. there is a problem with our politics but also with our values. it is a problem with us and that's why we say we have to get back to what we used to be. we have to remember what used to be us and go back to that. host: let me read one of the critical views of the book from david from. -- frum.

guest: one of the things that everyone is looking for is the press the button, and we go back to where we were. the reason there is no press here button is because we got here by getting away from our formula for success. the only way to get back is to get back to the formula for success. education, infrastructure comic imitation, incentivize, and government-funded research. i do not know how to be more specific than that. everyone wants a simple, quick answer. we are are there going to have a hard decade or a bad century.

we're going to spend this next decade, and do what got us here, this formula for success, or we will have a bad century. there is no quick fix. there is no simple answer to this. do what we were -- getting back to the fundamentals. host: in history, when was the last time that we rolled up our sleeves and got back to work? guest: we have the example of the greatest generation in world war ii and then we sacrifice during the cold war. we understood we had a major challenge, that it was long term, and we all had to contribute and make some sacrifices in order to prevail, and we did. but at the end of the cold war, as we say, we misread our circumstances. we thought that this was a great, historic victory and it surely was. but it was also something else. he created a world in which individual americans would be and are more challenged economically than ever before.

it was not at time to roll up our sleeves and take up our shoes. it was time to redouble our efforts in education and research and infrastructure. we need to understand that we face a challenge in some ways just as great as the challenges that the greatest generation faced, but not so obvious but just as serious. guest: let me make another point that we emphasize in the book, almost half of which is about education. why is that? as mike alluded to come something has happened in the last seven years and we have not been talking about it. we went from connected to hyper connected. in different talks, we say in the book, i wrote "the world is flat" in 2004. the world spend -- has become connected. when i read that, twitter did

not exist, the cloud did not exist, clinton did not exist -- linkedin did not exist. skype was just a typo for most people. there is a camera in there, there is a camera man there, there was a cameraman there. host: we may have been in a different study of them. guest: now there is a robotic camera and someone is that a toggle state. they have outsourced. here is what has happened in the last seven years, we argue. what blue-collar workers are feeling in the 1970's and 1980's, now white-collar will feel it. we've gone from the threat of cheap labor to the threat of cheap genius. it is a huge challenge. there is only one answer,

education, infrastructure, rural and government infrastructure. it is getting back to basics. host: are you talking about high skilled immigrants? guest: anyone who wants to come here and work hard. caller: i have a question. where did you get your research -- who did you speak to chris marker to just people of the government? and now like to make a comment so do not cut me off. mr. george soros has organizations, tend to 15 different names. every time that they are on, they do not say, well, we are funded by george soros. a multi billionaire in brazil right now investing in oil.

host: betty, what are you referring to? caller: he supported obama. he funded obama for his election. host: a little bit off track. we will take the first part of it. who are your sources? guest: that is an interesting question for weast talk to some government officials, members of congress, who were leaving congress and could speak freely. guest: all of the republicans. guest: in one chapter in particular, we talk to employers and ask them, what are you looking for in an employee? we talked to a white-collar law firm. we talked to an indian outsourcing firm, a call center. we talk to dupont, and to the largest green collar firm, the u.s. army.

we talked to general martin dempsey, who is head of education for the u.s. army, and now is the head of the army and the chief military officer of united states. very interesting, because they all basically said the same thing. we're looking for people with critical skills and initiative and a good educational background. and when we find such people, we will give them an interview. we will not necessarily hired them. first, they were all looking for the same kind of thing, white- collar, blue-collar, a green collar, you have to have advanced skills. and those skills show how difficult it is going to be to get and keep good jobs and how important it is to upgrade our system of education in order to train americans and prepare them for the jobs that we need. in answer to your question, we went out and talked to people who are doing the work of america every day. " we found was surprising and i think that people will find it

interesting. guest: and just to the caller's question, this is a non-partisan vote. we do not have a candidate. we have an agenda for america. we are not funded by george soros or anybody else. we're quite self-initiated. host: jim hines as this tweet. guest: it is certainly part of it. when the cold war ended, we unleased 1 billion people just like us. our dominance would naturally not be what it was. others were going to catch up. what we want to prevent is an absolute decline. we recognize that india will rise and china will rise. they are customers and collaborators and competitors. but we want to make sure we do not have an absolute decline at

the same time. guest: if i could just add, to summon our view of this, change is inevitable. decline is not inevitable. we do not have to decline and we will not decline if we adapt successfully to the changes going on around us. and that -- we wrote this book to say what changes we need to make to make us successful adaptation. host: thomas friedman we are talking wet and michael mandelbaum, co-authors of several successful books, including this one, "that used to be us." let's talk to dorothy, a democrat in baltimore, maryland. caller: this is great. this is wonderful what you're talking about. i do not know what is wrong with people now. some people want to go back to a horse and buggies, typewriters. you're right -- we need technology. i do not see how this is

partisan. this is the future of our children and grandchildren. and obama has strive to priestess' the people. and they call them partisan. host: both of you talk about education in this book. you use the advance -- the example of singapore. what is singapore doing right in education? guest: it is waking up every morning and asking one simple question, what world we living in? we are a little question. how we take advantage of those trends? no natural resources. the import sand, ok? they have to import their sand. and yet they have a better standard of living.

a singapore economists said something that struck us. we feel every change increase in temperatures and we adjust. you live in a brick house with central heating. you're not feeling anything right now. they are so alive to what is going on with the i.t. revolution. and they take education very seriously. on any given day in singapore, trust me, they are not talking about vaccines for whatever. on any given day, the entire singapore government can be thinking about how we better teach fractions to third graders. i exaggerate. but that is what they are thinking about every day. they start their day by thinking how do i take this crowbar and stick it into the wheel of the other party and other to bollocks them up for that next cycle on c-span or cnn and. that is how we start our day.

it means you can never get optimal solutions. you only have suboptimal solutions. how long do we remain the greatest country when all we can do is produce about to pull out comes -- suboptimal outcomes? host: a headline about the protests taking place in spain, israel, india, and it quotes by 27-year-old woman saying our generation feels that voting is worthless. guest: voting is not worthless if you have the right candidate for whom to vote. we have a chapter called "shock therapy," this says that in order to get the political system on stock, we need a shot from the outside. we put forward an independent candidate with a platform of responding seriously to the challenges that we face.

but another point worth making -- we're not going to get out of this fix with one policy or congress or president or one presidential term. this is a long-term challenge. we have to understand our circumstances. we have to ask ourselves the question that tom post -- what world are we living in? we would be a lot better off at the people in that building would ask themselves that question every day. but ultimately we each use them and therefore we have to ask ourselves that question. host: margaret from connecticut. caller: all like to ask about the policy of outsourcing. i saw on cnbc a documentary on the production of the boeing streamliner -- dreamliner. a senior that in 2001, engineer warned against outsourcing up to 70% of this

project. he warned that things would not go well. it seemed that virtually everything happened as he predicted. they have several boeing upper management on the documentary. there were so many problems, they admitted damage to their reputation, they needed to build a plant costing $1 billion just to solve the problems that came along, and like a said, a lot of parts to not work out coming from some entities -- different sources around the world. there were three years behind in the production. and japanese customers weren't happy about that. they got up to a 50% discount. they all seemed to say at this policy of outsourcing to not work. it seems it could produce good american jobs in manufacturing. if a company like boeing had a problem with outsourcing, what

you think the future policy of outsourcing for corporations should be? guest: an important point and a good question. in the last decade, a lot of companies have experimented with outsourcing. some have found that it worked for them and they continue to do it. you're at all ipod is assembled in china and i do not think that that would change. other companies have discovered it has not worked as well as they wanted. they are brought those jobs back. -- they have brought those jobs back. it will not be one size fits all. but the most important question we should focus on, and i am glad that you ask it, is another big shift in the globalization, the term made in america or germany or china is really on its way out. the new term in the business world is made in the world. made in the world.

the head of the trade organization uses that. designing and here, manufacturing and in hong kong, that is over with. it is designed ever wear, made everywhere, sold everywhere. even at outsourcing is no longer -- we send it out and it comes back and, we have leapfrogged that now. it is not outsourcing. it is made everywhere, designed everywhere, sold everywhere. host: a republican from texas. caller: thank you for c-span. i am tired of being treated like a blob of goop, only good as a monthly payment. my question is, is there enough to go around for everybody? can we work together as individuals and looking out for the success of each other?

it is a waste of time to listen to some of the comments that i hear from the young people today. they are being distorted in the way that they can work together with each other. host: michael mandelbaum. guest: we need a minimal level of cooperation to do what is necessary for our prosperity. we have to arrive at a formula for deficit reduction. otherwise, that deficit will be there for life. but everyone has to sacrifice, and neither of the political parties has the proper formula. there has to be reduction in spending including some modifications to our entitlement programs, sells a security and medicare. and anyone who says that you can never touch these programs is not being serious. but at the same time, we have to find more revenue, whether by modestly increasing marginal

taxation rates, or as we believe, having wholesale tax reform and eliminate some loopholes and especially an energy tax which would the world of good. but we have to have more revenue, and anyone who says we can never raise taxes is not being serious. and in addition, and we make this especially in "that used to be us," we have to spend more money on our historical formula. we have to invest in research and development and much more in infrastructure. we need cooperation, we need compromise on this issue and other issues. and if we do not get it, we will continue our decline. host: john is in massachusetts, an independent caller. caller: no one is blaming our politicians for anything. if you talk about that

complicity of the politicians, who in this country has all these policies benefit? the rich and the corporation. the blue-collar worker and everyone else gets poorer and poorer. guest: a very poignant question and a very serious question, one we deal with in the book. i wish we had a simple answer. i wish we had a pleasant answer. one chapter talks about this world, when you have access to all of the robots and software, and not just cheap labor, but cheap genius, fall whole global curve has risen. what is average before will not return average wages them.

i now have a robot camera instead of a regular cameramen. as the caller indicated, it is putting huge stress on everybody. you might think, you are in new york times columnist. let me tell you about my life. i inherited james reston's office at the "new york times," agreed journalists. people used to come to the office back in the 1960's and said, i wonder what my seven competitors will right. and he probably knew all seven. i did the same thing. i come to the office and ask, i wonder what my 70 million competitors are going to write today. how wonder what the people on twitter are going to write. if i write about india, i come in on sunday morning, you could have in front of you the "

hindustan times," and we have but tweaked here -- we all have of our game. i wish there was an easy answer. polls are gone. in this world, there are many more opportunities and for people or entrepreneur, i can start a multinational almost overnight with almost no capital. if i have a great idea, i can go to taiwan and get a cheap manufacture, cut amazon and get distribution, and get my accountant. those are all commodities. if i have an idea, i can do that. unfortunately the down side is that we all are going to have to be a little more entrepreneurial. michael and i are fuddy-duddies. we are retiring baby boomers.

we had to find a job when we graduated from college. today they will have to invent a job. host: most of what you have written about in the past as foreign policy. had you come together and decide to write this book? how was it different from what you have done in the past? guest: we've been friends for 20 years and we talked frequently about foreign policy. but over the last couple of years, we discover that no matter the subject that our conversation began, it always came back to the condition of the united states. we concluded that the condition of the united states and the need for american renewal is the most important foreign-policy issue for the united states and the most international issue in the world. the world depends heavily on the united states. we are the 10th pole that holds up the tent of the international system. that kind of role that the

united states plays in the world, we both believe, is unprecedentedly constructed. it requires a vibrant united states in order to sustain that role. if we do not solve our problems and meet our challenges, we will not have the resources or the political will to continue our global role, which means so much for global stability and prosperity. when people say, why did you not write another book about our policy, our answer is that this book is about farm policy. host: thomas friedman, how does this differ from your past books? guest: i have never written another book with another person and i found it was quite fun. two heads are better than one. they're really help contribute to the book. we wrote it for the reasons that michael said, we discovered that america, its vigor and vitality,

are really at the biggest questions of the world today. if we do not get this right, greta, your kids will not just grow up in a different america. they will grow and a different world. we have -- we are at an important juncture right now. host: from your book. how you quantify 50%? guest: let's use a simple one that people are familiar with. the old debt and deficit fight. i'm not even sure that we reached 50% in the conclusion of that. we know what we need to do. we need some short-term

stimulus and invest in infrastructure. we could easily dip into another recession. we need the short-term stimulus. the second thing that we need is long-term spending cuts. we have made promises to the next generation we cannot keep. and if you'd do just the stimulus and not a long-term fiscal work to get our budget in balance, are you going -- i tell you what i will do with my stimulus. i will put it into gold. i will go into mattress' warehouse and buy a new mattress. i have no confidence to spend my stimulus except on cereal and milk. we need to do both together. in the long run, we also need to invest in those pillars of our success. we know that. but that, and amy dog's breakfast that came out of that budget debate. does anyone think -- they say in

the middle east that that camera was up -- a camel was a horse designed by committee. it is not going to solve our problems. host: michael mandelbaum, a member of the tea party rights in the "usa today" editorial pages that we will not back down. we were sent to washington to change the status quo. and that every federal dollar is worth fighting for. guest: we certainly need deficit reduction and spending cuts. to the extent that the tea party has put that on the national agenda, that is a good thing. the that's not the only thing we need to do. we won't be able to have a

to have aant vigorous firebrand market economy which we need for prosperity without a safety net. it will be too risky and dangerous and people will simply refuse to sustain that system, so we've got to have revenue increases and what is necessary for our future prosperity as well. i don't know representative walsh, and i haven't had a chance to read what he said, but i will respond in this way, he and all of his colleagues were sent to washington to solve the nation's problems, and their responsibility so identify their problems and find solutions to them, and so far each of the two parties has only found at best a partial solution, and that won't get it done. >> we're talking to thomas and michael mandelbaum. we're discussing their book "that used to be us." caller from cleveland, ohio?

caller: yes. i live in cleveland. i'm a 70-year-old lifetime democrat. you guys can tout your book all you want, but you missed the point in your talks this morning. the main problem is exports. we export millions and tons of raw materials, which takes minimal amount of people to get into the exports, and we import the finished products that are made by these raw materials that takes thousands and thousands and thousands of people. host: all right. so we're sending all the jobs overseas. guest: until last year we were

the world's largest manufacturing power in terms of total value of manufacturing. just in this last 12 months china leapt ahead of us. but here's the problem. china exports the same dollar value we do roughly with 110 million people and we do it with about 11 million people. so we're high-end manufacturing, but the -- we're super productive, but it's the opposite of what the caller is saying. we're designing the products here, the ipods and then we're having it assembled and manufactured abroad and there the caller has a point. how do we not just design things here but manufacture them at scale here? and that's something that will require a real strategy to do but we're not here exporting raw materials and importing the

finished product. we're importing tennis shoes and t-shirt. they are importing technology and that. host: good morning in san diego. guest: isn't it early in san diego? what are you doing up so early, honey? caller: my nights and days are turned around. anyway, we're the people on the street here, and i respect your education and what you're talking about tremendously. the problems we see here in our community, which you know, you hear about it across the country. we see people here who are unemployed, underemployed, but there's a cash flow here that's incredible. you go to the local market and you see individuals with lots of cash and they are doing a lot of the oh, housekeeping and what have you. and actually, i have a neighbor

who is renting a house out, and there's like three families living in it now. and we were offered gee, we do carpentry and this and that, and they are a wonderful family that moved in, but what we see here is we see our education in the state of california has plummeted to the bottom. we see people are pushed out of schools because of their age. they have aged out of the system. got to move them on. more children coming in. we see kids coming here from over the border, and i'm not knocking them, because they really attempt to get the education they need so that they can do for their families what the rest of us wanted to do years and years ago. host: so gloria, do you see an immigration problem? caller: i see that but also a huge welfare system that has

gotten so out of control. we just had our tax dollars driven into our little sidewalks here so people are not tumbling out into the street. host: either one of you have a comment on that? guest: i'm a native californian and i grew up when california was the golden state and the things that have happened to california over the last four decades are tragic, and one of the points we made in "that used to be us," california could be the future, the future of the whole country if we don't seriously start addressing our challenges. we have a jobs problem in our country. it's a short-term problem. we need hope to get people back to work but even as we have over 9% unemployed, we have jobs customers can't fill because they can't find people with the qualificationings for highly skilled jobs. the burden of that problem

rests on our system of education. that's why a huge part of "that used to be us" is about our system of education. because that is the key to sour economic future. one of the points we make is that we've got to trays people who are at the lowest end of the educational achievement spectrum at least to the average. because these days, if you don't have a good high school education, plus something else, vocationalnal or military or some college, you're not going to be able to make a living. that's the result of the global realization. the people the caller sees on the streets in san diego and that we see on the streets all over the country are people who don't have the education that's necessary really to survive in the 21st century, and that is a huge challenge for us. guest: unemployment for people with a college degree is significantly lower if -- education is still your best

ticket out. host: fript michigan, good morning. caller: good morning. i'm taking that book from a different perspective, "that used to be us." and we used to be our unto the lord, god, jesus, but now we've gotten away from that. you're talking about china. china is on top for a little bit. but we'll get back to christ and god. we're not going to -- because god made -- and he tears them down. so the point of "that used to be us," we used to be a godly nation. we've gotten away from that. so bank on that. guest: well, we don't really say too much about religious faith. in fact we don't say anything about it in this book, and religious faith is an important thing and important in the united states. but i would mention one old saying in which most americans

are familiar, which i think is relevant to the theme of this book and relevant to american renewel and that is god helps those who help themselves. host: the united nations meets again tie discuss the bid by palace for statehood. we're going to have live coverage of that starting at :30 a.m. eastern time in about 20 minutes. tom, i wanted to get your thoughts on what palestinians are trying to do here? guest: they want to get recognized as an independent state and use that as a over there pressure into negotiations. i don't think it's going to work. i understand their frustration, why they are doing it. if there's one thing i have learned, it's that in any of these norningses, the person who wins and gets what they want is the person who has the

israeli public on their side. because ultimately it's about israeli having to give something back. when anwar sadat got his republic on his side, he got the west bank in principle back. right now we have to look and ask the question why is -- it has to do in part with the fact that israel did withdraw from gaza and got rockets in return and the is rail annual prime minister made sweeping offer to the palestinian leader mahmoud abbas. and really didn't get a vigorous response. it has to do a little bit with netanyahu with his draw backs, in my opinion considerable, they gave them things and the

israelis only showed up at the last minute. the israeli sentiment is inin an effort. you can say netanyahu doesn't want to negotiate, but unless you can say they are really for a secure peace, i don't see anything happening. and there's a lot more israel could do, as i wrote this morning. so i think israel should do another settlements freeze. test the palace. stpwhinet what's the span of a 10-month freeze if you can bring about a peace agreement? i think nothing is going to come out of this that's good, and that's sad. host: let's go to democratic caller in michigan. caller: good morning. the reason i was calling is i

think that they need to hold these politicians accountable. let it be democrat or republicans to see what people is actually taking money from these lobbyists and selling america out. and i think that they really need to put politicians' feet to the fair to. host: let's stick to the point. michael mandelbaum. we had in the first 45 minutes, we asked viewers how to fix washington. if you think it's broken, how do you fix it? one caller said you've got to get the money out of it. lobbyists have too much information. guest: money is a problem. lobbyists are too much of a problem. these trends have gone much further than ever before. but we have to be realistic. we're never going to exclude money from politics. we do have a proposal in the next to the last chapter and

that is for an influential candidate running on the platform of radical centrism and proposinging solutions to the four major challenges we outline in "that used to be us." such a candidate would not be elected. but if that candidate did appreciably well as well has the they did in previous years, that would send a signal in the two major parties and create incentives for both parties to move to the center and it would mean that whichever candidate was elected, would have a powerful incentive to adopt some of the program of the independent candidate nord get that candidate's voters in the next presidential election. we think in short that the political system needs some shock therapy and the proposal that we make is perhaps not the only proposal, and but we think one well worth considering is an independent candidate for

president next year. >> you give me an insight sfwoof c-span program run every night. and looking at those who ran and lost but changed political history nonetheless. ross pro-, you referred to his bid in 196. george mcgovern and going back to henry clay. so fur interested in that. tune in 8:00 p.m. friday night and go to journal@c-span.org you can find a the contender's series. and next republican in kyi. caller: goofpblgt i had 10 quick questions for your guests if they don't mind. i eye agree with the potential for entrepreneurship everywhere. but the first question was when they spoke about little to no availability of capital with entrepreneurship. what's the best way to go about that? and the second question is what are the three most importantly

rules or guidelines or steps to entrepreneurship in their snn thank you. guest: well, it's a really good question. the point i was making to the caller, and we actually profile companies in the book who demonstrate this, that if you leverage global zphation i.t. now, you can actually access talent and markets and suppliers more cheaply and easier than ever, but it's not free. people that start up things have having trouble to get access to capital to grow. that's something we need really be thinking about. i would be for a tax cut on capital gains saying if you fund a successful startup, you pay no capital gains. at the same time we have to remember we cannot bail our way out of this crisis.

we have to invent our way out of this crisis ultimately. we have to invent zwhroobs make people more healthy, educated and comfortable and more scumplete host: wright today, every job requires an entrepreneur. what we can do and absolutely must do is knock down all hurdles that create disincentive for business. >> yes. guest: that's true, and we say in our book, "that used to be us" we need more regulation. we surely needed more regulation of that in our book. it cost us $12 trillion of -- in wealth but we have a huge thicket of regulations that make it hard for people who want to start new businesses and we've got prune that away, because new businesses are where the jobs are going to come from. so we have to encourage

entrepreneurship in every way we can. host: we should always start with the assumption that a politician or a ceo is saying something, they are not telling you the truth. now they may be telling you the truth, but the burden should be on them to prove it. >> editor of "mother jones" magazine directed and produced three of the top 10 grossing documentaries of all times. it also is a best-selling author whose latest a memoir is here comes trouble and sunday on and have your chance to call e-mail and tweet michael moore live at

noon eastern on booktv on c-span2. >> this is a confession in front of a large and airy important and influential audience. i have never embarked on a book about a subject that i knew all about. >> for the 11th year more than 100 authors and c-span2's booktv returned to the national mall for the national book festival. here about the latest releases from the history and biography civilian from the authors themselves on line at the c-span video library. all archived and searchable. at his it is washington your way. >> government officials say many cancer patients are not getting the care they need because of a drug shortage. health and human services and fda officials along with a panel of doctors told the house energy subcommittee on health vet drug scarcities have tripled since 2005. the hearing is just under three hours.

>> this subcommittee will come to order. the chair recognizes himself for five minutes for an opening statement. in 2005, 61 drug shortages were reported to fda. by 2010, there were 178 reported drug shortages, 132 of which involve sterile injectable drugs. so far this year, fda has continued to see an increasing number of shortages, especially those involving the older sterile injectable drugs. the shortages have involved cancer drugsdrugs, anesthetics used for patients undergoing surgery, as well as drugs needed for emergency medicine. and electrolytes needed for patients on i.d.. it appears that there are many

potential causes for these drug shortages. in some cases shortages have been caused by quality and manufacturing issues. additionally, production delays at the manufacturing level including limited production lines, for certain older drugs and difficulty in receiving raw materials and components from suppliers have caused drug shortages. many raw material suppliers also experience capacity problems at their facilities, causing delays that ripple through the drug production process. shortages can also result from a company discontinuing a particular drug. certain drugs are susceptible to shortages particularly those such as injectable drugs that require longer lead times. fda cannot compel a company to manufacture a particular drug and if there is a shortage of that drug, it cannot compel other firms to increase their capacity. further, companies are not

required to notify fda in advance of a potential drug shortage unless a company is discontinuing a sole-source. medically necessary drugs. in that case the company must inform d.a. six months in advance. drug shortages have real effects on real patients. due to shortages patients have not received the appropriate drugs for their conditions, often getting a less effective drug or a more costly substitute as a result. according to a study done by premier health care alliance of 228 hospitals retail pharmacies and other health care facilities nearly 90% of hospitals reported a drug shortage in the last half of last year that may have caused the patient safety issue, resulting in a procedures delay or cancellation required a more expensive substitute, or resulted in a pharmacist compounding a drug. i look forward to hearing from our witnesses today about their

experiences with drug shortages and burning what remedies they believe are necessary. i would like to say a special hello to richard paoletti from general hospital in my home district. it is the largest employer in the 16th congressional district and 410 of the past 13 years it has been named among the top 100 hospitals in america by thompson routers a leading source of health care intelligence. the hospital is also helping to revitalize the northwestern part of langston city through partnership with franklin and marshall college. again thank you to her witnesses and i will yield the balance of my time to congressman shimkus for mel and i. >> thank you mr. chairman and we want to welcome our folks and the two panels. obviously this is of concern. i'm a market-based conservative capitalist and whenever there is a lag in a commodity, good or

product, you have to really wonder about the demand and the supply and the available cost, because when there is limited supply and a hide demand cost should go up. that begs the question, what is constraining the market signals and producing the product that consumers need? is that insurance companies? is that government reimbursement rates? is that state medicaid provisions? that is what i will be looking out, because the bigger the government is, the more manipulative, the less stability for services to consumers, so we appreciate that and look forward to it and i yield back my time. mr. chairman, thank you. >> the chair thanks the gentleman recognize that ranking member of the subcommittee for five and is. >> thank you mr. chairman. i want to thank you for holding today's hearing on this important issue. i'm encouraged by the bipartisan

nature of this effort and thank our witnesses for joining us. today we will discuss the recent increase in drug shortages that have been the subject of numerous reports. drug shortages appear to be on the rise at an alarming rate and are threatening the supply of some of our most important medications. from lifesaving oncology drugs to antibiotics to anesthetics that get us through the most minor surgical procedures these drugs have become an important part of our health care system. patients are told their chemotherapy must be postponed because the only drug to treat their cancer is unavailable and likewise no anesthesiologist wants to begin the work day with the realization that they will have to use subpar drugs on a patient because one they normally rely on is out of stock indefinitely so we can't let this become the new norm. we have depended upon the medications on the fda's drug shortage list for years and continue to look for them for health and well-being. it is alarming that drugs that

have been around for so long would suddenly be the most difficult to keep hospitals, pharmacies and doctors offices supplied with. furthermore these drugs tend to be low cost generic which are an essential component of health care for most americans as they seek to keep their health care costs low. in this fiscal climate, having a ridley accessible supply of generic medication is a profound of importance and to that and it has been disheartening to learn that the so-called gray market would take advantage of such a dire situation to engage in price-gouging at the expense of those desperate enough to pay. so i'm hoping that we can begin today to identify the cause of the shortages and discuss solutions for replenishing our drug supply. we must address the sudden increase so that americans can continue to receive high-quality treatment at low cost and remain confident in both the pharmaceutical industry and health care providers. unfortunately companies are not currently required to report to

the fda when a shortage will be occurring. whether because of change in investment strategy or manufacturing difficulties, there is currently no policy for notification unless a company is the sole manufacturer. my colleague, representative degette, has introduced bipartisan resolution h.r. to 245 the preserving access to lifesaving medications act of 2011 and as a first step in addressing this issue. this legislation would require manufacturers to notify the fda of any actual or prospective drug shortages and i want to commend representative degette on tranmere and this effort and hope that as a result of hearing from our witnesses today, we can identify additional solutions to this growing problem. this hearing will allow us to learn more about why drug shortages are occurring, with the administration and industry are doing to address the problem and what new authorities the fda might need to prevent shortages from happening in the future. i would encourage as we are

exploring this issue in our subcommittee today, look forward to working with you chairman pitts as we get to the bottom of this issue and again thank you for having the hearing. i yield back. >> the chair recognizes the ranking member of the full committee, mr. waxman for five minutes. >> thank you chairman pitts for recognizing me and for holding this hearing. recent media and other reports indicate the drug shortages are now at an unprecedented level. indeed according to fda the number of drugs in short supply in 2010 was almost triple that of 2005. shortages affect a broad spectrum of critically important drugs including oncology drugs to treat lymphoma, leukemia, and other cancers and seizure drugs without which surgeries have to be postponed and antibiotics to

remedy life-threatening bacterial infections. without these drugs, patients lives are at risk. drug scarcity is generally affecting sterile injectable drugs. these drugs are technically difficult to make and each drug is usually manufactured by only one or a handful of reducers. if any one company develops manufacturing problems, which is not uncommon, other companies may have little excess capacity to help fill the need. with the aging of our population, the outsourcing of drug manufacturing, the increasing consolidation of drug companies and the general adoption of a just-in-time approach to drug production and distribution, this problem may be significantly worse and less immediate measures including congressional action, are taken to address its multiple causes. representative degette has introduced legislation that would be an important first step in this process. h.r. 2245 the preserving access

to lifesaving medications act of 2011 would require manufacturers to notify fda of any actual or prospective drug shortages. such advance notice would enable fda to help avoid and mitigate the shortage by both working with the manufacture and alerting hospitals and physicians of the problem. while this is an important piece of legislation that has broad bipartisan support, i don't think anyone believes it alone can solve the drug shortage problem, so i look forward to hearing from our witnesses today to better understand the causes of what is already a crisis for many patients and to find out what we in congress can do to help prevent shortages in the future. we already have been working in a bipartisan manner to learn about this very disturbing issue and i trust it will continue to work together to develop and enact legislation to help address it and address it quickly. thank you mr. chairman and i yield back my time.

>> the chair thanks the gentleman and that concludes our opening statements. our first panel of the assistant secretarsecretar y for health of hhs mr. howard koh and mr. koh you may begin your testimony. please summarize and five minutes and we will put your entire testimony in the record. >> thank you chairman pitts and distinguished members of the committee. i am dr. howard koh assistant secretary for health of the u.s. department of health and human services. i'm very pleased to be joined there by my colleague dr. sandy kweder deputy director of the office of new drugs. as you have already heard, the growing problem of drug shortages is a troubling situation and one that the department and the secretary take very seriously. this growing trend has a potential to impact on our entire health care system and as we discussed this problem today, we should always remember our goal is to protect the health of people affected most by the shortages, patients and their families, and i say that as a

physician who has cared for patients for over 30 years. according to the of d.a. center for drug of vibration and research, the number of drug shortages has been rising steadily over the last five years as you have already heard and although shortages can occur with any drug, generic, sterile injectables currently make up the largest increase of the sharon impact and 2010 some 74% of of the shortages involved these older sterile injectable agents. so these include critical products such as oncology drugs and anesthetics, parental nutrition drugs and many drugs used in emergency rooms. there is no single reason why drug shortages occur. so ultimately, in any given situation, many factors are involved and underlying causes may operate either alone or in combination to cause a shortage. these factors include but are

not limited to, industry consolidation, major issues of quality and manufacturing challenges, changes to inventory and distribution practices, difficulty in producing a given drug, production delays, discontinuation's for business reasons, unanticipated increased demands and shortages of underlying raw materials. these are some of the causes, but more importantly, we at the department are trying to focus now on finding solutions that protect patients. in 1999, the fda formed the drug shortage program within seater in an effort to proactively begin monitoring and negating, that is lessening, the impact of potential and actual drug shortages. and when the fda becomes aware of any potential shortage, it works collaboratively with the affected the firm to return to profit -- product to its usual availability and as quickly and safely as possible while

striving to prevent any harm to any patient. although the fda cannot require firms to continue production of a product or increase production in response to a shortage, it does encourage other firms to do so. fda also expedites the review of submissions for manufactures which may include request to extend the expiration date of products come increase capacity, use a new raw source, licensed to manufactures and permit changes in product specifications. the fda is committed to working with drug manufacturers to prevent shortages whenever possible. and in fact, as a direct result of this commitment, and the work of the fda drug shortage to staff and experts across the agency, last year in 2010, 38 shortages were prevented and so far, 42011, this year, i am pleased to report for the first time that 99 shortages have been

prevented. also at the same time, the fda goes to great lengths to mitigate shortages that is lessening the impact when they occur. one notable recent example involves the well described shortage of the drug site. been used to treat certain types of acute leukemia. crystal formation in the vial of this drug represented quality and manufacturing problem that led to a disruption in production and a shortage they receive tremendous publicity across the nation within recent months. in this case the fda worked with the manufacture, found that the files were warmed the crystals would dissolve in the drug could then be safely administered to the patient and as a result of this collaboration, the manufacture was then subsequently able to ship the vials to health care professionals along with the letter from the fda notifying them to inspect for crystal formation and if present warm the crystals and this way the collaboration led to ensuring up

holdings patient safety. as a result of this work we can report today that this drug shortage, this well reported drug shortage has been recently resolved. in limited circumstances the fda can allow the temporary importation of critical drugs and when the shortage came not be resolved immediately however there are several factors that permit the applicability of this option. the product may be in short supply abroad and could exacerbate the shortage. fda must also ensure that drugs imported are from a manufacturing facility that meets fda qualifications. to discuss these and other possible solutions the fda will be hosting a public meeting next monday, said number 26, and this meeting is being held to you in additional insight of causes and impacts of this challenge and possible strategies for solutions. then on friday september 30 the fda is conducting a webinar for the general public and this is

an opportunity for people to learn more about what the fda is doing to address this challenge. there will also be a venue for citizens to ask questions strictly to fda experts who are working on this topic every day. although i focus my comments until now on the fda i should stress the entire department of health and human services has been fully engaged on this topic for quite some time. we view this as a pressing public health challenge and we want to resolve this on behalf of the department and indeed the entire country. this past summer i personally convened a series of meetings with representatives from fda, and sierra national cancer institute the cdc or centers for disease control and prevention the office of the assistant secretary for preparedness and response the office of the secretary for planning and evaluation, the sense in -- cms and others. we have joined together as one department to explore more deeply the root causes of this problem and the possible steps

that can be taken to address them. these have been productive meetings and we pledge to continue them until the problem is solved. we look for his many ways as possible to maximize our efforts within the department to protect the public health. also earlier secretary sebelius along with other senior leaders in the department hosted a meeting with over a dozen representatives from pharmaceutical any fractures, professional organizations hospitals insurance companies group purchasing entities and patient advocacy organizations and this crucial meeting gave us first-hand insight into these challenges, generated a good discussion with stakeholders and also served as a foundation for future collaboration. shortly, later on this fall the fda will release a report which reflects an even more detailed analysis of the problems and updated recommendations for the future, potential solutions are being examined. one suggestion is a mechanism for manufactures to report

impending supply disruptions to the discontinuation of drugs which could help curb shortages and improve the continuity of the drug supply. the sooner the fda learned the drug shortage the more effective they can be in helping to notify providers and the public in upholding patient safety. so we remain committed to working with all parties, manufactures providers patient advocates and other stakeholders to help minimize and solve this problem. so in conclusion, the department is committed to addressing and solving this critical public health challenge. it is our goal to advance this dialogue with all interested parties both internal and external and we also recognize and deeply respect the important roles of the members of congress and we welcome the opportunity to discuss this important topic with you today. said thank you very much and dr. kweder and i will be happy to take any questions you may have.

>> the chair thanks the gentleman. dr. koh, why have drug shortages and increased so much in the last few years? >> well, again there is no one single reason, but there are changes here that we are seeing in the backdrop of an economic and business climate that is leading to market consolidation, a complicated manufacturing process that is being conducted increasingly and aging facilities. it is leading to qualitative manufacturing issues as we have heard now. sometimes products are discontinued or business reasons. oftentimes the production of any of these agents is a complicated process of all these factors converged to create the issue we are facing right now. >> have other countries experience shortages such as we have? >> unfortunately the united states is not unique in this situation and yes, we are indeed

seeing similar situations in other countries around the world. >> and where the shortage occurs in another developing country, how is that situation resolved their? >> we want to learn more from our colleagues there. i don't know if dr. kweder wants to say more about that particular issue. >> we are often contacted by a regulatory regulatory colleagues from other countries, looking to collaborate on finding solutions to particularly when there are worldwide problems. different countries have different ways of producing drugs, of assuring production of products, but we work as much as possible with others to try and make sure that the shortages are limited and mitigated. >> does europe have a particular method of resolving this situation? >> i believe the method in europe is pretty much similar to ours, particularly since they are our multiple countries.

they look and they seek other sources of supply from other countries. >> do you know what is causing these drug shortages in these countries in europe? >> many of them are the same sorts of things. many of these products are marketed globally. they are not just in the u.s.. the sources of the drug substance itself are, most of them are foreign sources so if there is an interruption of a source in the u.s. at a u.s. plant, if a source in -- a manufacture in another country has the same source, they will be in the same situation and everyone will be out looking for alternatives at the same time. >> okay, dr. kweder what specific steps has the fda taken to prevent or alleviate drug shortages? >> first, we'd often, we tend to learn in terms of preventing

drug shortages. when companies let us know that they are experiencing a problem, it is usually a problem in production. sometimes it is a business decision to discontinue a product. when they inform us in advance that is the case, we work very closely with them to understand the problem, and assess whether the shortage would be something that could be critical for patients. so, for example if a company is making a product that 20 other companies make, that is not likely to be a critical public health situation but particularly for the sterile injectables that is usually not the case. so we will work with a company to help them develop solutions to fix the problem and avoid an interruption in production. that is not always possible. it is just simply not always possible. when it is not possible, and it looks like the company may have

to interrupt production, we go to other manufacturers and we talked to them about their capacity to increase their production. they usually can't turn that around on a dime, but we work with them to facilitate ramping up in order to supply the market with the usual sources. if it requires -- we will work with the original company having a problem. we have a number of tools in our kit that we can use to help them address the problem. dr. koh gave you an example of the kinds of things we can do in some cases to look at the end product itself. if there is a problem with the end product itself and in that case it was crystallization of the actual active drug. and we work with the company. they got right on the case to figure out why those crystals were forming, what could be done

to mitigate that, inform providers and since then the crystal problem has been fix. >> do you feel you need earlier warning than you currently have? >> we always could use earlier notification. there certainly are circumstances where things have been very very unexpected, but the fast -- the majority of cases of shortages, we could have been notified and in the majority of cases we are not notified in advance. it is getting better. i will tell you it is getting better, but we still have a large percentage of actual shortages where we were not aware that it was coming. >> thank you. my time has expired. the chair recognizes the ranking member for five minutes for questions. >> thank you mr. chairman. would like to initially ask unanimous consent to enter into the record the testimony of the national coalition for cancer research.

i think you have a copy of a. >> without objection, so ordered. >> thank you mr. chairman. dr. koh, we all agree that drug shortages are the real problem, are a real problem and from what i understand it is actually getting worse. but, i guess it is hard to figure out at least for me, with the cause is, and i would like to ask some questions about the cause of the problem. the fda has said that in 2010, last year, over half of the shortages were due to manufacturing product quality issues and i understand and i think you mentioned that a majority of those are sterile injectable drugs. why would these drugs be prone to manufacturing and product quality issues in particular? >> well, many of these products are the result of a long production process and those production processes are now

occurring in fewer manufacturing sites because of industry consolidation. there is also aging of the facilities, where this work is ongoing. there are business and economic factors in the back round that are lowering their profit margin, so oftentimes, businesses will make a decision to perhaps discontinue a particular product for business reasons, and as a result we are seeing the quality of manufacturing issues congressmen that you are referring to. sum of these quality issues are quite disturbing, where we literally are tracking products that have articulate matter, even pieces of glass and pieces of metal and what should be sterile products that are injected into patients. so, this is the reason why the fda continues to uphold its mission of safe and give drugs, also high-quality drugs in the

middle of this challenging requirement. >> now, in their written testimony they state that it takes two or three years to get fda approval for a new supplier for ingredients or an alternative -- alternate i should say, manufacturing site. is that really true? is a really take two or three years to get fda approval and why would that be if it is true and does it take that long if there's a drug shortage issue involves? >> let me start and i'm sure dr. kweder can add. one of the advances of the fda in this situation is to prioritize generic drug applications, expedite and accelerate approval in every way possible and particularly if the public health is threatened. so, there are efforts to try to advance the timeframe. that is also the goal of the generic drug user fee act which is under review right now. so these are issues that are very important to the fda and

they take it seriously. >> but i mean is that time period that was mentioned, with that generally be true and is there any kind of flexibility that you have to expedite the review and inspections of new facilities so they could address the shortage when it exists? >> there absolutely is flexibility and we do that routinely when we are aware of that say a new facility is needed or a new supplier is needed and when there is a circumstance that might lead to a potential shortage of an important medical products. we do it retain they. we can often turn things around in a matter of weeks. >> but i mean, you haven't answered our two or three year time. >> sure i would be happy to do that. the two or three year time span is what is being referred to under usual conditions when a company, when there is not a shortage situation or not a shortage -- go.

>> then you deal with a quick or? >> absolutely but even the two to three year timeframe as dr. koh said we are happy to see there is an agreement on generic user fees that will change that and make that a matter of months. >> reporter: my concern is, we face these extraordinary fiscal pressures. the house passed budget for fda contained a 21% cut in appropriated funds. i mean, is this cut -- with that adversely affect her ability to work with companies to avoid or mitigate shortages and i know you mentioned generics. are you negotiating with the developer user fee and can that help prevent or alleviate drug shortages? this is about the funding now. >> we are negotiating and have reached agreement with the generic industry about user fees. and that will be coming up for discussion. by yourself within the next year. >> what about the house budget cut? >> there is no question that

resources matter, and these are not automated processes. they take people with judgment and knowledge in having enough people makes a big difference. >> alright, thank you very much. thank you mr. chairman. >> the chair thanks the gentleman and i would like to request the following statements be entered into the record. i think you have copies of the statement of the national community pharmacists association, the letter from the american society for hematology to the house energy and commerce and the statement of the generic pharmaceutical association. i have no objection. >> we have an objection, so ordered. i recognize the gentleman from illinois, mr. shimkus for five minutes. >> thank you mr. chairman. i think all would agree that resources matter in this tough fiscal. as the ranking member

said. i think also part of our issue will be prioritization and especially in lifesaving issues and water agencies doing to put first things first and what can they do to obviously redirect funds in a different direction? ..

>> manufacturing issues and possibly delay issues in what's often a complicated production process all contributes to this situation that we're seeing now. >> and who are the big payers? >> well, there's a process where purchasers -- hospitals and physicians and providers -- buy these products, but there are also group purchasing organizations and pharmacy benefit managers who are involved who are trying to drive down the price for understandable business reasons. so these are all the stakeholders that are involved in the purchasing chain. >> and i do appreciate your, your opening testimony because we had some, a series of questions and, really, you answered them in your opening statement which is -- and i'm just going to highlight one of the things was a question we were going to ask was closely collaborating, and you gave the example with the drug crystallization, i thought that was very helpful.

the other issue i was going to focus on was alternative sponsors, and that's where you talked about maybe temporary easing import restrictions, importation or -- i can't p even read my writing. temporarily doing something else. but you said that's constrained based upon if there is a shortage overseas which is the same product and something we've talked about over the past years and with ranking member dingell is the ability to make sure that the drugs that we are importing are inspected by our o inspectors so we know the efficacy and safety of that. >> right. >> i've always been a risk-based person, um, on the focus point of saying that those that are more questionable facilities ought to get a lot of look. if they have been operating

safely and they've been inspected, like a u.s. facility every year, then it might make that you could go every two years or maybe 18 months, and that's the whole issue of schefting sources -- shifting sources, too, from the more critical elements and safety versus known products and industries that you all have real confidence in. we wouldn't expect you to do that to industries that have a poor record, but those who are, you know, you have a really good confidence in, that's the fund funding issue. you also mentioned, um, you know, business reasons and aging facilities, and i think you mentioned increased regulations. is that, is that part of your testimony? >> well, the standards, the quality standards that the fda puts forward in areas like this have been unchanged for the last

four decades. and, in fact, the fda has really gone the extra mile, in my view, to show tremendous regulatory flexibility here. so, again, since we can't require any manufacturer do much of anything, all we can ask is for information, communication, collaboration. and then the fda shows maximum regulatory flexibility. this rewarming of the, um, that i mentioned to you is one example, filtering out particulate matters so, again, these medications can be used and be not put aside is another example. >> yeah, let me -- i only have 12 seconds left. >> sure. >> and i wanted to focus on -- i'll go back to the statement in the testimony because i did scribble something of comment on increased regulars, but why doesn't the shortage of a product in this sector then send

an increased price signal to manufacturers for them to then produce the good? >> well, we have come to learn that the standard economic principles of supply and demand -- >> and the question is why is that distorted? that, i think that's the basic, fundamental question of this problem. what has distorted the fundamental principle of supply and demand? and my time's expired, but i think that's the heart of this issue. i yield back my time. >> would you like to respond? >> sure. and i'm sure the doctor can add too. first of all, these agreements are made often through these long-term contracts, and so also this whole process involves multiple stakeholders, especially and including the pharmacy benefit managers and the group purchasing organizations. so it complicates this environment and sort of does not, um, make relevant this is our standard supply and demand economic principles that we'd see in other businesses.

>> dr. >> he said what i would say. >> recognize the gentle lady from illinois for five minutes for questions. >> thank you, mr. chairman. i, too, am sponsor of the legislation that would ask for early notification. just wanted to mention we actually have a chicago-based injectable drug company that has endorsed the bill, and they, um, already do many of the things including proactively reporting to the fda about potential drug shortages. you've explained, um, dr. koh and dr. kweder, the advantage of that early notification. let me just raise a question that some have raised. early warning could exacerbate the problem and lead to hording of critical drugs. is this anything we need to watch out for, account for?

i mean, i'm hoping that that is not the result of this legislation, obviously, which i support. have you heard of that? is that -- >> i'll respond to that question. when we are notified of a potential shortage, we do not automatically turn around and put that on our web site and notify the public of a potential shortage that might do -- which would have the opposite effect of what we want. we judge very carefully when is the right time to make public announcement about a potential shortage. first, we assess what type -- what are we talking about? is this a true product shortage, or is it an imbalance in distribution? because sometimes you see things that are, seem to be in shortage in one part of the country, but there's plenty of it and more so in another part. but, so we take that potential for making things worse very, very seriously. we, meanwhile, are working on it

to assess it and assess what we might do to mitigate it if it is real. if it is real, we usually announce the fact that it exists and try to let, let the public know what we are doing to try to address it. >> so early notification, then, is something that is a useful tool. >> right. early notification to fda is a very useful tool. we see that as different than early publication. >> got it. let me ask you this. um, the fda has limited authorities. let me run through some of those. cannot, at this point, you can't require manufacturers to do this early notification. you have no authority to require companies to increase production of a drug during a shortage, you can't impose an allocation plan when a shortage causes life-threatening conditions, and fda has limited ability to post timely information on its web

site for health care professionals and patients regarding reasons for shortages and timelines for resolution. i don't really understand that one. but, um, are there in addition to early notification, are there other authorities that you need that would help mitigate this problem? >> i think the most important thing, there are two things. one in the early notification is something that helps us in the mitigation and prevention greatly. what we need to be able to do is we need to be able to have the industry assure that they are making a quality product and upholding their responsibility to produce high-quality products where these things won't happen. our goal is to prevent even the potential for a shortage from occurring. not always possible. in the case of many of these threatened or in real shortages,

um, these are, as dr. koh said, these are in plants that manufacture multiple, multiple products. in you look at the record -- if you look at the record, the things that led to the actual problem with production are things we've been telling the companies about in routine inspections for years but only became critical, you know, they needed to address these, modernize so that they could continue producing quality product without a glitch. so that's first and foremost from our standpoint. assuring that we are aware so that we can step in and use every possible communication tool and flexibility in regulatory action -- >> let me just ask you, to what extent is the issue of, um, business decisions, um, what percent of those cases where we have shortages would you say this is a business decision? >> you know, i can't give you an exact percentage. i'll be happy to provide that in follow-up. >> is there a major issue, and

is there anything that we can do about that? >> i would say that that is not -- in the case -- that is not the major issue. >> okay. >> i would say by far and away the more common scenario has something to do with manufacturing and product quality. >> thank you. thanks to both of you for being here. >> thank you. >> chair thanks the gentle lady and recognizes the gentleman from kentucky for five minutes for questioning. >> thank you for being here. i'm just going to follow up a little bit on congressman shimkus. you answered a lot of the questions in your opening testimony, but i had a group of oncologists in the other day, not people who make or sell drugs, people who have fda issues or whatever you want to -- these are just guys taking care of patients, and they say they literally have to make choices about who they take care of because they don't are is -- they don't have the drug available. so i asked questions, and they told me that this particular type of drugs, the generic, are

priced different in the federal government. so the medicare/medicaid has prices different than these other drugs, is that -- is what they were saying true or -- >> first of all, congressman, thank you again for your attention to the patient. this is a dire situation for patients, and i have actually trained in cancer as well as other fields, so this is very personally and professionally important to me. we have a role of medicare here that reimburses according to what's called the average sales price. so that is one factor here. but we don't view that as a significant issue in deriving the shortages that we're seeing here. >> but these generics are a different system than others. because what we're seeing is, you mentioned that pharmacy benefit managers, all these are driving down drug costs. well, they're doing it, you know, if i was a benefit manager, all drug costs.

>> sure. >> but we seem to see this particular class of drugs having a bigger problem than others, and the only thing i can see that's different is that, the way the federal government treats them, they treat them different than other drugs. >> these are concern i'm not sure i can answer your question, but these are generic drugs, they are off-patent for the most part. you know, there are some that -- so they are, they're at a point in time where the profit margin for the drugs generally because they are a glerk and you can have -- generic and you can have multiple manufacturers is lower. >> right. >> and it wouldn't be just, you mentioned medicare, cms, but there are other group purchasers, many other group purchasers -- some of them are government-related, others are private insurance companies concern that are negotiating in bulk, basically, for prices. and they are no different than what the federal government does. it's the same. >> but why isn't that happening in other classes?

>> i mean, this seems to be particularly more than others. >> well, in the other classes, in the non-generic world there's one source, and so they're in a great bargaining position because they are sole source innovator product, they have a patent. >> but they are priced, i mean, there is a different system for -- >> sure. they are priced, they tend to be priced lower. >> priced lower. >> absolutely. and that, of course s the advantage -- that's the access point for the public. >> but -- right. if you have lower costs which we all want to drive lower costs, believe me. but you have lower costs, then you get less supply, as you're saying, and be you have less quality of people producing. and so is there not -- it appears according to the oncologists there's not a mechanism where if you just pay a little bit more, you're going to get the drug that's going to take care of -- there's not a price mechanism that says we've got a low supply that congressman shimkus was talking about, therefore, we get the supply we need to take care of

patients. >> the situation is, as summarized by dr. kweder, but we can get you more information and work with you. >> okay. i was wondering if we could do that. the things that you mentioned, business decisions, that's all part of the mix. there are some things we can do from this side. >> thank you. >> and one other thing just quickly on the fda, the two to three years, now you've got the flexible teams s. that relatively new? i reached out to some people, and they did talk about some issues with inspection and inspection time with congressman shimkus. so it sounds like that's -- is it, it's being addressed -- >> it absolutely is being addressed. it absolutely is being addressed. >> maybe just hear from the ones that have the worst experiences, i guess. but that's good. i understand with your physicians and the oncologists i met, you want to take care of patients, so we appreciate your attitude. thank you, and i yield back. >> chair thanks the gentleman and be recognizes the chair, the

ranking member emeritus of the full committee, gentleman from michigan, mr. dingell, for five minutes. >> mr. chairman, thank you for your courtesy, and thank you for holding this hearing. let me begin by asking this question, yes or no. do you have authority at fda or at hhs to waive any of the requirements with regard to efficacy, good manufacturing practices or safety? yes or no. in the event of shortage. >> yes. >> you do have it? >> we have the authority to use flexibility in how we implement the regulations. >> okay. >> regulatory discretion. >> i would like to have a further answer on that particular point. >> but the requirements are the same. how -- >> they are. >> -- one reaches them is, is flexible. >> okay. i'd like to have further

statement on that for the record so we can understand what your authority there is. it's my understanding that the fda's been working to address shortages of medically-necessary drugs. can you, please, define what medically-necessary means? please? >> medically-necessary is defined as a product used to treat or prevent a serious disease or condition for which there's no other product available to act as a substitute. >> i believe you've indicated in your testimony that the vast majority of shortages experienced in the united states is attributable to sterile injectables, is that correct? >> yes, sir, that's correct. >> and according according to yr testimony, some 54% of these shortages were due to product quality issues such as particulates, microbial contamination, impurities, stability changes resulting in crystallization s that right? >> that's right, congressman. >> were you finding those in american pharmaceuticals or imports? >> we were finding them here in the united states.

>> what about imports? >> well, those are exactly issues we try to prevent which is why importing is always a challenging issue. >> yeah, but you have really no authority to address the question of the manufacturing practices abroad. you have no real authority to deal with good manufacturing practices, you have to real authority to see to it that the requirements that are imposed on american manufacturers for safety, efficacy are there, and be you have very little power to effectively inspect those foreign manufacturers either of finished pharmaceutical products or components and constituents, right? >> that's correct, congressman. >> and you have no ability, really, to know who's manufacturing these things or trace them through the product line, is that right? >> that's right. that's why the importation process is done very carefully and selectively. >> i've got some legislation to address that, and i hope that we'll be shortly addressing it

here in this committee. i have a bill, as i mentioned, that would address the problem of quality problems in drug manufacturing process by requiring that drug manufacturers implement an effective quality system that complies with gmp. the quality system would also be required to insure risk management procedures that would address all relevant factors through the supply chains including original source materials and their origin, on-site audits and methods to detect or include potentially risky substances. do you believe that enactment of -- oh, manufacturers would also have to maintain records and establish that the drug was manufactured and distributed under conditions that insured its identity, strength, quality and purity. would legislation of this kind help you address quality issues? >> yes. tracking quality every step of the way would certainly uphold -- >> this is a matter on which

i've worked with the gentleman, my colleague, mr. shimkus. now, it's been widely reported that when information becomes public about a drug shortage, an active gray market tries to sell drugs in short supplies to pharmacists or hospitals. does this prevent a safety concern? >> yes, it does, congressman. >> why and how and what can you do about it? >> well,s this is largely unregulated. the federal trade commission is involved to some degree, but unfortunately -- >> they don't have the expertise that you have, and would you submit to us a proper answer informing me what we have to do to address that particular problem? >> be happy to do that. >> now, ed in the -- purchased in the gray market, do we know whether the drugs have been diluted or whether the drugs are free of filth and contaminants or adulterates, yes or no? >> no. unfortunately, we know very little about the products in the gray market. >> as i mentioned, i have a bill that would require manufacturers to maintain records establishing

where the drug and its raw materials were produced including all information relative to producers, manufacturers, districters and importers. would such legislation and such power assist food and drug in assuring the safety of these kinds of pharmaceuticals? yes or no? >> yes, we want to uphold safety and quality so, thank you. >> at the end of the day, american consumers and patients are facing three problems. one, the drugs they need available and affordable. two, are the drugs they need safe, and, three, are they efficacious, do they work? i believe the committee needs to examine these issues carefully and swiftly. our colleagues in the senate, mr. harkin and mr. enzi, have already called on food and drug to improve its oversight of the pharmaceutical supply chain. i would hope this committee would follow suit, but i would like to have you give us a statement of what authorities you need to adequately carry that out. i don't believe that sending you a letter asking you to do

something for which you have no authority works. would you submit, please, for the record -- because my time is up -- what it is has to be done to give you the authority to address those problems. >> i'd be happy to, congressman. thank you. >> thank you. mr. chairman, i thank you for your courtesy, ask unanimous consent that the responses be inserted in the record. >> thank the gentleman, recognize representative cassidy for five minutes. >> there's issues raised regarding adequacy of quality control if you will. we think of heparin from china causing many deaths, right? one of the issues that was raised here in a reeves hearing was that the -- in a previous hearing was that the inspectors

as part of their union contract are not -- can refuse to go overseas. and so i think mr. pallone spoke about inadequate resources. but the issue was that here there's enough money to inspect our requirement to inspect a pharmaceutical every two years, and there it's happening only every nine. and when i ask could woe just redistrict -- could we just redistrict resources by expanding importation, the point was that the unions would not allow this to occur, that they had the right to refuse the overseas assignment. is that true, and to what extent is that limiting our ability to prove the apis -- i forget the acronym, but you know what i'm speaking of.

>> we find that our staff are extremely cooperative and willing to roll up their sleeves and step in. we, um, we are addressing the issue of our inspection force more broadly in parallel to this, but it has not been a critical issue in mitigating or reventing drug shortages. >> but there's a heck of a lot of generics being manufactured in india and other third world countries, so are they just not ruing the ones that we are in -- producing the ones that we are in short supply of, or are we just not confident of the quality of the product which they produce? >> i'm not sure i understand your question. >> so is there a worldwide supply of drugs that are currently in shortage here, it's just that we are not trusting the manufacturing process by which they are produced and, therefore, do not allow their importation? is. >> i would say the lack of allowal of an imported -- to

import a product has been unusual. if there is a foreign source, we are usually able to work through and get it approved. there have certainly been circumstances where there have been important problems that would prevent that, but in most cases if there is a foreign source -- and going to a foreign source is necessary, we are able to work through that. >> okay. there, um, in the gentleman who's going to testify from teva, he speaks about how dea has a quota for controlled products and that if somebody goes out of business, that quota might not necessarily be assigned to another manufacturer. and so you have a kind of centrally-planned economy-induced shortage. any comment on that and any way we can address that? >> i can start. i know that controlled substances represent only a very small part of the drug shortage situation that we're talking about, so we do work with dea, but it's limited only to several

instances. and dr. kweder might -- >> and it is more complicated having the dea involved for, obviously, good reasons. it does create an additional step and complicates this. but we work closely with the dea when a controlled substance shortage is at issue. >> but i understand that, but is there any plans to make it so that if somebody stops producing their quota is transferred to somebody who would, because i gather that's not the situation now. and although we're working closely, that's a obvious solution that i'm not sure is being implemented from your statement. >> we are continuing to try and figure out how to expedite these kinds of issues with dea, and i don't have an answer for you about exactly when that will be resolved, but we are committed to doing it, as are they. >> okay. teva also mentioned just because i like to read what the other panelists say, and i'll quote: speaking of a source of an active pharmaceutical

ingredient, they say that the qualification process to identify a supplier for such can be very onerous to qualify and gain fda approval for a new api supplier for an already-approved supplier can take as long as two to three years. now, i am channeling my inner teva, wherever teva is. you don't have to testify anymore. but what would be your response the that? >> again, these are areas where we're trying to show as much regulatory flexibility as possible to accelerate approvals when necessary. so we're hoping to address these things through the maximum flexibility possible. >> and we already do. whenever there's an issue related to a supplier with, where it requires fda to approve a new supplier or even a new facility, i think that was one of the other concerns. we turn those around very, very quickly. >> and what would -- >> these are not business concern in a matter of week -- in a matter of weeks, weeks to

months. these are not business as usual where there is a long wait time. we understand that patients are at the end of this, at the end of this line, and we need to do everything possible to, um, get on the case and work with the companies. and we've done that with teva. >> okay. i yield back. thank you. >> recognize the gentleman from utah, mr. matheson, for five minutes for questions. >> thank you, mr. chairman. i appreciate you yielding time to me, and i appreciate you holding this hearing. i think we've established the problem. i'm sure lots of people talked about circumstances in their district. i represent the university of utah, they project more than 360 products having shortages and that many products by the end of this year. and i was at the huntsman cancer institute just two weeks ago, and they were talking to me about the challenges they're facing. i guess everybody has a story, but i wanted to tie it to my backyard. i was wondering if you could address for me some of the concerns about gray market activity as a result of these

drug shortages and the integrity of what's out there in terms of quality of the medications, if they're counterfeit or how we can address some of these challenges of gray market in these medications, shortages? >> well, i can start. first of all, thank you, congressman, for your commitment to research. we didn't say explicitly, but we can say now that this drug shortage issue is a dramatically effecting clinical trials as well in cancer and disease in many parts of nih, so that's very, very troubling to us as a nation that prizes scientific advances. the gray market, unfortunately, is very poorly understood, and it's, as we've mentioned already, it's largely unregulated. and to have, now, this dimension complicating an already complicated situation is very disturbing. >> yeah. >> so we appreciate your attention to that, and we want to address that as well as all the other factors that are involved here. >> other actions we should be