begin a brief pro forma session here on c-span2. ..

the presiding officer: the senate will come to order. pursuant to the constitution, the hour of 12:00 noon january 3 having arrived, the senate

convenes the second session of the 112th congress. the clerk will read a communication to the senate. the clerk: washington, d.c, january 3, 2012. to the senate: under the provisions of rule 1, paragraph 3, of the standing rules of the senate, i hereby appoint the honorable mark r. warner, a senator from the commonwealth of virginia, to perform the duties of the chair. signed: daniel k. inouye, president pro tempore. the presiding officer: under the previous order, the senate now stands adjourned until 11:00 a.m. on friday, january 6, 11:00 a.m. on friday, january 6, >> so the senate has gaveled out of this quick pro forma session. more to come over the next couple of weeks with another one scheduled for this coming friday. the senate officially returns to legislative work on monday, january 23 rld, when members are expected to consider a judicial nomination for a federal judge position in nebraska. also that week a bill targeting online piracy.

follow the senate live, as always, right here on c-span2. >> that side's already made up his mind, this side's already made up his mind and the, i call it garbage, dr. rice -- >> dr. brinkley, rice is the university. >> i'll call it anything i want -- you set in that chair. >> you be quiet. >> you don't own me. >> gentleman will suspend, and i'll remind members -- >> i work for the private sector. >> mr. brinkley -- >> the confrontation at a congressional hearing between representative don young of alaska and historian douglas brinkley ranked as the fourth most-watched video in the c-span kid owe library. watch it for yourself at our home page, c-span.org/video library, and click on the most watched tab to view other videos from the past year. it's what you want when you want.

>> again, our live iowa caucus coverage gets underway at about 7 eastern tonight. we'll have the latest on the day's campaign events and look at how the republican presidential candidates are lining up. live coverage begins on c-span. and then live cameras in a central iowa caucus to show the voting followed by statewide results, candidate reaction and phone calls. also c-span2 we'll be live at 7:45 eastern with the western iowa caucus. a look, now, at some of the campaign ads run anything iowa. >> born and raised in iowa, only one candidate has been a consistent conservative fighter who fought obamacare, fought increasing our debt ceiling even as other republicans were cutting deals with obama. an expert in tax law who will fight for deep cuts in spending to reduce america's debt, restore our economy and create real jobs, and she'll never back down. one of our own, michele bachmann for president.

>> i'm michele bachmann, and i approved this message. >> america is in trouble. >> washington is in a disgrace. >> government has become too big. it's overtaxing, overspending. >> we need to change direction. >> we really need change. >> we can't afford to make the same mistakes we've made in the past. >> mitt romney's reputation as a flip-flopper -- >> he went the other way when he got paid to go the other way. >> there is need for economic stimulus. >> it's about serial hypocrisy. >> there's been one true, consistent candidate, and that's dr. ron paul. >> ron paul has been so consistent from the very beginning. >> he seems like a more honest candidate. >> he tells the truth about what he believes whether you like it or not. >> never once voted for a tax increase or an unbalanced budget. >> he's what we need. >> when he says he's going to cut a trillion dollars in the first year, i believe him. >> if you don't like how things are going and you're tired of politicians, do something different. >> ron paul -- >> ron paul -- >> ron paul -- >> ron paul is the one we've

been looking for. >> i'm ron paul, and i approved this message. ♪ ♪ >> we appreciate all of you coming out this morning so early and being here and caring. i think we all care right now. i think we're all concerned about our country. i believe in him. i believe he has the experience. i've seen him in every situation. i've seen him as a husband, as a father, as a governor and as a respected businessman. everything he does, he does well, and he does it with his heart and his commitment. if there's ever a time when this country needs someone like mitt romney, it's now. >> this election is about more than just replacing a president. it's about saving a vision of america. we still believe in the america that brings out the best in all of us, the challenge of each of us to be better and bigger than ourselves. it's time for this pessimistic president to step aside and let

american optimism that built this greatest nation on earth build a greater future for our children. ♪ ♪ >> if you can get out here in this cold and this wind and with the rain coming down, then you can certainly get out on tuesday night, and you can sure find a few people to bring with you. and on the way to the caucus, you can tell 'em just who you're going to vote for. i believe in restoring the principles that made america great, and i will do that with your help. [cheers and applause] ♪ >> justice department statistics show that 60% of american children have been exposed to crime, violence or abuse, and 40% were direct victims of violence. the attorney general's national task force on children's exposure to violence is looking at the problem at this forum in baltimore. the task force heard about the importance of mentoring kids and the impact of prosecuting

children as adults. this is just over an hour. >> thank you. would everybody be seated, please, so we can -- [inaudible] [inaudible conversations] >> thank you. the impact on people and communities of children's exposure to violence, that's what this panel will be focused on. this panel will explore the effects of cev on the bodies and minds of young people and on the social fabric they live within. panelists will discuss a wide range of questions about the

impact of cev from brain development to juvenile justice system contact. this panel will also explore innovative and collaborative approaches to protecting and healing young people exposed to violence. the honorable patricia m. martin is president of the national council of juvenile and family court judges. she is a former lead judge in ncjv -- oh, this is good for me here. ncjfcj's child victims act model courts project and promotes alternative court processes for children such as court-appointed special advocates. dr. steven berkovitz is a child and adolescent psychiatrist and an associate professor of clinical psychiatry at the university of pennsylvania, department of psychiatry. dr. berkovitz is director of the penn center for youth and family

trauma response and recovering. dr. lauren abramson is founder and executive director of the community conferencing center in baltimore. dr. abramson has examined how childhood exposure to violence correlates to juvenile offending and how alternatives to detension that incorporate trauma healing for youthful wrongdoers reduce recidivism. dr. adam rosenberg is executive director of the baltimore child abuse center. prior to directing the center, he served as the prosecutor in a domestic violence unit and the sex offense unit of the baltimore city state attorney's office. we will start with the honorable patricia martin. >> thank you so very much, mr. chair. ladies and gentlemen of the task force, i am honored and privileged to be here and have a conversation with you this afternoon. i have rewritten my oral

testimony five times, i believe, today. [laughter] so i hope that my written testimony does provide some insight. what i'd like to do with your privilege is to address some of the questions that were posed earlier today. i do have the names of persons who asked the questions, but rather than take that time and go remind you back of the conversation, i would like to just go through a couple things that i think help address some of the issues that you rsed this morning. i think that there was, there was a question posed to how do we bring the creativity of individuals or families and formulate that and pack that some way to make a recommendation to the attorney general. i would submit to you that the creativity and caring adult is what you would like to pull together and somehow formulate. so in cook county, for instance, don't tell the legislature down in springfield, but i've changed

the goals for every child in the child protection division of cook county. i'm also the presiding judge of the child protection division in cook county, illinois, and just as a way of background, through the national council of juvenile and family court judges i, along with los angeles, new york and chicago are the three largest child protection jurisdictions in our nation. over the last decade, the three of those jurisdictions of themselves have been able to reduce safely our caseloads from anywhere from 40 to 80%, and i would say safely because our recidivism rate has not increased. and we can talk about how that was actually done, but what i'd like to do is give you some of the information that we've learned over this last decade. and this is not only cook county, but i would suggest to you new york, l.a. and chicago. by the way, you've heard two judges' names today. both of us, judge sidney leerman from miami and myself, we are

members of the national council, serve on the board of trustees, and i currently serve as the president of that organization, so i would strongly suggest if you're looking for innovative courts, the national council's a laboratory where we take programs, we figure them out, we work through them, we come back at all sites, have our lead judges' meetings where we share this information, and we are heavily supported by ojjddp, so a big thanks to them. back to my point, createivity and caring adults. my benchmark hearing, no child leaves foster care without what i call an aunt kitty. i am a member of a family of three children. our parents died more than 26 years ago, and i'm the oldest. i was the only one out of school, my brother was in med school, and my sister was still an undergrad, and i could not figure out how we were going to get out the next morning after my mother died. my mother had closed his practice years ago, and the way

we got up at home was my mom would sing "precious lord" through the house, and that's how we got up. when she died, i literally could not figure out how we were going to get up the next morning. long story short, my aunt kitty woke myself at 6:00 every morning central time. i am an old age pension on the other side of this life, i will suggest to you, but i will tell you that was the one rock and, ultimately, got my brother and for to a point where we feel as if we're providing some benefit and some productive measures to our society in general. so i would suggest to you, i would make, if it was my world, it would be my recommendation that every child in foster care has to have a protective adult. i don't care if it's a drunk uncle, but if drunk uncle calls my child on christmas morning

and says merry christmas, if drunk uncle calls my child and says happy birthday and is there when my child needs my child, that is a caring adult. so i'm not looking necessarily for placement. that's another segment of my job. i'm looking for someone who loves my child. too much of my work is involved in safety and placement and not enough focus on appropriate love. so that is the new goal in cook county. i would suggest that's your recommendation. in other language, but that's your recommendation. we also, um, talked about improving the practice in courts, especially proactive courts. i've already mentioned the national council of juvenile and family court judges. i already mentioned the lead judges in the model court project. what i would suggest to you is one of the things that the model courts do is we collaborate. so i have medical schools working with cook county child protection divisions. i have child, um, children's memorial hospital ped residents

rotating through my court for a day trying to understand what we mean by child protection. my judges go to their grand rounds and listen to what happens in grand rounds about broken arms and spinal fractures and taking in the totality of the circumstances before making a determination of how a child has been injured or whether it's abuse or not. so there is a lot of collaboration in these model courts. another collaborator or a big collaboration for us is our chicago public schools. you're speaking with a judge, we've gotten off the bench and gone to an iet, and i will readily admit i had no idea what an iet was or what was supposed to happen there. but someone had to go. so i work with chicago public schools, but the one thing i learned when i walked in the door, we speak two different languages. i don't understand what they're talking about. but through that effort we have a member of the chicago public

school who is on a level of a principal housed in my courthouse. she has a computer for the chicago public schools and a court computer. so when my judges are trying to figure out where this child's academic history is and performances, what grade did they fail, why did they fail, how many more credits do they need to graduate, i don't have to wait 30 days to have a worker go to the chicago public schools, figure out their system. i call barbara up to my courtroom, give her an hour and tell her go back downstairs, figure it out and come back and tell me. things like that even though we don't have status systems that intercommunicate or communicate together, at least we can figure out ways short of trying to change a whole system around to get the information. so i would suggest demanding that courts be collaborative similar to the model courts is a requirement because we can't do this work alone. we have to rely on others. all of us in this room today know that states do not raise

children well no matter how good our court system, no matter how great our foster care system is. families raise children, and we have to figure out ways to treat our children and families more holistically, and i would suggest that this is one way to do that. we talked about domestic violence. i will admit to you this is kind of a duh as my nephew says, but we were taking the perpetrators out of the home when it was a domestic violence situation, and we were charging the custodial parent -- typically the mother -- with failure to provide adequate support or supervision and then taking the perp, which is typically the father, out of the home. one day we realized that trauma is affected on all of our children whether we have to move the child for life preservation, but that still produces trauma for the child, so we go to the duh moment and started taking the perp out of the home and

leaving the child in the home. even to a point where it's a financial burden for the family, we still take the perp out of the home and even sometimes move the mom and the children to a relative ice home. even -- relative's home. even if that's what we have to do, but we keep the child with the family unit as opposed to isolating the child. those are things we learned, somehow we couldn't figure it out in the beginning, but we finally got there, and that came from a suggestion from one of our other model courts. so it's sharing information once question go back to our -- once we go back to our laboratories and share information. so i would suggest every jurisdiction should be charging on domestic violence and figuring out ways to address that trauma and violence for the children as well. we talked about a lot of our courtrooms across the city whether it's a juvenile justice courtroom, a child protection courtroom, a divorce courtroom, a child support courtroom. we focus on providing services for parents. i would agree with you even though my charge is making decisions that are in the best interests of children. so what we are doing now in cook county, i have this benchmark

hearing that's for older adolescents, and all we focus on is the older adolescent to the point that, for instance, if i terminated the parental rights on a parent at 3, when the child was 3, the risk factors and support factors for a child, that same child at 13 are vastly different. so what i've done even though the mother is no longer the legal mother of the child, i've invited her back to my benchmark hearing. i've put in a legal relationship, a legal guardianship so the department has a way in which to funnel funds, legal gymnastics maybe -- [laughter] but funnel funds back to support that relationship. at 13 i'm not asking mom to get off drugs. if she does, great. if she does, great. what i'm doing now is making certain my 13-year-old knows how to navigate his mom. so when mom's a druggy, what do you do? when mom's okay, what do you do? each and every one of us in this room has an uncle or aunt that we were told not to sit next to

at a barbecue. it's no different than my children in foster care, and we also have to teach them to navigate the not-so-positive parts of their family, and i feel i have an obligation when my children get older to look at their permanency a little differently. i would hope i can find a home and a family, but if i can't, at least give them the tools that they need to be able to find their way through this life. we talk about gaps. i would suggest cross-training is the absolute answer. it is no longer sufficient for me to go to judicial trainings and learn how to make determinations from the bench. i need to understand what a spiral fracture -- when i first came to the bench, they told me the only way you could get a spiral fracture is from abuse. ladies and gentlemen, when they tell us that, when docs tell us that on the stand, we believe that until we have doctors come anything and actually telling us what we need to do and training us. so as a presiding judge one of

the things i do once a month is i buy lunch for my judges, but i invite a doc in, a psychiatrist in, someone from the substance abuse community in, that's where we found out that substance abuse providers were starting to use medicine. we had no idea about that stuff until we brought them into our court building and started asking them to talk to us directly. we work with the, um, police department in chicago and our sheriff's department. we've had problems with serving our child protection warrants, trying to find kids who run away from placement. i've found numerous opportunities with them to help me figure out how to find our kids. my kids go home. when they run from institutions, they go home. so talking with my police and sheriffs, we were able to execute those warrants a little better. i'm told that i have to stop, but i want to say just one other thing and that is this: that in cook county the national council of juvenile and family court

judges, i have been the presiding judge for the last decade in cook county. we would not have been able to reduce our numbers from over 38,000 children to foster care down to 7,000 children in foster care without raising our rate of recidivism if we didn't reach out to the medical field, if we didn't reach out to the education field f we didn't reach out to juvenile justice. and i would just encourage you when you look at court and making recommendations for court, do not look just at juvenile justice and child protection, but you have to look at divorce court, domestic violence court, child support court, even paternity court when we talk about siblings. >> thank you, your honor. just to make, for the record, we didn't want you to stop. [laughter] >> well, typically speaking, i don't. [laughter] but i just wanted to be mindful and respectful of the others -- >> the attorney here did not ask you to stop. [laughter] >> that's a first. [laughter] >> thank you very much.

dr. berkovitz. >> thank you. it's really an honor to be here, um, and it probably shouldn't be a surprise that just sort of everything i thought i was going to say has been said. maybe that's one of the good and bad things about being the last panel. but especially since most of or many of the people who testified and are on the task force are friends, colleagues and mentors. and as many of you know, i was at yale with dr. marans for 15 years as a deputy director of the nccez, so i have to acknowledge his mentorship over the years. one of the things i was asked to talk about is the neuroscience of trauma, and i'm going to do that briefly. um, but i want to also do some -- i did a lot of writing too. we really have, um, in terms of

neuroscience probably learned more about the effects of trauma and stress in the last ten years than by any other psychiatric or neurologic disorder. and i think that's really quite remarkable. um, so we do know now that experience changes the genome, we know how it does it through methods of genetics, changing methlation on specific parts of the gene which change gene products which then has impact on brain structure and on the body structure. and we have to remember that the brain is in charge of everything. so anything that effects the brain will effect the body. that's why as you've heard time and time again that exposure to violence and trauma early in life and, actually, throughout life has such negative effects

not only on psychological health, but on physical health and on functioning in general. if you look at the data, unemployment, homelessness. 100% of men on death row were abused as children. so i think we really need to understand that very carefully. and it is a biological mechanism. we are biological ha chiens. machines. that's how we operate. and everything that happens is through a biological process. and it's not a surprise that the most exquisitely sensitive aspect of that process is about survival. and trauma is about an attempt to survive. and that is what's changed and disregulated when children and adults are exposed to traumatic situations, particularly chronically.

so i think it's very important to keep in mind. completely disregulated systems. we have brain scans that show brain sizes decreasing, we know about cardiovascular disease increase, we know about cancer increase in all of these situations. what's really interesting to me is when you look at expenditures in terms of treatment and research. for every $100 that's spent on the very diseases i just talked about, five cents is spent on interventions and research when it comes to child trauma. i think that's startling. when we talk about costs. sitting next to the judge here and hearing about what she's doing in chicago reminds me about, of what i don't have. um, and in philadelphia today i sit with children on a daily

basis, about 50% who are in foster care who have been abused, neglected, shot, um, most of the cuds -- kids in foster care not only have been traumatized in multiple ways, but have been exposed to in utero substances, alcohol and other such things, and already come into the world with two strikes against them. and my job -- and i see our job -- as to instill hope. and trauma and traumatized individuals are helpless and hopeless. and our goal is to instill hope. but that requires not just a village, it requires a nation. i spend more time on the phone with attorneys, child welfare workers, um, i wish the judges would return my calls -- [laughter] child welfare workers, foster

care workers than i do seeing patients because it does take that many people. and i can tell you that one of the greatest dilemmas is that we don't speak the same language. we don't have the child as the focus of our language. and i would argue if we want to make a systems change, if we really want to change what we're doing, we're all taking a short view. the long view is we need a new language among all the child-serving agencies. courts, judges, etc. that have the child, have human development and trauma-informed understanding at the center of that language. that is what's going to change things in the long view. that's what's going to change the funding in the long view. when we recognize the child maltreatment, trauma and abuse is really the number one public health issue in this country, i think the data's clear. you've heard it time and time again.

$100 billion was the statement, that's probably -- that doesn't even include the rates of incarceration, of court hearings, so on and so forth. it is the number one public health issue in this country, and we need to change the paradigm across the board. so one of the dilemmas with this panel being the provocative person i am is that it's only doj who's sponsoring this. where's everybody else who's involved in these issues? shouldn't they be here? shouldn't we be talking about how to create that common goal and that common language? we do know how to intervene. we have lots of effective interventions. you've heard about some of them. you've heard about a wonderful way of thinking about things in the court system. but we don't do it across the country. we don't have that common, shared language that everybody believes and everybody agrees with. i have an antidote; the

defenders' association, a very controversial case where i was completely blindsided, um, and actually, frankly, called unethical by the public defender. and she was wrong. and i called her to task on it. and then was asked after calling her to task to give a talk about what it means to provide trauma treatment. well, it ends up that nobody, none of the attorneys in this, in this setting actually knew when they were requesting trauma-focused treatment what it was. and i had to teach them what it was and what really to ask for. to ask for an evaluation, not for treatment. they, you know, they thought they saw a terrible thing happen, they must have trauma treatment. no, it doesn't work that way. these are, this is the language that doesn't exist among all our various agencies and facilities

and what not that needs to be imbued to change the paradigm. and i would argue that that needs to be throughout the secretarial and cabinet posts and agencies and at every level of government and every level of the community, that we need to be talking about children and families and development from the same perspective, sharing language and creating a language that can allow our interventions to grow and be effective. ..

what i would like to talk about and address is why we need to change our responses to violence and how we can do that. so why do we need to change our responses? what we're currently doing is not working. what we currently do is we separate victims and offenders and we punish offenders and we don't give them a chance to learn how to do things differently and how to do it better. in fact when they go into detention what they do learn how to do is how to be better criminals. the research shows that over and over and over again. what do we do with victims?

we don't include them in the justice process. they're isolated. and if they happen to have symptoms of post-traumatic stress which many do, the research shows that they do not seek treatment for it. so victims are often stuck in their sense of victim hood. and they're stuck with this identity as being a victim. so how can we do it differently? in baltimore for 13 years we've been at the community conferencing center which i founded we've been using a restorative justice intervention called community conferencing which what we do is, we bring together the victims and the offenders and their respective family members and supporters and anybody else who has been involved in and affected by the incident, the person who cleaned up the graffiti, could be a pastor there to support them, a coach,

anybody. there's a facilitator. everybody sits in a circle and has a chance to do a very radical thing. they get to talk to each other. so those who caused the harm get a chance to say what happened and describe what happened and then everybody in the circle gets a chance to say how they have been affected by what happened in a very emotional way. after next is -- affect is why this process is so putwerful. in everybody having chance to share share story, offenders are beginning to take accountability for what they have done and victims have a chance to put out in the external what they have been carrying on the inside. as everybody does that they get a chance to really learn different things about each other. and once everybody has spoken then we ask the group what do you want to do to

make this better, to repair the harm and prevent it from happening again? if they can they couple up with a written agreement. we follow through to see if there is compliance with that agreement. we use this as an alternative to arrest and court and incarceration, not just for misdemeanor offenses but for felony offenses as well. the more serious the better. and when i tell you the outcomes that will help explain why. we've also been doing this since in schools as chief goodwin said in baltimore city schools as alternative to school suspension and arrest to help stem the school to prison pipeline which maybe all of you are familiar with. about 100 students are arrested out of baltimore city schools every month. and we know that it works. there's a lot of research that shows that conferencing, that victims feel much more satisfied if they go through conferencing then if they had gone to court. offenders feel more

satisfied. there is even research that shows that victims who are experiencing ptsd who went through conferencing have significantly reduced symptoms if they have gone through community conferencing than they went through court. let me give you one example of how it's worked. we had, there was a bullying case that started on facebook. very often, i which facebook, should really should fund half of these kinds of programs. [laughter] >> and google. >> yeah. somebody made a comment about somebody else's boyfriend. before we knew it, there were three girls jumped two girls and one of the girls had a broken eye socket. so we have a community congress -- conference and what happened in that conference with that bullying incident is what happens in 10 out of 10 bullying incidents we handle this way. the girls who bullied the other girls ended up in

tears talking about the times that earlier in their lives they were bullied. so we get this snapshot about how violence begets violence, whether you are a victim of it or you're a perpetrator of it. it becomes this cycle. and so the parents agreed to pay the medical bills for the girl who had the broken eye socket but what all the girls agreed to do and decided to do and figured out that they would do it there and then, is that they would get together after the community conference and create a presentation about their experience of bullying. and they were going to give that presentation not just in their school but in four other schools. then each of the mothers and parents agreed they would provide, rotate and provide transportation when the girls made these presentations. so there are no longer victims and offenders. there are young people who are, have made bad choices who have learned how to do

it differently. 10,000 people in baltimore have participated in the community conference and 95% of the time they come up with an agreement that they abide by. but not only that, there's 60% lower reoffending with the kids that go through community conferencing than if they went through the juvenile justice system, at 1/10 the cost of going to cart. the maryland department of juvenile services with a $270 million budget can't find one penny for this program that they refer cases to year after year after year. we know what works. we know what doesn't work. the jerry springer model of dealing with each other doesn't work. right? but we need to change our culture. we seriously need to shift funding to programs like restorative justice programs that get better outcomes than the antiquated, costly,

ineffective, you get how i feel about our current system? ways of responding to harm. we need to give our young people experience opportunities. this is not about a curriculum. this is experiencing ways to learn how to deal with conflict constructively because conflict is part of being human. and we need to learn how to have healthy, we need to learn how to have healthy relationships. if i can borrow from my sailing buddy, when something breaks on the boat, we have the technology. what we don't have is the political will to use it. thank you. >> thank you, doctor. mr. rosenberg. >> thank you. good afternoon, chairman torre and chairman. my mom sent me a texting tell joe i love him. i have to share that. >> i'll take it. >> members of the task force, friends and colleagues who are here today those who care about reducing violence

to children wealth come to baltimore. perhaps you have received a copy of this report with your material. we collect over 850 butterflies every year and that number continues to grow. this is a very real manifestation of the scale of the problem here in baltimore city and nationally as well. we proudly hang each one of those butterflies from the ceiling at the center and recognize every butterfly is different. everyone has its own unique story. each one symbol lieses transformation that occurs with each child in each case. today i believe we have all had the privilege listening to many stories from victims and survivors. we hear those stories every day, baltimore center. 24 hours days a week. seven days a week. child advocacy center and in my written testimony but a child advocacy center like baltimore child abuse center provide as single interview

and reported contact for every reported case of sexual child abuse in baltimore city. we break the silo. we watching and participating in these interviews our detectives and child protective workers and prosecutors. for some the interview results in the bad guy going to jail. for others it results in a child protective services intervention of some sort. and for many this is a start of a connection to therapy, to treatment, for both the child and the nonoffending family members who frankly when they come to bcac they report they too have been victims of abuse. abuse is a multigenerational situation where many are getting help for the first time when their child has been abused as baltimore child abuse center. we have one of 700 centers nationally. we're the third in the country. these are centers that are urban and rural. they are suburban and nonreservations and governed by standards set by the national children's alliance in d.c. and child advocacy center in huntsville, alabama. they came about by unique

circumstances. former congressman bud cramer, former district attorney in huntsville, alabama received his first case as d.a., whether by fate or the office was making his life difficult they gave him a child abuse case. when bud went to interview the victim, in bud's own words the victim says if you ask me another question i will kill myself because bud realize the child had been spoken to 14 different times. everybody spoke with the child. he had a radical idea. he broke the silo. i bring together police officers and social workers and everyone said but you're crazy. 25 years later that model works. that is what we have here. yet not every case and every child gets seen by the cac first. the amazing part, i echo judge martin my testimony has evolved, maybe disadvantage of our ipad culture, i was sent this disturbing report by our clinical director just this morning. she reported to me that a 6-year-old had come home and

asked his parent if he was going to jail because two police officers came to school with guns and another person, a cps worker was also there. he reportedly was crying and scared and he told them he couldn't talk about what happened with his cousin. apparently a report of abuse had occurred and police, rather than bringing the child to us, had brought the child, had responded to the school. and doing what they meant to do best but they show up with guns there and asking police-like questions. the child displayed ages sight that week and had disruptive sleep the mon indicated, she filed a formal complaint about the process. and stated that what she experienced did not put her child's needs first. and the reason i'm able to share this story is because our process is able to share the failing of our system as well as the successes. so we can take this incident and send it to the leadership of these different agencies. so when reports are different, these cases are very different and reports of abuse need to be handled

differently than a regular investigation. cops, prosecutors who come in contact with these cases often need to unlearn their basic skills and use their investigatory traits differently. we all live in a world where inconsistency is normal, impressions change and people who protect those who harm them don't know why they were harmed by those who were charged to protect them. these victims respond differently to violence than other adult witnesses of crimes. those factors have taken into consideration in every interview. our center reduces trauma by providing a single point of contact at a child family friendly facility. this multidisciplinary team meets weekly to make sure no case falls through the cracks and adherence to protocols and procedures by law enforcement. we provide that training and that urgency as well. we also educate the community on a very tight shoestring budget to urging adults to take responsibility for protecting kids. as we learned unfortunately over these last few weeks with penn state and syracuse adults have to report abuse. it is not strung enough for the child himself or herself

to report what happened to them. we need to be on the lookout and stick up for these kids. there are great need for community collaboration. that is how i met jackie kuhn who testified before you. she wanted to start her own nonprofit. i said running a nonprofit i said last thing you want to do. i encouraged her to work with us. she is model volunteer. i would hire her today if i could find more funding. we need more community collaboration. that is one of the recommendation that is the task force can make. programs need to work together to support successful and existing efforts. we operate a big tent so we can bring everybody under this tent and we do more than just helping in cases of child sex abuse. as local law enforcement agents many who have been here today, have come across their cases they recognize the fact we can help make their investigation better. not just in a child sex abuse case but also in cases of human trafficking, witnesses to domestic violence, other forms of child maltreatment. we're breaking the silos and inviting those people to

come to our center to help them with their investigation. however there are still other systems need to be a part of this the school system, juvenile and justice, parole and probation. these systems need to be added as well. three things need to happen. i defer to my colleague to distinctly outline next steps and i see these are good recommendations that can happen to all of you. one is, funding to defend childhood must be made a priority. there are just insufficient funds to support even understanding for these most critical programs. nationally they are simply cobbled together through a variety of local and federal and philanthropic funds. here in baltimore we barely get funded less than 10% by the city we strive to serve despite the fact our process has been estimated to save over $1,000 per child which translates to one million dollars saved per year. congress recently reauthorized the victims of to 18 dal million. it is money that is

appreciated but woefully insufficient to fund the cacs and make any significant change. we are the best practice of cacs. i off the fenn cite studies we help those abused and recommend greater funding be readily available so centers like ours and collaborative agencies to provide greater support to our communities. two, i have to agree with what many people have said. we need public awareness and prevention education. this needs to be brought to the highest level. this is the public crisis going on right now in our country. if this was a disease we would have our mission to the moon process of bringing everybody together to find that cure. and yet the numbers of 75 million children who will be abused over the next 18 years dwarfs anything else that we're doing. and those become the root causes for all the other ailments we're throwing money at right now. bullying and childhood obesity and truancy in school. not to minimize those but we can help affect that change if we begin to publicly

educate people on need to stop abuse. there are many great models of prevention education that exist. they need to get into the hands of parents and of schools. chief goodwin is correct. many children feel safer at schools. we must find ways and fund ways to this in there. many states are starting to go online do that. vermont, illinois, texas, north carolina some examples are beginning to have mandatory education in their school systems. i believe that is recommendation the task force has, every state, every state must have some form of child abuse education available to it. finally data sharing. doctor maringer is absolutely right. we need access to the great trove of data out there are still many silos that exist. i love judge martin's suggestion that you have principle in the courthouse accessing those data. even if we can't innovate someone look at the data. we need better data sharing here. qist oven the school system doesn't know the child they are about to put out for

truancy is a child abused. i commend you for opening this up today and answering questions and taking first step at reducing child abuse and maltreatment and children's exposure to violence and know that we're here to help. >> thank you, mr. rosenberg. i want to open it up for questions. we have about 15, 16 minutes for questions. >> thank you. thank you very much. i have learned a lot and in a very short amount of time and i just, i have a question about the, i guess for judge martin and dr. abramson. are there any cases you would screen out of the work that you do? in other words, are there cases that are so egregious that sitting in a circle could potentially create more problems than it could potentially solve? >> first of all, i wanted to mention earlier that our model courts also include tribal courts. the national council of juvenile family court judges

i went as an individual to testify on congress on the hill to include tribal courts in the cip funding. so tribal courts this year are included in cip funding. but your answer is no. we do child protection mediation in cook county. i do domestic violence cases and all other cases and the way we do it may be different. so i have team mediators. i have two mediators. i never do them with one single mediator. i have the deputies around. if the person is in custody i have extra protection for the staff and the mediators. we do put in different protections but i will not preclude any case from going to mediation. i might make it go more than once because mediation in my jurisdiction talks about all the non-legal issues. who is going to help the kid on visits to drop-off? drop-off visits? parenting time with the dad when mom is in new relationship and dad can't stand mom or the new parter? --

partner? those issues how to get along with the family. even if the person is in custody and not a murderer they will get out some day i have to be certain they know how to communicate on behalf of my child so i demand mediation. the more serious the case, the more serious the felony, the more violence involved the more i require mediation. >> even if the victim is a victim of the violence doesn't want to participate? >> i will still require the mediation. the victim doesn't have to participate. and i have an advocate there for the victim. if the victim chooses not to participate that's fine but i still, they still have to, they have to figure out how to communicate. families have to communicate for my kids. >> i would say the same thing except for that we maintain the process as a voluntary process. so if anybody, any of the key participants decide not to, then we won't do it. >> thank you for asking that

question. i had the same one. thank you very much. but at the end of the last panel i asked a question i was told this panel should respond to. over and over again we've heard about the importants of multi-displinl nary, multiagency community and public sector collaboration, sharing of information. my question is, what are the impediments, if any, that we should address to multiple agencies sharing information own a case-by-case basis or on an overall program planning level? >> may i? >> excuse me. thank you each of you. you were excellent. it is late in the day. >> in baltimore one of the impediments is territory and silo and sort of the need that there is a, a lack of will power sometimes or even a lack of understanding that we can share that information. so it steak as lot of time, you know, for me as an executive director. i meet with school administration as well as school principal. we have to educate both the

top level and the bottom level, we're here to help and we can provide some information-sharing. frankly it is perhaps confusion of the hipaa laws even, that people are so deathly afraid of violating hipaa they don't realize we have that multidisciplinary agreement in baltimore, that the state attorney's office can share with the police who can share with the department of social services who can share with health practitioners. howard and i sit on a committee where we talk about how we bring in primary health practitioners so we can share that information with them as well. it is remarkable in year 2011 we're still so far away from that, we're intricately wired and connected every other way and follow my tweets and postings in one sense but in another sense i have no ability to sort of tie the various portals of information together that serve a child or a family. we found sometimes four and five agencies may be serving one household at any given time. it is a waste of money and what a waste of time and resources if we could

streamline that. some of it -- >> your recommendations? >> the recommendation? i think the recommendation needs to say, there needs to be a recommendation that these people need to work better. that there can be information-sharing. there can be, i guess laws that can be put out there, sort of opening up greater exceptions so that information can be shared. that there can perhaps be incentives put in place, if information is shed up and shared setup that, you know, these are programs that may be available, you know from federal government down in terms of that. similar to how we have incentives on your highways there is lot of highway money tied up based on what the state or local jurisdiction does. why can't we do the same thing with federal justice money. >> this would relate to your common language issue. >> absolutely. and i think there are, regulations that forbid certain information-sharing and schools and others in particular often don't want to share the information that they can share because

of turf issues and other such things. and i agree that it should be incentivized. just like we've incentivized the, federal government incentivized electronic medical records, why not incentivize appropriate information-sharing at that level? i think that would make a big difference. >> i'll just say on a very local level all you need is the judge's order [laughing] we had the sail problem in cook county. all i have done is issue an order to hospitals to get medical records. i sent the order saying it has to be first in line in the medical records department. no one questioned my jurisdiction so i kept going. going to public schools, likewise. i told you went to iep. i had no jurisdiction to be there but i was issuing orders. the guess appellate court has to tell me i'm wrong or no one fixed it out or taken a court order. >> i will file that order.

get a copy from you. >> really quickly. we you all are wonderful and like to have all of you in my community and everywhere in the country. i do want to, we're a big country and there are lots of reasons why things don't proliferate but we keep hearing the same story anywhere you go around the country. at the rate of getting you going, dr. abramson and mr. rosenberg, could you please briefly say something about come, out of $240 million your program doesn't get any money and how come there is so little money going to you? lastly for the two of you, how come we're not talking from the child's perspective as a guide to addressing? what is going on here? >> we're not very smart [laughing] i'm -- >> anything you -- [inaudible] >> sure. 90% of the juvenile justice

budget is going towards those kinds of detention interventions that dr. mccarthy said, not only don't work but often make people worse. why? i would loaf an answer to that question. >> i think some of it is due to priority-setting. that children are not a priority. children don't vote. children aren't, your taxpayers. i think that is easy to sort of shuffle them on the side there. in baltimore specifically, we are obsessed with the homicide number. it is in the paper every day. we look at what the count is for the number of homicides this year and yet when you look at the number of other crimes that are occurring, you know, blows away what the homicide number is. if we reapportioned our focus, your impression of baltimore is the wire when perhaps should be charm city cakes. i think that is part of, we're just focused on the wrong thing. we need to have more people saying let's look at children there. let's prevent this child from becoming a homicide

statistic later in life by giving him services today. >> i think one answer our science and our knowledge is way ahead of our political will. and that the more complicated the issues are, we're talking about a very complex issue as we disever coulded today. the less, it is not sound bite and that's one of our great dilemmas. people don't really want to delve into and think about the most complicated issues and child development is very complicated and the impact of trauma on children's functioning and the development into adulthood is very complicated and that is something that takes time and effort and that we, it is, as i said it is not a sound bite. it is not something that people regularly and easily pay attention to. >> mr. rosenberg, i have a question for you. i was pleased to hear you say that in addition to the

mainstream child abuse cases that we're so accustomed having sent to a child advocacy center that you all are starting to provide services for sex trafficking victims? >> right. >> can you explain to the task force, first of all, i think the task force is already aware that these are victims who really experience exposure to violence, perhaps more than most victims and so, could you explain how you are able to get your cac to embrace that as many cacs are not willing yet to evaluate or provide services for sex trafficking victims? . . look, i got this

great program. use it. and i think part of it is just again breaking these silos and, you know, that our program runs in contradiction to some sense to other cac's nationally who are very governmentally focused and this is our box and this is what we shall do and this is what we shall not do. so even neighboring counties in this case simply because they recognize we can do this better. but the centers need to have your backing from both the department of justice and i think they need to have the funding in order to make it due. every interview cost business $800. and i'm eager to do these

interviews and we've gotten some grants and we cobbled something together but i also can't unring the bell at this point. once we started the process, how can i not give an interview now to a victim of human trafficking? so we do it. >> i'm going to try to get two more questions in, ms. mendoza. >> first of all i want to thank you for sharing your stories on expertise and your time and commitment. you run excellent programs but i wanted to see if there was any component or opportunity for you to become leaders. and step out of the shadow of just being victims and those that are in need of services and be seen as someone who is powerful and a real stakeholder in our community. that's something that i hear a lot from the youth directly, you know, when they say things like me, when i go to teen lounges and hang out with them in jeans and they say, well, who are you to tell me, you know, what i need? who are you to tell me what services are best for me. and i'm stunned.

you're right. let's talk about it. so i want to know is there any program or components to your program that give the opportunity for that youth? >> i want to mention two programs that do it very well. one of my benchmark is as most of the jurisdictions in this nation -- all of my kids are older today. most of my kids coming into foster care are not newborn infants. most of my kids are 13, 11, teenagers. and so this program is designed for older youth. the whole hearing is a two-hour hearing that's set aside. i don't accept reports from the doc. the doc has to come in. i don't accept reports from the staff person at the intervention centers. they have to come in. and the idea is prior to the hearing beginning, the youth sits down with the social worker and talks about and fills out the forms that are developed. one of them is what do you want to be? so a kid came in and told me they wanted to be a lawyer. the social worker said she

wanted to be a cosmetologist and i said, that's a little different. and the worker said, well, she's reading so far below grade that she will never be a lawyer. and i said i know a lot of people that have degrees that can't read so -- [laughter] >> but the point is it's focused entirely on the child. it's focused entirely on what the child needs for the adults to do to support his or her dream. the other ones are mediation program and my exit interviews with the participants talk about, this is one of the first times throughout the entire court system that they feel their voice has been heard because they have the privilege of sitting down and saying how this affects them and what affects them the most and what they need out of these hearings. so i think there are programs throughout the nation and those are just two right in cook county that work very well. >> i just -- we actually had just started a program with some of our teens who have gone through treatment and come out to be peer mentors to some of

the younger children and actually everyone we've asked has agreed to do it. so we'll see how it goes. it just started. >> all right. dr. macy? >> so i wanted to thank all of you for speaking both from your expertise but i think particularly from your hearts and especially the rewrites at the end of the day because you boiled a lot of the information but it wasn't all just from your intellects, which are profound and experiences are from your heart and you all spoke from your heart -- and i think this is an upper, not a downer but to bring up a concept and to get a quick reaction from each of you, maybe something you can think about and help us out as we move forward over the next 12 months to get this report done. if we think about as steve has brought up, child development and what we would called child-centric language, right, and how difficult development becomes when there's disrupted

attachment, trauma that impacts development, underneath that trauma, i'm going to propose is oppression, transgender enslavement so that at this point in time in america, we don't have birth equity. we don't have employment equity. we don't have educational equity. and that it is in my view anyway a large feeder cycle of trauma. would you have any comments with respect to the structural racism oppression that continues to, unfortunately, keep a large portion of our population in a place where it's very hard for them to even catch your breath? >> yeah. i'd love to respond to that, robert. i actually think if we -- if we look at what is also called deep poverty, you know, we use poverty as a sort of wide range term but there is something called deep poverty,

multigenerational poverty of families that have been impoverished as long as we have measured. and if you look at those families, and the studies have shown in, i think, the nis3 -- i think it was 1992, if you made under $15,000 a year, the rates of maltreatment were 22 times than if you read over $30,000 a year. 22 times. that is the cycle of violence and it's also the cycle of poverty because those same things who are mal treated they are unable to learn well, they don't do well in school. they have health problems and they end up homeless and we continue the cycle. one of the issues we're never going to address, unfortunately, in this country is ensuring a liveable wage and we know that

makes a huge difference in breaking the cycle we're talking about. but that said, i think we can intervene with families, with communities to interrupt cycles of maltreatment and abuse and trauma. and i think there are multiple ways of doing that and every time we identify a child, we're using the family and the family needs a whole intervention as do the child and that's the opportunities we have and that's what i see as really the outcome and the positive outcome of identification. but it requires the nation, not the village. >> i would suggest that -- two things. one is that the nis studies are based on reports of abuse and neglect. it's not based on actual abuse and neglect. i would suggest there are some very rich families and some white families that have abuse and neglect in their households

as well. i don't see many of those. as a matter of fact, in cook county when a white family comes in, my office is on the eighth floor. i hear about it before they have the temporary custody hearing. [laughter] >> i actually as a presiding families were charged with abuse and neglect until i went down to south dakota and south carolina. i honestly didn't know that because in cook county they're all black. so to the point that i have no coke babies from cook county hospital, they're all from -- i mean, they're all from cook county, not from northwestern. that either means white child-bearing age women don't use drugs in chicago, which is possible, not probably, or something happens in the social investigation and workup at cook county that's different than northwestern. so i called the ama and they don't -- they haven't returned my call yet. >> i told them not to. >> my point is there's institutional racism no doubt. but institutions are developed by people. and we have people who are racist but we have implicit bias

that we overlook constantly. and i have it as well. each and every one of us has implicit bias. i mean, when i grew up -- let me use a black example since i'm black. black women have back. well, my sister runs marathons. she doesn't have back, do you know what i'm talking about, right. [laughter] >> i apologize. >> i'm with you, sister. [laughter] >> i was in kentucky talking about implicit bias in racism in court and i said that and there was a gentleman just like colonel sanders and he got beet red and i figured out i better get out of the conversation. but the point is we have implicit biases and they've been built for a number of years for a number of reasons but i have to teach my judges how to understand that they have implicit biases. hang it up like a trench coat in their chambers and go out and in their courtroom and make decisions that are devoid of that implicit bias.

likewise, i would suggest that the residents coming in, the medical residents, the social workers, the law students coming in have to learn that too. and so that's one of the reasons. judges aren't the answer. but we are part of the answer. and when we understand that racism is about implicit biases as well, that means there's something we can do about it. so contrary to what you said, this is something that we can change. we have to be willing to change it, but we can impact it in a positive way. the national council has developed a bench cart on implicit biases for judges so that we can start looking at this issue. and i hope that we'll have an opportunity to supplement our written testimony or provide additional oral testimony on some of these specific issues for you because these are issues that the court is looking at and working towards eliminating. >> thank you. >> can i take a really short -- >> real short. >> okay. i'd really like to refer to the task force a short book by a

woman named grace lee bogs called the next american revolution. she's a 96-year-old activist. and she offers that the next american revolution will not be about equality. but about who we are as human beings. and she talks very cogently about what we need to do because all these jobs that are lost are not coming back. we need to restructure our education system. we need to restructure our criminal justice system and we need to learn how to take care of each other and in the process, healthy as a community. and i feel like the restorative justice work that we're doing is about bringing together human beings in a circle, not ignoring the fact that there is racism. that there's all sorts of biases and oppression but letting people be human and figure out a different way to be with each other so that those biases --

get broken down and get recreated -- people re-establish relationships in a very different way. >> thank you. thank you very much to our panel. very informative. what can i say? thank you very much. it's time for public testimony right now. so -- five minutes? will is telling me -- you had a big hand there, will. [laughter] >> that's closer to 10 minutes, 5 minutes. [laughter] >> great. >> the c-span network will have live caucus coverage beginning at about 7:00 eastern. we will

♪ >> we appreciate all of you coming out this morning so early and being here and caring. i think we all care right now. i think we're all concerned about our country. ♪ >> i believe in him. i believe he has the experience. i've seen him in every situation. i've seen him as a husband, as a father, as a governor and as a successful businessman. everything he does, he does well. and he does it with his heart and his commitment. >> this election is about more than just replacing a president. it's about saving a vision of america. we still believe in an america that brings out the best in all of us. the challenge is each of us to be better and bigger than ourselves. it's time for this pessimistic president to step aside and let

american optimism that built this greatest nation on earth build a greater future for our children. ♪ >> if you can get out here in this cold and the rain coming down then you can sure find a few people to bring with you. and on the way to the caucus you could tell them just who you're going to vote for. i believe we're restoring the principles that made america great. [applause] >> and, again, coverage of the iowa caucus begins on c-span at 6:55 with a preview program, the caucuses get underway at 8:00 and c-span2 will have coverage starting at 7:45. go to facebook.com/c-span for more coverage of tonight's

caucuses. exclusive pictures on the scene ground and the white house video clip of the day. add your comments and vote in our facebook poll question will the winner of the iowa caucus become the republican presidential campaign. >> this past november the center for a new american security released its report on military suicides. the report was called losing the battle, the challenge of military suicide and they identified challenges associated with service members and veteran suicides. according to the report, between 2005 and 2010, service members took their own life at a rate of approximately 1 every 36 hours. this is about an hour 20 minute minutes. >> good afternoon, ladies and gentlemen. thanks for being here. my name is john nagl. on behalf of all of us at the center of new america center.

i would like to welcome you on this discussion on the important challenging and very, very right now question of military suicide. our nation has now been engaged in war for more than a decade, the longest period of continuous combat in our history. the all-volunteer force has performed magnificently but is showing signs of strain, including troublingly, a steady increase in the number of service members who are falling by their own hand. the problem is urgent. a good friend of mine currently serving as a brigade commander has lost five soldiers to suicide just this calendar year. this problem demands everything we can do to solve it. those who volunteered to serve us deserve our support when they themselves are suffering. dr. meg harrell, des senior fellow and director of our joining forces initiative has written a policy brief titled losing the battle, the challenge

of military suicide. losing the battle examines this crisis dispassionately and suggest the number of solutions that may help diminish this horrific loss of our most precious national resource, the lives of our sons and daughters who have chosen to serve their country. to discuss this issue with meg, we are honored to have back with us general peter chiarelli, vice chief of staff of the united states army. no one has worked harder or done more to solve this problem. no one has done more. >> thank you, sir. mra[applause] >> we also welcome dr. an kemp mental health director program of the veterans affairs which has an important role to play in helping those who continue to carry the scars of their service after they have taken off the uniform. the panel will be moderated by

juliet kayyem, national security columnist for the "boston globe" and a lecturer in public policy at harvard university. from its founding, it's an important component of our national security. the reason soldiers fall by their own hands are many and complex and they re-enforce each other in ways that are hard to understand. solutions are also complex. no one agency or organization can do everything that is necessary to solve this problem. but many can help. we are honored to have the support of a number of philanthropic partners listed at the end of losing the battle who share our concern about the health, employment prospects and education of those who have sacrificed to serve us. our partners have joined forces with us to think about this public -- this pressing public health issue and to attempt to

find solutions. thanks to them, thanks to all of you here and to all of you joining us nationwide via webcast for being part of this important discussion and juliet, the floor is yours. >> it is an honor to be here and i want to thank cna s nancy betterglass who a co-author who is not here and the whole community in their efforts of exploring the issue of suicides among our service members and veterans. i have been in government and recently left as assistant secretary of the department of homeland security and returned to boston where i do write a twice a week column for the globe and it was starting to write about the wars and how they were ending that this issue began to interest me and didn't seem to have enough national focus as it should warrant. for someone like me not familiar with these issues, my several-month exploration with the help of dr. harrell and nces

and how the wars and the impact they have had on our military is surely going to be a critical challenge for not just our military but the united states government, our political leaders and our citizens in the decades to come. the wars may be ending in some respects but they are not over. the report, which i have had an opportunity to read is a straight-forward examination of what can and should be done to address one persistent and troubling problem, suicide. as the report reports from 2005 to 2010, service members took their own lives at a rate of approximately 1 every 36 hours. the va estimates that a veteran dies by suicide every 80 minutes. we'll talk about drilling down on his numbers. now, these numbers are complicated. the army is in a different position than the air force or the navy or the coast guard. veterans data are difficult to manage given the challenge of data-collection but as you read and examine the report and listen, there are two important take-aways, i believe, for those

of us who are grappling with the policy, of course, for many of you the personal consequences of this issue. first is the how. how can we best adopt policies indeed some of the recommendations are in here at a time when resources are scarce, congress is divided and much of our political focus is, of course, on the economy. and then the second is the why. i know this sounds obvious. we have given the issue we're talking about, but an important aspect of this report is making clear why we need as a government and as people to get this right. it is, of course, about our service members and our veterans. but as the report and dr. harrell and nancy betterglass talk about the future of our military an all-volunteer military. so i want to begin with setting the stage for the report and the findings in the report with the co-author, dr. harrell. >> thank you to everyone for joining us today, both here in this room and also online.

thank you especially to my copanel members for bringing your tremendous expertise to today's discussion. one challenge of the topic of suicide is that research is unable to quantify fully the number of lives that are saved by the tremendous efforts of individuals such as general chiarelli, dr. jan kemp who devote considerable energy in improving the resources available for our service members and veterans. today's panel is the first event of our joining forces initiative at cna s. as an independent partner, the white house is joining forces initiative, cnas has an agenda and research in analysis in three areas, employment, education and wellness. this work on military suicide was conducted in the context of our wellness research. i have been asked whether for

the first cnas joining forces product and event we should have led with a different topic rather than military suicide. after all, there's only a small minority of service members and veterans that die by suicide. we feel, however, that it is too large a minority and too significant an issue to ignore, given that these tragic losses affect many individuals besides those victims. the army brigade commander that dr. nagl mentioned recently brought his command team to cnas for a discussion. our conference room was overflowing with his officers who only wanted to discuss military suicide with him because they deal with this every day. because it's happening now and because changes can occur now. further, the importance and urgency of this issue pertain to more than the service members and veterans who tragically die by suicide and their families. military suicide is a national security issue. george washington said, the willingness with which our young

people are likely to serve in any war, no matter how justified, shall be directly proportional of how they see the veterans of previous wars will be treated by their nation. if washington was correct, suicide among service members and veterans threatens the health of the all-volunteer force. mentors and role models including parents, teachers and importantly veterans play a critical role in the enlistment decisions of young men and women. we should realize that these mentors and role models will not steer youth toward the military if they perceive damage to service members or failure to address the mental health care needs of those who have served their country. our policy brief acknowledges that eliminating suicide among service members and veterans is an unreasonable goal. however, there are some obstacles to addressing suicide that should be resolved. some of these obstacles can be addressed within the military services while others cannot. some of these obstacles are

especially difficult to eliminate. at cnas, we felt urgency to host this and guess to release our policy brief because we believe that we have actionable recommendations that can help address this issue. there are actions the services can take internally such as continuing to address the stigma of mental health care, establishing a post-deployment unit cohesion period, encouraging service members to answer their post-deployment health assessment questions truthfully. and coordinating legal investigators with unit commanders to ensure the safety of service members. some of these actions are being taken in some of the services. and with some success. there are also measures that can be taken specifically for the guard and reserve to include establishing communication plans so that unit leaders have interaction with their troops between drill weekends and developing a system-wide suicide prevention program for the guard that does not depend upon dwindling state resources.

we also have recommendations that cannot be addressed solely within the military services. dod military treatment facilities needs the authority to conduct take-back programs of excess prescription medication. military leaders need to be able to discuss personally owned weapons with their troops. and military service members and family members need to be able to maintain a relationship with the mental health care provider that they have invested in, even if their service moves them to a distant installation. finally, we need to understand how many veterans die by suicide and who these veterans are. that will require the coordination and cooperation of the department of defense, the department of veterans affairs, and the department of health and human services. we know that the number of active duty suicides nearly doubled over the last 10 years from 160 in 2001 to 295 in 2010. by va estimates, every day

equates to the loss of another 18 veterans by suicide. this is happening now and we need to address this now. >> thank you. thank you, dr. harrell. i'm going to turn next to general chiarelli and first thank him for his tremendous work. if you just begin this issue, the work you've done has saved lives as meg has said. i want to know if you could provide a context for the understanding of both the problem and the solutions and the work that's being done to address this problem immediately. >> well, thank you very much. and good afternoon. i appreciate the opportunity to participate in this important discussion. i must correct those numbers. we had 162 active component soldiers commit suicide in 2010. 162 active component. that's before 700,000. 295 was the numbers of the suicides of the entire force.

1.1 million to include guard and reservists. as many of you know for the last two and a half years i have served as the army's lead for integration of the ongoing efforts to reduce the incidents of suicide across our force. back in january of 2009, then-secretary of the army pete geren and general george casey tasked me with lowering the rate of suicides. evd i approached it like i did y other challenge going back to my days as a commander at just about every level. i'm an operator. and i approached it like an operator. they wanted me to lower the rate of suicide, i was going to lower the rate of suicide. i quickly learned it wasn't that simple. in fact, the challenge of suicide has proven to be most diflt in my0ears i the litary aifhe's one thing and ing t psh backittle bit because th's what you would expecte to do wodn't you? if there's- s one tng

in parcul i would take fense to, with the response of the report is that we have d little and certainly not enough. to addre thiscould nobe further from the truth and i do not believe we are losing the battle as the headlines say. to the contrary, i believe we've made tremendous progress in understanding very, very complex issues in making sure that leaders and soldiers understand them. i sit through a senior review group meeting which is once a month for two hours, to review every single suicide in the army. we have unit level commanders, members of the medical community, all together in discussion, and i can attest after doing this for two years, the circumstances surrounding each suicide are as unique as

the individuals themselves. that's what makes this issue so incredibly tough to influence one way or the other. that said we greatly expanded the resources and support services available. and we're working hard to eliminate the long-standing stigma associated with behavior health care. and that's just not a military problem. that's all our problems, the stigma associated with mental condition. the funding programs and services in instituting them army wide -- that's the easy part. the really hard part is eliminating the long-standing stigma, breaking down the invisible barrier that is prevalent in society as it is in the military. and the key to doing so is raising awareness. we take a step back in my opinion in what is already a very difficult, very difficult endeavor when someone writes or speaks about this topic in an overly alarmist way.

for without accurately conveying all the facts, both in terms of the complexity of the challenges and the efforts underway to address it effectively. one of the most important lessons we learned early on in the process that suicide is a symptom, albeit, the extreme of a much, much bigger problem. i've got this chart up at the top that tries to put this problem into perspective. we can really only gather good data on active component soldiers, although there are 570,000 in the active component, that big blue ball represents about 700 to 750 because we have soldiers who were mobilized which expand our force. that's really where i can only gather the best data because i send a medical examiner every single time that applies the same feds to every death to make a determination of death. as you can see there, as you

follow this down, you see the different kinds of high risk behavior and finally you see the little dot that we've had to go ahead and shade that shows the number of suicides in comparison to that big blue ball. finding in that big blue ball of 225 to 50,000 depending on the year, the 250 that will commit suicide is the most difficult task. and that is why we have focused on trying to identify the high risk behavior. soldiers on active duty, the red sphere represents soldiers receiving behavioral health care. that's good news. the green sphere represents those soldiers currently on prescription medication. again, in many instances, that is good news. however, as you continue to the right, you get further and further into the risky and high risk behavior. and the most extreme cases, of

course, are suicides. now, these challenges are further complicated in many cases by the physical injuries to the brain. you simply cannot have a fruitful discussion about the issue of suicide without acknowledging the immaturity of brain science. pure and simple. every scientists, researchers or doctor you'll ask will agree. we simply do not know enough about the brain. yet, the most common injuries of this war are not amputation or burns as you might think. the signature wounds of this war are actionably post-traumatic stress and traumatic brain injury. and they have been of every war. i don't know how many of you saw the hbo documentary, war torn, 1860 to -- 1861 to 2010 where they talked about in every war -- we've only changed the name of what post-traumatic stress is.

in order to reduce the incidents of risk and high risk behavior including suicide across our force, we must continue to find ways to reduce stress, promote health, build resiliency and eliminate the long-standing sigma of seeking and receiving health. in other words, we must focus on the area indicated by the red sphere and address these issues and challenges as early as possible. to answer your question, what are we doing to address the issue of suicide, over the past 2.5 years since the establishment of the health promotion risk reduction suicide prevention task force and council in march of 2009 and the subsequent publication of our report in 2010 often referred to as the red book we instituted a number of very effective program and policy changes across our force. these include access to behavioral health care that includes telehealth and the most comprehensive health program, stigma reduction efforts, mental fitness and resiliency training

program, expanding family support programs, expanded substance abuse programs. this list merely skims the surface. and the programs initiatives are having an impact. we believe we are, in fact, making progress. now, i expect many of you will respond, well, then, why haven't your numbers gone down? reality is it's impossible to improve a negative. and when you look at active duty suicides last year in the army, they went down by 6. the reality is, it's impossible as i said to improve that negative. i can tell you how many did tragically make the decision to take their own lives in this past year but i cannot tell you how many contemplated suicide. yet, as a result of our collective efforts did not end up going through with it. the fact is that behavioral health encounters increased 12% in fiscal year 2010.

virtual behavioral health care benefits soldiers located in remote locations or apart from installations have also increased significantly and that is very, very encouraging. now, i'll be the first to admit there's still much work to be done. any suicide or high risk death is one too many. this is an enduring challenge that requires an enduring commitment and we must continue our effort. we owe it to our men and women in uniform and their family to ensure they have access to the very best care, treatment and support when serve on active duty as member of our reserve component and also as they separated or retired from military service. the army is continuing to work closely with our sister services and with dod and the department of veterans affairs toward this effort. i'll close my opening comments by simply stating for the record, i am incredibly proud of all we've accomplished today to reduce the stress of force, reducing the risky and high risk

behavior, reduce stigma or help-seeking behavior and ensure soldiers and families in need have access to the appropriate care and are able and going to take advantage of it. thank you again for the opportunity to participate in this event and i look forward to a great discussion. >> thank you. [laughter] >> general chiarelli. before we went on to the doctor i think it's important those listening on the webinar so i'm going to go out of order here. dr. harrell, where are we on the numbers? why is there this disagreement so that maybe even if we're just talking about a different set at least everyone is on the same page? >> it's a great question. 'cause the numbers are tricky. so the number that i cited is the active duty number. that includes active component personnel but it also includes guard and reserve personnel that were activated at the time. >> what numbers? >> the 295. >> that's not correct. >> well, let me speak to that

for a moment because it matters literally what day of the week a reserve or guardsman dies by suicide. that affects which number he's counted as. the numbers also shift as investigations occur and past events are resolved into suicide or not suicide events. the numbers change a lot. it's important to assess that. i think we agree in many ways -- i think one way that i do disagree is i think we're losing the battle multiple times a day right now. >> i just have to correct those numbers. the total number of activated plus active component soldiers is somewhere between 7 two have 5 a -- 725 to 250. the year before it was 1 cirque 2. we had a decrease of six active component suicides last year which included mobilized reserve

component soldiers. it's important you understand those statistics because in those instance when a soldier is activated i send a medical examiner out for every single death. that medical examiner applies the same standards to that death in determining whether that death was accidental or suicide. that's why we parse the numbers that way. that is a total between 725 and 750 depending on the year. we had a huge increase last year in suicides of soldiers who were not on active duty, and that's the 295 number when you include that number in with those who are on active duty. the problem with that number is, it's probably underestimated because every single community investigates and applies different standards to death. and we all know the pressure that is sometimes put on medical examiners not to categorize a specific death as suicide.

so i think the numbers that i have the most confidence in, are those numbers of folks who are on active duty, actual guard, reserve and active component soldiers when they die because we're able to apply the same standards in making it a determination. i'm not saying the standards are right, but there's the same every single time because that's how we investigate those numbers. >> are those numbers for the army only? >> okay. my numbers are total. >> okay. and we haven't even gotten to veterans yet. so the numbers -- the numbers issue gets more complicated. i think everyone is sort of on the same page. the numbers are going to be different depending if you look at active units which is now 156 and the -- and your number is -- >> 95 all-service. >> 295 all-service. in any event, everyone at this table agrees a problem that's too big for anyone's purposes

and we have not gotten to the veterans so i want to turn to dr. kemp to discuss -- dr. kemp, when i read the report and the work that's being done for the veterans, of course, a primary issue is what number are we talking about? and then if you could talk a little bit about how are you approaching this systemically given what we're about to encounter as folks with the afghan and the iraqi war veterans? >> i'm actually going to make the numbers debate a little easier. >> okay. >> and tell you i have no idea. [laughter] >> many veterans a day die by suicide and it's silly to think that we don't at this point. i think if you read the report, you'll certainly understand basically in the recommendations that we need to solve the numbers problem. and we're making huge strides in the va with or dod and our cdc

partners to do that but it's not happening quickly. secretary shinseki has taken on this goal himself, has brought in the support of the governors of our states. we're now getting data on a more timely basis that talks about veteran suicide and we're able to put that together and come up with some estimates which you've seen. and you've seen the estimated numbers of 18 veterans a day dying by suicide. honestly, i don't know how correct we are in that. it's our best guess right now. i also want to address the title of the reports a little bit. i think as long as any veteran or service member dies by suicide we are, in fact, losing the battle. but i do maintain that we've made huge strides towards winning the war over the past

several years. and we will continue to do that. the va has taken the stance that suicide prevention is based on ready access to high quality mental health care. and to that end, we've instituted a whole series of programs that i won't go into now but certainly am available to talk to any of you about it at any time. probably the most visible excess mechanism that we've instituted in the past four years is the veterans group which has taken over 450,000 calls into the line from veterans, families, and service members. the fact that we continue to take those calls -- i have to tell you, when i was first approached about opening the crisis line, i said, you know, i don't think veterans will call. i think we have crisis lines in

the country. why don't we use those? i'll help facilitate those connections. and i was told, jan, why don't you start a crisis line. i said, okay, i'll be glad to do that. [laughter] >> and i have never been so wrong about anything in my entire life. veterans do call. all genders, all ages, people with all sorts of needs. if the services are there and help is there, people are reaching out to get them. and so our task has become being available, which you all know is a slightly different take on va services. and it's working for us in all sorts of ways and shapes that we didn't imagine. and we'll continue with that effort. getting people into services is a major issue, providing those

services, once we have them is another major. and we too have expanded programs. we've opened up telemental health programs. we've increased mental health services at community-based clinics but you're all sitting there looking at me saying, it's not enough. and we know that. and we'll continue to find out where we need to put more services and more time and more energy. and we will continue to grow those programs and to offer people what they need. and that's a promise we're making. >> dr. kemp, i wanted to -- on the numbers because i think this is just a key part of the -- of the -- we'll get into the recommendations as well but the key part of the report. no, no, can you explain to the audience why is it so hard for the va? because i don't know if people understand why that part of the numbers is difficult for the va? >> if someone is active duty and they don't show up for work the

next day or they're missing out of their unit, they're obviously gone and someone looks for them and finds them and finds out what happens to them and knows that they died, veterans have no obligation to check in anywhere at any given point in time, ever, about anything. and so [laughter] >> and either do i, you know. and we don't have the luxury i should say of knowing when someone chooses to take their own life when they choose to do that. so we need to rely on -- for veterans who get care in the va which is not everyone by every means -- them not showing up for an appointment which may or may not be scheduled. if you or i don't go to our doctors' appointments very

seldom does someone call or find out where i am or why i didn't come. but we have instituted programs in the va to do those follow-up calls and find people. if they don't get care in the va we don't know that they've died. so we rely on the state. death certificate data to provide us with that information. not all states collect or report veteran status to the center for disease control, which is the overarching group that maintains death numbers in the united states. there's a small percentage of states, 17 right now to be exact, that rewards these numbers on a regular basis so we've had to take those numbers and draw conclusions from that. there's a huge time delay. right now we're working with the cdc to get the 2009 data. and we don't -- so it's not

available yet. [inaudible] >> right. >> any data that compares civilian suicides after the economic downturn 'cause the cdc hasn't published it. >> so it's a struggle to figure out -- even if we're making an impact with the programs that we have. >> general chiarelli, i want to follow up on the important one that you made on the review of each suicide every -- every suicide is a different story. if you could, though, make one sort of systemic recommendation for at least the army, either it's an obstacle that should be removed or something should be done, what do you think it would be. >> the number 1 systemic recommendation would be the study of the brain. i promise you, if there's anything we need to do, that's what we need to understand. we just don't understand enough. now, please don't take what i'm going to say as saying we don't want people to seek help from

behavioral health specialists we do. but we want them to seek help. but in studying those suicides or every single suicide, 50% of the soldiers who commit suicide in the united states army had behavioral health care. it's 50/50. it's a complete wash. they've seen someone, sometimes numerous times, sometimes and bonnie will attest to this. we sit and listen to cases where they were seeing a behavioral health specialist who indicated they were a low risk case and within 24 hours they were found dead. i mean, that is what is so perplexing about this. and until we understand more about how the brain works -- until we understand the effects of post-traumatic stress -- i mean, one number that i've seen out there is that if you have post-traumatic stress, you are six times more likely to commit suicide than if you don't have

post-traumatic stress. if you have post-traumatic stress, you are six times more likely to participate and partner aggression which is a nice term for something else. i mean, we just don't know. and if anything, we need to continue the research. now, we think we're close to having a biomarker for concussion, which will be huge. there are no biomarkers for the brain right now. i mean, the scary part for me at my age is going to the doctor, is not the examination, it's when the blood work comes back. you just hope the guy has a smile on his face because he can tell from that blood work just about everything about you except how your brain is doing. and we think we are very, very close to having a biomarker where we're going to be able to -- when a soldier is in some kind of an event which we think is a concussive environment. we can go to them and brick their finger not like you can do for a diabetic and we can tell

whether that individual has had a concussion. why am i talking about concussions. because the comorbidity between the symptoms because post-traumatic stress and traumatic brain injury are like this. comorbidity to doctors means they share the same systems and part of the problem is trying to diagnose those folks when they come back who -- the ones that produce themselves and indicate they have a problem as opposed to to those who try to hide it because they're type a people who just -- because of the stigma attached to this, they just don't want to tell anybody. >> okay. i'm getting the cue for q & a, which i would like to begin and delve into the recommendations. a couple things on the q & a, we know this is, obviously, an emotional issue for many people and want to respect that but also to utilize this form, this open forum for a discussion about some of the recommendations and some things that can can done by the government, by citizens, by

local and state governments to help with this. so i wanted, if you could, announce who you are and ask a question. if it's for the whole let me know, or if it's for one particular person, let them know. there's a microphone. i'm sorry. >> thank you. one of the myths about suicides in the military is that it's somehow tied or related to the quality of the volunteers who have signed up over the last 10 years and relate it in particular to recruiting decisions made during the midpoint during the iraq war. it's not mentioned in the report, meg, john chiarelli, you probably have the best data on this. if you could speak to that and tell us if there's any relationship between fitness measures, recruiting measures, et cetera, and the folks committing suicide. >> we found none, whatsoever. i mean, one of the difficult things for us to do is to do the evaluation 'cause hipaa kicks in, as the report points out.

there's all kinds of hipaa requirements for soldiers who have behavioral issues. many of our srg briefings go, we see many, many times an individual who commits suicide had mental health problems prior to joining the service and that only becomes visible to us after they commit suicide because we can't get at those records. but we have seen nothing in data that would show that there's anything to do with waivers or anything else that leads toward a higher incidents of suicide. i think that when you look at our numbers, when the cdc corrected numbers and i totally agree -- we don't have numbers for 2009. our latest numbers are 2008. when we collect that -- correct that population or the population we have in the service, we -- in civilian life it's 19 per 100,000, just over 19 per 100,000 suicides in the military, in the army it's been -- last year it was 22 per

100,000, an increase of 3. that is 3. that is 22 too many. and in no way do we not want to attack this problem. but the issue for me is, is trying to understand it. and it is so much more complicated than i thought it was when i set out to solve it. i mean, one statistic that i can tell you right off the back is the cases that i look at -- 72% of those cases is an individual who's got a relationship problem. 72% of the cases in the united states army last year had a relationship problem. and you say, ha! that's the reason. anybody who has a relationship problem goes into a higher risk category. well, that's not necessarily the case. because what you see with post-traumatic stress is relationship problems are the result of all the other things that happen, from alcohol abuse, drug abuse, to problems getting along with your partner, you name it, and finally, it ends in

a relationship issue. that relationship issue could be the culmination and the straw that broke the camel's back, i don't know. but that is what makes it so difficult, but i won't say relationships cause suicide. >> other panelists want to add anything, just let me know; otherwise, we'll go to -- right there. >> hi, my name is christie. i'm a 10-year army wife and the director of the coda support foundation. i really appreciate this in depth foundation, general chiarelli and i have spoke in depth about some of these issues. i think one of my concerns is when you have a title of report dealing with military suicides and no one's mentioned the suicides we're seeing among the family members. i know that there are tracking challenges to this and general chiarelli and i have talked about them but if you're going to really start trying to track the veteran population and if you look at the collaborative efforts that you mentioned with the dod, va and health and human services -- unless we can get some numbers behind this, i can

stand up to these conferences and i always say the same thing. i've lost three army wife friends to suicide and anecdotally if we don't have the numbers it's difficult to develop any kind of traction behind it. based on some of the recommendations that you made, i would say that the federal exemption of the state licensing is a huge one. it's been a big problem for us within a community when you build a relationship with a therapist and then having to leave that therapist. dod had something called in-transition. i'm not sure it still exists but it was a program that tried to deal with that. that did not apply to the family members. that's kind of the issue is that when we talk about these suicides or suicide prevention or just mental health in general, we have to be better at looking at holistically integrating. when a soldier commits suicide, they have a dod suicide event report. there's really no sop's in place

or policies dealing with what happens when the family member attempts or commits suicides. and unless we have that data, again, it's going to be difficult to get to some of the issues. finally, i just wanted to say, even if everything the dod is working perfectly and we know it's not, we simply do not have the resources in house to take care of the need after 10 years of war. so there are internal changes we need to make whether there's a joint ethics law, regulations or interpretations thereof and then there are external challenges that we all on the 501c3 need to be more effective in integrating our services into that community. thank you. >> i think you're absolutely right. there are lots of data challenges. and the need to know more about not just service members veterans, whether affiliated or unaffiliated. i think we need to know more about military families and families of veterans. >> that tracked all the military veterans through the veterans or -- >> we're tracking civilian suicides of family members.

this year we've had a total of 10 as opposed to last year we had 12. i think most of you know, because -- the cdc tracks suicides on a calendar and we use a calendar year which confuses people so our suicides are calendar year and not a government fiscal year numbers. this year we had 10, last year we had 12. we tracked civilians and this year we had a total of 22 and last year we had a total of 26. >> i think the -- one of the things the report calls for is a strong partnership between the dod and the va and the department of health and human services. and the department of health and human services has taken on somewhat of the cause of family tracking, and i think we need to work closer together. >> but i just would remind everybody. i can't make a family member report a suicide or even attempted suicide. that's one thing that lies outside of our ability even in

the military to do. so i look with suspect at even the numbers that i'm collecting. [inaudible] >> particularly, officers and nco wives and we have get our messaging that translates -- oh, microphone, sorry. >> okay. thank you. steve, i believe? >> i'd like to thank you for the report. it's going to spark a lot of conversation. meg, this question's for you. military leaders must eliminate stigma. and eliminating stigma must include a multipronged approach which must include accountability. ..

>> i will. thank you. we do think that leaders need to continue to address stigma. that may be the hardest challenge of this report. it is something that leaders at all levels and the military have taken on. i don't think anybody would say that we have reached success yet. it is something that needs to continue. it is, again, it may be the toughest thing there. as far as accountability, i would like to underscore that this policy brief was not about pointing fingers or signing blame. the real point here of this policy brief, our intent is that things need to be done as removal were to try to address this. >> we have to go back and take a

look at some of the policies we have put in place that make it difficult for military members or anybody else. one of them is that we used to, because of the stigma associated with behavior of, there is a very complicated and legalistic way that if i want to commend direct some of its behavior help the have to do it, and if i violate that as the vice chief of staff of the army after a system in front of me that i have had to adjudicate where the individual has done exactly the right thing in insuring that somebody got to a behavioral health professional but in doing so did not follow current policies that require certain things be done lockstep before you're allowed to do that, and i have had to take action on those cases. the action i have taken is to call them into my office for a counseling ride tell them they do very much for what you did in, but we have to change those kinds of things so that we can get into the 20th century and understand the behavior of the issues and injuries more real

looking injuries, and that is what we, i think as a society have failed to do, and i hope the military can up lead an effort to do that. >> have had over here. >> this one is for you. the after action review the you do after each suicide, and i'm wondering if you could talk a little more about the process and is that standardized across all the services? >> i can speak for the other services. i can tell you that a debt in the united states army starts what we call a 36 liner. we are bay into reports. partly to analyze more than these to be, but is 36 lines. in that we go into everything. this is opera was material that comes to us. once the medical examiner has indicated, yes, this was a suicide we hold what is called

this srg and discuss each case of the commander who, in fact, talks about the individual case, what was right and what went wrong, and it is always well or wrong. what they could have done about it. it is just an open discussion to try cherubim past lessons learned to all of the commanders who are listening to this. i talked to folks in afghanistan and iraq. no one is immune from having to be up to talk these. they have cases. they have to talk in brief to the vice chief of staff of the army every single month. we are trying to learn from those. and they have proven to be very beneficial in pointing in some of the policy issues that we have. you know, i just recently -- we just recently published a policy, and i think the report correctly points out that i am not allowed to ask a soldier who lives of post whether that soldier as privately owned weapons. i have to go through a very

distinct process, a commander does, of oregon as those questions for a soldier who lives of post. when you have somebody who is moderate to high risk in seeing a behavioral health specialist, the studies that i have spread indicate that when you can separate the individual from the weapon because a suicide is in most instances a spontaneous events, often accompanied without all or prescription drugs abuse, when you can do that you can lower the incidence of suicide. we have issues and even been able to do that. >> we have lots of questions. yes sir. >> thank you. army reserve. i would like to hear you speak about the real successes and how we intervene with those who actually do, and declare themselves as suicidal, having some kind of suicidal ideation.

because i am reservist, 48 days a month. part of that is with the local suicide prevention taskforce in our county. and there is not despite all of the mental health resources available, there is not within the general population the kind of attention to end trading that people can identify and respond to someone who is suicidal. my whole point, sir, and i would like to see use the to the successes. those. we deal very effectively. >> we do. some of those are the most of her cases. made dozens of just exactly as they're supposed to do and follow exactly the way you would want to do that, but if the person was to commit suicide it

is very, very difficult to stop him alternately from doing that. there really is. you can get them the help you can do so much. we have many, many success stories. how well did -- tell you, the viejo line is truly a great national resource in being able to get to somebody who can help you over the phone. they do a fantastic job, but there are all kinds of success stories out there were soldiers have intervened, got a soldier to help and get them past the immediate crisis. we are concentrating quite frankly on those. we don't have success, and we are trying our darndest to figure how we can fix that. >> thank you. >> there were a few interventions that i think but the dot in viejo have found to be effective in the immediate need arena. i think that everyone in america should know what those are.

and one of those, you alluded to, and that is removing the weapons from the person's home. at that point when someone is in danger temporarily making it difficult for them to seek any means from which to hurt themselves is effective. there is a stalling technique involved. there is -- there are studies that say if someone president of a bridge in the bridge is closed there will necessarily walk to another bridge. they will think about it. if they go to get a gun and the gun has a gun lock on an orange sun in their home there is a stalling technique there. i think that that in itself and his the single most effective thing that we can do as a society hands to help anyone knew we think i think the other about things that we have learned over time is that making

sure people know that help is available. they have a number to call. they have something in their pocket that they can pull out and use. we as a society are not afraid to ask questions. are you thinking about hurting yourself? you thinking about killing yourself? i don't want you to do that. i care about you. and i helped you get helprin's. that is not public service announcement. the report said that 48 percent of military suicides happen with privately-owned weapons. could you explain what some of those as it relates to hand guns ? >> one of the trends we worry about is the population. veterans are at a higher risk than non veterans that die by

suicide. the numbers vary depending on what state deedee you're looking at and he did a study in how they control for age and gender, but what it boils down soon, the way for veterans in general is steadily higher than it is for the general population. within that there is a deeper concern, one of the concerns is that women veterans are at a higher risk than non veteran women to die by suicide, which is concerning because in the national numbers we know that women, while they may be more likely to attempt suicide, are much less likely to die by suicide overall. so the fact that we have this group of women veterans who may be changing the dynamic for themselves is worrisome. one of the reasons we worry about that is that there are more likely to use firearms as in that sense method.

we know that firearms are more legal method and the rates of nine is higher than if they try to kill themselves using a gun. so i think those are themes to be aware of. >> this gentleman here. >> good afternoon. vietnam veterans of america. think you for putting on this. with all due respect, i want to return to the question, and perhaps not using the term which is only mentioned once some of the report, let's call it command structure. when we looked at the reports the corporation cannot earlier this year but on resiliency programs as well as on suicide risk prevention programs. let's call its command structure. mentioned very specifically in both of those reports. reasons why in the case of the resiliency programs there have been failing.

so wish that the general would please comment. >> about the role. >> well, i think one of the programs that will be the most effective is one that we rolled out called comprehensive soldier. we have an online test, a gap that measures resiliency. it is evidence based, but most people leave the seven. there are always some of those pseudo because when you get 15 psychologists in a room and ask them to answer to questions are going to get 15 different answers. upon receipt. but the gap measures resiliency. and once you take it that it recommends this series of modules that are on line that a person can take in order to reduce the stigma and make this something the soldier goes to perry required a ticket, but we do monitor their progress and how their work on increasing their resiliency. we have also had master resilience traders a we're

rolling out who will go along with the unit and help teach resiliency techniques to soldiers because we really believe that if we want to get to the left of the event we have got to increase the amount of resiliency are individual soldiers have. >> you need a microphone. >> as a follow-up one of the criticisms of the report on resiliency studies was that there were no evaluations done. so how are you in evaluating this program we just talked about in a meaningful sense? >> one of the things is we entered into of $50 million study with the national institute of mental health, the first-ever in stay and look good suicide in this entire country. it is being framed after the very famous framingham report, a reduced the incidence of cardiac death in this country by over 66%. i think this will go longer,

we're trying to do is come up with an algorithm, not that says is going to a common suicide of its 49, but one that is much the same as when you and i go to the doctor. do you have a family history of our problems, take an aspirin every day, blood pressure, cholesterol. all those came out of framing. we think in the national institute of mental health thinks that there will be able to do the same for us live comes to behavioral health and these issues. this study i think is going to be groundbreaking not only for the military. we are right now in the middle of an all soldier study. a survey and an all army survey to gather this data. we will be able to track this along with house soldiers stormed, and we will be able to draw some inclusions to exactly what is the impact of resiliency on suicide. i really feel that within to the three years you will see things

coming out of the study that will have a huge impact across all of society. >> i have a question appear. thank you. >> he mentioned that you were close to having a mile marker. is there a link between because of events and the propensity for suicide? >> well we know is that there is -- i mean, if you look at the work up in boston that is being done, if you are one of the believers like i am underworked, it indicates that a very important protein in the body is the maryland assistant. it seems to with excess of blows to the head mutate. i am not a doctor. but it bends over itself, comes up, collects the the brain, and it has the effective beginning to eat away at the brain.

the football player is committed suicide here not to recently. really in a defer way than most when do. most men put a bullet to the head. he went into the chest. he wanted and the key to the biopsy of his brain because he had a very successful nfl career , very successful in business, and he started to display all the symptoms. early dementia, problems getting along with people, and your management issues. he killed himself. the elected his brain, and he had this same build up of cal proteins she is seeing in just about every single case he has looked at in the nfl. it has also been studied. so that is the kind of research we need. a really exciting thing is their are many people who believe that this will help us with the problem of dementia because they're is a believe that this same kind, and it is research. not finished yet. this same kind of build of a protein could be when of the

reasons why people develop dementia in later life. >> that is consistent. there is research issues the veterans that have traumatic brain injury are about one-and-a-half times as likely to die by suicide. a lot of questions. the issue we have not discussed. we talked about the length. two years of war. in the findings of all of your dealing with, is there something unique about these multiple the plummets? we have not talked about iraq afghanistan specifically, whether compared to previous wars or it in the findings about veterans is different than what the veterans are from vietnam war the gulf war in the data. if we could talk about those were specifically. >> i think we have alluded to some of the difficulties in determining that, and that is

our tracking a veteran suicide and actually suicide in the military and in the general population in the early years. we don't have good comparison numbers to go back and looked at. and the information that i have and what informs me is information about veteran sued to did care because those of the ones that i can track. i no know that our numbers are somewhat by mogul. when we look over the spectrum we have an increase of suicide the people who are under 35. now we have another peak that corresponds with national suicide numbers are just passed the alleged.

probably our vietnam era. so there are two groups of people who now we are concerned about. over time we will find out what happens to this early groups. but i think that one of the things we need to remember is veterans of people to. and so they're also subjects of the stresses and normal life span changes in suicide rates and imposing that on top of their veteran experience is something we are not quite figured out how it makes a difference. what i do know is that the way we are dealing with and working with our new veterans is different than the way we dealt with the vietnam veterans and they came back. we hope we have learned. we are doing things differently.

we hope we're doing them better. and i think that, perhaps, this is a positive outcome. the fact that we are even having this discussion in a public forum with the rental people speaks to the differences in both of our agencies perception. >> and i said a couple words about the link between deployment and suicide. it is always seen that obvious and intuitive these things will be late. until this past summer the prevailing wisdom was actually that david did not support them all. and now as of some analysis of this past summer we are seeing is that there is a link for the army, but it varies for the other services. even before we saw this clearly we still live the time between pti and ptsd in suicide, for those service members that comeback from theater with those types of wounds, they were a

risk. will we now see an army date is those sued deployed or about one 1/4 times more likely to die by suicide than those who did not deploy and all. but we don't see that in the other human services, and the extreme of that is in the air force. the air force will tell you that those who do not deploy have never deployed, three and a half times as likely to die by suicide as those who have deployed three times. exactly the opposite relationship. it's a complicated relationship. >> and we don't know what happens over time. >> second though in factory after factory, but be very careful about numbers. you see reports of an individual post cancers nations. the first thing you should ask is what is the rate of suicide. rated system will be higher when there are 40,000 soldiers.

we follow reports of increased suicide. normally it is because the increase is based on people coming back home and oppose being full soldiers as opposed to when they were all deployed. the most likely person to commit suicide is a 29 year-old. as we found. you ask yourself why? i would argue that if he joined the army at 29 years old one a few things happened. you either got a shot of patriotism and decided to go down 19 sign up, or you're going through some life experiences that you are reaching out for a lifesaver. what we find with these kids is there left with two kids, they have no medical insurance or health insurance. we bring him into the army, but then threw six months of training. it think they have made it, go to the first post can't and four months later they're looking for somebody to take care of a kid because they have to go down range

one thing we told them is when you get these kids to come in at a later age, those are kids that are probably a high-risk category. you need to take a little bit more time interviewing them and talking to them about what the condition of their life is. >> this is also on the web and are, so i think we have questions from twitter. >> have a question from twitter. for the entire panel. what can the american public to? >> within the american public to to reduce suicide in the military? of this go down. >> all-star. i think awareness and support. this is an american problem. it's a permanent defense problem. it's an american problem. the suicides in the military affect all aspects of american

lives. we have heard families, children . being aware of the people have needs and our military service ended the talks but these appearances, but the practical lessons as. then the jobs. they need support. any friends. they need community involvement. being there for people and each other is probably the single most positive thing that we can do. >> i would argue pretty simply, help us eliminate the stigma. not only the stigma and the army, but the stigma in what i term as civilian life. that is really what needs to happen. we need standards that are applied across the board so we really understand the breadth of the problem.

i would hope that we can give a little quicker and reporting statistics. i think it is really a problem like this, you know, there are 30 to 35,000 votes than the country that commit suicide every single year. it's going to be somewhere in that number, and we need the statistics. we need to track the statistics so we can start to get at this issue and end as much as we possibly can. some. >> a stigma in the data. >> further questions in the back. right there. yes, you. then i will head to you. >> their comments about the 29 year-old privates notwithstanding, i believe you said finding those or identifying those at risk is the hardest task. assuming you can do that, assuming you can find those coleworts of people who for various different reasons are combinations of reasons were highest risk to commit suicide,

given the policies and procedures and constraints that you have to follow, what do you think you can do that would impact the incidence? >> well, i mean, one of the things we tried, and give you an example of. we tried to change our own regulations. he used to be when individual reported to alcohol abuse center to get help that it was automatically reported tuesday in a command. we started a pilot with that is not the case. the individuals of reverse itself for what we call the twitter program, army substance abuse program, we do not reported to the chain of command. relieve those centers open late at night so that people can seek the help that they need. on weekends the vacancy to help that they need. that program was initially rejected by commanders, but in each instance where rebel to do it we have had tremendous success that bringing in portions of the population high

risk that does not want to admit there are high risk because they don't want to be branded as an abuser of of all. the problem might have enrolling and out throughout the entire united states army is the national problem, problem with health care. we do not have enough behavioral healthcare folks. someone who is an army substance-abuse counselor has the ability over time to gain the experience they need to move up to become a behavioral healthcare specialist with this problem of trying to fill up the number of counselors to get this issue. i don't want somebody to suffer for themselves. i want to make sure we can provide immediate help. i read the we have collected that. we have to make massive use of tell a behavioral health, and one of the problems is getting doctors to believe in tell behavioral health.

this group of populations, the next as of today, there's nothing they like better than communicating over some of the things that those of us who are a little bit older and might not like to do. we found will be ruled out these pilot programs is a kid who gets on sketch talks to a doctor is much more forthcoming on talking about is our problems than they would be if there were sitting across in you and me. this is one way we can make use of access. rather than use the pha, the post deployment health assessment we give every single soldier starting with the brigade commander in the brigade command sergeant major a 20 to 30 minute evaluation to see if they will have a problem reintegrating into their community. >> i promise. thank you very much. nancy sherman of the woodrow wilson center. um this really follows on your

market general, and that has to do with the art of being a condition. finance, and the stigma. your statistic was alarming that 50 percent of the suicides have been in behavioral care. so resources aside, is there -- and standardization aside, is there concern about what this so-called art of building report and getting people to trust you whether it be through skype or phone calls or one-to-one consultations. is that something that the army's looking at and recommendations regarding that? >> well, we are looking real hard at it. i wish -- in this country we used to make use of boards where

doctors when they got together would sit around and talk. somebody is loss of printable. they sit and talk but the operation, what happened and what went right and a possibly went wrong. my understanding, a tanker and other doctors. many of those have gone by the wayside. the fear of an individual's being sued. malpractice insurance. one of the things that we have in the military that is a blessing is we can't do that. and they have been working very hard to get my clinicians in high risk for what they thought were immediate risk cases where things go bad to get together and talk about lessons learned, about what they possibly could have missed that would have caused them to put that person in a high-risk category and make him an inpatient rather than an outpatient. but it is difficult to do that, even in a hierarchical organization with four stars and

a caller across. >> one of the things we tend to forget is that we are well aware that generations like to communicate over electronic media. we had almost 30,000 shatters into our chat base to talk less suicidal issues. we have a whole new generation of medical professionals now coming out of academic institutions who are psychologists, psychiatrists, social workers, who are going to be providing mental health care to not only the new generation, but generations that are already available. they to prefer to communicate over different mediums that we are used to. and so i think it really behooves our academic

institutions now to take that into consideration when they teach people and prepare people to provide mental health care, not only in the future, but right now. we know in medicalize dishes across the board suicide is not a topic that even today is discussed or talked about or people talk from an internal medicine or breaker perspective how to work with suicidal patients. it's all in our institution to do a lot of political turning for all sorts of reasons columbia only been one of them. >> i have one more. there was a woman on the side here. and just to let you know, i have about 30 people in the minutes. i think we will be able to discuss after. my apologies. this is an interested audience.

that's good. >> you must know me to treat me. can you talk about some of the things you instituted dealing with prescriptions, part of the reports will we talk about abuse? >> the prescription drugs. >> prescriptions. well, i agree with the report and wish we had open season to collect drugs that people are using. one of the things we had to do was close of the prescriptions. the person who goes in and gets wisdom teeth pulled and has an open prescription for per cassette. we have gone back to close that. we have seen -- we are working very hard to reduce the reliance on psychotropic drugs. at walter reed a low we went from 83 percent of our soldiers in our w t you on some kind of psychotropic drug. but one of the reasons why we saw an increase, and i saw it

when i went out to talk to soldiers, visited six installations. i talk to soldiers. i see the liberals health specialists in the me three questions that throws me a bag of drugs. well, they're not bad people. the fact of the matter is their are 15 other people lined up to see this person. they say maybe this will work. this works in some cases. we were throwing in dispensing out too many drugs. that has to end. we were working very, very hard alternative pain methods and trying to get this whole issue. there were all kinds of policies that make it difficult for us when we want to try to pull that back. i think the report clearly points out, i wish it was easier to do that. we have a request and that will allow us to collect those drugs. we will see if it gets approved. >> do you want to add on a recommendation?

>> we are going to close this event. certainly not the discussion nor the report. i wanted to give everyone an opportunity, quick opportunity. any final comments and statements about the report? >> i wanted thank you for the report. i think it is important to keep remembering that those issues are not going away. my other plea is to remember that veterans are going away. and this is going to be a problem that we will deal with over many years to come. it is not going to go away when the wars are over in the conflicts are over. that veterans will still need our help and support. >> i want to thank you for the report, as difficult as i can be of the subjects. anything that would pull this group of people together to talk about this, web cast around the

country, it's something we should all be thankful for. it's a complicated subject. you have done a good job in trying to lay out some of the issues. i would just make that plea to a people to help us and the stigma associated with folks getting the help that they need from behavioral health issues. >> i would like to thank my panelist and thank everyone for coming in for listening online. this is a tough issue. we have laid out recommendations that we felt were actionable, but in no way did we mean to imply that any of them were easy this is something that's going to take continuing work. and he's absolutely right. veterans are in the public eye right now. these wars face down in our military downsize we will have more veterans out there, and there will be less in the public eye. >> a want to thank all of you.

thank you for your questions. something that he said, this is an american problem. your energy and interest in this subject is something that we welcome. thank you very much. [applause] >> follow the iowa caucuses on the c-span network tonight starting with the preview program at 655 eastern on c-span. 7:00 eastern. 745 will give you coverage from a caucus and our window in central illinois with results in

speeches and the phone calls. a caucus in western iowa, and that is followed by results from western media. follow the race online and on our facebook and twitter pages as well. a look now at a campaign ad that is currently one in the republican presidential candidate ron paul. >> america is in trouble. >> washington is a disgrace. >> government has become too big and overtaxing and overspending. >> we need to change direction. >> we really need changes. >> we can afford to make the same mistakes. >> his reputation as a flip-flop >> she went the other way when he got paid to go the other way. >> economic stimulus. >> serial hypocrisy. >> this election is about trust. >> one true consisted candid, and that is ron paul. >> ron paul has been so consistent from the very beginning. >> a more honest candidate. >> she tells the truth about what you believe whether you like cannot. >> never once voted for a tax

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remarks now from the ceo of merck pharmaceuticals on health care issues in the pharmaceutical industry. he has been the ceo for a year and prior to that he served as the company's defense against litigation concerning the drug by rocks. from new york this is about an hour. >> thank you, ken frazier, for being with us this morning. you have been in this job for about one year. >> about one year. a long one. >> how was it doing? >> i think it is going relatively well. it has been a challenging time for our entire industry. the number of important challenges that we face, including a fundamental challenge around research, productivity. on the whole i think is going well.

a very strong performance. a topline. be introduced products into the market. we had 19 products. file the next couple of years, so we think things are going relatively well. >> i want to talk about research. that's a big part of what we talked about. an interesting book. >> i've read it. >> you have. your defense of the company from my action plans. but will give you there is overseeing innovation, a new generation in the nation and drugs. very different skills sets. >> i think you are completely right. i guess i would say a couple of things about that. first of all, the defensive by

ex ultimately the defense of innovation. when you're inside that company that is very much committed, research integrity, defending how we handled by zacks was critical to who we say we are is a company. lax was one of the most studied drugs in the history of pharmaceutical industry. the charge that we in some way try to cover up what the true safety was was belied by the data, and we are fortunate that when the case was tried, they could see it from both sides. the most often cited with the rest of the back to your question, i have been very fortunate in my career. three ceos going back to the early 1990's. he hired me out of the law and insisted that i not be in a

legal department. for six years in the company i was responsible for public policy in key indications. one of the great communicators of all time. i learned a lot about the need to communicate. will we are communicating with the value of pharmaceuticals and the importance of innovation. i then had to send illegal the parma which we talked about. capacity of the just retired as chairman last month said, allow me to run the business for three and a half years. i did have some experience of such illegal apartments. i think it was very helpful. >> and his legal training itself couple? >> that's our question for me to answer. i think that some aspects of it can be helpful. the ability to sort of cut through the clutter of discussions and try to find what

is fundamentally important. i think that's helpful. but i don't think by and large business and law are very close to one another. i think the way that business people think is very different. the way lawyers think about protecting businesses is a different thing. in some ways i don't think it's proper preparation, but i think i'm very fortunate. for the majority of time in my country. >> you started about year-ago. strong statements shortly after. research and development was the core of the company. mason very different statements talking about slashing costs, slashing the r&d budget . in the 12 months since pfizer has increased about 20 percent in terms of its stock price. marquez state about the same. what is the marketplace tell

you? >> that is a thing. i am very pleased. for a long time we were very much down because of our stock prices. >> because of vioxx. >> no, this year. initially i think the issue had to do more with an issue that came out with the drug called taxol which is one of our most important drugs. i would just say this. i think that that merck translating cutting edge science and provided a products has always been the core of what merck has defined as its purpose of the world. without commenting on anyone else's strategy, i think that the position i took was consistent with the core values. so i think that when runt runs the company there a long lead

times in terms of development. it's important to keep in mind the you're not necessarily running the company for the immediate reaction of the stock market. obviously i can tell you it's better to have your stock go up and down. we're really trying to do is run the company to create sustainable long-term value for our shareholders. from my perspective and management team agrees, the most sustainable strategy is really a renovation. the marketplace will try very hard to come monetized goods and services. the only way you can escape that, the only way in which you can provide a sustainable high returns for your shareholders, much less for customers and patients is to do the innovation. >> clearly people out there, investors include to think the big farmers are, indeed, broken. you know, a company like merck can productively invest eight --

>> 8 billion. >> $8 billion in a way that will get a decent return. is that part of the message you're hearing? >> i think i do hear that from some of the investors, but i would bet that if we were sitting here four years ago, 2007, merck would have been introducing eight new important products. at that time no one was saying you should not invest in r&d. the problem is it is not always consistent. it is not like engineering where you can incrementally innovate and make another version. we are trying to do something we have to reinvent ourselves. we have to come up with a completely new molecule, a new

compound. different patient compilations. provide some benefit in terms of equity. that does not happen regularly. it happens up in down. if he looked in the past there have been other times, but over the long term science has always made progress. basic science has always made progress. there is a lag time between the progress and basic science and the ability of companies like merck or pfizer to apply what we learned about basic science in, but the new drug. i guess what i am saying is, having looked at the path, having seen these stages, i'm confident that if we focus on cutting edge styles, the red turrets, if we put into place the kind of environment inside merck were world-class scientists want to come and make a career, i believe over the

long term the return look come back. >> what can you do and what have you done to maximize that? >> so first of all i would say, look, my colleague who runs a research lab is focused on this question as much as anybody. and what we have done is, for example call we have looked at the degree areas that we were in, made some decisions to narrow the therapeutic areas where we want to focus our basic research dollars going forward. we continue to hire the best talent. we continue to work internally and organizationally so that we can make better decisions to kill compounds earlier because the cost of failure in this industry is what is really managing. can you make it 98 and 99? it is brilliant warned that if you're going to fill your info early before you spend a lot of money. those the kinds of things we're

focused on internally to ensure that we improve our return on investment. >> one of the things that has soured some people is medical r&d. the fact that ten years ago we have this decoding of the human genome. so much excitement about that scientific discovery. ten years out nothing seems to have changed that much. what do you say to those people he tell you that? >> i said a couple of things. they have to be patient. you look back. the late 1970's, the predominant way to discover drugs was in vitro testing. soil aliments and plant extracts and you extract chemicals from them. then we learned how to synthesize molecule's. but this debt chains between in vitro and the chemistry approach

was not overnight. took a while for people to take these approaches and figure how to apply them in the context of industrialization of pharmaceutical discovery. i think the same thing is happening right now with the human genome. i'm not a scientist, as we have already established, but i talked to my scientific colleagues. they looked in areas. what used to be a black box, they're now beginning to understand. they understand that often multiple targets are involved in cancer or asthma. it will take some time before people can master that and really pick the right target and find the right interventionist. a small molecule. but i am convinced that it will happen. >> next decade. >> absolutely. >> what will that mean? you mentioned cancer. forty years since the war on cancer was declared?

it sometimes feels a little bit like the war in afghanistan. progress is very hard to measure. are we going to see that changed? >> we have made a real impact on certain types. i think that gives us reason to believe that we continue to apply the science in that context. we will be able to caulker specific types of cancer. the cancer is an interesting word that describes a lot of diseases that actually involves tumors. so i think one of the issues that we are dealing with is it is not something like hypertension or high blood pressure where medication can treat the very broad population of people. what we are learning is how to find drugs that affect specific he returns. i see progress. a couple of drugs that have a phenomenal impact.

common types of cancer will have effective treatment. >> i can't quantify it as i sit here today. i would just be making a wild guess. i can say -- >> we are fine with a wild guess >> let me say this. all bonds. i am convinced. when you look at the progress we have made in the last in years that you see an acceleration of our understanding in oncology, and i think that as we begin to understand the molecular targets we will be able to target compounds that actually affect those in specific patient types and specific tumor types. >> limited as far as the conversation. making reference to public policy. you are a pretty tough piece in the "wall street journal" to be this summer i guess it was thought by attacking some of the

aspects of the health care bill and say that they would prevent innovation. >> well, one of the big challenges of the industry, had to spend the last few minutes tell you how said we are. we are very excited about it. but one of the challenges we have, what kind of marketplace will there be when we come up with the drugs? that is a public policy comes in. globally before we get to the united states governments tend to be our customers outside of the united states. when you're dealing with public policies and the economy around the world is really important that there be a public policy that is conducive to the kind of innovation that we're talking about. our business requires significant investment over a long time. reaping significant amounts of scientific and regulatory uncertainty, it's hard for us on top of that to have a

marketplace where public policy does not release support new drugs that actually have a profound impact. >> are you saying by and large the government's who procured drugs and most other countries don't give you the incentives for innovation? >> i think over time the incentives have been lessened. in europe right now those countries are now facing major problems, which we all know about in terms of the deficits that they have been the lack of economic growth that goes along with those. many countries are struggling, and social welfare system can afford health care at the level it's a climb for the population. one part of the health care bill . >> 10% of health care costs. the other 90% had to do with

other ways of providing health care in hospitals the opposition's, a diagnostic procedures. frankly allot of an addition in how those services are provided. we are to percent of the health care bill. i think frankly we look at the use of drugs, the proper use of drugs that tends to be cost-effective. it is an easy target if it is one sector in a part of the health budget. it is growing because the new drug, people say, let's keep that static. that is an hysterical. i give you an example. we introduced, as i mentioned a few minutes ago. the importance of that drug, only about a third of patients were able to clear, effectively have a cure. now it's up to around 78%. i was just with the german health minister, i am a man who looked like he was 35 years old.

the fact of the matter is we were talking about then in germany the health technology assessment agency has determined that this change from 1/3 to 78 percent is not represent a real innovation that has to be paid for. if that is the case it is pretty hard to have an industry like ours. nor is happening is people put their finger on the scale because the notice and economic problem. it's important for us. i wrote the piece in the wall street journal. important to ceos and others to be very loud about the importance of paying for innovation, real innovation. >> one of the things that frustrates the american to have looked at this question is that we seem to be paying for innovation for the world. we were delighted to have the most innovative pharmaceutical companies in this country, but the cost of innovation seems to be linked into the cost we pay for drugs. >> let me start by saying before we get to the cost, recognize

that the u.s. does have the benefit of a very strong industry. european countries look at their pharmaceutical businesses in the united states. 800,000 excellent jobs. one of the few net exporting industries that we have left in the united states. let's not -- the benefit that it provides to countries. a very strong industry. the computer industry. we don't have that many really strong american industries. a great deal of transparency. countries like the united states and germany. germany wants to pay the same price as croatia and bulgaria. well, that is the world in which you live, two things happen. first of all, you take away the incentives for innovation as we talked about in the past couple of minutes. the second thing is you renew --

remove the incentive for differential pricing. people who can afford to pay more are forced to pay the same amount. what you're actually going to do is discourage the use of drugs in those four countries. to me that is not actually a moral position to take. i understand the frustration of looking at other environments and say we wish we had those prices. one more thing i think, let's go back to the story. the other problem in many of those regimes is that the newest drugs take longer to get the patients. so you also want to have a situation where you have a free market where physicians can make individual medical judgments about whether this new drug is going to provide a zillion benefit to a particular patient. i would say that you can't have everything. you can have cheap prices in the most innovative industry in the world. one of the things we have to think about is how many strong sustainable industries do we

have that are located in the united states. place your fear is that the united states is moving in the direction of the other countries? >> i think that what you can see, it's under way. the process by which as the u.s. government becomes more and more an important customer ties. if the u.s. government has its own financial to know we have to find sensible ways to reduce health care costs. ..

the good news is most of our big investors think that is the right thing to do. two thing. you have to work on the r o i internally and promise that you are going to engage the public policy environment to ensure you get a drug across the finish line if you get reasonable reimbursement. >> how are you doing on that score in the policy conversation? talk to the president about it? at what level did you engage? >> i had the honor of being received in the oval office earlier this year to meet with the president and i did have an opportunity to express my views on these issues in terms of the health care law and the fda. he was incredibly gracious and talked to me for half an hour. i did do that. at the same time -- >> did you get a good response?

>> i did get a good response but don't know if it has been translated into action but certainly a good conversation and i think the president understands the need to maintain a strong viable industry here. the other issue is how much time to spend on the economy because that is where the action is. we spent a lot of time on the hill trying to persuade people that put additional rebates on the part d benefit which -- it is very well received by seniors the personal i say that with some hesitation because possibly being viewed as one. but also it is one of the few government programs that come in under budget because it has used the private market sell i think is a mistake to tamper with a benefit that provide such satisfaction to people and comes in under budget.

if we put price control in the united states like the ones in germany and other countries i think we are taking away a huge amount of incentives for innovation. >> last year we had on stage ibm, talking about visiting with the president. oldest of ideas for how the government could save money. so i said we will get an example. the top example he gave was i told the president that if the government would buy in to negotiate for -- directly from the pharmaceutical company rather than going through intermediaries it could get a better price and save billions of dollars. >> i think it is a terrible idea. first of all the concept, having had the experience of negotiating with european -- that is not where it is. not a negotiation. they set the price of that. i go back to what i said. the part d benefit is one of the

few benefits that has come in under what it was scored by cbo. the reality is there are lots of people who go to health plans that provide a balance between cost effectiveness and the benefits are poised so for -- the congress has the benefit for the federal employee policy bill of the -- benefit plan. the effect of the matter is the private market is working pretty well when it comes to drug prices. we provide very significant competitive rebates on our product in order to get them formulated. i don't see that there is a problem that needs to be fixed. [talking over each other] >> you could say the problem is price but when you say that what you are really saying is you don't want new drugs because i can't be in a business where i take this much risk, spend $8 billion. i am going at the new target

with a huge uncertainty. through that got what i get to a regulator who cost $1 billion according to the most recent study. and the problem is priced. the reality is every drug that was on the market in 1995, has already generic. even the american people want to live with today's standard of care and want a drug for alzheimer's. we have four programs. one of the most important programs that tested one of the fundamental hypotheses of alzheimer's was the details could not have the extent of my knowledge. a program that we're spending a significant amount of time on. if that program is successful we have a drug that -- think about the societal cost of alzheimer's. we can't possibly charge in terms of price not to make that drug a net benefit to our

society but if you say the drug costs too much and you got to be intellectually honest, i think the drugs we have today are good enough. i don't mean the ones to come up with tomorrow. >> you were talking about the importance of merck engaging in public policy. we had a flap this year about a merck engagement in texas. >> i heard about that. >> where the governor mandated the garden seal in the state and the lot written about his former chief of staff who became a lobbyist for your company. it was sort of a case study in our involvement in public policy can get you into a corner so that is the trouble. >> i agree. the story is many years old. >> wasn't under your watch. >> the point is fighting with the context of political -- among other things we were told

this drug which prevents cervical cancer. the vast majority cause mental retardation. the level of political discourse around it is pretty low. effect of the matter is governor perry did sign an executive order, texas legislature, interesting innovation -- maybe that is a good thing. i don't know. in the interim he decided given what he had learned, not just from the lobbyists -- told people about the importance of it. this vaccine in terms of preventing cervical cancers that he would sign an executive order. it created a firestorm in texas because the difficulty of this drug in cervical cancer is caused by a virus transmitted sexually and so again it becomes an issue about whether you are

promoting promiscuity versus protecting girls from cancer. so that blew up in the governor's state and he immediately retracted that. the discussion this year frankly was what happens when people are running for president? there are issues and at the end of the day the concept of the governor of texas would sign an executive order providing for vaccination of every girl in the state simply because somebody would become a lobbyist but that is in direct. >> it doesn't trouble you. >> it doesn't trouble me. although the appearances i have to say i do get why with respect to the american people, people are concerned that various elements of society have too much access through the political system but political contributions and lobbying efforts, what merck has always tried to do, we are known for

this, lobby for what we believe is a sound public policy principles. what is good for the patient is ultimately good for us. >> but you do make significant contributions. >> absolutely. no two weighs about it. the reality of the world is the political system is a difficult one in this country. if you run for office or house of representatives or senate or governor or anywhere else the challenge is to state elected. it keeps going up. we think is highly appropriate for our political act -- action committee to contribute so that we can support people who support that. >> we had the spectacle of republican debates, i have lost count. over a dozen. and the standard line about health care is to repeal the obama health care plan. is that right approach? >> i don't think so. there are a lot of things about

the obama health-care plan that i think are really positive. focus on prevention is something i would point out. people -- first dollar coverage. that would be an example. i think it was highly appropriate for our country to get to a position where we could take the uninsured and provide some basic level of coverage. there are aspects of the obamacare -- i don't want to call it that. the affordable care act. one of those political slogans. that we actually -- chief among them is something called ipad, body of people not accountable to congress whose job would be to sit around and decide which drugs really art first. which drugs or medical inventing -- >> like the german health benefit. >> i'm worried about that.

one of the geniuss of the american political system is we believe by and large that decisions made by groups of people are better than decisions made by concentrated groups of people and physicians are able to look at data and decide whether a new drug or intervention for a particular patient is the right way to go. >> we know there is lots and lots of evidence, a lot of physicians not all of to the state of the arch of best practices, what drugs or treatments are most effective. do you really believe that distributing those decisions over all the physicians -- >> i absolutely do. >> can't we do a better job of informing them? >> we should provide medical education. no question. >> a lot of their information seems to come from the drug companies spend a fair amount of time on that. the best way to do it.

>> interesting you say that. what is happening in the outside world with social media or any thing is there's more access to information today than has ever been in the history of mankind. you go and look at data around what people seek when they go to the internet, health is one of the primary things people give information for. so the critique is dependent on our sales representatives for information. sort of 50 years too late because everyone has access. >> what would you do to raise the level of knowledge and education about new treatments physicians have if you leave those decisions -- >> i think cme, continuing medical information is important. we just talked about the pace of science changing faster and faster. it is important for people to have access to unbiased medical education. accompany we support.

unbiased independent continuing medical education. i think that is the way people need to keep up with their art and society. >> turning the focus for minute to china and i want to open up for questions. you just announced more recently that -- a major investment in china. for research and development. why take that research and development to china? >> we have to recognize we live in a global society. merck is a global company. emerging markets are a big part of our business from the standpoint of failure to anticipate 25% of our sales in those markets in china as the leading market by 2013. at the same time look at the low cost of human genome sequence occurring in china

revolutionizing -- if we are going to be an important player, we have to seek the best medical and scientific talent wherever it is. to give a data point, merck and united states in terms of statisticians something like 16% of -- 60% of our statisticians at merck are native born chinese. that we brought into the united states to work and are bio statisticians. so this tremendous talent, we have to access that talent where is. >> last november we brought together our ceo council of 100 ceos from different parts of the world and in a survey prior to that, talked with them about their concerns. the number one concern was intellectual property protection.

does it bother you to be doing research in china when there are concerns about the protection of intellectual property that are critical to the survival -- >> very valid question. i would say we chose specifically which parts of the research value chain we are doing in china or made decisions about what we are not going to do and we have done that with ip protection. >> in certain industries china has been explicit about the quid pro quo. if you want to operate in this country must do certain high end research and development. anything like that in your case? >> there is something like that in china in every sector but it didn't relate to this installation. the issue indochina as relates to market access has to do with if we want to sell that to chinese children, a huge part

and merck is one of the first western companies for the chinese market going back to the 80s with huge hepatitis-b problem. merck ended hepatitis b technology to develop that. tens of millions of lives in terms of children having had hepatitis b. we had a long history there but many of them deal with the chinese government in terms of access to their children. there are demands being made around manufacturing and negotiating with them and chinese own vaccine companies to see if we can come to agreement on technology transfers that makes sense. >> final question i want to ask before i open it up. if work were not a big enough challenge you have also taken on the challenge of some -- investigating the jerry sandusky situation at penn state and what it says about a culture of penn

state and why it wasn't spotted earlier and dealt with earlier. why in the world would you do that? >> the question my wife asks all the time. because she has a list of things she would prefer that i do. i think the bottom line here is i was already on the board of trustees. a school that frankly in the inner city sold off four years of free education and completely changed my life. so when this thing happened in the board room people looked around and said is there anyone in this room who has had the experience with this kind of widespread public situation before and i didn't raise my hand. the second question was is there anyone here who handles talks? [laughter] >> i guess it was pretty clear i

had been outed. it is really hard to step away from an institution you have pledged for support for. we were able to get the former fbi director louis free to take over the investigation. now that i am back, the public would agree to takeover it should take less time. >> some people have been critical of the choice that reason. they say what you did was protect the company from excess liability and what should happen in penn state is not focus on liability but what went wrong. >> i said earlier on -- people on the outside tend to look at the fact that the sabers saying as high as $50 billion, much less. >> $6 billion. >> was 4.85.

but as shelley and others will tell you inside the company it was defense of the institution. i am a big believer in the institution. institutions are one allow us to have continuity in our civilization and merck is an important institution because of what it can do 20 were 30 or 40 years from now in terms of alzheimer's and cancer. so too is penn state and important institution. i took on that responsibility because i believe in the institution and it is important to maintain institutions. it is a horrible situation that occurred. i don't know what the facts will ultimately be but it is important in times like this that people step up and remind people of the value of an institution to the country and that is how i do that.

>> question. yes please. >> jesse mark cohen. you mentioned the independent advisory board as part of the obama health law that troubles you. the courts may strike down the individual mandate for the medicaid expansion. if not, the nation may elect a republican president and congress and push for repeal. thomas what parts aside from first dollar coverage you would like to keep in the obama health block and what other parts trouble you? for example the controls on doctors to treat privately insured patients. will that interfere with clinical access to medications? could you tell us a little more what you are thinking? >> i would have thought that was 1312. the things that concern us most,

i talked about the independent advisory board. and institutional rebates are the big fin. i think the benefit to the law, providing medical actress for broader percentage of our population is going -- >> is a mandate essential to that? >> i don't think it is. you don't think you could achieve that goal and get rid of the mandate? what would you be in favor of? >> i would be. i don't know how the court will deal with this case. it could strike down the mandate and keep the rest of the law. or it could strike down the whole wall. we could get repeal legislation with republicans in the house and senate repealing the health care law. i do think that the law has some goals that are laudable. i think at this point there is no law coming back to the

earlier discussion to remove some disincentives around the efficiency that we have. you see the studies compared to a particular city with respect to back surgery. one has a lot of specialists on staff and the other doesn't. very different amount of back surgery in hospitals. those are the things, the overutilization and efficiency. it didn't really aim at where the costs are going out of control. i come back -- >> is that what the ipad was supposed to do? >> it focuses only on new technology. >> not on broader practice. >> back to that point. >> you think drugs are too expensive? >> they try to be -- our expensive these are. 10% of the budget. if you're going to focus on that 10% or not focus on the efficiency of the downstream

health care delivery system your missing a big opportunity. from my standpoint, the most important thing that i think they missed was focusing on some sectors that create the inefficiency in the system. >> yes, sir? right here. >> i would like to talk or ask about your r&d. particularly, one which both genomics -- when you do clinical trials you can now look at different populations. not just race or age or sex but gino types and so forth. in many cases you are likely to discover certain drug is very effective for one substance that useless for another and toxic for third. it is great for you to discover

that. it means in theory you can target the drugs to a smaller population or charge more. but the ipad and the o p a need to recognize -- i am curious where you think they are. you talk about the doctors and how much more the doctors know. they are going to understand the need to know more about their own -- diagnostics are going to be more diagnostic and more important. and so the whole amount of knowledge required is going to be much greater. how does that happen? and the third thing -- >> how many are there? >> the last. i believe it was merck that long before you were involved came to a $25 million per drug tested in russia proved to be useless. >> i don't think it was. we didn't get that one. >> but --

>> we have our own prophecy. >> the question is in a polite way, how reliable do you think that research is? >> let me start with your first question. sort of personalize that. that is what is happening. as we get more information about the genome and personalized gene expression as it gives us the opportunity to talk about and focus not only on broad populations but also populations that might respond better or badly to those medicines. i think the fda is very much focused on those issues. i would say one of the things we can do as an industry and a society is spend more money on the fda so they resources to stay current. regulatory science to keep up with basic science so these things -- that is an exciting thing about our industry.

as the cost of drugs increase and the economic pressure on the system is greater it will help us to be able to demonstrate utility of that drug for benefit in a specific patient population. i see that as an exciting thing. a way to provide value going forward. i think that will only help innovation. not hurt innovation. on the china thing, i would not take one example of a clinical trial that we have done and not have it replicated and say the problem is necessarily in china ever since the united states. the fact of the matter is our industry is one where most drug candidates fail and often in smaller trials you can't read complected -- replicate them but we learn about a side effect that didn't appear in a smaller trial. so i would say what we do when they come with the same drug is trying very hard in our due diligence to ask all the right questions to make sure we are not wasting shareholders' money

to get access to the underlying data or give ourselves the right opportunity for those judgments that back to the main thing, the fact the we have diagnostics and by 0 markers and genetic insight into these drugs open the a whole new avenue of valuable drugs intervention and innovation. >> question back here? >> louis dyson with reuters news. questions from penn state. you mentioned the investigation. i wonder if you would let us know how the investigation is going. you brought up louie free and that might speed up the process. any sense when the investigation might be over? >> i don't have a timetable. he has complete free rein to do the kind of investigation, and he is very much early in the stages of the investigation. i would hope it would be done by

the end of this academic year so we can come back in a new academic year and have that behind us but i can't put a timetable on this. judge free is the right person to do the investigation. he has the skill and the background. all i heard so far is he has been cooperative. i am not in a position -- i don't want to ask for a report. that is part of the independence. he has to carry out an investigation as law-enforcement to the extent they are required for an interim report that compromised that investigation. >> question right here? >> speed the market of new drugs or unnecessary ways the -- i wonder what you would comment on that and how to balance a given that so much is on the market or the same market? >> i think for companies like merck our goal should be to work

constructively with the fda. i think the fda works on difficult circumstances. i just alluded to funding that they have. a fair amount of challenges from congress that we saw the other day. the administration overruling the fda with respect to a determination on plan b and they felt they had pretty good evidence it could be used safely. i am not a person who knocks the fda. very talented people, my interactions with them, first rate people who work for our government and they know they could make a lot more money in the private sector. we have terrific people. i think the challenge we have is to find ways of meeting their needs in a more expeditious way. a little more transparency about what the standards are going to be would help us because we have

to design clinical trial years in advance and evidenciary standard shifts, is hard to adjust. the big thing for me is open this, back and forth in terms of dialogue and transparency and what quantum of proof around benefit risk is going to be necessary to get a drug approved. .. >> well so i think every

industry has to figure out how to compete with the marketplace that it actually has. you don't get to choose your customers. your customers choose you and it's very clear that health care generally has been viewed as a pretty administration marketplace with a lot of responsibility so i think is a challenge we have inside merck is to adapt to that environment. i think there is still unmet medical needs. i think people still value innovation. i think the challenge for us is directed nice that the customers out there, let's be clear. our government customers in europe are mostly bankrupt, right? so we are going to have to think about innovation not just technical innovation, but low-cost innovation so it will be a big part of our business model going forward so we are stepping up to the challenge at merck. i know via reid and his colleagues are doing the same thing as fisa. i think these companies are going to have to think about running themselves in a way that is sustainable to provide not

just benefit from a therapeutic standpoint but benefit from a health economic standpoint so to me the biggest change that's occurred since i've been in industries the rise of health economics. before it was just a physician sitting there making an individualized medical judgment. now physicians are not necessarily the decision-makers anymore because people who are looking at drugs and managed care provider or in the u.k. these are the help -- health technologist inside baseball. they are people who are now trying to ensure that there are evidence-based ways of deciding which drug should be used on people, including not just benefit and risk but also cost and i think we can lament that all we want that everybody else gets measured in the world and everybody else gets challenged to provide a better service. i mean if you get a new cell phone, each subsequent one has got to be better and in fact

cheaper so i think in many ways our industry has had the luxury of not having to compete on the basis of cost and going back to the question that allen s., i am not the -- on the basis of cost. and say the problem is if you're only customers the government and the government gets to decide the value without regards to input from others, that is what worries me. >> other questions? yes, someone right here. >> thank you. you mentioned plan b and i realize that this is an issue per se, but do you feel it would have a chilling effect on the industry as a whole? >> i think that's a special circumstance. i think the link between that and the discussion we started off with respect to the tax is as governors read executive order, think every time you are talking about children and sexuality, you are in a space where the political dynamics are

going to dominate the science. i think that is what both of those cases have in common and i think that you no scientist tend to look at it from the perspective of we need to provide young women with options when they have unintended pregnancy. that is a medical problem and we need to protect young women from the risk of cervical cancer. that is a medical problem. but when you move from that sort of public health arena into the political arena, then we know that we have different kinds of considerations and as the president said himself, he thinks that quote common sense needs to be applied. i guess that implies that science and common sense are not compatible at some level. i'm not sure about that but the fact of the matter is it's highly politicized so i would think it won't have a chilling effect because most of our drugs are not used in that context.

>> there is another question from that table. >> yes, i have a question with regard to cost and innovation and there is a significant amount of drug development, financed by the venture capital market and by individuals who are in drug discovery. i am just curious as to whether that is important or de minimis in the terms of merck and development of new drugs? >> it's very important. i think one of the challenges that we have in terms of ensuring that we have the right kind of a tone is to get the balance right between work that we do internally and basic research and work that we do extra early so a lot of fantastic work is being done by startup companies. many people would argue that big drug companies have to spend less in terms of what is being done on the outside so i would say it's very important and one of the things we have said to our investors and others lately is that mark wants to be a good

partner. i think the fact of the that the biotech industry is struggling -- struggling a little bit now i think their struggles are sort of their image of our struggles. we have the resources to take some of these medicines into broad populations and so that is the benefit that we can provide, if you will, the resources and the ability to do these big clinical trials. you'll often see a biotech company that will try to bring a drug to market and they simply can't afford to do the large clinical trials so to me that kind of partnership is one that will create value for the biotech industry, will create value for industry but most important you will create value for patients. >> we had one of these cumbre stations with marc andreesen who invented the netscape browser out in california earlier this year, and he said that he thought and we were talking about bioscience and why it hasn't had the same kind of explosion. he made the argument that when it gets to the point that you can put the human genome and you can put some of this data in

open databases and 12-year-olds and 13-year-olds can start playing around in innovating the way they do with computer software, that is when it would explode. do you buy that argument, sort of a more open innovation? >> i think that is the world we are going into and i think it has been shown before that the more access you have, though more people would try to solve a problem so to speak the better you are in terms of getting a good outcome on that problem so i think that will be beneficial. i still think there is a role for our industry because it takes concentrated amounts of capital to take something from the very beginning stage of discovery all the way through large-scale clinical trials, fda approval and then brought commercialization. so i think that frankly i'm excited by what you just said he does the more discoveries we actually can validate, the better off the industry will be in terms of the pull through on the other and. >> i think we have time for one or two more questions.

there is a question right there. >> hi, diane brady. i just wanted to go back if you don't mind to penn state for one second. which is -- i know. >> it is so predictable. >> i ask you to elements. one is coming in no i know there's an investigation into the actual case but how do you feel the trustees handled the prices since you have got a lot of experience with crisis. i would love to get your response from this center for exploited children or whatever is being set up by penn state because i think there is some question of whether that is the best use of money. so's adjusters and said maybe if you could go back and anything you might have done differently? >> i think the board of trustees acted rather quickly after the information that came out so i'm not going to go back. register member what it was like, how shocked we were to hear that information when it

became public and i think it became public on a saturday evening and i believe we took action with respect to the president and the head football coach on wednesday evening. so i think that given the fact that we are a large board, geographically dispersed, i think we reacted in a fairly quick period of time and i think that we did the best that we could with the information we had and the circumstances under which we acted. i will leave leave it to others to decide whether or not we did a good job on that point. on the center for exploited children, i think that is a positive thing. i think one of the things that is being missed in this tendency, which is an unfortunate aspect of public life and media and the american people is that among the strongest forms of rhetoric in our society is what i like to call the rhetoric of blame. when these things happen we spend more time trying to parcel out blame than we do looking at

the broader societal issue. so the issue here is that too often children are being exploited in our society. this case alone at penn state, subsequently we had issues at syracuse in the aau. we have had the issues in the catholic church. these are not unique to any particular strata of society. i just read in "the new york times" the issue that has occurred in new york with respect to the children, the orthodox jewish community. my point only is that it is happening everywhere and it's happening much too much. i think the real disappointment of this thing is that this could have been a moment in teaching for our society as grown-ups. we could focus on our role and not looking carefully and not being willing to talk about these things with our children and to expose these things when they happen. my biggest disappointment in this is that no one is focusing on that. they are acting as though this is a penn state issued, because

it actually arose on the penn state campus. i don't think there's any reasonable person who doesn't understand that this is a broad societal issue and we really ought to be protecting each other. my wife and i get thanks everyday for our children and i think you ought to be thinking, what can we as a society do to protect our children? >> i think we should and it was bad and give a final word to one of our sponsors with bcg. >> thank you very much can and thank you allen for a terrific and inspirational talk. i think it met all the expectations that robert said earlier for therapy without side effects and thank you too for the cause of innovation which i think is important to society. as i have become a senior citizen, alzheimer's is important particularly given what what i know it's happening to my memory. so thank you again.

it's a tough challenge of course managing a pharmaceutical company apart from the general leadership challenges. we have heard a confiscated biology is and we have heard about the marketplace and so we look forward to following your success kent as he moved forward your tenure at merck. thank you. this brings to a close the fourth, very successful year of the viewpoints series. we at the consulting group along with "the wall street journal" are absolutely delighted to be associated with this and look forward to another good year and look forward to seeing you next year and with that tank is very much and have a touristic holiday. see you next year. ♪

>> last month to former national security advisers discussed some

of the issues that arose during each of their 10 years. we will hear remarks from henry kissinger, stephen hadley and former deputy national security adviser, james steinberg. the associate program is an hour and 25 minutes. [applause] >> my name is ruth robbins and on behalf of -- is a pleasure to welcome you here for our program. before begin i would like to remind you to turn off your cell phones, blackberries or anything else that might make any kind of noise and also to remind you photography or videotaping of our program is -- [inaudible] tonight we look at the world of the national security advisory, one of the most important jobs.

the advisers are appointed by the president's to advise him on issues related to national security, which has we all know can take many different forms. we have an excellent and esteemed panel of experts with us tonight to help us explore these questions and many more, doctrine or kissinger, stephen hadley, james steinberg and jane harman. we will meet all of the speakers in a moment but first i would like to introduce our moderator for this evening. ken walsh is the chief white house correspondent for u.s. news and public report and a good friend of the smithsonian associates. i'm sure some of you in the audience may recognize him from past programs. we are pleased to work with him so often with the presidential campaign to national politics since 1986. you have a complete bioin front of you and i don't want to take up too much time so i can turn the program right over to our speakers.

[applause] >> thank you with. we have a wonderful audience. we have a wonderful panel and i want to thank you for coming in thanks to the smithsonian for having us -- assembled such a great panel and for asking me to moderate again. i've served as moderator for i believe it's now five smithsonian panels in recent years and our goal is always to generate, to shed light on things and not generate heat so i'm sure we will keep that to that premise again tonight. talking to our panel in advance, just before we started, they have a wonderful breadth of knowledge not only of their time in office but also our history for the last 40 years as we have a panel that encompasses one of the most consequential periods in our history, the foreign-policy and national security. we are going to be talking about that tonight. and we will have some time for questions at the end.

but i wanted to also thanks c-span for being here. we will be broadcasting this a bit later and of course i want to acknowledge my mother has come up or this from south carolina. [applause] i can't not mention her. but, the president's national security adviser is actually one of the closest people to the president. the president, national security adviser is there in moments of great triumph and tragedy, success and failure, is there with the president when decisions have to be made on life or death matters, war and peace matters, really nothing is more important then what the security deals with in the life of any presidency. our panel will deal with that this evening. our panel is not only eyewitnesses to history but they have also helped to shape history and we will talk about a lot of that this evening.

one thing i wanted to mention also his doctor kissinger has to leave to catch a plane at about 10 minutes to the hour so we will get him moving along to the airport there but we will have money of time for our discussion. he hasn't early call in the morning so we will recognize that and logistically make that work. i will just introduce the panel now. i think we will go right to some questions from me. henry kissinger was sworn in on september 22, 1973 as the 56 secretary of state, position he held until january of 1977. he also served as assistant to the president for national security affairs, national security visor from january 1969 until september of 1975 and he is currently a member of the defense holds a court. anyone of course who is familiar at all with our national security a foreign-policy for the last 40 years is familiar with dr. kissinger. at present is chairman of

kissinger associates and international consulting firm and among the awards dr. kissinger has received where the nobel peace prize in 1973 and the presidential medal of freedom which was the nation's highest civilian award in 1977. i also then would like to introduce steve hadley in order on the dais here. state completed four years as the national security adviser in january of 2009. of course he was a national security visor to president george w. bush and in that capacity was the principle white house foreign-policy visor to president bush director of the national security council staff and ran the inter-agency security policy development execution process. from january 2001 to january 2005 he was the assistant to the president deputy national security adviser, serving under the national security visor condoleezza rice. and it in his consulting

practice today steve hadley represents the u.s. corporate -- doing business overseas. jim steinberg is the dean dean of the maxwell school of syracuse university. prior to becoming dean in july, this past july he served as deputy secretary of state serving as the principle deputy to the secretary hillary clinton. from 2005 to 2008, jim steinberg was the dean of the lyndon b. johnson school of public affairs in texas and from 2001 to 2005 vice president director of foreign-policy studies at the brookings institution here in town. he served as deputy national security visor to president clinton in 1996 to 2000 has a very extensive resume in government service. on a personal note, when jim was the deputy security adviser, covering the white house in those days, i would travel around the world of course with president clinton and we got to know each other quite well. i became very familiar with his

diplomatic skills and we would order wine because jim sometimes would use very diplomatic language when i picked a white wine that he didn't particularly like and he would say, this was a little less successful. [laughter] i always remember that phrase so i use it myself on occasion. and jane harman of course is the director of the woodrow wilson center and president and ceo as well. she resigned from congress in february 28 to take this position. she was a congresswoman from california for nine terms, served in all major security committees, six years on armed services, eight years on intelligence, foreign homeland security during the long public career. she has been recognized as a national expert at the nexus of security and public policy issues and she received the defense department medal of distinguished service in 1998. jane harman is now serving on

the board of directors for "newsweek" and "the daily beast" as well so there is a media connection there i want to mention. so with that i'm going to just go and take my position here on the stage and go right to questions. so just bear with me while i moved to my next spot here. you can hear me okay, right? i wanted to start out just basically, just ask each of our panelists the same question. how did you do find a job national security adviser and jane how did you see this from your perspective on the hill and what works and what doesn't work in dealing with the president on national security issues? let's just start with dr. kissinger on that. >> well, the fundamental objective of the national security adviser has to be to enable the president to make the best decisions in the national

interest and that means that nothing should fail for a reason that was discovered -- that was not discovered. that means in turn to dredge up bureaucracy. the best range of options. when i was appointed, i had no such perception. i didn't know exactly how to organize the office because it didn't exist in that form when i was appointed. and president nixon, whom i hadn't met before he appointed me, then assigned the secretary of the national security council

under president eisenhower and we jointly called on president eisenhower who was at that time in the hospital. he really designed the outline, and eisenhower's conviction was in effect that no department should run the process because this would be difficult then for the other departments to accept and that led him to propose that the chairman of the committee should be in the white house and that of course, that should then funneled the areas -- various points of view to the president. less this is how it has been maintained. how what it then is processed

depends on the personality of the president, how he prefers to work and of course on the attitudes of the various cabinet members and of the security adviser. but that is the outline of the system as it emerged actually in its present form in the nixon administration and that is how it was involved. not that i had a clear conception in the department of maneuverings. this is how it evolved then, as every security adviser or ghostly but there was a real

continuity here. a lot of people talk about how divided we are but in the sort of national security establishment if you will, there is continuity. steve do you agree with that? >> right, the national security council was established in statute. congress set it up i think in 1947 and it has only got four members, the president, the vice president, secretary of defense and the secretary of state. and it is given a general charter to coordinate all aspects of foreign-policy. and that is really all it said. and the question was, what structure would come under that? dr. kissinger really establish that structure and is jim will say, subsequent presidents have modified it and change the labels but the basic structure is the same. under our constitutional system, the president is given a lot of authority in foreign-policy. and, it is true the national security council system that the

president organizes the government brings up the information that he or she needs to make decisions and having made decisions is the vehicle by which it gets translated to the various governmental departments and agencies that have to carry it out. but, how a president really runs that system changes dramatically with the president. the details of it are not in the statute during executive order. they are changed by the president because the genius of the system is that it can adapt to the management style and personality of the president. and that is also chu i think of the national security adviser's role. your role is heavily dependent on the president, the president style and the kind of relationship he has with the president. i guess the last thing i would say is, it's a great job but it really is a staff job. you are helping the president do

a job. you are not running any agency. you are not conducting operations. that is what the cia, the department of defense and the state does. but your job is to try to coordinate that process and to make it succeed for the president. we have a little saying at the nfc that if something went well, it's to the credit of the president or the secretary of state or the secretary of defense and if something went poorly, it was because the national security adviser and the national staff fail to coordinate properly. that was basically right. [laughter] >> as you have heard there is a tremendous amount of continuity and how the nfc and the national security adviser operate but the flexibility is really an important part. not only adapt to the needs of the president also but also adapt to the needs of the -- so when president clinton became president the cold war had come to an end. the challenges we were were facing revolving so the nfc allowed you to adapt in bringing

people from the table so economic issues took on a greater threat prominence and there was more participation by the economic agencies. issues of health, fades and communicable disease became national security because they have impacts on our security and so people from those agencies would be an bald, environment and other things. that is the beauty that the president can take the basic structure that is served so well over a overlong period of time since dr. kissinger's time but use it to grow his knees and also the challenges of the times. the other part that is important to remember and is being touched on today is part of it is this policy formulation process making sure the information and the perspectives and the choices are made available to the president in which you really want to have your bust agency and hear the different ideas and get the different perspectives but there is also the output side which is the policy implication. the nfc also plays a critical role in the security adviser in making sure that once a president makes a decision that

decision gets implemented and the perspective and a mandate, the ideas for the president are carried out across the board in a very diverse community of actors that are necessary to implement national security policy. >> jane you have seen this from a congressional perspective and of course at the wilson center. do you agree about the continuity point and how does that come across in congress? >> well let me start from a different vantage point. i did work in the white house too but not in the national security council. i worked in the carter white house in the west wing as the deputy secretary to the cabinet and the nfc was right down the hall and a rookie named madeleine albright worked there. [laughter] and aside from the fact that madeline and i were good friends because we had worked on capitol hill in the senate together before then, something that stands out to me a visit was a fairly small office. i'm sure when henry kissinger was there he was a fairly small

office and you know small enough for him to be a hybrid to have that job plus the state department. that was a two year period which i don't think that has ever happened before or since. >> relations between the white house and the state department -- [inaudible] [laughter] >> okay, with a small comet was a small group of people. now it is enormous so yes, i'm sure there has been continuity in many ways but the growth has been geometric. i am a member, or i was a member of a totally dysfunctional body called the united states congress. [laughter] feel sorry for me, will you please? so i worked on the security committees and certainly the dicey period was 9/11 forward, and i intersected the national security apparatus of the two

bush terms plus early obama, and what stands out as a member of congress to remind us that is the independent branch of government. it writes the checks. it is supposed to write the laws, and to adequate oversight. how hard it is to get information from the executive branch, especially on various controversial issues because at least over time, as i perceived it as a member of congress, more and more the decisions and on national security were made in the white house, not in the department headed by conference secretaries. the white house, as steve said, the nfc our staff positions. they are not confirmed by congress. the president deserves to have personal staff. i don't quarrel with that at all and there is such a thing as executive privilege, which when used responsibly is the right

thing for the president to have. however, it was incredibly frustrating in a number of instances to do robber oversight in my role as ranking member on the house intelligence committee for many years, when i could not get briefings or information because, for a variety of reasons, the decisions, the information, the decision-makers could disappear into this large space called the white house national security space, the nfc and other roles. >> i wondered, we could talk a little bit about the presidents that you all worked with. what were they like and dealing with national security issues? did they all insist on being what president bush is to call the decider and it failed want the census positions brought to them? did they like arguments to be made in front of them or did they preferred had that not happen?

i just wondered if we could get a little insight into the presidents themselves on this? >> well, i worked with two presidents in that capacity, nixon and -- nixon knew an enormous amount of foreign-policy. he studied it, he traveled, so he was intensely interested and it was not an imposition on him. he had ideas that he knew what he wanted, but he also wanted to hear the options. he preferred to read them then to see the confrontation in front of him, and he had a

personal aspect that he did not like to order somebody to do something that he knew that person did not want to do. so, he would prefer to do it by them all. [laughter] so the procedure of the nfc was there were full discussions and detailed papers that were too long for investigative journalists. [laughter] but then he would listen and he would withdraw and a day or two later, i would receive -- and of course the losing party was absolutely convinced that i

i -- it was very systematically done. president ford had no such inhibitions but he was less of a reader and less of a previous student of foreign-policy, so that affects the sort of information that the president requires and the sort of design. president ford was in his second term of resident nixon so in the air of watergate, so he could not develop the designing aspect to the same aspect that nixon had although he did

extraordinarily well considering the handicaps, so it was two different systems but you cannot draw the conclusions from either system because nixon was president in the period of the vietnam war so there were tensions that would not exist in a normal situation and there was watergate. the nfc actually was very systematic and the options were presented but the acceptance of these options were somewhat handicapped by the fact that they were really transmitted with an explanation, but simply

from the oval office. >> i think one of the things that sometimes washington doesn't appreciate and off is how much the president is the decider, does make the decisions. there is a lot of speculation, press reports, about what the secretary of the state thinks and secretary defends. what matters in our system is really what the president of the united states thinks and the nfc system is really designed to put the prsident ia to make those decisions. we were talking earlier, most presidents, by the time he run for the presidency and get elected, you think you are ready to make these decisions. and they aren't. so then the question is how you design a system to help the president make those decisions and it varies with the personalities. the president i served, george w. bush, he wanted wants his national security principles,

his secretary of state and secretary of defense to have talked to the issues and to have worked the issue and we would do that sometimes informal meetings but in the last three years, i started having what we call the tuesday afternoon snack time. we would have the other principles in my office at 4:30 tuesday afternoon and i would serve soft drinks and cheese dip and the widow for the next two and a half -- it sweden peebles disposition. [laughter] and we would walk through the most difficult issues and we would air all the disagreements and in the end somebody, usually the vice president would say this has been a great discussion. now we need to have it in front of the president. and we would have it in front of the president and that is what he liked. he was not a memo man either in terms of reading them before or writing the most after. he wanted to have a direct interaction with his principles and we would have a good discussion and then he would go

off and in the quietness of his own contemplation, he would make a decision and he would come back and because of the problem henry talked about, when he would come back and he would say, and made my decision and here is what it is, you call condi, condi rice or call bob gates and tell them the decision. i would say no mr. president, you have got a phone right there. it has a button that goes right to the secretary of state. pushed the button. you need to tell the secretary of state so they know it comes from you. they are the chain of command. i am the staff person. you need to call them yourself and he would. >> well it won't -- you won't be surprised that president clinton liked to be part of the conversation. [laughter] that made for a very lively set of interchanges. he is a voracious reader and had a lot of sources of information and respected beyond what he was hearing through the formal process and the like to get people in a room discussing.

he was inherently suspicious. if you gave him a consensus view he would argue the opposite. he gave and advisory to think you should do axe he would tell you all the reasons why that was a bad choice. often he would come around and agree with the consensus but he wanted to test it and they want to hear what the thinking was behind it. it was informal. we had some more formal around the cabinet room type meetings especially when there were consequential decisions to be made especially about the use of force but in general he really wanted to understand the thinking and to test his own questions against the thinking of others. sowa was a very interactive process with him. he didn't usually decide on the spot. he wanted to come back and think about it but he liked to come back and tell people why he decided that and he also also comments seat mentioned this as well, he became very conscious of his own responsibility for these decisions. he would always say after difficult debate, he would say at the end of the day this is my decision.

i'm the one who's taking responsibility. i value your advice but i'm not looking to point to your view and say i did it because so-and-so advised me to. certainly as time went on and i was in the white house during the second term, the confidence and responsibility grew and it's very impressive when you think about all the burdens and the temptation to say well i got bad advice or -- the president step up to the plate and they say this is my responsibility. >> yeah, well a couple of things. i haven't worked in the nfc, but from reading about president obama, he came to the presidency with very little foreign-policy experience. he has turned into a voracious reader of intelligence information. apparently loves it. it is fascinating to read that stuff. and, has spent a large part of his presidency and foreign-policy issues and has stepped up to some very tough ones like the takedown of osama bin laden for example.

from the congressional perspective, let me raise a couple of examples of frustration dealing with this stuff. [laughter] one is bush one and then i was ranking member on the intelligence committee and we were briefed -- i was one of the so-called gang of it. the gang of eight are the leaders, democrat and republican of the house and senate and then the leaders, democrat and republican of the intelligence committee. that adds up to it. we were brought to the white house and the situation room and told about a surveillance program that the bush administration was undertaking. we could not bring staff. we could not take notes out of the room and we really couldn't ask anybody other than the briefers about anything because it was so highly compartmentalized and so secret. this exposure to this kind of material comes under a procedure in the 1947 national security

act. at any rate, it was not until the president, president bush, revealed the existence of the surveillance program publicly that i could call a few people and check a few things out at which point i learned that the program on which i had been briefed was being conducted outside of the law congress had crafted. the foreign intelligence surveillance act. i had not understood that from the briefings, which i can't describe the briefings even now. they are still classified. i have not understood it although i believe i'm a reasonably trained lawyer and what happened after that was a lot of jockeying around and finally, congress was more fully briefed and fisa, this law was amended to cover the activities in question. i think that was the right result. it was awkward and painful, but the law has to be followed and

congress has to exercise oversight. that is issue one. issue two is libya. and, the involvement of the u.s. during the obama demonstration and the nato exercise over libya was arguably, arguably -- no one is absolute about this -- something that should've been briefed to congress and much more detail on the front end and the war powers act should have been a -- possibly should have been invoked. there is an issue about that too. at any rate that didn't happen. it didn't happen and there are still enormous resentment by many in congress. this panel may not a sympathetic. [laughter] but members of congress, including a very senior republican -- maybe that will get some more attention on this panel -- are very upset about basically congress being disrespected in a process that certainly did

involve, although fortunately no u.s. life was lost, an expenditure of a billion dollars and the employment of considerable defense assets by our country as part of an international mission. >> we talked a little bit in advance. obviously we have little discussion before we came out. one thing we talked about is isn't much different when a president is reelected and has another term? is the president more confident generally? is that the re-election magically take the present more confident in dealing with national security issues and i wonder in your experiences, you know we have a wide range of threats to deal with and jane harman can talk respectively on this as far as what she saw from the hill, but is the second term president much different and that sort of has more direct relevance to our second campaign where president obama is seeking a term. >> i can testify to that because at the end of the first term,

one thought one had everything lined up. the vietnam war was over. there have been had been an opening to china. we had the triangular is asian asian -- triangular relation with europe and that design could not be implemented because within four months, watergate blew up and so the second term, part of the second term that nixon served, he still did some extraordinary things. we managed in 73 the mideast war that write about -- from the soviet side to the american side but that is not a good example. that is an example of crisis management under extreme circumstances and it's not a good example of how the energy

system, maybe the only thing you can say for the energy system is that it survived and that it enabled nixon to continue making decisive decisions on -- at key moments but i don't think for the sake of the country the watergate experience, i think it was a national distraction and self-inflicted that also pushed to an extreme that maybe historians would think is -- >> let me stay with that for a moment. as the watergate crisis intensified, what was that like dealing with national security issues? how did you fill those gaps? >> throughout his term, throughout his period in office, nixon made an absolute decision

between domestic and foreign decisions. the nhc personnel headed by me were not invited to participate in any domestic decision, so we didn't even know the evolution of watergate case until it, and tell it blew open. so as we endeavored some problems that arose, the challenge by the north vietnamese over the agreement in the mideast war, and we continued the system but the amount of time that the president could devote to the detailed exploration -- as it

does anyway in the second term because the first part of the first-term has to be used to establish an agreed interpretation of where we are in the world. and much of the second term is the implementation of that vision. that was accentuated so it was really -- we set up something called the special action group which was really a group in which operational decisions were pre-discussed in that group before it went to the president. there was one period which when haldeman and ehrlichman had yet been appointed, where secretary

schultz who was treasury secretary and i and the head of the federal reserve sort of screened the decisions because there was no system working. it was obviously only a three-week period and i mention it only to indicate the really painful atmosphere at a moment that could have been, that we thought had all the evidence of substantial achievement. 's beyond the notion of a second term, you know i think no one elected president really knows what they are in for. i think no one is really fully prepared to be president and i think most people don't really

know what the job is like. if you have been vice president for a period time, if you had a father who is president, but you know when it really is yours and the responsibility is on your shoulders, it is all the difference in the world. so i think nobody is really quite ready for that job when they step into it. secondly, everybody hopefully learns on the job. and i think presidents do and they learned very quickly. thirdly, over the first-term, they made a lot of decisions, very tough decisions. president clinton had his, president bush obviously had the attack of 9/11, the invasion of afghanistan, the decision about iraq. these are very tough decisions and you have been through the crucible with this. and the fourth is as dr. kissinger said, by the end of the first-term the president

knows, make a lot of decisions, said a lot of policy frameworks in place so the second term tends to be more about implementation and execution. so i think it is very clear that a second term president is really very different than a first-term president. in the national security adviser's role and in some sense the nfc system needs to adapt a little bit to that transition. >> clearly the case that this is, there is an awful lot of learning on-the-job and that there just is no job before this that prepares you. and so all presidents have faced enormous challenges in their first year or two and they have had some very difficult outcomes. i actually wrote a book before coming into the obama administration about the first year of a presidential administration in foreign policy and if you think about her history and help many perilous moments we have had during that time. so you have learning curves about how you make decisions. you have learning curves about

how you work with your teen. you have learning curves about how you interact with your counterparts around the world. you have learning curves about the dynamic world you are living and so you develop a sense of confidence, sense of how what you need, while kind of information you need, what kind of process you need and where you want to take it. i think that is why there is a sense in which people really do step up to the plate overtime and especially in the second term, the president can then say i kind of know where i want to go. i can set an agenda for my second four years and take it there. if i could just, one other thing because i am going to rise to james provocation about congress. [laughter] i worked in the senate for five years old i have a great deal of respect for the institution in the body and i think it is a challenge to how to make this work. it is true that the national security adviser doesn't testify before congress normally in the white house staff doesn't but certainly in the clinton administration with tried to find a lot of other akin isms, both i and my boss sandy berger

had leaders and staff members down to her office regularly. there were a lot of informal consultations i have to say i'm not here as a representative from the obama administration bet on libya the president called the congress down to the white house three days before he made the decision to intervene and we had extensive conversations. there i was a senate confirmed official. i justified it a number of times both to the senate foreign relations committee and the -- so understand it is obviously, there's an deeply felt in congress and i don't dispute that at all. there was not enough in gauge meant and i know exactly the senior republican, guzman harman is -- whether we have succeeded, the white house administration feels we are doing a better job than congress does but i don't dispute the basic proposition that there has to be engagement. there has to be dialogue to reflect and respect the confidentiality and the advice

the president needs but also to reflect and respect the role of the congress. >> i agree with that, but it is important to remember that our constitution provides checks and balances and it does that for a reason and a good break on presidential action, when it works, is a function in congress congress -- [laughter] that has bipartisanship and seriousness and, and, and great expertise as some members and foreign-policy. so when that relationship works well i think it helps the country and it helps us make better decisions some, so a couple of comments about a second term. presidents in their second term are not running for re-election and i think that frees them to some extent for good or bad to do things that they would have been reluctant to do as they were seeking re-election. many people talk about president obama in terms of well, when we

get through this election if he is reelected, he might take on some issues that have been put off before the election season. i have my personal list and i hope he does that. but that is another point. finally though, the experience, the prior experience that a president has does matter. i'm thinking about eisenhower, who i think as a, an extraordinarily skilled military general broad organizational skills to the security job in the white house that have been unrivaled since. he had a committee the name of which i have forgotten, that took a 10 year look forward and his -- yes, the solarium project and his cabinet meetings which i did study because i was the one who took the minutes of the clinton cabinet, the carter cabinet meetings, were much more interesting than those of some

other presidents. i would even say then-president carter conducted because rather than have a kind of show and tell exercise where each cabinet member would report what he or she had been doing, he put a topic on the table and the cabinet was aware in advance, and they would interact and discuss the topic, which i'd think is, i'm not sure how much of it was on foreign-policy, but i think that is a much more interesting way to organize very talented people who need to bond with each other and to actually one would hope, bring their own skills to this. so i think it will be interesting to see if president obama wins a second term, how his foreign-policy changes because he is freed from the re-election process. >> dr. kissinger has to leave shortly so we will have one more question for him before he leaves. and that is, and i will ask this to the entire group.

all of you have had to deal with very tough decisions over time. president nixon, president ford, vietnam, china and the soviet union, president bush obviously with the war on terror, iraq and afghanistan, weapons of mass destruction, all these issues came up with president clinton had many issues to deal with including the transition from a cold war national security policy to something beyond that. and i wondered, what was the toughest decision looking back on it that you had to make? >> it's a very good question. do know in the literature on the subject, we went on alert twice in the crisis but we didn't

agonize over that decision. that was done under tremendous pressure and you had to make a quick decision. .. >> when you are the leader of an alliance in the middle of the cold war, and how do, at the

same time, you maintain the position of the united states as a potential leader of the free world. and maintain the options towards the opening to china and elsewhere that we have in mind that's a long-range policy. we went through many agonizeing periods whether to try for a military outcome which we thought was sort of precluded by previous experiences. we, of course, were overwhelmed by proposals of sudden withdrawals that were not made when our predecessors were in office. and we chose what we chose. but you're asking me about what was the -- >> right. >> there were many crisis points, very long nights making decisions.

but the curious aspect of crisis, at least in my experience, is that it gets very quiet in a crisis because decision makers fall away, and events impose certain necessities. and to then have to feel your way fairly quickly to a decision, at least that's how it was in my experiences. so it was a strain, but in my experience the key people who made the decision in the crisis moments were together and were not, were not arguing. so i would separate strain and -- i apologize for having to leave. this is not, this is something i

told the organizers about that would happen. i was eager to do this, and i just want to make one final point. in this year of division, one should remember that people like us who come from different parties and secretaries of state, over 40 years we're here, it would be the same thing. that on the main outline we'd be pretty close together. and we would feel we had built on each other, and we would look to each other. and we still consult each other. and so this country is not as divided as it looks. [laughter] [applause]

>> thank you, doctor. [applause] >> great. well, we're glad to have dr. kissinger for the time he was able to be here. i want to continue our discussion on the toughest decision that your president and you had to make when you were national security adviser. >> i think for president george w. bush it was three things. one was how to respond to 9/11. he told a group in 2008, he said, you know, i didn't campaign as a national security president, i campaigned as a domestic president. and he had a very robust domestic policy agenda. and a lot of it he got accomplished, some that he didn't. but on 9/11 he would, if he were here, he would say that all changed. and after 9/11 i became a

wartime president. and how to respond to that, we can have all kinds of discussions. you know, what was right, what was wrong. i think the bottom line is that as you're -- as you've seen with president obama and through iterations now belatedly in some cases with the congress what has emerged is a national consensus about how to deal with the war on terror. there's still some disagreement. how to deal with the terrorist threat that has transcended two administrations, republican, democrat. that's a good thing. second was iraq. if you read the reports that i read in 2004-'5 and into 2006, you know, we were losing this war. and i know when the president asked me to be national security adviser, i was very concerned about iraq, and i thought, great, i'm going to be national security adviser when we revisit the vietnam period which i remember; social division over the war, an outcome that was

problematic, an army that felt that it had both not succeeded on the battlefield and then been rejected when it came home. i mean, it was -- those of you who remember, it was a dark time for our country. and the toughest decision, i think, the president made was the surge, the additional troops, the change of strategy which transformed the situation on the ground. and presented a situation whereby the end of this year all american troops will be autoof iraq with honor -- out of iraq with honor having accomplished their mission. the future of iraq is uncertain, it'll be decided by the iraqi people. but i think that was the toughest decision he made, and it was certainly a right one. and then the third was the financial crisis. which was, you know, at the end of eight years in office -- [laughter] you know, at one point condi said, mr. president, i think you've had everything in your

administration except the earth being, you know, hit by an asteroid. and he said, shh, there's still time. [laughter] and that's kind of how we felt at the end of the eight years. but, again, very difficult decisions the president had to make in order to prevent a repeat of the depression of the 1930s. so i think those were probably the -- >> it's, obviously, a hard question, ken, and there are different kinds of hard decisions. i think the decision, the decision a president has to make to send american servicemen and women into harm's way is the hardest decision almost by definition. it's a tremendous personal responsibility to ask people who volunteered to defend their country to put their lives at risk. and i know, you know, being involved in the president's decision, ultimately to intervene in kosovo, was something that weighed very heavily on him. he was persuaded it was right, but he had to continue to ask himself, will i be able to look into the eyes of their loved ones, the families, their wives,

their children because you can't assume that you're not going to lose -- we were fortunate we didn't, but you have to assume going in that that's going to happen. there's no way to share it, and there's no way to really understand how weighty a decision that is until you have to watch a president make that decision. second decision will probably surprise you, but one that i really gave president clinton a lot of credit for was his decision to go to pakistan during his trip to india. not only because there were questions about would that have an effect on the image he was trying to portray in terms of building our relationship with india, but because of the serious risk to him that he was receiving from the secret service and from others about the dangers of going to pakistan. but he was so persuaded that we needed to not lose that relationship and that the consequences of simply going to the subcontinent and not even trying to go to pakistan were so consequential that he decided he was going to do that over a lot of advice to the contrary, as you can imagine.

again, this is the kind of decision only a president can make for himself, but it was one that he stepped up to the plate and made for himself and, i think, was the right decision to make. the third was more of a policy one. and that was the decision on enlarging nato. and the reason i cite that is because the president, president clinton had invested a lot at the beginning of his term in his relationship with president yeltsin and the attempt to build a new relationship with a new and democratic russia. and he knew that a decision to move forward with nato enlargement would be deeply resented and had deep consequences with the relationship with russia. and he had to balance against that the deep yearning of the people of eastern and central europe to be part of this community that had been their vision and aspiration for so long and to weigh these two choices about what the landscape was like and what the different risks are in a very deep and long-term, consequential way for american policy. and there were different views about how that should persuade, different ways of waiting and prioritizing different senses of the risk.

and there was one in which the president really had to think deeply about what he thought the core values were, the core strategic interests before and then make a decisive choice. you couldn't split the baby on this one. you had to go one way or the other, and ultimately, he decided that sustaining the democratic movements and keeping faith with that commitment was important and, again, i think it was a sound decision. >> right. well, i remember that -- that was the islamabad trip where he was -- and i remember the secret service having covered that period in the presidency were very concerned that, i guess, was really concerned that someone would fire a missile at air force one. and so there was a lot of precautions taken on takeoff and landing and so on, and as i remember when he left to go to islamabad -- and it was a very controversial decision. as i recall, he didn't even want chelsea and hillary to be with him because of the concern about his safety. it was that serious. and, um, as i remember, when he was taking off there was at one

point a plan to have him pretend to get on one plane and really get on another plane, and there was some debate, well, he won't get on the first plane, but people will think he's on that plane, and we'll put the press on that plane. [laughter] sort of a decoy moment. we didn't appreciate that when we heard about the discussion later. [laughter] but i don't think they did that in the end, so anyway. but your perspective on this -- >> well, yeah. i'm -- congress gets involved deeply in some of these decisions too. here i've been ragging on the executive branch. but on 9/11, for example, um, i was at 9:00 in the morning headed to the dome of the capitol which was then where the intelligence committee was housed. it's now in a bunker called the capitol visitor' center. but out of nowhere came these attacks. well, that's not really fair. i'd actually been on something called the congressional

commission on terrorism which had been one of three commissions that had predicted there'd be a major attack on u.s. soil. but nonetheless, to the surprise of everyone on that beautiful morning and all of you were involved in it, too, this happened. and as a member of congress with senior responsibility for national security, it was very personal to me. and i, congress immediately did the wrong thing which was to close the office buildings in the capitol at a time of great crisis. the congress needs to be open serving our government. and it finally reopened later in the day. but trying to find the right roles and to be supportive of an enterprise where there was no disunity on that day. not any. everybody understood this was an attack against america, not an attack against a political party or some subgroup here. it was all of us. and trying to find the way to forge that unity was an enormous occupation of every member of

congress, probably still is. but we represent, i used to represent 700,000 people who looked to me to represent them here. and i always took that very seriously, and i think members of congress do that. we're much closer to, you know, the ground level than a president is representing 300 million people is a slightly larger group. and so the decision since 9/11 have been excruciating, very, very tough decisions. the votes on some of these issues have been very, very tough. some were right, some were wrong. the mistakes that congress made that i think the president's made have been, there have been a number of mistakes. but i think, um, something henry kissinger said is sticking in my mind, and that is that, um, if you are focused on national security wherever you are, if

you're in a fairly senior chair and very serious about your work, there is a bond that is forged among those people. and i was in a rare position in congress where i got to know the senior national security people in both bush administrations and in early obama on the intelligence side and the defense side. and i now serve on the defense policy board too. i got sit next to henry kissinger for a day and a half this week which was quite amusing and interesting. but all these people know each other, and they're different ages and from different administrations, but that's a good thing. you want that to happen. doesn't mean we have agreed on every decision, but the fact that there is some collegiality and some spirit of shared enterprise, i think, should make everybody a little bit more assured that, that the primary work of the united states government which is to protect

the security of the american people and defend our country is getting a lot of brain cells focused on it. >> if i could just add something on that that people probably don't appreciate, and it's a chance for me to express my appreciation to steve is that one of the times most important is presidential transition. you can't imagine how per illous a moment this is when one president leaves, especially when there's a change of party and a new president comes in. these are moments when the world is watching, people who would not wish the united states well are especially watching, and i've been transitioned in and transitioned out as has steve over the years, and it is remarkable the degree of cooperation and support and commitment that takes place. when we were preparing president obama's transition and what steve and his team did in terms of providing us the information, the continuity, the work that needed to be done was extraordinary, was absolutely extraordinary. and it's something that is not only a testament to the

professionalism of the people involved, but even when there are differences and often very vivid differences that were highlighted during the campaign, but still a sense that came from president george w. bush to president obama and to others about this being a common enterprise. >> well, i wanted to, i want to open this discussion up to your questions here, so if you have questions, if you would make your way to the microphones. i do have one other question that i would ask the panel, then we'll go to your questions. and that is i'm not going to do what the moderators of the debates do and just ask you to raise your hand in answer to a question. that would be a little bit too simple, but i would ask if you could just rook at the range -- look at the range of challenges we have, and i'd like to ask what you think the single biggest challenge to our national security is today. is it still terrorism? is it the war in afghanistan? is it our dealing with china? with iran? with nuclear proliferation? there are so many things that we're dealing with now, but if you had to pick one, what would

it be? >> you know, one of the things about the modern world is, you know, the people in national security positions now are dealing with 12 or 14 things at one time. it's just the world in which you're in. but i think -- and so there's a lot that's got to go anywhere. but, one, getting our economy back on track is a national security issue. [applause] >> yes, it is. >> it undergirds everything we need to do and want to do overseas, so that's number one. secondly, i think there are two areas over the next decade where a lot of important issues are going to get decided; what happens in asia which is where most of the economic growth is going to happen over the next decade and what happens in the middle east with the arab awakening. and these two things have to be a real focus. and after some conversations

today, i will tell you i'm very worried about what's happening in europe. on the economic and financial challenges and the potential blowback here. so challenges we've got as my old boss used to say when i would come in at 7:10 in the morning and tell him what the challenge of the day was, he would say, hadley, inside of every challenge is an opportunity, and your job is to find it and take advantage of it for the united states. [laughter] well, that's what the folks in the white house have to do now big time. >> jim? >> well, i agree with steve, and, you know, president clinton would certainly agree it is the economy, and it's not stupid. [laughter] it's, and it's more than just the kind of getting our fiscal house in order, it's the broader sustaining of our competitiveness, our -- i'm a dean now, and i'm very focused on making sure that we have opportunity for our young people. it's deeply distressing to me to see people coming out of college

and graduate school without a sense that they're going to have economic opportunity and a chance to build a future for their children. that we have the infrastructure that we support science and technology which is our huge comparative advantage in the world. that is the platform for america to sustain and preserve its interests around the world. without that we can't do anything else. we know, i mean, if you look at the history of the competition with the soviet union, the reason we succeeded was because they couldn't sustain it, and we could. we were free, we were entrepreneurial, we had well educated people, and we have to sustain that. we will not be able to meet any of the challenges -- i agree with steve's list. i'd add to that concerns about nuclear proliferation which i think we're on the cusp of a very, very dangerous period not only with states acquiring nuclear capability and the risk that it will really become a domino effect if iran moves forward, then others will feel the need to move forward and concerns about nuclear proliferation in asia as well, but also the danger that nonstate actors will get access

to nuclear materials. and, you know, it is a concern of mine as we think about the challenges of what's broadly called cyber and the need to sustain our own interest in an open, vibrant use of these technologies that can sustain our economy, that can support our freedom, our vibrant civil lives in ways that don't also threaten our security. so there are big challenges out there. but we can meet them, and we can meet the challenge of rising powers and all of these things if we do what we need at home to make our, to sustain those sources. >> last word on this, jane. >> well, i agree, but a couple of additional points. david ignatius has a very interesting piece in "the washington post" today about the future in this arab awakening, and he points out that the most important thing in these emerging democracies won't be constitutions, but they'll be smartphones. and if you think about that,

smartphones that enable us to be linked to each other and smartphones that enable these early courageous protesters to build the crowds and communicate the messages and not be shut down. but the world is geometrically changed, and the challenges we have going forward are going to be ones we could not have imagined ten minutes ago. what i was going to say at least in the foreign policy side, i think our biggest challenge is fashioning a narrative about what america stands for that is not perceived in much of the world as we are anti-muslim and what we do to project our power is we bomb muslim countries. i think that's a misunderstanding of what we're about, but i think it is very important to talk about the values that were just discussed and say that is what we're about and demonstrate to millions of people all around the world that those are the values we actually live by. >> good. now, we'll take some questions.

let's go, we'll alternate one side to the other. yes, sir. >> unfortunately, you have preempted my question. [laughter] so i'm trying to think, it's a fallback question, and it has to do with how important it is for a president to have some kind of understanding of the culture and history, be sensitive to that, of different peoples in which in a shrinking world we're much more intimately involved. i know the state department is supposed to be their expertise, but nixon seemed exceptional in his grasp of the big picture. and i was wondering whether it is, do you recommend a president actually do some kind of scholarly boning up on the history of china or the middle east or so forth? >> jane, why don't you start on that one. >> the question was about whether people really need a cultural understanding of the different parts of the world.

i would say, yes, and a respect for differences in the world. i'd say yes to that too. i'm not sure any particular president needs to bring all that inventory into the white house, although here's a plug for woodrow wilson, our only ph.d. president, who was highly skilled and schooled at foreign and domestic issues. so he only was a politician for two years as governor of new jersey before he became president of the united states. always before that he was a professor. but i think not only a president, but congress needs to have some skills and understanding about the different parts of the world. [applause] and i think it is just appalling to hear numbers of fairly members of congress bragging about the fact that they don't have passports. it's not that everybody needs to take a vaca in beautiful wherever, pick one, but it is that being willing to travel to

and learn about the trouble spots in the world, to take the tough trips. you know, i personally went to north korea, libya twice, syria, all the garden spots -- [laughter] iraq and afghanistan, more than i can count. but it was extremely useful travel and helped me do my job better. so i think that's a very good question, and i think we have a culture sensitivity gap that's huge, and it's one that we should pote recruit people in our -- both recruit people in our government in those skills, including language skills, but also reach out to people living around the world to learn from them how they perceive their own lives and how they perceive us. i mean, a little humility would go a long way. [applause] >> you know, i think what i always found remarkable is that with all the things that a president has to do, it's amazing how voracious they are as readers. it's extraordinary.

i don't know where president clinton had the time to do it. i would drop at the end of the day, and he was working harder than i was. but i think presidents do have this understanding that they need to deepen and find broader ways to get through -- that they're not just reading options papers or memos from the nsc staff. they're looking for different sources of information, different perspectives in history, in culture, in other things, and i think it's great. i think people are well served by that. i do think, though, there is a need to get to this broader community. in the old days it was only a matter of heads of state and foreign ministers dealing with each other are long past, and so understanding how what we do is going to be understood by the people of pakistan or indonesia or brazil is every bit as important as understand what the president or the vice minister is going to say to us when we meet at high-level meetings. and i think some of the biggest challenges we've had is not because policy was poorly intended, but because we don't have the good sense of how whether we think we're doing the

right thing, how it's perceived -- as jane said -- by the audiences we need to reach. so having that understanding and tuning your ear to how what we do will be perceived by others is critical to making sure that we actually achieve the intended results that we want to get. >> i think the more cultural experience and understanding you have the were the, but i would echo two things. one that jane said and one that jim said. one is respect. you may not understand all these cultures, but if you go in and show respect to people, whatever their cultural background, it gets you a long way. and secondly, presidents and members of congress travel. you get 70% credit just for showing up and showing people the respect to come to them rather than expecting them to come to you. >> yes. [applause] >> there is rightfully been a lot of discussion on the about the process of the national security council and how the

decisions are managed when there's time to make a decision. i'm sort of more interested in when there's a crisis moment, how is national security adviser do you manage a crisis, and how do you make sure the president is hearing from who he needs to hear from? >> anybody want to start with that one? >> i mean, i think you're always in a difficult situation in those kinds of moments when you have to respond quickly or just a failure to act quickly is consequential in it own right, and you're balancing the need for a prompt and decisive -- [inaudible] with having the information that you need. just one example, you know, from the clinton administration, after the bombings of our embassies in africa, um, we -- there was a clear, you know, impulse to just act very quickly and respond because there was a need to show that we were not going to just take this, we were going to get out and have a

response. there was a fair sense of what, where it had come from and why it had happened, but there was a back and forth about do you want to take more time to develop can a stronger case and conviction before you respond, or do you, are you risking by delaying that you won't have an effective response at all? and that was through the period of time which ultimately led to some military action by the united states that was constantly being balanced. more information versus prompt response. and i don't think there's a magic answer to it. you have to decide in each case how confident are you that you have the information you need to make that decision, what would be the consequences of turning out to be wrong because you thought you knew what had happened, and then it turned out it was otherwise. and i don't think there's a magic answer. but it's an enormously difficult challenge, obviously, for the president but also for the team to decide how you make those trade-offs. and i think in each case it really does depend a little bit on the experience that the team

itself has in being able to come together quickly to use the ability especially now with technology being better to convene the senior advisers instantly, to be available at all times, to try to get at least that first cut about what do we know, what don't we know, what might we know more of if we wait a little bit, and what are the consequences of waiting? >> but you can be sure that you won't -- despite all the best efforts -- you won't know all you should know. you just won't. and yet you'll have to make a decision. and you'll make a decision on partial knowledge. and if it goes bad, as a lot of them do, there'll be some commission of inquiry that will have hundreds of people spending 10,000 hours, and they'll, they will find all the stuff you wish you had known but didn't know and couldn't have known. [laughter] and that's like, you know, that's how it is. and a lot of tough decisions you've basically got an hour and a half to makeca