castor joins us to discuss the u.s. policy towards cuba. including the obama administration's decision to restore diplomatic ties with havana, cuba. you can join the conversation on facebook and twitter are in ashington journal is live everyday at 7:00 a.m. eastern. >> with that power comes individual responsibility. unfettered for 35 years. it just doesn't pass this when it comes to a modern democracy. >> sunday night. changes that he would like to see in the supreme court, including opening up oral arguments and imposing term limits on the justices and requiring justices to hear to the same code of ethics that other judges follow. >> this affects all americans.

all of them are aware of the third branch of government and in the last 10 to 15 years it has become so powerful. the idea that issues on voting in marriage and health care and immigration and women's rights, discrimination. these issues than maybe 20 or 30 years ago congress and the executive branch would get together and figure out a bill. that doesn't really happen anymore. the buck stops in a way that is unprecedented in our history, given this way that they have very impactful decisions shows them this modern transparency and accountability. >> sunday on "q&a." >> the national football league vice president of health and safety said today that there is a link between football and degenerative brain diseases.

he was one of a number of medical experts before a house energy and commerce committee using diagnostic tools and how awareness can help to prevent brain injuries. this is just under 2.5 hours. [inaudible conversations] >> good afternoon. i would like to welcome all of our panelists here. this is a forum and not hearing. this is a time when members are just arriving. we will have them arriving throughout this forum here and

so no one is going to be swearing to tell the whole truth. representative alone, and the other members here yet? we will introduce them. let me just start off with a brief opening statement to set the tone. i would really like to thank all of you for being here for the roundtable to evaluate research and applications from public health. we are here today because a lot of people are paying attention to therisk of concussions. there's a new provocative movie getting a lot of attention. this is help bring us into the public eye with mounting evidence regarding the prevalence of concussions in sports and military and a broader population and we know that most concussions don't even occur in sports and military. but from parents, patients, athletes, service members, people are worried, to hear more and more about the dangers of the potential long-term effects,

they want to know if their family members are at risk and that has not always been the case. less than two decades ago concussions were barely a blip on the radar screen, whether you detonated a breaching charge, there was a lump or they said that you saw some stars provider bell wrong, i remember you got knocked out on the field, they weave some ammonia in front of you and you got back up and finish the play. we've come a long way with the tough it out attitude of the not-too-distant past and the public is now concerned looking for answers. where do you draw the line between the getting an injury and going to the hospital? is my memory loss due to years of college football? that wasn't me, i didn't play college football. are they somehow tied to training what took place 10 years ago to it's a good thing

that we are asking these questions are it unfortunately as we sit here today we do not yet have all the answers and therein lies the challenge. the public wants answers that science is not ready to provide and so we are dealing with the challenges and the fear what we don't understand, they need to get greater clarity regarding traumatic brain injury is of the utmost importance. in 2010 it accounted for 2.5 million emergency room visits. however, it's important to note that they are not just limited to the athletic deals and basketball courts. 40% of all documented cases are due to falls and 10% to assaults and those age 65 and older had the highest rate of death which brings us to this today. today we are beginning a new chapter in the national dialogue of concussions and we are not pointing fingers, we are here to take a step back and it's not a

problem. we are joined today by some of the most prominent experts in this field and this is a wonderful opportunity for members to sit back and listen to these individuals as well as decades of experience. we are here to talk about the science of concussions. what we know, how do we address the gaps which have meaningful short and long-term solutions. we are also here to make something clear that this is not a sports and military issue but a public health issue. every year millions of americans not serving in the military suffer concussions and it could have been anyone anywhere. some will recover with no noticeable effects and others will have debilitating symptoms. why the difference and the disparity? that is why we are here today to ensure that we are on the right path although it may be long to provide this answer that they

deserve but we begin with a brief presentation from the cdc presentation who will provide a general overview about what we know about the injuries and the prevalence and the information providing a baseline for this conversation. then we will put forward broad discussion questions that focus on the four themes. the first is prominent misconceptions are an underappreciated fact and that knowledge gaps in understanding and specific objectives that will lead to meaningful progress and minimize the risk of concussions as well as achieving those objectives including coordination within the research community. these questions are intended to guide conversation among participants to provide us as members to have a chance to listen. august the members are welcome to ask questions are joined at this discussion. it won't be formal like a hearing but just let us know if you have a question and we will keep track of it.

if we have time we will have question-and-answer to cover any outstanding areas of interest. i would like to thank the ranking member for her support on this. your wish is granted. [laughter] >> i now recognize you at. >> thank you so much, mr. chairman, for this roundtable. sometimes it seems like the format is concerning, but we did a lot of these when we worked on our initiative and it was a good way to get a lot of information in one afternoon. i would also like to thank the panel of experts who have come today to talk to us about the importance of the concussions and head, understanding the facts of impacts to the head as well as how to prevent and treat injury that results from such, which is critical to the various segments of our society. from military to parents of

young athletes all around the country. so given the diversity of opinions i believe that we have the opportunity for a lively discussion and i hope that this has been communicated to us at the staff level and a beginning of hearing from us on this topic. i think that targeted discussions on this matter would be useful as we start to think about what congress' role is. as we move forward, and hearing processes going to provide us with important organizational tools as well as structure. i don't think the most important thing is that people be under oath, but i do think that it helps to have testimony on the record. you know, 10 years ago not much attention was paid to concussions as you said. as we learn more and more about the potential short and long-term effects of concussive and sub concussive situations. constituents have many questions as well as concerns about their

children's involvement in contact sports. young athletes may be particularly at risk of lasting brain damage due to repetitive head even when those hits do not rise to the level of concussions. the studies have shown that young athletes who do not sustain concussions but did experience repetitive hits to the head exhibited are logical and pearman over the course of a single athletic season. according to a recently released study by the mayo clinic in december last year, about one third of men who played amateur contact sports in their youth displayed evidence of the cte typology. one third. that number is surprising and is deeply concerning as it shows that you do not have to have professional football play time or hockey play time to suffer from contact sports. while we still have not

established as for cte, the study suggests strongly that the diseases more prevalent than we originally thought and frankly not just with those diseases but also with girls soccer and also other diseases affecting both the girls and boys. i do understand that with any scientific endeavor there could be a disagreement and uncertainty regarding what we know or what policy actions we should take against the backdrop of knowledge. but uncertainty does not excuse inaction. i'm interested to hear from our panelists today about what actions we should take right now as well as how we need to move forward in our continuing investigation. you know that i had to say it, as the reigning champion of the denver broncos and somebody who had their season-ticket, and someone who graduated from a

division hockey one school and now represents one, the university of denver, we love playing and watching contact sports and we appreciate the fitness as well as the other benefits of the activities. but at the same time the head injuries associated with some of these activities do appear to have consequences that are long-term. and even deadly. therefore if there are ways to make these activities safer not just for the kids but also for professional athletes, we need to make sure they are being implemented. so in other words we want to enjoy the thrill of being a fan or participate in the with the confidence that as much is being done is possible to inform players of the risk and to minimize that risk that is associated with the contact sports. so thank you very much for recognizing me. i know that we have a lot to discuss and many people to hear from. i am glad that we are kicking off this effort and i yield back my time.

>> fred upton, you are recognized. >> thank you. i have a statement. i want to get to the business for the day and i appreciate everyone being here. i think that we have learned a lot and we have a lot more to learn. primarily this is why the format is a little bit different than normal and it is, i understand, my friend got a letter for me and i look forward to working in a continuous space and this is not the first step. i know that we are all truly very interested in this and i intend to make sure that that happens. i visited with my thomas center at bronson hospital and one of the photo we took down is what we have identified a simple concussions are not quite as simple as they seem to be in that underscores what we are

facing. i yield back my time. >> thank you. ranking member? >> i would like to thank all participants joining us. concussions are a critical situation affecting many people each year and we have strong indications that the effects of repeated brain trauma can accumulate with consequences their long-term debilitating and life-threatening. these consequences can stem from injuries once considered minor known as sub concussive hits and recent studies show that exhibit evidence shows significant brain damage to hits in the head even when they do not suffer concussions. the work of a group of researchers at purdue found significant structural changes of the brains of high school football players even among those that do not have a concussion diagnosis. what is particularly troubling is that these changes persisted even 12 months later, suggesting lasting damage. many other studies have

documented the sub concussive significant changes, behavioral changes and the release of biochemical markers as part of brain damage. there is also a degenerative brain disease known as cte which is a devastating disease associated with memory loss, impaired judgment and depression and eventually dementia. so i want to welcome the gentleman from boston university. she and her colleagues have defined this and examined the brain tissue of dozens of deceased nfl players as well as individuals playing football at the collegiate and even high school levels. they have discovered the presence in athletes as young as 25 and many adults that are played well since they were kids. they have confirmed that it is a unique disease with a unique signature and their work is

culminated in this definition of characteristics. it's unfortunate that the work has been questioned by those who have a vested interest to maintain the status quo. i understand the unwillingness to acknowledge the linkage. it's what's called inconvenient truth. some of our greatest national pastimes, that includes lasting brain damage and that includes the mounting evidence because it is time to do something about it. there is research that still needs to be done in order to answer all the questions, they should not be an excuse for inaction. we should be examining doubling the state of this but also looking to how we can apply what we know right now to protect our service men and women and athletes and our kids. and i hope that today we are paying it forward in our discussion will not obscure the

science around this issue. i'm also pleased that the chairman agreed to invite lisa today. not only the director of family relations or the foundation but advancing the science of concussions and she's also the wife of a player that had cte. we would like to hear from lisa with her experience and she will pay for to address this disease. so let me say and conclude my remarks by suggesting and that includes we need to discuss the

process and how it affects everyone. you mentioned that i am sending you a letter. [laughter] asking that we jointly expand the committee explanation of prevention of concussions. i mentioned about this proposal of committee hearings that would give it the attention that it deserves, this critical public health issue. and so thank you again to all of our participants and we thank the chairman and my colleague as well for putting this together. this is only the beginning and i think that we can work together to be able to address this public health issue. i thank you again. >> i want to mentioned some of the members that are here.

joe pitts of pennsylvania is also part of this. doctor michael burgess is also on the subcommittee and as well as richard hudson. it is clear that what i said before is actually part of the centuries. it is the order which i have been so do captain and director of the centers of excellence, thank you for being here, captain. >> here you are. i'm sorry i didn't see you. the director of division at the

national center for injury prevention, jeff miller, the executive vice president of the national football league. bryant, chief medical officer for the ncaa and clinical professor of neurology at the university school of medicine. good luck with march madness in indiana. >> jeff manley, chief nurse surgery, professor at the university of california seven cisco.

[inaudible] >> we have in the, professor and chairman, chief of medicine, rehabilitation services and finally the director the rehab, sciences and engineering. [inaudible] >> director of the safe concussion outcome recovery school program. colonel, we have met before. a consultant recently retired with the dod care research

program in 2008 through 2014. consulting a number of organizations including the ncaa to advance the research brain health progress improvement program. and the key, i read some of your papers recently. >> let me do this. i recognize that most of you here as scientists may know each other by papers you have read. >> is it something that you know about when we comment upon this, we are limited and have a hard

stop time later on. if it's something you disagree with, part of this is part of a different science. members have comments and questions and we are going to try to keep this going and we won't be giving speeches. let me do the first tossup here. and then we want to have some baseline information. >> great, thank you very much. i want to thank the house of representatives and other members here as well with this health issue often referred to as the cochairs that have been champions for many years. as was mentioned, my job is to help to set the stage to provide

an overview of traumatic brain injury including chairing the latest data on the burden to americans. the chairman noted there's a lot we don't know. [inaudible] so nobody ever wants to hear or even in admit that this is the case. [inaudible] and it ranges from a car crash to falling in a bathtub or on the stairs, provided with another player in a soccer game, assault salt or suicide attempt or the field in the military like we have seen in iraq and afghanistan.

and they are frankly sustaining another caution. and they have one thing in common, it is preventable. there are many injuries related to tran-eightran-eigh t. that means that there are 500 emergency department tbi visits, 64 deaths. and this may be a significant underestimate of the burden.

and that includes many presenting in urgent care or primary care settings. these are outside of the scope of our current need of ability. costs are great. many suggest the tbi untrammeled sultan $141 billion loss annually. and the leading cause of sports and recreation includes bicycling, football, basketball, playground activity and soccer.

and including to this they had a better understanding of addressing the problem. and that includes actively determining the sports related concussions of youth 5-21 years old. for example our current system does not capture the concussions occur outside organized sports were those that are not seen in the emergency department and they do also not document protective equipment position played like offense or defense of lyman. and there is no record of concussion history or long-term recovery. and so the cdc is proposing a new national household survey and that includes all ages across the lifespan.

and they use a symptom base situation is possible, probable or more definitive depending upon the symptoms experienced and their temporal association with this. someone that is sensitive to light could have had a possible concussion. someone who is losing consciousness for any amount of time it would be categorized as having had a concussion. this but after system has been extensively vetted to make sure it will deliver and will be able to provide state-level concussions.

and we developed a survey and are ready to take this to the national scale and so the budgets are appropriated as well. and so as we look towards the future of the cdc is ready to do our part and we plan to them can better understand this and a relationship between outcomes through old-age and to improve implementation of essential and edited based strategies across

this. >>

>> but i will throw this out as a question talking about mr. collins, where the most prominent missed communication are under appreciated fact about concussions? from the national institute ltd. in a you be called on first by want to bask there are some underappreciated facts that we need to know about at the onset? >> it is a pleasure to start and open a conversation. the perceptions are many unfortunately fuelled by a lack of knowledge.

a and it is important to think about concussion as part of the spectrum of traumatic brain injury. it goes from the mild to the severe and it is not as though there are distinguishing costs in the progression of the stage. and the other misconception that needs to be said if you look in the brain you wouldn't see anything i don't think that's true. ended brings into the brave. so i think the biology and we will learn a lot more overtime there is a lot going on in the brain during

a concussion and. thanks to the cdc and the work of multiple groups in those have been taken by those around the country and that is important. that we don't know enough to cancel parents. it is that repetitive concussion that gets the kids in trouble initially it can be bad because there is a spectrum of head injury, but the kids that i have seen and heard about to run into trouble the first

concussion their bad a couple days the second couple weeks the third is a couple of months. then it is clear so getting that out is important. it is important when there is a huge allegiance as they take themselves out of contention. >> my daughter was playing baseball in high school my senior year and was hit directly in the head and suffered a concussion and basically they said we don't know where she will play again because if it happens again you will have a serious problem.

she went to college as a freshman and in she fainted but doesn't play sports anymore. and we're told that don't play contact sports in a more. although she does a job but in my concern is you don't necessarily know about it. but if you had one of these how would you even know? but it seems like more and more to cause damage.

but tell me about the spectrum and the sub concussion how does that relate to the specter of the you mentioned? >> but the terminology is a little bit address so it depends on how you think of the concussion. initially somebody that lost consciousness and then it went by the wayside but now it is a change that is really recognized at the time of injury. there are changes in neurologic function in so in these that one could study

to see there is the changeover time sullivan said taking care of concussions 25 years dealing with brain injury and the sky is not falling. within one dares to of a concussion not contact sports being in a darkroom staying at home is not the treatment for injury. but it is in science for its efforts of concussion it is

bad for our to spread that believe we need a way more research. >> talk about that. is very hard to use a survey but months after words in to help set that up to do the research and then you make fun of a diagnosis. and their risk to get another concussion the we

are all less risk to fall down in a much higher risk to get courtesies' a psychological problems if you don't go back. >> said she was hit in the face and told not to go six weeks. >> that's wrong. >> deal the reason she graduated they let her do things after tonight she should have been activated quicker spanish she was told not to. >> i know that. >> but the second time -- since mikhail alaska this after an initial confession when should they return to activity? >> in in you pointed out to me you have done a lot of

research in this area. and that is a myth we need to dispel. we've made tremendous progress to match certain treatments that we need much more research to understand the timing in the dressing and collectively added is a treatable injury but what we don't want to do the pendulum has swung very rapidly pop --. it is rare so i thought it

is never safer to have a concussion it is renowned in talk about putting kids with chronic anxiety in the major and his advances hourly diagnose and treat. >> but it is individualized. >> you have a question you want to elaborate? >> i'd like to make a more general background commentary but confession

has gone from total obscurity 10 or 20 years ago in this sport setting and a military sector dominating the national narrative. in the unfortunate position we are in is we reach that awkward stage of maturity that we made enormous strides if to be in a position to have this discussion but at the same time the topic has been elevated into a public spotlight that all the stakeholders assume we already know the answers and there is no more unenviable position they had to catch up with the public

narrative. we have made great strides to change how we take care of the sidelines and during those ensuing days the treatment regimens the expression we often use is a concussion and a supportive environment used to be managed on us which several-- prior to be a symptom 31 dash symptom free the you would be returned to full contact. we have learned about clinically canal manage them on a dial. reintroduce low-grade no risk activity under a period of no exposure to a contact and allow that athlete to graduate to stages of

rehabilitation to reach a point to be completely centum free than return to activity when they are safe. we have data through 1989 in the current study there is a zero% incidence in the first 10 days in the average for those same season repeats conditions to 75 days instead of five. sold many have had a direct impact how we take care about bleeds some people from lavalin trauma centers.

in we know how long it takes for the individual to tell us how to be centered three but we know very little how long it takes for the brain to recover in with those critical questions with recovery atta abrade level. >> in what he is referring to is basically what we have currently acquired adolescent and young adults not is applied to girls or young her children so we're making some leaps of faith with how we apply this to have better evidence to know.

and when should i allow my child to do xyz? into those that are discussed about willie -- about sports so the application of knowledge to be more cautious no doubt and it may or may not be appropriate. that we have to better understand of a different biochemical responsive forces in the same goes with younger children as well. there is the perception that we know more about this injury but at its lowest

with younger kids. >> first-ever like to bring the conversation back. that it affects more than just athletes. is highlighted in the brief in we look at the athletes and military personnel because as our colleague just pointed out there is at least 2.5 million people per year coming in to emergency rooms with more moderate and severe tornadic brain injury there is at least 23 million people that don't seek out medical care. and we have studies that show that over half our midst. with the ongoing in i ah steady we're asking patients at two weeks were you referred for follow-up? actually diagnosed in the emergency department at 11 vestron the centers in the country in less than half

are referred for follow-up. there is a very low bar to follow-up with things that we know. there treated congestion and brain injury as an event and not a process. i've been taking care traumatic brain injury patients for years and we don't follow up like diabetes or heart disease. so now we look like a process any we are finding a single concession can alter the course so i applaud them to bring this to the forefront millions are sustaining tv i is suffering from the aftereffects and we need to do more. thank-you.

>> want 2.0 with concussions the movie was called concussion but with our experience we have never seen that to be associated with duration been head in packs and/or low level head injuries so that we do see consistently to be associated with the risk to lung replay at the higher levels the greater the risk. >> mr. chairman i appreciate

that i was a heart surgeon before congress. so with primary prevention and age 23312 and i play hockey research we be done in adults but i am not an expert cutting significantly into your 20s. so what do people think we should be doing in our elementary and grade schools

in what is currently available information to make carrot -- parents afraid it end with that said what is the potential differences or should we do things differently? >> who wants to respond? >> i am happy to start off the conversation. i am on the medical advisor leeboard in the meeting we had several weeks ago and at what age to reintroduce the different individuals? with the vial mechanics' hand physical maturity in and to appease these in different ways in american hockey has gone through the development model has a

model system for matching the person do we modified checking or tackling and blocking into wrap those researchers around those questions. isn't by reducing the amount of contact with the sports to not put them into a competitive situation and prepared is our challenge. certainly some of the work that has been done with the football program have and we can do more we still but note that answer and we start the zaph but it goes beyond that.

with physical education to understand how to rebuild that may be the preventive biologic factors? fatah we think of the introduction of sports at certain ages? her always reason i love contact sports but my eight sons and did not like that but we need to know we were prepared for. for boys and girls in frankly our bodies are built differently we need to take that into account as well. we need some studies done early. >> in there has been a transition about what level kids can check the is to be fairly young trying to teach

that was pretty hard sell when people are yonder whether football or soccer honestly usa hockey is out front and it is important. >> one of the cdc most successful communication campaigns is called heads up for recognition to have around for over a decade with over 6 million materials 3 million coaches nonrecognition migrated from health care professionals so now the next phase is focused on kids so we have some really creative ideas how to bridge into the older

part -- population with a game like rocket blades so one of the tools and the tool chest is raising awareness and trying to do that now for over a decade. >> awareness awareness awareness. nine will be as good as yours but it is unbelievable to teach kids but without the awareness of the coaches and the parent doesn't matter. even if awareness is good chemistry developed health care professionals that understand how to reintegrate people back in their lives we would have

relieved frustrated parents. that is to come to our center in their vote -- more focused on the fear in this organ they in their overall wilderness. >> in looking at the archaeological evidence. and some of guidelines. >> can we see them? >> of course, . >> it is live in the young

and in the old. and those that suffered the most consequence is from the elderly in declined rapidly. and it comes down to a matter of balance parents should not be afraid of the head injury the value of sports needs to be emphasized with teamwork and exercise of personal development sports has a viable contribution taurus society. oh we need to do a better job with youth in particular that there are no standards

in coaching even up of high school level even if they draw short straws. but when you coach kids to have trading in a way that would demonstrate and work needs to go one to raise the level or the knowledge of those who are responsible. event this year once they had a concussion that there is a mark that they should never participate again. the risk from a repeat concussion depend on a number of factors one is a time from the previous consent -- concussion in the

characteristic of the individual senate and the next question. >> in to look at sports as a public health model and three things are very important that can address the whole culture. one is that all 48 national bodies from the american development model in all the parent organizations to look at it as a long-term rally develops process. that is currently not happening well enough but everyone is on board and concussion in is a part of that. to be a coach believe have to do is hold up a shingle

to say i of a coach that is distinctly different in europe for you past several hundred hours of trading. and this is what pnc has been involved with. and we're doing specific conferences with the concept of coaching education but it has to start with what is exceptionally important. and also someone to protect our kids to empower the a flooded traders into be on-site from any type of contact an even in the state of california they're not even regulated. to say i am an athletic trainer or new york city

there is a one athletic trader than people really need to be empowered. we recently passed legislation were redefined the providers as traders and team physicians. to get those signatories to empower those that led traders those three things combined can do more than anything that i know of. >> it came to our attention that 37 percent have full-time athletic traders. 63% don't. that is ridiculous. the easiest way to protect our kids with the injuries of competitive sports

whether football or any of their. on the prevention and the trio decided to have kids that have catastrophic injuries seen -- a newly dead is a public health question believe has started programs and we will have an announcement tomorrow but it is a dramatic way and that is something we will continued to work on. and with the supporters around the country to get these laws passed. this came up from the young man who suffered a traumatic

brain injury as a 13 year-old to play the ball then returned to saloon in had catastrophic injuries and then have survived it is our inspiration they are pretty simplistic from any sport at least a baseline for those of our participating in youth sports but the first time it has been done in a model for improving youth sports. as the football program was to educate you coaches 150,000 coaches have been trained on concussion identification but that is

what i did 50,000 purchased it didn't know anything about concussion. but it isn't insurmountable. so you can make real progress. >> i still remember the press conference is set for a number of concussions and somehow it was determined he

cannot tolerate one more concussion or there would be trouble i did not know what metric was used or what test was used but i assume there was of mr. corry test where you could tell that is enough. in those two had repetitive episodes of head trauma. spin again to beat successful but only in football but put the question is a medical and with each team physician we have added an affiliated doctors in terms of lowe's diagnostics per as well as further independent experts before you return to play. so the standard is never

that medical staff comes to for that individual there is no concrete answers for those reasons why to know more about diagnostics. >> that was 36 years ago i would have expected the science to have advanced more than it has. because of the enormous investment the nfl has at risk. i did not see the movie but i did read the book but what you call the index base was webster from the pittsburgh steelers in a case pending for compensation for his long-term injuries and was eventually awarded compensation three years after his death. so the question is, is that

process better now part of that? is she does work as an advocate for retired players a and the answer is in those toward the retired player program. in addition there are numbers in place. in has been diagnosed. but there are more than 300

players. >> we will get into these. >> as we read about this illness is devastating for the family there is a non going to continue on to go from the family is perspective. >> i am not a doctor but i hope i can press a poillon have a difficult in tragic disease that this is. i hesitate to think of what they go through the day my

husband died he had no idea what was happening. to have the benefit of knowing there is a biological cause into blade himself but for the family is devastating i cannot overstate that disease with 180 your 190. for all those individuals that passed away very often very often ex wives to feel very guilty for not holding things together benefaction

leave more surprised there are sound benefits from the nfl to provide but part of the problem because even for the former players that they have to be vested in for treatment in in compensation. and i can tell you they are in dire straits in those individuals who are really struggling. >> a year-and-a-half ago this committee was involved

with domestic abuse in with the continuing of this disease while we focus on that is the issue with the nfl needed to focus but that there is already a component that makes itself apparent. >> unfortunately that is probably the case is the very strange thing that we may have gotten off easy that they do that the baby's cries set him off vizier

raged that is a very fall a tile combination and it would be a concern. for those similar symptoms. >> with the dot those that are physically active as a psychiatrist we're not seeing people with a concussion but downstream assets a psychiatrist need

to have ptsd with epee and disorder in folks just don't the the diagnostic clarification in a couple loved places with those very nexus that has policy issues and the like. many who have been diagnosed in the past have similar symptoms with short temper in now they realize. >> is very challenging to ascertain. it is tempting to use that

sports medicine bottle so it is a lot more to lerner have a two year-old he hit his head about 300 times before i tell him to walk off read some church it how can i possibly assess him? it strikes me my patients can give me a history about what happened then when it happened. >> cry just want to add because we're mixing a couple of things they concussion incident how du treat that and when you go back on the field? in in the second question is repeated.

but it could be a long history of repetition i am not a doctor but i am not sure we have that scientific data to support all of that. so what you are looking at in the movie was all about. to see we were looking for. but we cannot see what we need to see.

with the end stage for disease the brave and is severe the degenerated that will shot of the mri skean as severe atrophy. and the culprit is an abrogation of the protein in the nerve cells. ed is the signature of the ct with multiple different diseases in to be a bad actor. in those that are not severely dented it becomes tricky to narrow those differences. and you can only make bad diagnosis and then try to image the brain for the mri

signature than the next page is to move until longitudinal study to see when those images and it appears that this is an accurate diagnosis the bad is the situation you're in now. >> let me just finish shot. [laughter] the problem is initially had thought this would be a rare event. for those that have a thousand hits not that much of a revelation the high

school or college to mention a look at the mayo clinic in we don't know how common this is. if everyone will progress, we doubt it. have a couple of clicks but need to work that out. >> there are ways to diagnose early. they don't involve in regina the present time they may not. we have narrow psychological testing that dr. collins is a leader there is plenty of

ways to diagnose if you believe this guy is falling the intermodal approach is never a $1,000 mri not in the short term. but we have conditions that know how to do this and researchers can put together the intermodal assessments. and that is how we diagnose alzheimer's we don't wait until they expire and look at the of the stage but whatever the evidence of dementia and that involves other testing which we all do. >> is a the lesson we have

taken 30 years to learn with the dilemma that we currently face. we have been fascinated with the of magical discovery of a single solution theory to predict outcomes across individuals. one of the burning questions it is no wonder how can it be that two individuals with seemingly the same injury have much different short-term outcomes? how could it be that two individuals are very similar exposure profiles with a drastically different lives? it has to be a complex matrix. this condition in short-term and long-term with the

single predictor variable. what are the risks? who is a risky and why had we interrupt your protect those risks and its exposure to say how many or how much total exposure? is it necessary or sufficient to predict a long term risk? all of those remain unanswered. >> i.m. concerned to deny n

discredit with the risks of playing football pro -- publishing evidence from former player mike webster doctors went on a campaign to undermine the doctor to go as far as to debated a retraction of its peer review research over the next 14 years the nfl pursue a strategy to vehemently denied mounting scientific evidence. with bias to 9p review research with a growing consensus and that is linked to chronic brain damage.

in as recently as february february 4th 3 days before the super bowl a member of the nfl tonight there was a link between football and the ct and only grudgingly admitted that there can be found in association between football and the ctc because what some former players have developed but the disease to hear the affiliated physicians waffle about such a basic scientific reestablished connection is truly astonishing. the league may highlight the rule change of the narrow, a specialist on the sidelines at every game and the nfl has committed to reducing in managing concussions as

laudable as it may be to focus on concussions football is a high-risk sport not just diagnosable concussions what the public needs now is honesty of the health risks having clearly more research with that risk in the eric from the football. so a yes or no question question, doctor do you think there is a link between football n degenerative brain disorders and cte? >> unequivocal. we have seen and out of 98 of 94 players and 45 fatah 55 college players and six out of 26 high-school players.

immelt think this represents how common this disease is in the living population but the fact that over five years i can accumulate this number of cases it cannot be rare in we will be surprised at how common is. is not about confessions of an in head injury that occurs on every single player the game every single level. we have to eliminate some called the accumulative head impact to have sensors to gauge the number of impacts to limit to maintain safety for all the athletes especially at the youth level. we have seen many times and mature athletes come down with this disease is

devastating when you see this and a 25 year-old we have seen it over and over and it cannot be rare. to maintain the health of the shona athletes fifth there is something we can do to limit the risk. >> is there a link between the ball landed generative brain disorders like cte? >> research shows nfl players have been diagnosed with cte so the answer is yes but there are a number of questions that come with that. >> is there a link? >> yes. >> i feel that was not the unequivocal answer three

days before the super bowl. >> i will not speak for the doctor. >> you are speaking for the nfl? >> you asked and i definitely think based on the research there is a link between those football players but what that necessarily means and where we go with that information so to talk about the link that those medical experts are on the table. i do feel limited to answer much more than that but what does that science mean? >> i have another question with saturday's tribune the famous soccer player with her, she is donating her

brain to science because she wants more research in the knowledge is she has suffered many concussions but "new york times" and no female athletes have found to have cte but the article also talks about female athletes at greater rates above concussion in demonstrate greater impairment during psychological testing when compared with the male counterparts and there needs to be more research. nih just now 2016 says that gender has to be a consideration with all

pre-trial in clinical trials and the clinical trials. do we need to reconsider whether or not it needs to change for minders? . .

the study did for heart disease. what we need today is a longitudinal study to understand what is the incident of this. we need better diagnostic tools. we need better ways to predict who are those people that aren't going to do so well. i think really it comes down to funding. in your pamphlet here, you highlight in fiscal year 15, they are spending $93 million to understand a problem that cost $70 billion a year.

there are professional athletes that make more money than he had to fund research that were all asking questions about today. in many ways the gap to be closed by better care, better follow-up, follow-up, better screening. we need to make a bigger investment in this. i'm overjoyed that the american public has turned this into something they're interested in. there has to be a more sustained and powerful investment to understand the problem. >> definitely. >> i'm want to speak with cautious optimism about where we might be.

we joined forces about a year ago and we will be getting results real-time. this is a study that is involving 30 schools. each school whether your a male or female athlete goes through of rigorous examination. seven sports, three of them women sports, soccer, lacrosse and ice hockey and then same thing for men as well as football, they're getting blood testing, biomarkers and they're getting brain mris. just in a year and a half, we have done studies on 18000 student athletes and we tracked over 700 concussions. a large study before that may have been somewhere around 20's concussions. i'm happy to say the people at the table is a participant in the study. he is a principal investigator. we spent maybe a year putting this together.

we are now working in a cross functional way. that has never happened before. what we are doing, and i'm not allowed to evaluate the results firsthand because that would be a conflict of interest, we are on the executive committee of the study. we have oversight on this, but we don't have any voting power so it's really set up in a way that is a non-conflict of interest study, but we will be having a few things. one. one is the study will provide definitive evidence and in the short-term, within two years on what is the natural history of concussion.

just concussion. we will also be defining neurobiological recovery which is exceptionally important. that's different than symptom recovery. we will have that data. mike can speak better to that but closer to another year from now. it's very definitive data. what does it mean to be neurobiological he recovered? we are coming back to washington in three days. we are laying the foundations to put this into a five-year study. ultimately, we are going to make this the study of concussion. it will be a 35+ year study. it doesn't mean were waiting 35 years. it means that in very, very active five year increments we are going to be coming in with new tools including pet scans and more brain imaging to understand what we are seeing in these increments. are there problems for -- it's not just for athletes. every cadet in west point is enrolled in were studying these individuals as well. in addition for everyone who has a concussion, they have a

control in their contact sport and noncontact sport. for the first time we will have real data on those who have and have not been concussed. that's ongoing and very real. the first wave of analysis will be reported in the late spring. it will go on after that. even while we are waiting for these results, just two weeks ago there were 15 of the most prominent medical organizations in the country. we looked at the first round of the results including very, very detailed head sensor data. i'm not putting out a specific date, but you will see coming in the next three months some recommendations that will be called in her association guidelines. it will be equally endorsed by

the american medical society for sports medicine. the american academy of neurology on concussion diagnosis and management, with regard to our football practice, the ivy league was in the room with us. their information was leaked earlier than they wanted but there will be a new emphasis on absolute recovery. i'm a little optimistic that we do have something hot in the pipeline that is very real. we are getting active results. >> does anybody at this table think we should change the rules of the sports for our student athletes? that's what i wonder? is there any way we should change football? >> i just feel, and brian you brought so much to this field with the research you are overseeing and managing. i think we need science to lead the way.

i think it really behooves us to put science first in understanding these issues because if we make sweeping changes on sports without having the science, there could be unintended consequences that i see everyday in the clinic. >> i just want to make a pitch for science to lead the way. >> if we don't fund this for the longer than the two years that it's going on now, we'll be back working back here in five years. this is not a five-year problem. headers are not the problem in soccer. >> i have a question. >> did you want to say something to? >> i'm sorry. >> i would just say, i hesitate to to want to wait on the science when we know this can have such a tremendous impact on the safety of children. i would say, absolutely there could be changes and absolutely we should be having a conversation about the wisdom of putting our kids in activities where their heads are getting hit repeatedly over and over when we know for some individual

, those consequences can be very, very dire. we don't know yet about the risk factors. we don't know yet about those that will ultimately have the consequences of something like head trauma but we know that no head trauma is best. we can make changes without toying with the fundamentals of the game. soccer, absolutely they just changed when they will allow heading in soccer. the usa hockey change the age for checking. all of those changes will make things safer for children. i think we need to explore each and every opportunity to make every sport safer in ways that don't change the game, but absolutely that conversation should be had. >> i want to make sure we get our questions in. let me go to mr. hudson. >> thank you mr. chairman. thank you for this hearing.

i represent the home of the carolina panthers. i did marry a girl from denver so i do have to congratulate you on the super bowl victory. >> i appreciate you wearing the jacket today. [laughter] i've become very interested in the area of pediatric trauma. when we look at this issue, my interest was piqued by the children at the medical center in north carolina. they are doing a lot of work in trying to look at these questions. they have a study where they put sensors in helmets. one of the things that struck me is the disparity of care. if you are child suffers a trauma incident and you live near a pediatric trauma center your kid has a great chance of surviving and being healthy and not having long-term problems but if you live in another part of the country that doesn't have close proximity there could be a lot of problems. that is one of the things that

really nags at me. they have help me get a jo study to help me look at this study across care. it was neat when you brought this issue of awareness, and also how do we take the research and understanding that you are developing and have it available where the rubber meets the road and where the care is happening. i'll just throw that open. >> i mentioned the mild dramatic brain injury guidelines. another thing is clinical decision support tools within the children's hospital of philadelphia that's been leading the way where they are integrating and moving across their health care settings from their primary care's to the urgent cares and all their clinicians. whether or not they have advanced medical education in concussion management, the protocols are built-in to their clinical decision support so the care they receive regardless of

the setting they show up and is identical or near identical. i think that is really critical. since i have the microphone, the other thing i wanted wanted to mention is another active area of inquiry that mr. miller mentioned earlier of all 50 states having returned to play laws, we are interested in the best practices in the return to play laws as well is the return to learn protocol. we are actively evaluating if they work and how they work and what the components of laws that need to be in place. those are couple things. thank you. >> just to recognize what brian and that organization are doing with the dod, i think it's laudable and it's 18 years to advance point we need to do that with kids. we need the same kind of focused research forum for kids below the age of 18, below college level. part of the reason that we haven't is because we haven't had both advocacy or the

organize advocacy and organize research systems that are set up to some extent, by the way the ncaa and dod potentially have them. the children's institute is part of the consortium that we are developing on pediatric brain injury. dallas knows about this as well. it's really trying to model what is happening at the collegiate and above level for kids. really to look at that question, what are the risks, exposures and what are not. how do we understand the science of this and the treatment. i do think priorities need to be reset, not just to start with collegiate athletes but also to start with our youngest kids in moving that forward we can link with what is going into the ncaa and the dod. that means the cdc, the nih and others need that funding support to really make that happen.

>> one of the things that has happened in sports over the last 20 years that has made this more difficult, and i think there's ways to overcome that, in that the participation in school-based sports is actually declined while the club -based sports has increased radically. that becomes the wild west out there. we need to have some way that even if the club -based, of course they get incorporated into the systems that we develop >> i wanted to just make one point that at nah we have looked at our portfolio and we agree that this issue of understanding these issues in children is a gap. we are trying to fill that gap with our research. thank you for that. >> to that point, i appreciate brian mentioning the care consortium. all of these things start to hang together with the four corners initiatives and other initiatives. within a year the care

consortium will have 25,000 collegiate athletes enrolled. we estimate we estimate we will be over 1200 concussed athletes who have arguably represent the most richly characterized cohort of injured athletes ever enrolled in a study. that provides a unique opportunity and i hate to keep coming back to this point, but the reason we are sitting here debating a number of very fundamental issues about long-term risk and outcome is because in large part, there has never been a truly population -based prospective longitudinal study of outcome after injury. the military and virginia has invested in the sense he to do exactly that in veterans but to date we have never done that in the civilian setting and they provide the most richly group of

cohorts affected by brain trauma. as brian pointed out, we not only have detailed data on clinical recovery but we have blood biomarkers, genetics, imaging that tells us about the neurobiology of this injury as the doctor was pointing out earlier. the fact of the matter is, again i keep preaching to the choir, the likelihood that a single variable, whether it is injury or exposure protects outcome, i think it has already fallen on failure because again, we look at two individuals with seemingly the same profile of exposure or injury with drastic different outcomes in the short range over ten days and over an entire lifetime. it will take a monumental effort and there are some low hanging

fruit that we can grab early on that would answer some of the fundamental questions in terms of what is the risk associated with exposure, whether it is sub concussive or injury but what's the multiple or the multi dimensional factors that predict outcome. we been chasing the single solution for decades. it's destined to failure and that's the lesson learned and the dilemma that we face at present. >> dr. you had something on that. >> yes, one of the things i want to make sure we do not miss and i think people are all very passionate about youth sports. were passionate about what happens with kids. we've talked a lot about the community impact, but, but i don't want to forget about the elderly. the fastest growing population of brain injury is in the elderly. there has been a 50% increase in the last five years. in california it's been higher than that. less than 1% of the literature has spoken to this. we've excluded these people from

all prior clinical trials. as best i can tell, we are all moving in this direction and the cancer doctors and heart doctors have done a wonderful job. this is going to be an ongoing problem. i know this is a big problem and there's a lot to chew. i'm glad that were at least talking about this but i don't want to forget the elderly because this is also a population we need to be very mindful of. >> thank you for re- directing us. that is incredibly important. >> thank you mr. chair. all the talk of ct and i'd like to take a step back and just focus on that for a moment. dr. mckie or whoever around the room, when was it recognized as a unique disease? is there a distinct quality to it that separates us from alzheimer's disease or other neurodegenerative diseases and

what likely is the biggest cause? i heard you talking about extending beyond concussions and head injuries. the final item i throw out as a question for observation, there is talk to of clusters of depression and suicide. are there things that we are already learning about the impact as it relates to suicide? or how it relates to mental illness or mental health disorders? >> so ct, i can't say what it exactly identified as a unique disease because it's been known since the 1920s. there was information in the studies about the characteristics, but actually i do think it was the ni nds conference that was held just a year ago that established this

is a unique disease, it can be distinguished pathologically from alzheimer's disease. it can be distinguished from aging or other diseases like super nuclear policy. it was done by a panel of expert pathologist who were blinded to all information and they got a box of 700 slides. they sifted through them and took about 100 hours each each. over 90% of the cases, they correctly identified cte. there is a character -- they even went further and said there is a characteristic lesion in cte that they never have seen in any other disorder. this panel of experts even said in their combined experience they have never seen this disease in anyone who hasn't experienced trauma, typically multiple episodes of trauma.

that is about as distinctive a disease you can hope for, at least at least pathologically. we are struggling with the specific clinical characteristics. there is a lot of overlaps with alzheimer's disease when it presents later in life. when it presents early in life, in the 30s, it can be depression or personality disorders or a lot of rage and aggression, domestic violence and suicide. it is very hard to sift through those symptoms because they are nonspecific, but we are certainly seeing that in many individuals with cte we found it postmortem when we look at their clinical characteristics during life. depression, very common, aggression, violent behavior, short fuse and memory problems would be the most common clinical disturbances. >> thank you. the advance research or additional research that goes forward? what's the most critical step as you go forward?

>> i think the new funding of the long term prospective cohort that will be following former nfl and some college athletes over time, they'll be collected and evaluated and yearly evaluations, yearly imaging, they will be doing blood tests and then they will follow them to death. hopefully we will be able to develop a way to image the disease with certain pieces to diagnose it during life. we want to diagnose it during life. if we can identify it in the young athletes we could pull them out of the game or have a good shot of treating it. we really want early identification during life. i think this seven year nih study will go a long way toward answering some of those questions. >> thank you very much. do you have follow-up you want to ask? then i want to ask a question to everybody here. >> you mentioned some of it, diagnostically, what blood tests

are out there that you can help diagnose the acute brain injury? obviously cardiac disease, you can tell right away in combination with radiographic studies, but i'm not aware of what there is with regard to the brain. >> i've funded most of the work in that field when i was at dod. there is nothing that's approved at this point. there are more than 20 different potential targets, two of which have actually been through the trials and are being analyzed and hope to be submitted to the fda by the end of this year for approval. the data that i've seen looks very good on it. the idea that you could in fact measure in the blood something that happened in the brain was denied for most of history until 12 or 15 years ago.

the blood brain barrier was the issue that you couldn't cross. we've actually shown with very high sensitive instruments, there are breakdown products from brain injury that seem to get into the blood, and i have strong hope that in the next year we will see approved tests and that will get better in brain injury just like it got better in heart disease. >> or cerebral spinal fluid. >> right, but just as in stroke or heart disease, awareness to the clinicians on how to make awareness when they come in without using a blood test blood test is a lot cheaper and a lot easier. i truly hope the years of dedication and funding will result in blood test, but we actually have test now just when a person comes in the er or on the field, battlefield or ball field, we can diagnose them now. >> i think as they do the research they should take blood

and try to develop it. >> sure. if that's part of the program protocol and it's being done quickly, and we do, but in the meantime the rest of the world is treating these people and we've been doing it with pretty good rigor for years. we. we are trying to refine that an object if i it, but clinicians can actually manage these folks and diagnose them fairly easily and acutely. months out, not so much. >> i'm going to ask a question i want everybody to answer as part of the panel. this is the oversight and investigation committee. our job is to gather information which can be forwarded to make legislative recommendations from budget issues and jurisdiction over health, hhs and jurisdiction over nih and professional sports. i want to ask this question i want each of you to answer it in whatever realm you want to come from. what do we need to know. this committee is the key

committee that will deal with it. what does congress need to know, whether it's a recommendation or information we have to have in the areas of causes, prevention, diagnosis and treatment. what is your take away that you want to make sure this committee knows. i will start here. >> so i would say. >> you need to do this and 30 seconds. >> we need a dose response, given the individual, what is the risk? almost like a risk score that they have so we can advise parents and people what their risks are long-term. i think that will take a while. before i lose my chance i want to say one other thing which is we should actually put on the table trying to understand the effects of last injury. many people around the table are studying sports injury. they're not to get the problem of the blast unless there is particular focus on that type of

injury. we have over 100,000 veterans who have been exposed to blast. we know very little or nothing about what happened to their brain. >> i think the recurrent theme has been that there are a set of fundamental questions that remain unanswered per the positive position right now is that were not starting from scratch. we have made enormous strides over the past 20 years that put us in the position where the people in this room and a number of our colleagues around the country and the world can design the studies to directly answer those fundamental questions. those studies are going to be major undertakings that will require significant investment on the part of public and private partnerships. then we can come back to the table and answer the critical questions that the public domain wants to know now. we can answer those with science. >> thank you. >> what we need our successful clinical trials to do something

about this. we've had 30 some failed clinical trials. we've had multiple analyses on why those have failed but we keep doing them the same way. as much as i am the strongest avid advocate of the longitudinal study, it feels as though they're just admiring the problem. we need to find solutions to the problem. we need to find out why the studies have failed. all handed over to jeff because he will say what i was going to say. >> so yes, we have 40 some definitions definitions of concussion. that means no one knows. what we need, we know there are multiple forms of injury and we need better diagnostic tool whether there imaging or blood

based bio markers. the heart is a great model. it's going to be more than one thing. it's not just a clinical exam, it will be several things. until we have a diagnosis we cannot have a targeted treatment. until we have targeted treatment we won't have a good outcome outcome. i think the work that we've been doing, and the good news story is that were working together on common data elements and databases which we are all sharing. we know not one person will be able to solve this one problem per we are working together in public and private partnerships, bringing in the industry to try to figure out how to make a difference here. one of the things we definitely need is we need more funding. $94 million is not going to cut this. this is a very, very big problem in the united states. there's lots there's lots of money floating around in different places. i know there's a lot of problems but we have heard from everyone here that this is a major public health issue. the weirdness is here. it's now time to put some money where the mouth is. we need to fund some of this stuff so we can make a difference for these patients and their families.

>> we don't enroll the right patients in the trial. it's just like cancer. it's not one single entity. right now we treat it like one entity. its multiple diseases in one. we don't enroll the right patients and the measures that are currently used to assess whether there's a difference in those patients is fundamentally flawed. what's your recommendation? what does the committee need to know. >> it's clear there is a lot that is known. there's certainly a lot that needs to be learned about concussion. of that that is known, it occurs to me that had this tragedy never occurred to my husband, i would be very much in the dark about concussions in general. i find that ideal every day with parents in children's whose lives have been derailed when

concussion treatment and whatnot goes wrong. there is so much more prevention that could happen by just this issue of awareness. so much more can and needs to be done about getting this critical information into the hands of the people where it will make a difference. that includes not just the coaches, not not just the athletic trainers but absolutely the parents and the athletes themselves. >> thank you. >> so i think we need to be able to diagnose the acute injury, the concussion with a better test. in an ideal world we would have a blood test and be able to monitor that brain injury until it was recovered and then we can let them go back and play safely. in an ideal world the diagnosis for concussion, we need to start measuring the number of infections are getting. we need to address this cumulative had impact and measure it so we can establish the response. we need to diagnose cte during life. blood tests or maybe the pet

scanning, but we need to be able to make the diagnosis during life. that will give us our best chance to monitor treatment and develop a treatment. lastly, we need to follow our youth athletes until middle age and maybe beyond in order to understand the variables that play into the risk of contact sports but we know sports are important and we want our kids to play sports but we need to understand the risks. >> thank you. >> around this table there are five massive studies going on that have all these questions embedded in them. all of them. they overlap and the studies are actually integrated. we actually talk to each other. most of us are on all of the studies together. we need those studies to just continue and finish as they are. we don't need 12 new studies are

5000 new questions. all these questions we've all heard at every meeting. were all aware. we even have little mice with helmets who are getting injured and were asking the same question. they go from children to elders and everything in between. what we need is to raise awareness, raise education because a lot of us are managing these folks effectively, but we need to continue with the path of the science we are doing and not overreact or under react but just have the folks that are all linked together work on it for the next five years, if not longer and then we will have the answers. then we don't have to have this meeting again with same level of basic questions. i think we need to just steady as she goes and push forward. in the military, in the sports association and with kids. >> i'll just reiterate, i think we are getting the answers and

the funding will be important moving forward in five-year increments. i think what the world needs to hear, and i truly believe this, is there is unparalleled collaboration working on this. i've been in sports medicine publicly for over 25 years. i've never seen this degree of collaboration before. it leads me to be somewhat optimistic. i will end by saying that the thing as a public health advocate for sport and i truly do believe in sport, it's much different the exercise, we need to focus back on youth and understand that where there are most vulnerable is in the lack of coaching education. it's great to empower parents but the coaches need to be educated as well. i truly do believe that we need athletic trainers. we need to empower them to make sure they are a part of every part of contact sporting events. >> thank you.

>> i would like to think you for the invite to be here. i also want to echo what i've heard many folks say here this afternoon which is we really need patience. i agree completely with the others that we have never been more collaborative than we are now. we never known more than we know now. we need to evolve the science before we make any rash decisions on these issues. i think the science is coming very soon to help answer those questions. i also want to stress that in pittsburgh we should see 20,000 patients a year and there's very few kids that i see that don't get back to play safely and enjoy the sport that they love. we don't see the morbidity that is being discussed here. i feel we need more research on cte to better understand that construct and to bring this all together. a lot more work needs to be

done. i don't think we've ever been more collaborative. i think the science is maturing and i think we need more time before we make any large-scale decisions. >> mr. miller. >> we take our lead from people on our midi who advise us we should be investing in our scientific research. we collaborate with the number of people around the room. you will be surprised when i say that my suggestion aligns with many of the others in the room. we have diagnostic concerns, prevention and treatment. we have a research portfolio with collaborators in excess of $100 million. those things can things can drive change. it's the people who are here and

many people like them who do the hard work who are going to move the science forward. i would suggest some of the things i've heard today like a prospective longitudinal study, more money being invested in the treatment, better education and advocacy. all of those things that this fine group of people is doing. maybe just more of the same will get us to a better place relatively soon. >> thank you. doctor joanne. >> last but not least, the kids. i'm going to reemphasize that the collaborations that are happening now are studies in the teens. we need to focus on younger ages as well. what can we take or not take, what do we refresh, how do we manage and keep kids active and have fun and competitive. we have got to prioritize the fact that it's a full-spectrum

injury that we have to understand. >> thank you. i'd say that we need to balance risk and benefits. anything that we come up with universal prevention strategy needs to balance those risk and benefits. not moving is bad for your brain. it's bad for your cardiovascular system. that's also bad for your brain. so right now my two-year-old is not hanging out in a crib. he's not wearing a football helmet around the house. he's moving. i think that's where the sciences right now. we need to move the science. i don't think we can answer the fundamental questions about dramatic brain injury and cte without longitudinal studies. we have a handful of papers from the first five years and then it exploded. i think certainly we have our research priorities in order. i know my colleagues in dod are very attuned to this problem and

i think we are going to move in these next decade. thank you. >> thank you for inviting me as well. from cdc's perspective we need better data. we need a cross mechanism and across the lifespan to and understand outcomes including disability and recovery. that will help us understand the problem better even at the state level and understand all the prevention efforts and if they're making it difference. >> thank you mr. million or i'm not a doctor but that never stops me from giving my opinion. i want to thank all of you for coming here today and sharing your knowledge. it's really instructive and that's why we like to do these roundtables from time to time. i am somebody who works a lot in my career on issues of

biomedical research. i'm really shocked at how little evidence we have for something we've known about. i've known about it since i was a little kid. it is really shocking, and i also happen to be a person who thinks that we shouldn't be doing public policy unless it is evidence-based. i look forward, i'm glad your all working together on research studies and i look forward to getting the results of that research. i just want to say one last thing as a mom. we don't have a a lot a mom sitting at this table. if i have a 5-year-old, i did try to get my two daughters to play ice hockey, but they decided to take ballet instead. there's not a lot of head

injuries. you can probably get a concussion in ballet, but if i had a five-year-old, girl or boy, who i was trying to get to do peewee hockey, having people come in and say we need to get more data before we can tell you, mom, about what kinds of play they should be having and when should they start checking and all of that, so don't worry in 7 - 10 years we will have some data from our longitudinal study. that wouldn't satisfy me as a mother. so as i say, i really hear what you are saying about the studies and i agree with that, that, but at the same time i think it's important to take some of the initial data that we have and start to at least put some protocols in place for kids, just like the nfl has with its players.

we need to try to prevent some of these concussive injuries that really can have long-lasting effects. i guess my sense would be better to err on the front and for prevention of something while at the same time you're studying so you can really drill down for both diagnosis, treatment and development of protocol. thank you mr. chairman. >> thank you. i want to thank everyone for being here today. this is quite a bit that we have learned. i feel like we should of gone continuing education credits for this. it's amazing to have everyone together and i'm sure you will continue to work in collaborative ways as you proceed. from a standpoint here, we've we focused a lot on sports and military and you mention some other things, whether people people are watching this on c-span or what our members are taking with us, most cases are from falls.

crashes is a leading cause for younger people, assaults is another reason. we have a lot we can learn here. being near a trauma center makes a big difference. having people around in the right place. i did see the movie concussion and it's one of those strange movies i know just about everybody in it. also knowing the people i know and how much things have changed in the last few years. things were entirely different just ten years ago than they are now. things like moving where you kick the ball on a kickoff has made a tremendous difference. i work in an inpatient unit and what really struck me is how little we know and how we've got

to learn more. playing a sport is a choice. we've changed sunday to be football day and not church day necessarily. the 1% who volunteer to wear the uniform and take the oath, it's pretty amazing. to watch and know that special forces are still out there and the patients are still there. whether their air force or green berets or the seals, they're they're still out there. people who have been in close air support and around bombs, for the longest time we would get back results from narrow radiologist that would say no problem, they must be faking it and they would have the very problems you were describing, the problems at home, the isolation, the nightmares, and

in many cases suicide. we have a lot to learn here. you are helping us tremendously along these lines. we deal with many things on this committee, but some things will lead to lifesaving efforts. this is helpful. we want you to stay in touch with us as we move forward with a series of hearings and where we go whether it's to make sure the brain initiative is fully funded. i know a lot of symptoms are things we have a lot to learn yet. we spent half a trillion dollars on mental health related problems. we are trying to find one or $2 billion a year to dedicate on this. to me that almost disgusts me that were at the level were at trying to find funding when we could be saving a lot of lives. it's the will, we have to find a way. inc. you. i'm impressed with your knowledge. please stay in touch with all of us. with that, this particular form is closed.

thank you.

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[inaudible conversation] >> campaign 2016 continues on tuesday with primaries taking place in missouri, illinois and then north carolina.

beer reaction begins at 7:00 p.m. we take you on the road to the white house on c-span, c-span radio and c-span.org. >> ohio's primary tomorrow is a battleground for both democrats and republicans. joining us from columbus is kristi thompson. she is politics reporter for the cincinnati inquirer. thank you for being with us. >> thanks for having me. >> let's begin with the gop. he writes that it's a fight for the soul of the party. can you explain the race between donald trump and john kasich? >> yes, going into this weekend, this was already shaping up to be a close battle. john kasich is trying to fight for and win a state that can propel him at least for the next few weeks in next few months and his presidential campaign. donald trump is trying to scoop

up ohio's winner take all 66 delegates in addition to the 99 he will pick up in florida. he wants to really cement his lead. on friday after the violence that broke out and the scuffles at trump's rally that was canceled in chicago, it really turned into more of as you say, a battle for the republican party. i guess what i mean by that is there are some of people saying that there are two different kinds of campaigns, two different kinds of candidates that we are seeing right now. this is a really, a battle to see who republicans are going to elevate. will they elevate someone like john kasich is more experienced as he attempted to run a relatively positive campaign or are they going to elevate a candidate who many people feel is condoning some of the violence and scuffles that we are seeing at these rallies. ohio is the quintessential state. no republican has one the white house without winning ohio. what these voters say on tuesday is very important to what voters

are going to say nationally and what the republican party is going to stand for this fall. >> the surprise development overnight are the two appearances by the 2012 candidate mitt romney with john kasich basically telling voters to vote for john kasich. doesn't pull any weight to these two appearances by governor romney? >> i think the biggest significance is that it draws a lot of media attention. this is the first time that governor romney has appeared with another, or with a presidential candidate and although he is not endorsing kasich, it's a strong show of support for this effort to stop donald trump and say john kasich has the best chance of beating him here in ohio. interestingly, there are several other appearances by bernie sanders and an appearance later by donald trump.

there's a finite number of reporters roaming the state right now. this appearance tonight in columbus is going to be a chance for governor romney to draw some attention from reporters who might otherwise be covering donald trump of the same time. that has been the big issue for john kasich which is just being lost in the media in his own sea. he's a popular governor here among republicans but there is some question whether he has a chance of winning the nomination. indeed he doesn't have a chance of winning it out right. he has to persuade people who tend to like him, but he is a guy who can take their vote and carry it to the white house. john kasich has never lost an election in ohio. with the polls essentially showing this dead heat between trump and kasich, why did senator cruise stop buying columbus yesterday? >> yes it was super interesting. what we saw from senator cruise was an attempt to draw up his space.

he has a chance of winning the nomination. the nominee in the fall will need a lot of ohio republicans on his side. that's one factor but more specifically, senator ted cruz has been really open that they want this to be a one on one donald trump come wednesday morning. they are campaigning heavily in florida to try to get marco rubio out of the race so even a knowledge and that that will have the state and hand it to donald trump, i think what we saw here in columbus with the same sort of tactic. it makes them nervous. they would rather have a two-person race instead of a three-person race. even if ted cruz can take some percentage points away from john kasich that would potentially cause him to suffer defeat and get him out of the race.

>> >> but we don't really know what the turnout will look like because it is pre-break all sorts of different factors.

bernie sanders was supposed to be defeated easily by hillary clinton in michigan and there is no question as to whether he can pull off a similar surprise in ohio the blue-collar state traditionally has supported centrist democrats. if bernie sanders were to pull off a victory that would really save more than just the delegates but the message is resounding in the midwest in the swing state aid could be a chance they promotable opponent. >> how significant was that court ruling to allow those 17 in ohio traneighteen to vote to the primary? >> i don't think it is very significant we ask the local board of elections how they

handled the 70 year-old in the past and they said if you look at the thousands of absentee ballots only 50 people have requested only tend turned bad in. there isn't that many up for grabs however this is brought forth by the bernie sanders campaign because if the state will be closed will be very close. even only a couple hundred or thousand students who decide to exercise the vote it could make an impact. >>host: the politics reporter for the cincinnati inquirer joining us from columbus, ohio. thank you for your time.

[applause] thanks for coming out today i have to it mitt this is something that really matters to be.

over the past years to the universities and high schools and colleges there is a great tradition politicians coming forward except i will try to turn this around a little bit instead of focusing on what the leader has to say to you i very much interested in learning from all of you read what you have to say to me. ultimately the work that i'm doing right now the work that the president's and i did yesterday wasn't so much focused on the coming months as much as the coming decades. we are focused on your future. in order to stay focused on your future in the right

way, that is the only way to build that prosperity that we need to have for coming generations with climate change whether opportunity for everyone, international engagement is to keep in mind to we're doing it for. in those decisions that we make could or dash in incredibly short-term world with the aspects of our lives where they're not being satisfied with our peats the 30 seconds out of the microwave. [laughter] looking at the political process there is a real instinct what have you done lately? in the etf of building for

the next decade in the next generation seems impossible looking at what politics is all about. because largely there is the degree of of cynicism to effectively deal with 10 in 20 years out. there is the tendency to want to throw up our hands will help me in the immediate and eventually things will work out. unfortunately it doesn't work as much anymore the pressures are global fraud to think responsibly of the impacts of directions this date or this month gore the

scheerer will have five for 10 years from now on after their current crop of people are making decisions. for me, one of the best ways to make sure that thinking pulls into the political process regular contact with and empowerment of all of you. it is about the need to mobilize young people to get out and vote but to recognize that mine said -- mindset from living at home to university for your space

in starting a family massive transformations is par for the course and the reality of this decade you are a part of right now for those who were settled in a career path, a mortgage, saving for retirement are much more set in the status quo we need you to challenge us why we do this why we do that for not doing this or how we do differently. and not just speaking of the getting involved. in instead of our jet short-term future where we

will need to rethink a lot of things in the coming year. climate change being a great example with a continental approach will go a long way to setting the groundwork to the understanding most people huss certainly the people of this generation to make a choice what is good for the environment and good for the economy. they go together. to have clean jobs and energy efficiency and that idea on economic progress to protect the environment only by a cherishing those services so to make strong

commitments toward the nyes strategy for what we need to build on following the success. and with the impact that it will have but to step up in say we need to do this anti-a part of it to businesses and innovators and entrepreneurs this is the way the world is going. now who can get their fastest in to make the most benefit? climate change is a very real challenge with incredible opportunities to rethink how we function and innovate how we succeed. on top of that there are

many other issues of diversity. from american university to save those backgrounds with in a crowd that i worked at. you see a tremendous diversity of perspective and we know that globalization in migration the challenges is the greater flow of people in with that diversity brings challenges with the bring strength to end to draw on different perspectives particularly

when they are brought together around a shared values with the willingness to work together with passion in value that has created needs to embrace in understand the path of success in the 21st century. i am excited to see that extraordinary mix at american university than the place we can lead on. kelly engaged in issues to create opportunities to succeed in follow their own potential.

with the success of the past with the good grades and then you were director vice president you get a gold watch at the end of your career if you could make it to the president did you very the boss's daughter. [laughter] that is the old way right now the career path we will have to jump around everywhere is preposterous to think of former snowboard instructor and nightclub bouncer could end up the prime minister of canada. [laughter] [applause] but the experience is that we accumulate along the way with multiple career path engagements to define us in shape us are extremely important and that is one of

the exciting things for me and ally parsley pull together a team in canada with a particular circumstance with dead distant third place with the majority government. but the big part of the secret was to listen to people and if you could take away all of the cynicism the kind of role do like to live in. it can't happen but if you could imagine the country what would it look like? we built a platform and the

approach to politics what they want to see collaborative them respectful and mindful of each other trying nonpositive instincts rather than divisions to make harder to govern in the long term for girl we present that. they said no. negativity works. sometimes. that people are tired of that. in that leaves us a search of the way to govern in a way that takes real decisions with their longer-term vision and to challenge ourselves to do

things differently in improve the way things have been done and i could not have done the without the voices them the challenges from rooms like this one across town and around the world. thank you for your great questions and i'll look forward to a engaged with them. [applause] i will try to keep my answers short and i very much appreciate if you keep your questions assure. you're sitting down and you're not asking a

question. >> in queue very much to talk to leaders internationally so i have the opportunity to do a study as an undergrad. bill is founded interesting and you have been vocal about this issue what have we learned from the indigenous people? >> i don't know with the

indigenous investment to make attempts in for quite frankly for a the country for the positive role model. over the past generation with those who quite frankly have never been up to canada in february. [laughter] to live in this extraordinary place. in with that tradition should based on respect in partnership to know that we

share this land as two words with the respect for the natural world and integration of harmony and environment with a cultural teachings and historical knowledge about how they have proper balance. i am serious about doing that. and the minister of justice has may look to the high arctic it is important to me as well and also the coast

guard with a strong indigenous voice. [applause] >> i am from mexico. have a do envision the north american trade agreement? and with the climate change. climate change has to be included. and had some good conversations with that continental energy strategy

with the u.s. to canada working on energy issues in to make significant and if we could develop those solutions from the big ones like india and china we could make a tremendous impact and perhaps even reach that target, in order to do that we need to be more collaborative to read engaged in a positive way to make sure that sheraton's like the mexican visa

requirement is done away with looking at the manufacturing supply chain there is tremendous work to be done to canada of this summer so we can't engage in these issues. >> thank you mr. prime minister. it's great to see so many in your cabinet. >> i have more seats in my cabinet. [laughter]

>> from the conversation with president obama yesterday he is criticized for the conservative hard-liners in he is being blamed so what are your plans for trump and canada? >> we have an election in the fall with a number of different narrative's from around the world certainly in europe with the challenges they are facing in here in the primary season we have a

conservative government with year in division as a way for broader cultural practices to be engaged a bird cultural practices they never could explain why that was the effective line in for that negativity that was compelling to gain a certain amount attraction but i find it hard to sustaining care for very long. we are a whole full people

we know in genuinely like our neighbors. [laughter] i'm dead within canada but that applies to the united states. [laughter] [applause] and having an approach that whenever you grab any disparate people together you realize what unites us is far greater than what divides us. ultimately that is what democracies keep moving steadily forward and i have confidence in the american electorate. that is in november. >> my question has a little tinge of humor but with a

presidential candidate right now who is building a border wall and american say i will leave and go to canada if trump is elected as president. so how do deal with an influx of americans to canada? [laughter] would you open your gates to american immigrants? [laughter] >> every election season there are people who swear if the candidate they go like gets elected they're moving to canada. [laughter] if over the past decade that has been the case we would have more people in canada in the united states. instead of one-tenth your size. every year canadians move to

the united states fetishes the nature of our friendship to link it to much to politics is humorous and what comes up before election season but the integration what we do together the engagement and one must never be disappointed. >> and following up for following reasons so the

first question those who are a big fan of view and happy to a advise you if needed. [laughter] >> there those energy producing countries in that there is no exception. into diversified the economy including those energy resources.

and those that we apply to the natural resource sector. the science and research that we're always doing better with that. we're going through tough time right now that the same time giving us an opportunity to rethink and insure when oil prices start to rise we have taken advantage of the environmental responsibility how we are engaging in cutting edge thoughtful ways to get through the years where we end up as quickly as possible where renewable energy drives our economy. where the oil sector

companies of geothermal in a broad range of solutions. event in terms of the wailes sector working with them to support them through this tough time. with anti-isis coalition to take on the greater role what about that shift the strategy is? >> there's 65 different countries all have different

approaches of ways of engaging canada has the past couple of years with the fighter jets with those ground targets with syria. became into office with the combat mission. with that far -- with the fight against isil and then to have those goals drake -- the goal states participate in the air strikes to because dash you know from

that experience to make sure they don't just try to fix things in different areas without a hard earned 10 years in afghanistan. in to be more effective that pushing back in now doing that against faisal. -- isil to support those neighboring countries in turkey that receives an influx to engage more in diplomatic levels without hold government approach

with military engagement is the part of it and reflects the evolving situation to bring forward different needs to make sure the troops have the capacity to be most effective to have a very useful way in the immediate to create a longer-term stability and a troubled region of the world. >> in america is seems to be a tense time in to be happy

and we look around and think what is happening. what is your approach to compassion at the government level? with bigotry and diversity with hate crimes against muslim americans the especially the last few months. we can agree rhetoric is a huge part of that. you welcome 25,000 syrian refugees into your country above my country to do the same. hagel address that people in our country and yours who are fearful? but a big part. >> is understanding if you

are worried about the next paycheck worried you can pay your renter the kids would have the future that you would want for them. it is easier to point blame to feel satisfied 2.0 those who are to blame to build a sense of optimism in shared identity if every lawyer street is doing better including you. with the closed-end protectionist dick approach

with the responsibilities of leadership to understand the countries like ours need people to work together and that narrative, if you, once people realize. from one of the provinces a few years ago it would do so without having religious symbols with a big cross of

david if they're wearing a turban to have those religious symbols is about freeing people from religion to allow people of men wear a turban they will no longer have that dominance over an individual. in that is a reasonable proposal and it was sold that way.

as a young woman to chose to wear her hijab could be fired they said that is not what we meant and the consequence and that was rejected. but to get to that place we have to have public discourse in that key elements and in so incredibly proud of canadians with an election campaign with that proposal of those illnesses that are convicted of terrorism.

and these are convicted of terrorism. and that is on the front of it. is someone convicted of dual citizenship and more than a canadian homegrown terrorists and is also sixth generation canadian in can have one and all. so i felt myself and the situation so in a man who

just stripped the citizenship should have his canadian citizenship restored figuratively army be even literally to lift up his canadian passport. in yet i stand here as prime minister of canada. [laughter] [applause] people need to understand in those and always easy or knee-jerk to how we would like the world to be.

but it isn't the central with the country that we are. with rights like feminism with respect to diversity is not always easy to have conversations about. and a path that has been rocked by generations so i have tremendous hope based on reasonable discussions

that is where the in that everytime. >> we've got to girls education bumper stickers for year. [laughter] >> my wife and michelle obama they certainly are great examples of extraordinary women standing up but i need more men to do that. [cheers and applause] men need to be comfortable calling themselves feminists.

and then we are all of but it is 2016. let's get with a program for girl. >> we have bomb last question. >> cassette tough act to follow nasa astronaut scott kelly just came back to earth with a stunning photography and canada has a long tradition of cooperation and chris hatfield with his performance in order. what do you see with the

space exploration of the final frontier? >> the fact is science and in general. , we innovate with the fundamentals of pure science to have the commercialization to make our lives better in the short term with the changes we didn't see coming. canada has a long history of cooperation as a civics professor of mine because we're really good putting

things into is some doubt. it is because of the winter. and it has to build solid the with that expectation. [laughter] but how we engage to push the limits to challenge ourselves with our responsibilities bely place we know of that we have to make this work just from purely scientific from planet earth and bring a little more order to the chaos that is the universe we have responsibility.

we have been inspired like the minister of transport in better to keep the trains running on time. but this idea of respect that is an extraordinary example to make sure we have canadian satellites that ago what. in the engagement that is extremely interlinked. thanks for the questions. [applause]

thanks for your engagement with the world. >> i love american history tv.

en achish that perspective. >> i am ac span than. >> back at the desk next month with baseball legend

talking about this morning it is a documentary over a series of lectures from the charleston shootings about race in america but i want to go back when jackiese robinson broke the color barrier in baseball.ovement in where was that civil-rights movement? >> there was always the civil-rights movement in america. those that didn't want to bes slaves but wanted to be free and after the civil war attempt of reconstruction to have great black leaders how and martin luther king hasn't integrated of military.rosa parks

brown vs. board of education rosa parks is the decade away from giving get her seat in the bus. that is an important part of understanding. in jesse e. owens with the republican left-leaning but jackie actually had to do a. >> but baseball was a bridge to the civil-rights movement.

and it is one in a tiny fraction with the national pastime. with that social significance of jackie breaking the color line. to produce a documentary. with that mythology. in the premature death and age 53. year he started pl it is a complex story multilo generational story of an

african american family. into very much kerry of the legacy. going to be and is the most impressive in expiring. >> over the next hour on "washington journal" ken burns is our guest. eddy manchin and rachel robinson said david j. jackie robinson story but let's look at the documentary. >> with our first spring training was terrible. this and david is that the

airport with the shoebox full of fried chicken andd city may need it. going to pensacola florida to put on in our place. i have never seen signs along restrooms so went into the white ladies bathroom just to recover and they did what i had to do in the ladies walk out sorry to the bus to spring training and jacksonville. cry we went to the back of the bus. because my great husband had been a fighter and a dignified person, one is by

segregation. and caved to what society wanted in the south for about the fried chicken was sayl great. >> en to make the film possible. -- th she started the jackie robinson foundation with scholarships but the most important we had access to her. and jackie was the center ofof the baseball series with stand-alone treatment as

they finish the film on the central part five to realize the he had the opportunity to do a. and not only to share the triumph iran the struggle she is essential. >> if you want to watch all four hours airing in two parts april 11 and 12 then :00 p.m.. -- 9:00 p.m. >>. >> caller: good morning.uch

but how much was there in to be precipitated. >> good question both of those are great i am not sure how to in is your first or precisely but the negro leagues were separate but it was the equal legal casino from the experience but we

were better end after jackie arrived in with those african-americans nine out of 11 years. one ye and then he plays one year in the negro league.her great it is the of spiritedness. and to talk about his own sense of discrimination. and that ricky branch told him to be an experiment for the ditchers aaa in 46.

and then the negro leagues interestingwhat they were. and send it was a bittersweet movement -- bittersweet moment. and of course, we know those accomplishments of skin-care and. almost as the eulogy implied i am 62 years old bible 63 he died at age 53 he looked 20 years older than he actually was. and then turning via their cheap -- turning the cheek to help others. the death certificate says

congestive heart failure and the symptoms of diabetes. she is 93 and went through that with him. . .

they called their slaves slaves after. the slaves that george washington set free. if every -- very heavy heart because the comrades that helps fight the british fog along side were called slaves after that. now these other channels other than george washington had different ideas. they did not want the people to have the power to vote that the generals wanted. the generals wanted to keep that power in its congress to be able to put things on the floor ofhi our house and then the only one allowed to pass things look at the civil war that could have been prevented.