if for example someone needs to see a retina specialist but that ophthalmologist doesn't provide a lot of retina services. should they be taking it down to the cpt level to find out? do we have, you know, an adequate number of retina specialists in our network to be caring for patients with very specific needs? so i think that is really important point. and you know i've heard of health plans using the geo access reports to help determine network adequacy. that doesn't go to the subspecialty level. so i'd welcome any thoughts that mr. web or mr. durham have or even mr. ginsberg on ascertaining whether truly there is network adequacy. >> let me say something quickly about the subspecialties and move onto the other questions. i would say, you know, we are on a learning process about how to

regulate and have transparency for limited network plans. because they are -- and i'm familiar with some anecdotes where say in ophthalmology, which i know fairly well where the issue about retina specialists was raised. and, you know, through the academy of ophthalmology went to the insurer who i think just responded. oh, we didn't know that. so we will make sure to put some retina specialists in the plan. so i think it's just discovery that this is an issue. and i would say yes, you know, the detail that is going to be needed in some specialties will probably have to go by sub specialty. and it is going to make it more complex but this is going to be a big part of our market environment. so we mights well ju as well ju that. >> anybody else? brian. >> it does vary by state.

but some do a deep dive and they go down to specialists, subspecialists. not at medicare venues though. we don't get to regulate that. so we're excluded. >> yes, go right ahead. >> i work with the american college of nurse mid wives and i want to give a little information and ask a question. we've been doing a survey of the plans that offer coverage through the exchanges calling them and asking them about inclusion of nurse mid wives and services in the plans provider network. and what we've discovered is that of those that have responded to our survey, which is about a third of plan, 15% of them flat out don't include a nurse-midwife in the network at all. about 40 percent don't cover birth centers either. and about 35 percent do not pay at the same rate they pay the physician for the same services being provided. and my question is in the

regulation cms very carefully stayed away from dictating what types of providerers need to be included so insurers could have the flexibility to do exactly what we're talking about and maintain lower preem yammiumlowt is understandable. maternity and newborn care is required as part of the benefits package. so i would look at that and i think i could argue reasonably that is a provider type that should be included in a plan's network. and i'm wondering e how you make decisions about what types of providers are and are not going to be in your network? and what is the criteria? i think if i was to argue that a plan could include a few family practice docs doing deliveries and therefore did not need to include any o.b.s, i think probably would say that is unreasonable. so my question is where is the line and how do you decide when

is a certain provider type necessary for inclusion in your network? >> is that an naic question brian? >> no we check to see if all the ones required by law are in there. that is what we do. >> dan, you are the default second place answerer. >> and again we talked about this previously. to be a qualified health plan, plans have to be certifiedem. and part of that certification process is review of how they meet the network adequacy standards. and if you don't meet those standards you are not a qualified health plan to participate on the exchange. and ocms is looking at in this year. they required health plans to submit a lot more information in terms of who was in their provider networks, the names of the doctors and hospitals and the like. so they have all this data now, the plans have supplied it so they can do a test using the

software they have to make a determination whether or not they believe the network is adequate based on their standards. and if it is not, then they can work with the plan to get to it a place where it needs to be to get certified. so really depends largely upon the rules and regulations that are applied to meet certification. but i'd also add that there is a measure of choice here. some plans go beyond what other plans are doing and they may have a higher price level because of that. broader network, lower out of pocket max mums, lower ductables. but it comes with a higher premium usually and a platinum plan or a gold plan. so there are tradeoffs that consumers need to look at before buying a plan. >> and i'd offer just one follow-up. and that is from an insurer standpoint, i think -- i'm not so much complaining about them as wanting to say that there is

this huge opportunity for savings for the insurer to take advantage of. because the practice pattern of the nurse-midwife is something that reduces levels of interventions and therefore reduces cost. but here is an opportunity for savings and i think it would be it would result in savings for mebts as well. >> i agree with you. a lot too depends on state laws. we'd like to see states go to a place where nurse practitioners can practice to the top of their license. and for other providers as well. so we could take advantage of those types of cost savings while preserving quality. >> thank you. >> if i can ask you to suspend for just a moment. i wanted to take just a couple of the questions that have come in on cards which actually dove tails nicely with a couple of questions we received in advance. and it has to do with the

question of essential community providers. first of all i want to make sure everybody knows what an essential community provider is. so i'd like one of our expert panelists to take a crack at that. bull the aca requires plans to include substantial members of them, whatever they are. and they are particularly important to the lower and moderate income folks and isolated populations that catherine was talking about. how effective is the regulatory device, which i think is a threshold of saying that you need to have 20% of all the essential community providers with a change pending to raise that to 30%. is that the appropriate way to assure that folks can provide -- that they can find the providers they need? >> i mean, as far as the neic on

our work on the model we just have to put in what the requirement is. as far as the regulation we're looking at it. i specially when it comes to native american and ak native and what they have to do there, they have to at least try to get a contract with them. whether you can get one or not is a question. and there are ha lot of things involved. and that has to be something that kind of e involves over time. and have we have thresholds no place and now we have to look at how we can enforce that. what is necessary. and that is something we're looking at in our model is get the thresholds in there, but then from there how do we move forward and how do we regulate and make sure they are contracting with them and reaching out to them and kind of what those things mean. so it will take time. but we're working on it. >> patrick. >> referee: i couldn >> i couldn't comment on 20% or 30%. it depends on markets and access. and but i will say we are

support oif the access requirements provided our history and footprint we do a lot of work and partner with qualified health clinics, as well as we are the safety net provider in many of our community, certainly right here in washington, d.c. we do a lot of work with unity the fqhc so we are just proponenting making that coverage is there to serve the poor and vulnerable. >> i'll just add the threshold had increased for 2015. so in 2014 plans participating in the exchange had to include 20% of essential community providers in their area and now it is 30% for 2015. and so plans are, you know, meeting that regulation. but again, it comes at a tradeoff in terms of price. to the extent you continue to expand the network access requirements and health plans,

that in turn will lead to higher premiums. so we have to be cognizant of that triedoff as we look to further regulate and restrict a plan's ability to provide that kind of high value to consumers. >> we have just a mu finns left. we're going to get this question and maybe a couple from cards before we finish. but i'd ask you do fill out the blue evaluation forms while we're finishing up the conversation so we can get some feedback from you about this program and others that we might do. yes, sir, thank you. >> hi, my name is doug jacobs. a medical student and intern with hhs. i understand that health insurance companies are using value as a way to select physicians. my concern is that they would also exclude physicians who treat sicker patients because those physicians would be more costly to include in the network. so i was wondering, is this happening? and also if anything is being done to prevent it from happening. >> i have seen no evidence of

that. >> i would say that when insurers are trying to look at value, which to me as two dimensions besides price. they are looking at broader measures of costs to see, you know, for an episode of care or for a period of time, which provider is less expensive. and then there is the quality dimension. i would think that insurers would want to adjust for different patient populations. but what they can effectively do is an open question. and so it is probably not ideal now. hopefully it will get better. >> and i would just note in our model and something says look for, is that non discrimination that you are not contracting with people just because they -- or providers because they happen to care for certain types of diseases, certain groups of people. so that is something we look for and will continue to look at that as we move forward. >> thank you. >> we've got a question here i

guess that would go initially anyway to dan. providers listed on plan networks may not be accepting new patients. how do plans inform current enroll lees potential enrolle es about which providers are the truly available? >> good questionali. plans and committed to provide updates on their website. but it's a two way street. if they are no longer taking new applications and fail to provide it to the plan. and the plan makes it easy to do so through special call-in and the like. but part of the responsibility of the provider to let the plan know. so we have to work on this collaboratively to make sure consumers have the latest information. >> catherine. >> and that is a fair comment. the providers need to be in contact with the plans for sure.

i can tell you in our hill system, if someone is calling for a position and that physician has reached capacity, we'll ensure they get referred to someone who condition within the area but that is our practice. i don't know that that is a regulation or requirement. >> brian? if i can go back to the related question of the, maybe, not completely accurate directories or mid-year cancellations as opposed to physicians who aren't taking new patients. who bears the burden of the lag in information? is it the patient? is it the provider? is it the plan? what happens when that surprise bill shows up? whose surprise is it? >> it depends on the circumstance.

we think it is important that for example hospitals that are in the network of the plan but employ anesthesiologists or pathologists or other specialists in their hospital that are not in the plan, you know, they have a responsibility to notify the patient before they, you know, go under surgery to say, well, you know, this particular anesthesiologist is not participating in the plan that the hospital is. and so it could result in higher out of pocket costs. so we think there is some responsibility there on the hospital side and that type of situation. >> one thing i can add is that outside of this issue of networks, that a number of states have put restrictions as to how much these out-of-network physicians can charge. just because, you know, these

anesthesiologists and other hospital-based physicians, where consumers are just not in the position to be able to make those judgments. >> you know, i'd like to add just comment to this point. and i do believe that, yes yes, providers are standing in the relationship with the patient and as we've done, we are educating we're working with them to know which proefrtd providers are fwh their networks and not. but i do come back to as the patient or family is signing up for a network they are entitled to know whose in and whose not. and that education requirement needs to be provided by the plans and something probably more robust than just directories. something something more like examples, scenario, things to ask to the patient can be more informed. >> okay. i think that probably is a very good note on which to bring our discussion to an a close. we didn't get -- i realize

apologize to those who spent the time to write some very good questions on the green cards. but it is a subject that we are not letting go. obviously there is a high level of interest in it. there are a lot of complex pieces of it. and so we plan on revisiting this issue in the fall probably with a briefing, perhaps with a webinar. keep tuned and we'll try to explore this question of network adequacy as it develops. thanks to our friends at wellpoint for helping us point this program together. thanks to our emergency panelists who filled if so greatly i think. and thanks to you for asking all the questions that we have tried to address. so if you'd join me in thanking our panel, i would very much appreciate it. [ applause ]

>> i thought it would be compelling to tell the story of a white family and a black family who come from the same name and follow them from the same place through the movements up until today and compare and contrast. >> on his family slave owning history in tomlinsonville texas and how it still affects society. he talks with the brother of former nfl runningback la deignian tomlinson. >> now a discussion on the foreign policy and diplomatic challenges facing the u.s. from washington journal. this is 45 minutes.

>> good morning. >> head line of the financial times says it is the eu that's pressed to raise the heat on russia. what is the strategy? >> well i think that as they make their case, as the u.s. makes its case and certain countries, certain leaders in europe make their case that russia was ultimately culpable for the downing of this plane, they are going to be taking a hard lobbying case to countries in europe that have been reluctant or resistant, for a variety of reasons, to increase the costs on putin for his actions in ukraine. to impose more sanctions. whether or not they succeed is a very open question. just this morning we see the european union foreign ministers are meeting. they are not expected to

announce anything new. the french are announcing they are going to go ahead with a delivery of a warship to the russians. so i it's very up in the air whether or not this strategy is going to work. >> what about the u.k.? >> well the u.k. has its own interests in keeping relations positive, shall we say, with russia. there is a lot -- a lot of russian money in london and surrounding areas. the oligarch's money. but at the same time we see the brits just this morning have decided to reopen the case of this russian -- ex-russian spy who is believed to have been killed by pa loadium poisoning. there is a lot of behind the scenes diplomacy. the problem is we don't know how

it will end. >> speaking yesterday about the situation, talked about the time coming for fundamental change when it comes to russia. there is a little of his statement. we'll get your reaction. >> this is a defining moment for russia. the world is watching and president putin faces a clear choice in how he decide to respond to this appalling tragedy. i hope he will use this moment to find a path out of this dangerous crisis by ending russia's support for the separatists but if he does not change his approach to ukraine in this way, then europe and the west must fundamentally change our approach to russia. those of us in europe should not need to be reminds of the consequences of turning a blind eye when big countries bully smaller countries. we should not shrink from standing up to the principles that govern conduct between independent nations in europe and which ultimately keep the piece on our continent.

there's been reluctantsy so far to stand up. it is time to make our power and resources felt. i agree with merkel and president hollande that we should consider a new range of hard hitting economic sanctions against russia. >> and strong words and calling out european allies as well. >> right and you have a new foreign secretary in britain too known to be quite a eurosceptic. but let's just remember that while cameron talks tough and makes his case in front of parking l parliament. it is not clear that is going to resonate. there are many countries in europe that are very fearful of what russia could do to them. not necessarily an attack but cutting off gas supplies, kind of economic retaliation for anything they might do. so, you know, it is a very -- it is a very murky situation and a lot of countries are looking very warily at what a tougher

stance on russia mayor will mean. >> does iraq overshadow decisions that will be made in this specifically. >> iraq? >> yes. >> well there is lingering concern over the whole situation. and not so much amongst the british government which, supported had iraq invasion. but -- amongst the british public certainly which was opposed. and remember old europe, as the bush administration called it, the french were very much opposed, the germans as well. and although i think it's far less than it might be or might have been immediately in the immediate aftermath of the iraq war, i think that sure, there is some lingering suspicion and lingering mistrust. >> what about the e.u. countries? how are they looking at the u.s. to respond? and will they wait further before they move forward. >> one thing we see going on right now is this enormous

propaganda war between washington and moscow. and i think that until we have or until evidence -- as solid evidence. not just social media, youtube clips and tweets. until that evidence is presented, i think that you are going to see some caution on approximate part of european countries that are concerned about russian retaliation. until, you know, there is a case with certainty that can be backed up with intelligence evidence, not just people saying this is what we assess but showing why the assessment is such. i think it is going to be more difficult until that point is reached, until we get to the point where an investigation comes to final conclusion. >> and the head line from the "new york times" this morning. russian's message on downed plane:con silgs and blustered

towards west. >> right. and thus far actually until yesterday until the russian defense ministry had this rather unusual press conference at which they raised a whole bunch of questions about what actually happened to the plane, is that russian officialdom, president putin the u.n. ambassador to foremost blamed ukraine for creating this kind of environment that allowed this tragedy to happen. but they haven't actually denied and they hadn't until yesterday in this russian defense minister, they hadn't said no all the u.s. allegations, all the allegations from the british, the australians, others who are joining and making the case against russia. they hadn't specifically denied any of these charges and it certainly looks as though they could be setting the stage for some kind of move to acknowledge what really happened.

if in fact what happened was what the u.s. claims it was. so i -- you know, there is a lot of moving parts here. and until it all plays out, i don't think we're going to be able to make even a very educated guess about what is going to happen in the future state of russia/western relations. >> how much has the state department revealed on this situation? what are they telling you? >> well the case they have made is the case that samantha power, ambassador power made at the u.n. security council last week on friday. and the case that secretary kerry made on the network sunday talk shows. and not much beyond that. and that case is based on a large body of circumstantial evidence involving intercepted phone calls which don't necessarily prove much of anything. or youtube videos showing that

the rocket launcher. now the americans claim that they have imagery of a missile being launched from this rebel-held area in eastern ukraine. they say they have it but they haven't shared it yet. and i think that it is not necessarily that one should be automatically skeptical or think that is false. but i think that the problem they are facing, particularly in the wake of the iraq intelligence failures is that one shouldn't automatically assume or believe that this is the 100% truth. and i think until this kind of evidence is actually presented, skeptics and russia are perfectly within their rights to raise questions. >> matt lee of the associated press with us to talk about the diplomacy efforts on several fronts. you heard about ukraine, other topics as well.

202-5853880 for democrats 3881 for republicans. 202-585-388 for i3 for independ >> the u.s. is doing exactly what it needs to be doing. president obama is doing exactly what he needs to be doing. for starters he doesn't need to tell everybody and announce his strategy to everybody in the world so they are, you know -- so they know what he's doing, okay what we're doing, what our defenses are. we doesn't need to notify the media, you know, what his strategies are. so they know what he's doing. they complained about him coming to california. but if you look back, he was aloof it looked like he was. it was en't. they handled the benghazi arrest. same thing with osama bin laden.

they said he wasn't doing his job. he captured bin laden, when nobody else could do it. you know, everybody just needs to chill out a minute, okay. there are so many things going on in this world at this time. look at putin. he was in, if you remember he was in cuba a few weeks ago. excuse me. a few weeks ago. what was he doing there in cuba? stirring something up for everybody else? sanctions. president obama is doing what he needs to be doing. >> thanks caller. matt lee. >> well the beginning of her statement that the president doesn't need to say what his strategy is i think -- well i would disagree. i think this is a repetitive democra representative democracy and the people should know what he has in mind in terms of how he's going to address the policies. specifically putting out invasion plans or something like that, no, of course not. but a general -- a general sense

of where the country, where the administration wants to see american foreign policy headed i think would be most welcome. i'm not saying that we don't have that necessarily. but i think that the president -- that there's been a lot of valid criticism of the administration for not presenting kind of a coherent and broad overall strategy for how to deal with these multiple crises that keep popping up all over the world. >> we knew about the phone call between the two gentlemen early on. have there been other phone calls between the president and mr. putin that we know. >> not that i'm aware of. >> sarah, good morning. >> i just want to make a comment on the israeli/palestinian conflict. i'm so disturbed because there is so much suffering now. and what just gets to me is that to revenge the four of teenagers. three jewish and one palestinian, we now have an

additional over 600 people killed of which 75% are basically civilians. neither hamas nor the israeli government serve the people. and what makes this so clear is the violence, the deaths and the suffering that both sides have unleashed shows clearly that they have no interest in serving their people. but rather listen and give into the dark side. somebody got to stretch out the hand and make peace happen. and you have to be a courageous leader to do so. peace is hard. war, bombs are easy. and we have also tens of thousands of homeless people now in gaza. and there is something where i think israel could have taken the higher road by saying hey, you know, what, the dome is working. let's just wait until they run out of missiles. and i know some may say there is going to be a constant stream of

missiles. but if they would have not answered with such violence, you know, reaction, maybe the world not that the people in palestine would have said hey listen this is enough with these people. >> thanks. >> the main point that people need to step up and end the conflict is exactly what's going on right now. whether or not zheesucceeds or again an open question. like, you know, a lot of these things are. secretary kerry is in cairo right now meeting with the egyptian president who has said he is very you aren't and committed to getting a cease fire done. you know, the u.n. secretary general ki-moon is in israel right now. he and president netanyahu are meeting as we speak. it is not a question as there not being an effort to end this from people outside.

i think it is more a question of neither side, the israel israelis or the palaestinians showing any sign of wanting to end or back down. and it is a horrible tragedy that is going on. there are the suffering in gaza, which is a very small and very compact, tightly packed population center is horrendous. you can see it in the pictures. that said, you know, hamas is firing rockets into israel. and those are attacks on civilians as well. israel says that it doesn't target civilians. they may target civilian structures that become appropriate under the strict rules of war, may become appropriate targets.

but, you know, there is -- there are problems and issues on both sides of this in terms of the suffering and suffering people. >> tony from texas, you are up next. independent line, hi. >> hello. hey, how you doing pedro. from what i plainly see slapping me in the face is the corruption from the top of the president, the president's bosses all the way down all, including the media, all these polls. there is just so full of lies and so controlled by the corrupted group. i don't understand why the american people can't stand up and demand. i'm done asking people, the government, to please do something. i now as an american citizen demand that all this corruption stop, all these wars have to stop. and this wasting of money and

these bad decisions. you can't keep opening up one jar of conflict after another to keep us focused. so in every other direction, instead of what is going on in our own homeland. i mean how long is this going to have to go on before the american people i guess just fall off the side of the earth. because we are not being -- our president is not working for us. i don't know who he's president for. but he is not for us. >> okay. tony, thanks. >> you know the corruption of the president's bosses, the president's bosses are us. american voters. so i don't know what corruption actually he's referring to. there are a lot of problems out there. and, you know, it is impossible to come one an instant solution to every single one of them. it is just the way of the world.

the frustration is completely understandable. but blaming -- blaming all of this and saying it is all -- any u.s. administration or everything is america's fault i think is -- it just doesn't hold water. >> democrat's line here is paul from st. petersburg, florida. >> yes, i agree with president obama. 100%. and i agree with -- i also think he should call putin and talk with him about it first of all. have a conversation. talk things over and if putin -- everybody makes mistakes. not thinking about it -- think it over before it happen i don't

know if he did it or not. but if he did he ought to come forth and say i did. and i made a mistake. everybody makes mistakes. i did wrong. >> matt lee. and part of putin's response that was on television was printed up in which part of the statement said no one should and no one has a right to use this tragedy to pursue their own political goals. rather a tragedy of this sort should bring people together. >> and i think from the american point of view or the european point of view that bringing -- peopling yoe using this tragedy come together would require some kind of acknowledgment of what actually happened and not a presentation of a series of questions about air traffic controllers seeing a ukrainian jet near the plane just before it went down. i think those questions should be answered. but just raising them without --

raising the idea of a giant experience is not the same as acknowledging the truth or what happened. and i think, you know, it is going to be very important for a credible international investigation to come out with its findings. >> how much does russia influence the investigation now? >> well they volunteered. they said they will send people there. i saw some reports earlier saying the separatists who were in control of the site at actually gone -- taken chain saws to some of the wreckage. so the wreckage doesn't resemble what it did before when it first came down. i don't know if those are true or not. but i think the west is going to be highly suspicious of a large scale russian involvement in the investigation. >> don up next from toledo -- sorry, reed from washington, republican line. go ahead. >> good morning. you know, i don't have a

question for your guest pedro. just more a couple quick kments if you would like to comment on it. the main reason i called is i can't believe i think it was a caller from milwaukee that said she believes israel should just wait until they run out of missiles. now if you use that logic hypothetically there is some criminal next door or on the street firing bullets into her house. according to her she should just wait until the person rubs out of bullets and takes no action. israel has been more than total tolerant. they have nuclear weapons and they could have wiped any of their adversaries off the map if they wanted without retaliation. and the comment secretary of state kerry said about off microphone i believe it was yesterday about criticizing israel about not having enough of a pinpoint response. i mean, what was he referring to?

does hamas firing missiles randomly? is that a pinpoint operation? it shows how incompetent this administration is. and i believe in israel's policy that when they started this conflict would destroy the house of a terrorist. because that family knows that the person in their family is a terrorist and they have a responsibility in their own community and to the world to stop and if they don't they deserve their house destroyed. the last point is this. israel should do this. instead of taking out the tunnels when they find an area missiles are coming from they should announce that within 24 hours this entire town is going to be destroyed with overhead bombing, get out. >> i think the last option is a little extreme. i will say that there are a lot of people who have the same opinion who believe that israel

has shown remarkable patience and restraint, not necessarily right now. but in the runup to this. i'm not aware of the actual context of what secretary kerry said in this off mic. i don't know what preceded that. so i'm not able to make a judgment as to who he was being critical or just making an observation. i will say though that the u.s., president obama, the state department, secretary kerry in the past and even right now have said that israel should do more to live up to its own very high standards of prosecuting this conflict. without question, there are a lot of civilian casualties in gaza. and without question, i think israel regrets those casualties. the nature of this operation is

such that even if you take the most extreme measures to avoid collateral damage, it is not always going to be successful. i just go back to the point i made before. about hamas rockets being fired into israel. if that is not targeting civilians, i don't know what is. it's not as if these rockets have very good guidance system asks can be fired with pinpoint accuracy on to an israeli military target. these rockets are going up and just trying to do as much damage as they can. it doesn't really matter where they land. civilian target or not. so, you know, there are issues, again on both sides of this. and both sides -- both sides need to address it. >> toledo, ohio. don, up next.

republican line. >> dwoogood morning. i've been listening for a while and i don't know if a lot of the callers realize that back in the '90s, clinton and i think -- signed it also a treaty with ukraine. that if they get rid of their weapons that we would defend them if anybody attacked them. and i think what is going on is they are being attacked by terrorists, supplied by putin. and i just -- i think we should have given them weapons and there is a good chance if we would have gave them weapons right off the bat when this first started happening they wouldn't even see the terrorists -- i call them -- wouldn't even be in eastern ukraine to shoot down that plane. that is just what i think. >> the caller is referring i think to the -- what's known as the budapest memorandum which was the agreement that was signed back in the '90s when ukraine gave up a after the break up of the soviet union when ukraine gave up its nuclear

weapons in exchange for a promise from both moscow and the west that it would not become this kind of pawn in a new cold war, as one might call it. it does not -- did not bind the u.s. or nato to defend ukraine. but it certainly made clear that ukraine and other countries of the -- well, ukraine because -- specifically with ukraine. should not be or not become exactly what it appears to have become today. so i think we can safely agree that the budapest memorandum did not stand the test of time. >> matt lee, the "new york times" has a story about the sa-11 missiles and the diagram of of it. how much this missile system a key of what happened overall? >> it is the key.

if it is correct that this missile system is the one that brought down the plane, possession, ownership of who had them, where they actually were, did a missile launcher leave the area where the u.s. says the missile was fired and head back to russia minus one missile? all of these are going to be, you know, huge parts of the investigation, i think. and the other part of course is the black boxes, which some people say the plane's black boxes, some people have discounted the information they might provide. but i think that what you can say is that they could rule out whether or not this plane was being followed, if the pilots noticed anything unusual before whatever it was that happened happened and the plane came down. the whereabouts, location of the

missiles, location of the black boks, witness accounts and the whatever imagery satellite imagely they have are all going to play a big part of the investigation. and i think the key is to present enough of that evidence to convince the public that what is plausible is in fact true. and that what is implausible is not. >> also photos of some of the damage shown provided by the "new york times" this morning. this is by noah snyder. some of the wreckage there. our next call is don from maine, independent line. >> hi. i don't see, and i wonder if your guests can tell me, if there's been any clear path towards resolving this moral outrage that we feel over this

tragedy in ukraine against the economic interests of, not only all of the parties concerned but the whole world economy to separate one part of that economy on moral grounds and say you are no longer going to be able to participate in trading with us and in the kind of world system that we have now. it just doesn't seem to be happening because all of our humans are running up against our economic interests and which is going to triumph and which is going lead us to the resolution of these kind of problem? which keep occurring. these problems are going keep occurring all over the world. >> the caller makes a good point. for most of the time since the break up of the soviet union the

west has been try to integrate the russian economy. joining the wto and other types of economic and trade agreements. so there are serious questions and serious concerns among people who have spent the last 20 years trying to bring russia into the fold. serious concerns about do we completely throw them out of the fold? the g-8 has already going to the g7. the russians are effectively out of that for the time being. and whether or not the isolation grows, i think going to be dependent on the amount -- whether, as the caller said, whether the outrage over this if it is proved the russians had a hand in it, whether that outrage can outweigh the very entrenched economic interest that for the last 20 years the u.s. has been

promoting. >> michael on the line. go ahead. >> hi, i haven't heard a whole lot of this but i did hear the last bit. and it puzzles me, a statement that we are trying to bring russia into the fold, whatever that is. it seems that destabilizing the ukrainian government and then actively working to put into power a neonazi party like svoboda which has called for ridding the nazi party of jews russians and other scum wouldn't seem to be promoting that kind of policy. >> what i was referring to was people trying to integrate russia into the west is prior to the ukraine situation. maybe perhaps even prior to the russian invasion of georgia. those efforts are on hold right

now, clearly. now there are -- there's been a lot of rhetoric spewed around about the new government in ukraine. you know, the russians say that they are nazi thugs. they deny it. you know, i think again it is an open question as to what this government's policies are going to be if and when this crisis ever ends. but i think you will see -- i don't think, i know that the u.s. administration and others in the west have looked to president poroshenko as a calming or a patient and calming voice. whether that turns out to be the case -- when i say that i refer to his calls for cease fire, his willingness to allow autonomy --

a great deal of autonomy to regions in the east of ukraine. but whether or not that holds true once if and when this crisis crisis comes to an end we'll have to see. >> you were talking about russia's economic influence to turn that around can russia with stand sanctions by the u.s. and the eu? >> it is clear to this point that president putin has a very high threshold for pain if that's a right word. the sanctions that have been imposed thus far since february, since the annexation of crimea do not appear to have had any significant impact on russian policy, and, you know, i think that's why people are looking at this plane incident, if, in fact, it was russia responsible or was complicit in it as something as a shock to the

system, as something that will not only galvanize or americans in the west hope to galvanize the europeans to increase the pressure but a shock to the kremlin itself saying it is impossible to defend on the downing of an airliner in which almost 300 people, civilian, completely innocent, having nothing to do with the conflict died. you can't defend it. you can say it was an accident. you can say and take some kind of responsibility or acknowledge that there was, you know, mistakes were made, but to defend it is quite something else. >> and you brought this up a little bit only because the headline for this reuters saying sanctions were threated by france's president going ahead with the delivery of a war ship to us know. can you expand on that?

>> president hollande say the russians paid for this, they paid for it 2011 well before these sanctions or the ukraine crisis was ever on anyone's mine or before it started so it should not be subject to the current sanctions. you know, he's running into -- the americans in particular are very upset about this. they don't see how this sends a consistent message to russia if on one hand you're saying, you know, add and the other hand you're delivering a war ship that's supposed to go to the black sea, i believe, right into their hands. regardless of whether they paid for it or not. so president hollande said there were two ships involved here. the second ship would depend on russian behavior, but it

certainly has created a bit of a rift between the united states and france and what prime minister cameron was saying yesterday in the house of commons looks like there's a rift here. >> here's matthew from florida on the republican line. >> hi, matthew, hour you >> good morning. >> good morning. i have a question for you. i'm kind of curious. do you actually believe that the ukrainians and the russian military or their military might are working in concert with one another because i tell you i think that the american people are being naive if they believe that they are not working in concert. i mean i believe that they are one and the same. >> i'm sorry the ukrainian

government, the ukrainian army and russian government? >> i think they are working in concert with one another. >> that's an unusual assessment i would say. the ukrainian army has been conducting these counterterrorism offenses against the pro russian separatists in the east for weeks now. and there's been, you know, it's been quite, been quite bloody battles. i'm not sure you can make a case that the russian military and ukrainian military are working together. i think you could make the case as many have done that the russian military is supporting or advising, training and supplying the separatists in the east but not the ukrainian army proper of the government of kiev. those are two different things. >> this is colil from tennessee, independent line. >> good morning.

>> good morning. >> my comment is that i believe american foreign policy should be diplomatic instead of military considering the fact that america has ignored the continent of africa for decades and now we see radical islamic institutes coming in and treating these jihads all over the continent. i know in my opinion there's going to be a detrimental effect to america in the future and how do you think america should proceed in dealing with that? >> i have mixed thoughts. i think that the suggestion that the u.s. completely, has completely ignored africa over the last two decades or so, i'm not sure is entirely correct. the bush administration, for example, poured tremendous amounts of money into africa

into health and anti-hiv/aids program. that said in terms of strategic issues, in terms of what you refer to the rise of radical islam in africa, i do think that there has been not enough attention paid to that by the united states, but also by other countries outside of africa and, in fact, countries inside africa. there's been strong criticism of the government of nigeria for not doing enough, not taking seriously the threat from boko haram and to spread into the central african republic. this is not just a u.s. problem, it is one that the united states should and needs to be focused on because it is a growing threat, not just to the people

in these countries, but outside, the export of extremism and violent jihadism is a problem for everybody. >> oklahoma, this is lisa, republican line. go ahead. >> i would like to know why was the malaysian flight over a no-fly zone? >> well, i think that technically it was not over a no-fly zone. the no-fly zone was imposed on u.s. carriers by the faa was closer to crimea area and not this area. now, that said, i suppose and i think it's a good question, why was any plane flying over conflict zone. when you're flying at that altitude, 30,000 feet you're out of the range of portable, what

we call man path, man portable rocket shoulder missile fired rockets, which have been since the early or the late 1990s the primary concern about terrorists, extremists getting their hands on these and taking down planes at altitudes lower than 10,000 feet or lower. if you're high enough the only thing that will get you is one of these, you know, ss-11s or the buk missile systems. so it's a good question why would any airline want to have its plane fly over an area of active combat, but it's also, you know, not entirely unheard of. it happens all the time. it's just in this situation, what the u.s. and others have put forward that this was a missile attack and this missile

did hit it, it was a very unfortunate wrong place, wrong time, and combined with a very active war zone. >> matt lee, a couple of other issues when it comes to what's going on in the middle east. why is egypt such an important player right now? >> egypt has traditional seen itself and been kind of the leader of the arab world when it comes to dealing with israel since the camp david accord between president sadat and president carter. egypt has really played a leading role in terms of managing from the arab side the israeli-palestinian conflict. that's a role despite the passing of the coups, that they want to maintain and be kept. now, one of the reasons that they have leverage over hamas even though they are not good

friends at all and certainly further apart than they were when president morsi was there is that egypt controls the border between the sinai and gaza. and they are able to open and close that border and tunnels almost at will. so, they do have some influence with hamas whether or not they like it or not. >> matt lee writes about diplomacy for the associated press. thanks for your time. >> thank you. in a few moments dr. thomas frieden the helped of the considered cdc on combatting the threat of antibiotic resistant infections. in an hour white house briefing with josh earnest. head of the peace corps discusses the corp's recruitment process. later transportation secretary anthony fox calls on congress to pass a long term transportation

spending bill. the head of the centers for disease control dr. thomas frieden says action is need freezing drizzle te to protect antibiotic resistance. he spoke at the national press club for an hour. good afternoon. welcome. i'm an adjunct professor at george washington university and 107th president of the national press club. the national press club is the world's leading professional organization journalists committed to our profession's

future through our programming with events such as this while fostering a free press worldwide. for more information about the national press club please visit our website @press.org. on behalf of our members worldwide i would like to welcome our speaker and those of you attending today's event. our head table includes guests of our speaker as well as working journalists who are club members so if you hear applause in our audience i note that members of the general public are attending so it's not necessarily evidence of a lack of journalistic objectivity. i would also like to welcome our c-span and public radio audiences. can you follow the action on twitter using the #m pclunch. after our lunch speak concludes we'll have a question and answer period. now it's time to introduce our head table guests and ask each of you to stand briefly as your

name is announced. from the usedenses right, thomas snyderman. barun. jmal iliani. ruth katz, director of the health medicine and society program of the aspen institute and member of the cdc foundation board. anna miller associate editor at psychology magazine. john lewis co-founder and executive director of the peggy lillis memorial foundation and guest of dr. frieden. donna lagier reporter for u.s. today, vice chair of national

press club speaker's committee and former president. doris mar fwmpb olis president of editorial associates and national press club speaker's committee member who organized today's luncheon. faith mitchell, president and ceo of grant makers in health and guest of dr. frieden's. susan heavy correspondent for reuters. carolyn block publisher and editor federal telemedicine news. hirito. this time last week dr. tom frieden was busy cramming for his july 16th appearance before the house committee on energy and commerce. the director of the centers for disease control dr. frieden had been summoned to washington to answer questions about the startling and potentially dangerous lab errors at the cdc

and while that topic is likely to come up again here today, dr. frieden joins us to explore a much bigger and broader issue, looming worldwide health threats including the pathogens that put modern medicine at risk. he'll explain the mr. mers coronavirus a disease that has no known cure and has recently immigrated to our country. it haunts the arabian peninsula and is showing up in travellers through other destinations far away. the virus has reached an arrival in the united states, sent hundreds of cdc staff into emergency mode. and some now refer to this illness as public enemy number one. other issues that dr. frieden will tackle this afternoon includes the dramatic increase in the number of measles cases in america and the growing

threat that draws new pathogens pose. they can hitchhike rides and crisscross the globe detain. he'll update us about the new program the cdc launched three weeks ago combat drug resistant pathogens. some of these killers microbes jump from an mols to humans and a growing number of them are resistant to currentry known drug treatments. dr. frieden has been director of the cdc since june 2009. a physician with training in internal medicine, infectious diseases, public health, he's known for his expertise in tuberculosis control. from 1990 to 2002, dr. frieden worked for the cdc starting as an epidemic nuclear weapons service officer at the new york city health department. fluent in span injuries he's a graduate of 0 berlin college and

received both his medical degree and masters of public health degree from colombia university. he completed his training at yale university. dr. frieden has won many awards and honors and has published more than 200 scientific articles. his talk today is titled "mers public enemy number one?" dr. frieden last appeared last september. ladies and gentlemen, please join me in welcoming back to the national press club, dr. tom frieden, director of the centers for disease control and prevention. [ applause ] >> thank you very much. it's great to be here. and thank you so much to the national press club, to the president and doris margolis for the invitation and thanks for

your interest in health and what i would like to do is talk to you about some of the biggest threats facing us today. some of you may have heard about problems at the cdc laboratory where we've had two safety lapses in recent months. these lapses should never have happened. the cdc laboratories are some of the best scientifically in the world and now we're taking rapid and decisive action to make sure that they are also some of the safest laboratories anywhere in the world. i'll be ethiopia talk about that later but right now i want to talk a little bit more about some of the challenges that we face. sometimes at cdc problems like the one that has come to light recently, occur because people are so used to working with danger. we're currently mounting a substantial response in west africa where three countries in that region are battling eboli. there's more than 1,000 cases and 600 deaths from eboli.

i had been in uganda, which is as you imagine a cave with a very large python, about 15 feet large and about 10,000 bats and those bats turns out our researchers have identified have a 5% infection with the mabird virus. it's similarly fatal and there were two infection, one fatal one not a few years back and our staff went in there to try to figure out and understand how the bats were moving around the region and what might be able to be done to control mabird there. i asked weren't you scared to go into this cave that had 10,000

bats, lots of them with mabird often fatal virus and this notorious python and they said the python didn't worry us and the bats didn't worry us because we were wearing those moon suits and the mabird didn't worry us because we have the protective equipment on. the cobras worried us. [ laughter ] and underneath their moon suits they had to wear leather chance so if they had a cobra strike they wouldn't be killed by it. so we have to always remember above aldo no harm needs be more than a motto. it needs an organizing principle for all of our work. now, like other health care workers i have my personal experiences with risk, sometime back i was working in rural latin america on public health programs in communities and i'm sorry to say this over lunch i

won't go into details communities that didn't have great sanitation and i became extremely ill. it was in the brief period between medical school and starting internship and residency and i had learned in medical school what a rigor was but if you ever had a rigor you under it's not a shaking chill, it's a violent shaking chill so violent the bed shakes. it's a reflection of having grand negative bacteria in your blood and i became quite ill. i returned to the u.s. feeling a little bit better to start my internship and i was tested and found to have an organism from poor sanitation, it was in my bloodstream, i was very ill with it. highly infectious. ten xx organisms can infect another person and just give you a sense of scale you can fit about a million organisms on the head of a pin. so when i went in for testing

the doctor said you not shagilla and resistant to every antibiotic known. i said i have to start my internship. [ laughter ] and the infectious disease attending said you need to go home. but we always want to be part of the solution. in health that can be part of the problem. so now a little footnote to that story. that episode of illness -- i did eventually get better not as quickly as i would like and recovered completely. about a year later, a new drug came on the market and two players later i wrote an article published in jama on the inappropriate use of medicine.

so i have a quiz for you. what are the six organisms all have in common besides the fact that they are all infectious disease. that's too easy. mers. eboli. measles. tuberculosis. and cre. any guesses for what these three, what these six diseases all have in common these six infectious diseases. yes. they are preventable. yes. they are all preventable. that's one thing they have in common. how about how they spread? is there something in common. you have eboli from bats, mers maybe from camels. some are airborne, some are not. three quarters of the new infections we face are zornonic.

no. they are all very importantly spread in hospitals. we can be part of the problem if we're not careful. all of them and i'll talk a little bit more about that. now when i went to medical school they taught me to use some fancy words. i know reporters never use fancy words but, you know, we don't say we gave to it them in a hospital. we don't say the doctor made him sick. we use fan sip 50 cent words to avoid the uncomfortable truth. my most favorite of all we know exactly the cause of his illness, it's i diopathic. it means we don't know what causes it. another definition is patient is

sick and the doctor is an idiot. now mers is very concerning because like sars which occurred a decade ago it has a high case fatality rate. maybe as high as 30%. mers also could cause significant not only illness but economic dislocation. sars cost the world more than $30 billion in just three or four months. we're learning more about mers and that quiz i gave earlier was actually the key lesson we learned as we work close wli the saudis and we're now work very closely with them on a variety of investigations and control measures, we found that the overwhelming majority of mers cases in recent months or in the past six to 12 months have been associated with hospitals. they've been spread in hospitals, patients, staff, visitors, others associated with hospitals. that's bad news and good news.

bad news because it shouldn't have happened and should be able to prevent it. good news because we know how to turn off that tap. we know how to protect health care workers and other through infection control measures and i received an e-mail last week from the saudi minister of health to our staff who reported that in the past ten weeks they not had a single case of mers in a health care worker now they they implemented stringent control measures. when you know how something is spreading you can stop it. there's still more we don't know. we don't have a prevention. we don't have a cure or a vaccine. we don't know how it jumped from animals to people. it does seem that camels have perhaps been infected by bats and perhaps have something like mers whether it's direct contact with camels orca medal products. we're under taking studies to find that out the prevent it. when we under something the better we the prevent it. the next pandemic is not likely

mers unless it mutates the capacity to develop easily from person to person. it may not be an influenza like the one that emerged in china and that's a wonderful story of how we have global collaboration. but maybe the thing that we are most at risk for is not the thing that we don't know but something that's hiding in plain sight. something that could kill any of us. something that could undermine our ability to practice modern medicine. something that could devastate our economy and something that could sicken or kill millions. now, someone here in this room, christian lillis knows about this problem. christian's mother peggy was a

beloved kindergarten teacher. she went in for a routine root canal procedure. within a week she had sepsis. and tragically at the age of 56 she died. christian and others have carried the standard to make clear what is the human face behind the tragedies that we read about because in public health we're at our best as bill fagy said when we see and help others see the face s and lives behind the numbers. i think of a 15-year-old who loved music had a congenital, a mall formation, not major and went in for a routine check up. two days later had a resistant bacterial pneumonia and died easter weekend.

i think of josh nahem, a young man from colorado, 27 years old, loved skydiving. had an injury from skydiving. got infected, began to recover then developed a highly resistant organism and also died at the age of 27. josh's mother victoria has christian elisabeth hasselbeck been be a activist, an advocate information proving the way we address infections in this country. antibiotic resistance could affect any of us. in fact, 2 million americans get resistant infections each year. 23,000 americans die from infections each year, resistant infections each year and another 14,000 americans have deaths like christian's mother from or contributed by. i'm an infectious disease physician. i treated patients for many

infections. and i treated patients with no antibiotics left. i felt like a time traveller going before the time of antibiotics. we talk about the pre-antibiotic era and antibiotic era. soon we can be in the post-antibiotic era. anti-microbial resistance is getting worse. it creates two problems that are worthying of a little separately. one of them are the thing that we usually think of as infections. urinary tract infections, wound infections. we're seeing more and more resistance from those organisms. but there's a second problem that we may not think of notally and that is how important in control of infections is to the

practice of modern medicine. 600,000 americans a year get cancer chemotherapy. when we give cancer chemotherapy we drive down the body's defenses so we can wipe out the harmful cancer cells and patients get if he verse and serious infections and we can keep them in check until the body's resistance comes back. so cancer chemotherapy may be at risk. we have more than 400,000 americans who are in dialysis. infections commonly complicate dialysis if we throes ability to treat those infections it will make dialysis much more difficult to do. modern treatments for everything from arthritis to asthma suppress the immune system. our ability to give these cutting-edge treatments is at risk because of the spread of drug resistance. every day we delay means that it

will be harder and more expensive to fix this problem tomorrow. bacteria are evolving very quickly. we need to move quickly to get ahead, to catch up and to control it. it's possible to keep resistant bacteria from spreading. it's possible for some pathogens to actually reverse the level of drug resistance but only if we act now and act decisively. what we've seen is that organisms can start in hospitals. our most resistant organisms start in the hospital. now we see it go out in the community so now the most common pathogen recovered from patients

with cuts and wound infections in the emergency room are mrsa. it's not too late. we know in cre we still largely are dealing with a hospital infection. we can keep it in the hospital. we can shrink the numbers and crow it. if we don't then common infections like urinary tract infections could be untreatable. to stop drug resistance we need fundamentally to do four things. first, we need better detection, second better control. third, better prevention. and fourth, more innovation. on detection, we need real-time systems to find out what's happening around the country. in fact, this week cdc will be launching for the first time a

system that will allow any hospital in the country to track electronically automatically with no extra work after the initial uploading work all of the antibiotics dispensed in that hospital and all the antibiotic resistant patterns of patient whose have infections. that will allow doctors to be empowered with the right information at the right time to make the right decision so that they can give a patient antibiotics that are needed neither too broad nor too narrow. so better detection is the first step in controlling drug resistant organisms, to allow us improve prescribing practices, to identify outbreaks, to figure out our outbreak control measures are working. the second key step has to do with control. as with the quiz earlier, much of this is a problem and we have to take seriously above aldo no harm. too many infections are being spread in our hospitals. too many patients are coming in

with one condition and leaving with an infection that they didn't come in with. but prevention requires work across many facilities, even the best of hospitals can't do it alone. they need to intersect with the nursing homes w-the outpatient providers, with other facilities in their communities and that can best to be done with public health departments serving a convening, collaborating and facilitating role. state health departments will be key to reversing drug resistant and reversing hospital spread of infections. third is prevention. the fact is that the quality of treatment for many conditions is nowhere near what we would like it to be. my father was a cardiologist. he used to say that when you see how other doctors practice

medicine you realize how resilient the human body is. [ laughter ] improving prescribing practices in all sectors is crucially important. we recommend that cdc that every single hospital in the country has an antibiotic stewardship program. this means that antibiotics are looked at carefully, the data from their hospital both resistance patterns, prescribing patterns are tracked regularly. and if things are not right they are improved. we have done a study that a third of all antibiotics used in this hospital are either unnecessary or inappropriate. there are enormous difference between one region of the country and another and those don't reflect undertreatment in areas of lower rates of utilization. team-based care, checklists, reporting, feedback, accountability, these are simple management tools that need to be applied systematically to

prevent drug resistance and many antibiotics being used are not necessary. with every medication, whether it's for infectious disease or other we need to think of the risk benefit ratio and always think about that ratio. there's no medicine without risks. and we have to balance that risk benefit ratio. that risk may include drug resistance. it may even include in the case of antibiotics contributing to the obesity epidemic a current hypothesis which there's some data. there's some data about a lot of hypothesis of what's contributing to the obesity epidemic. another area where we've seen a risk benefit calculation with medications get off kilter.

another area is opiates. so we have to keep track of that risk benefit ratio. ironically we underutilize a lot of medications that have a favorable risk benefit ratio. aspirin is only used half the time. blood pressure son lie controlled half the time. even among those at highest risk, statins which are very effective only used half the time. we have to get that risk benefit ratio to make sure that we're above all doing no harm and on balance doing as much good as possible. the fourth is innovation. we need to couple with new tools and while we need new drugs and new antibiotics there's at least five or ten years away that may or may not be available, may or may not work for our resistant organisms and today we can stop, slow or even reverse that drug resistant trend and there's also innovation needed in tracking resistance, understanding it better, figuring out what works to reverse it.

in the president's budget for 2015 there's an initiative that would allow us to build five regional centers of excellence all around the country so we can help doctors understand whether patients have resistance faster and in real-time whether there are outbreaks and how can we stop them. it would help us develop a bank of resistant organisms that pharmaceutical companies and others could use to come up with more rapid diagnostics. we project that if funded we could save money but more importantly save lives. we project based on real data that with this initiative over five years we would be able to cut our two deadliest threats in half. both cre, the nightmare bacteria that's spreading in many of our intensify care units and cdif.

we know that because places that have done that right have had that result. we can make this succeed across the country but only with investment. in fact, over five years we project we can reduce by 600,000 the number of resistant infections by 27,000 the number of deaths from resistant infections and by 7.7 billion dollars to health care cost from it. public health is a best buy. but we have to act now. anti-microbial resistance that's ability to kill anybody in the country, to undermine modern medicine and devastate our economy and make our health care system less stable. confronting this can protect americans from the moment they are born and throughout their lives but every day we delay it gets harder and more expensive to reverse it.

it's too late for peggy, for nile, for josh and for 23,000 people who died this year from infections that might have been able to be prevented. and although the problem is big and although it's getting worse it's not too late to reverse it by taking decisive action now we can reverse it and we can protect these antibiotics. the concept of stewardship is an important concept. we're protecting them not only for ourselves we're protecting them for our families, for our children and for our children's children. thank you very much. [ applause ] >> thank you, dr. frieden. according to a recent report by the fda, 80% of all antibiotics

used in the united states are fed to farm animals. this means that only 20% of antibiotics which were originally developed frwere mea to protect humans. >> we want to see rational antibiotic use wherever antibiotics are used. and i think that means, for example, in farm animals or feed animals that if animals are ill they should be treated. using antibiotics that are of importance to humans for growth promotion is clearly something that we, the fda, the usda and the food industry is concerned about. i think that's something that we'll see progress on in the coming months and years. it's more of an fda, usda issue than a cdc issue but we could recognize as cdc that some of the most resistant organisms we're seeing like cre which is a

nightmare bacteria, resistant to virtually all antibiotics and covers multiple different organisms that have a fatality rate as high as 50% in the hospital. some of our most serious resistant organisms are in the health care system particularly in hospitals. we want to see rational prescribing every where antibiotics are prescribed. >> antibiotic development is not as profitable for drug companies as drugs such as statins and viagra. how do we encourage pharmaceutical companies to develop new antibiotics to treat these emerging antibiotic resistant infections. >> we do really have a problem with the incentives. one of the, from a strictly business standpoint, a terrible thing about antibiotics is that they cure people. and then you can stop taking

them. that's not a model for a highly lucrative pharmaceutical product. you want a product that's going to be taken for a long, long time. and that's not what we want with antibiotics. so we have to figure out a way for government and industry to work together so that the incentives for antibiotic production, antibiotic development match the need and there have been important steps taken by congress in the past few years, bipartisan, new laws in place that improve those incentives but it's going to require creativity, going to require innovation, going to require a dialogue between government and industry, thinking about ways to reduce the risk for developers to improve the benefit and to ensure that there's reasonable profit without excessive profit that might result in a backlash. these are tough issues but they are important to address. we do want new antibiotics. they are important. but we also have to recognize

that we may or may not succeed. we don't know why the antibiotic pipeline has thinned out in recent years but it has. is that because of less investment? maybe. it is because the low-hanging fruit has all been plugged and harder to make antibiotics in the future. maybe. we don't know. we can't assume that we're going to develop new drugs to get ourselves out of this mess. we have to assume we have to make rapid progress with the tools we have and preserve the antibiotics we have while at the same time we promote development of new antibiotics as well. >> is cdc looking into natural cures in addition to prescriptions? >> there's some really interesting developments in a variety of ways to reduce infection. we know that lots of things will reduce your sues

septemberibility. there's some intriguing new data coming out on the microbes. we got trillions of microbes in us and they are important for our health and we're just beginning to understand that. some of the new tools, some of which congress funded cdc to expand the use of called advance mode less can you lar detection which allow us to sequence the genomes of microbes in real-time. it's teaching us new things about the microbes that are helpful as well has harmful. for cdif new treatment pros avoiding microbes that fight against cdif as a way of battling microbes. after all, if you go back to the first drug developed against tuberculosis, sheldon waxman and

his graduate stunt figured out that there had to be things in nature that fought tuberculosis. otherwise you would have tuberculosis every where. they went into the soil of staten island and figured out there were bacteria there that produced chemicals that killed the tuberculosis bacteria. so there are ways we can use fire to fight fire, if you will. >> can the cdc or the hhs take any regulatory steps to enforce responsible use of antibiotics in hospitals? >> we have to work in collaboration with the health care system. one of the biggest challenges for public health in the coming years is that integration of public health and clinical medicine. at cdc we've been delighted to have a very positive constructive partnership with the center for medicare and medicaid service. as an example we for many years have run something called nhsm.

we had many hospitals involved and then cms said by the way if you don't get 100% of your reimbursements you must participate suddenly we have 14,000 facilities participating. they benefit from that. they are given information that they can act on to improve their care. just yesterday the person who is leading much of our work here met with eight different health care systems to figure out how can we sustainablely achieve the hospital stewardship programs. it's not so much a question of mandating and enforce as figure out together what's need and making sure we have a level playing field so that gets done and tools like the national heart care safety network provide tools to hospitals to improve the quality of their care. >> in september 2013, cdc put out a report anti-microbial

resistance in which the agency identified new dreg development. congress is currently considering legislation to facilitate drug development by creating a new approval pathway for drugs to treat serious and life threatening infections for which there are few or no treatments. from cdc's perspective which are the infections for which we most need new drugs. >> well we have one success story. a new drug that's useful for multi-drug-resistant tuberculosis and the fda was able to approve that rapidly. there was some controversy about that. but the data was strong and cdc recommended it and cdc is in support of that decision. we need to look at the organisms for which we have the greatest risk. that includes the whole spectrum. includes the grand rods, things like eboli in our intensify care units but also the grand positive organisms like staph

where we have mrsa. there's a range of organisms for which we need better treatment and we also need to understand them better and the tools that we're now using of advanced detection are fascinating. we're learning many of our assumptions were real simplifications. if you have an infection it may not include one organism bath broad range. and how we measure that in the laboratory may be different from what's actually happening and causing illness in people. so there's a lot we need to learn about the patterns of disease not only within the population but within individual people so we can innovate and target our innovations most effectively. >> perhaps the battle against microbial resistance to drugs will have to be fought

genetically. >> i mentioned cre a couple of times. let me give you more detail. this illustrates the answer to this question. cre is something we really have not seen before. it is a jumping gene, a plasmid, a part of genome, a part of the dn sequence that can move not only between one organism and another but between one species and another and not only can it move between species but it can encode for resistance to an entire class of antibiotics, all the penicillin and penicillin-like antibiotics, first, second, third generation,

our big guns what we have got from text people np organism can spread its resistance to multiple species and multiple antibiotics and we've seen a couple different ways it can be spread. there's a dominant one in this country and a secondary one. if that's what the jumping gene is doing, if that's what's causing, was driving the resistance to our biggest gun antibiotics what can we do to counter act that across multiple species for multiple antibiotics. >> have you stein latest mers study saying it may be airborne and your thoughts, please? >> we're working very closely with the saudis and with other countries in the region to better understand and control mers. we have teams on the ground but we've done study, we did one in jordan a couple of years ago

that was fascinating. it showed if there were lapses in infection-control you had a lot of spread in the health care facility. but if you had good infection-control just standard infection-control even if you had several infectious patients and lots of exposure you had no spread as confirmed by check being serology workers. we're understanding how mers spread how it jumped the species barrier. from everything we've seen largely been spread in recent years in the past two years in hospitals and largely controllable by rigorous infection-control. that's good news. done mean it won't change in the future but that's where we are now with it. >> you have called the bird flu safety breaches the most distressing to you of all the breaches. why is that breach most

troubling to you? >> we had two laboratory breaches at cdc. one was anthrax where there was potential, probably not but potential expossible sure of workers to anthrax. they thought they killed the anthrax. but they hadn't. we've done subsequent studies which suggest it's not impossible some of the anthrax may have exposed other people at cdc but extremely unlikely. still that was a reflection of center policy and lapses that should never have occurred. the h5n1 situation of different. through means we're not sure of through our laboratory a nonpathogenic or nonharmful bird

flu was mixed up with a harmful bird flu and stoints department agriculture laboratory. all of this work was done and sometimes called enhanced bsl blah towers. very highly contained. people wearing what are called fancy respiratoriors. we were dealing with a deadly virus that had a big impact on agriculture and that there was a six week delay between people at cdc being notified about this and it being notified up the chain at cdc made me very concerned that we need to do a better job of encouraging a culture of safety, of encouraging information report problems or potential problems if they have the slightest concern that there may be a problem and whatever the reason, we're still investigating that second incident, whatever the reason, the facts that first off it happened in our flu lab and

without exaggerating i can say our flu slabs good as any in the world. phenomenal laboratory. that made me really stunned that if this could happen at the cdc flu lab where else could something like this happen and second i was deeply disappointed that it took so long to notify and still understanding the reasons for that. what we've done since then is take decisive action. we stopped shipment of biological materials from our high containment laboratories until i personally review and approve the procedures laboratory by laboratory. we appoint ad single senior scientist to review those protocols with then of a working group and strengthen them. we have also ensured we'll take a look at every aspect of our safety to improve the culture there and improve, again, as i said in the beginning we have

not only some of the scientifically most advanced laboratories in the world but also some of the safest laboratories in the world. >> this touches on your previous comments but let me ask. in a recent hearing you told congress you recognize the pattern of weaknesses within the culture of safety. how were those weaknesses allowed to develop? >> when we look back at the last few years we see that there have been isolated incidents and i believe in each of those isolated incidents the staff at cdc and i took responsible behavior to address the concern that was raised. and what i missed and what i think our staff missed was that these isolated incidents did reflect a pattern and it was a pattern of insufficient attention to safety in our laboratories. you can hypothesize -- the story i told at the outset about

python cave and ebol spampbt of it. if you work with dangerous or beganisms day after day, month after month, year after year there's a tendency to get lapse. what we have to ensure even though human error is inevitable, human harm shouldn't. we will do everything in our power to ensure there are redundant practices in place so if there is human error there will not be human harm. i think the broader lesson is that it's possible to minimize the risk of many things but maybe not possible to achieve zero risk and that has a lot of us thinking hard about what makes sense to do in that risk benefit ratio. if we're balancing a minimal but nonzero risk against a potential benefit we better be very sure both that we make that risk as

low as possible, and that we have a reasonable expectation that there will be a benefit. >> can you describe the sweeping changes in quotes that you initiate at the cdc and i realize you touched on some of them. you might want to expand. >> we have done a series of things. we have -- i've issued a moratorium on transfer of all biological materials out of high containment laboratories. we closed the two laboratories where these incidents occurred and not re-open them until we're sure they can re-open safely. appointed a single point of accountability to overhe is laboratory safety throughout cdc and his group dr. michael bell are reviewing first and foremost those applications to lift the moratorium lab by lab. they will work not just as an individual group but throughout every part of cdc to promote that culture of safety which has to be every lab worker, every

supervisor and team lead. we'll also take disciplinary action as appropriate. we have convened and i've invited an external advisory group of worked for cdc before come in and give us a fresh look. tell us what we can do different or better to improve safety. we're investigating the incident with flu that's not completed yet. we're looking at our function as a regulatory agency. we have something called the division of select agents and toxi toxins. we regulate over 300 entities that work with dangerous organisms. what are the lessons from our experience to make sure that we do that regulation effectively. >> do i hear that -- are you advocating for harsh punishment against those who brief safety in labs and what can congress do to improve lab safety? >> it's really important to balance two competing divisions

of how you deal with an insid eptd li ent like this. in another vision you fix the culture and policy and procedures. i don't think either of those on its own is the right way to move forward. on the one hand, you have to ensure that you have policies and procedures and a culture that promotes safety continuously that recognizes that risks are serious and nonminimal and does everything to analyze what are ways to reduce that risk. at the same time, you look at individual incidents and if there is negligence, if there is a failure to report, then you have to take proemt actiappropr. i think those are either or. that's a combined areport. in terms of congressional action, there are observers who said perhaps there should be a different entity to look at the dangerous path ojens. it's complicated to inspect

these laboratories to make sure they do a good job. we do as good of as job on that as we can but we will look at that and see if there are ways we can do that better. several years ago because of it looking like a conflict of interest, i asked them to inspect cdcs lab. we're open to all ideas to how to improve safety in these laboratories and more broadly, i think we have to look at do we have the right number of laboratories? do we have the right risk benefit ratio calculations for some of the research that's going on? you faced tough questions during last week's house hearing. >> i noticed. >> what was your take away from what you heard from the committee members? >> i think the committee very appropriately had concerns that if something like this can

happen at cdc first off how did it happen? are you going to fix it? what's happening elsewhere? so i think the questions were tough but fair. the approach that i'm taking with my staff and that i encourage congress to take is very much a trust but verify approach. we're going to do things to improve safety but don't take us at our word. we will review and share the results of that and ensure that what we do, we do transparently, openly, clearly. we always find that it's much better to be clear and open about a problem then otherwise. i think we have been about these problems from the moment we learned about them. that will be our way going forward as well to say here is what we've done, here is what's achieved and not achieved. i would be disappointed but not surprised if we identified other incidents in the past or other things happened in the future and that may well be a reflection that we're improving that culture of safety and that willingness to report problems rather than failing to correct

what is an important issue to address. i think the questions were tough but fair. we will continue to provide information because we have such important work to do. this work is not done out of idol curiosity. this work is done because anthrax continues to kill people around the world because it has been used as a bio lomglogical weapon. because these dangerous organisms are spreading in nature and could be used in a bio terrorist event. >> we have some media related questions. what is your reaction to the media coverage of recent incidents involving laboratory safety at cdc? i generally think the media has been responsible in their coverage. i sometimes wish it would be a little different but i don't think that's something that anyone wouldn't say at some point or another. i think the small pox discovery

on the nih campus somehow gotten conflated in some of the reported. what happens there was a researcher probably in the 1960s before there was small box reraddication put aside her p h small boxes. it was kept undisturbed and touched. the moment it was touched the fdia appropriately informed us to make sure that along with law enforcement we were able to go in safely and securely, secure the materials. transport them securely back to cdc and in a controlled environment in the only laborato laboratory that was allowed to have small boxes in a laboratory

who was the most experienced in the world safely opened it, analyzed it, tested it and determined that if fact it was viable small pox. what we will do with that as we said from the very first moment it became apparent is we will fully analyze the genome and once that genome is sequenced and analyzed, we will invite the world health organizations observers in and we will destroy the strains and all of the biologically viable materials associated with the strains. that's one part of the study that the story sometimes gets confused with the other parts going on. it really shows cdc staff working 24/7 to protect people and make sure we could understand and control what turned out to be not a risk but that required a very active response. we got that response. >> media related question on

behalf of some judournalists. despite the fact that in previous times there were no such restraints? >> as far as i'm aware the cdc is not prohibited from talking to reporters. we do like to have hemedia staf present so we can follow-up on questions and make sure you're talking to the right people. we try to facilitate that but we really do like to be quite open and the more information there is out there about what cdc does in this country and around the world 24/7 to protect people from threats, the challenges that we have as well as the programs that we're implementing the better. >> we're almost out of time. before asking the last question, we have a couple of house keeping matters to take care of. first of all i'd like to remind you about our upcoming events

and speakers. on august 1 his excellency, president of the republic of congo will discuss peace and stability and oil investments in his country. next, i'd like to present our guests with a traditional national press club mug you can add this to your collection. the traditional last question how is it your experience appearing before the national press club compare to your experiences last week before congress? >> the food was much better here. it's a pleasure to be with you. it's a pleasure to share with you what cdc does because despite the recent incidents the

fact is that the cdc has more than 15,000 staff. we work in over 50 countries in every state in the u.s. we provide 2/3 of our resources to state and local entities. we're there 24/7 to infect people from threats whether they are infectious threats, intentionally created, or nationally occurring in it country or anywhere else in the world. we do see a press as a vital partner in providing information and shedding light on the important health challenges that we face. thank you all so much. [ applause ] thank you all for coming today. i'd also like to thank you national press club staff including the journalism institute and the broadcast center for helping to organize today's event. here is a reminder that you can mind more information about the national press club on our

website. if you'd like to get a copy of today's program please check out our website at press.org. thank you. we aredjourned. [ applause ] >> the former head of proctor and gamble, robert mcdonald was before the senate veterans affairs committee thursday for his confirmation to head the va. you can see that in its entirety at cspan.org. he was asked why he wanted the job. >> in a sense i think you have answered my first question but i'm going to ask it again. you don't need thi