really need to make here in the west and threaten them saying that sanctions do not only apply if you breach with your contractual obligations in the nuclear gothss. there is also something called human rights and do not forget, the u.s. government and the u.s. president has on many, many occasions made direct addresses to the iranian public. how do you think the iranian public would feel this they are totally abandoned by washington and washington only cares when it comes to nuclear issue? this is a very, very important message that washington needs to send to the iranian government and to the iranian public. >> i would say the supporting dissidents is not just a moral issue, it's a strategic issue as well. there can be no peace between countries until there is peace inside of countries and how a government treats its own people is a direct reflection of how a government will treat its neighbors. it's a little silly to think that a government like iran when it's brutalizing and torturing

and jailing dissidents and bloggers and journalists will turn to its historic enemies and treat them with magnanimity. it's a silly contention. but that said, i think the way that the issue was used in the soviet context was that it was a tool to help bring about the end of the soviet union, not merely to contain the soviet union, but to end the soviet union and so, too, it can be used in the iranian context. when you look at the boldness of someone like senator jackson who confronted the soviet union and directly linked most favored nation status to improvements in human rights and free immigration, that was a tool which drove the soviets absolutely crazy, and if you read the memoirs of any of these guys, you see when carter and reagan would bring up the names of dissidents, they really, really hated it, and i think that's one sign that it's the right approach. i think that human rights is actually a real achilles' heel of the iranian regime because they are dependent upon external actors to some degree.

their economy is being hit hard, and i think if we understand this human rights issue not just as the right thing to do morally but opening up this closed society is absolutely critical to the peace and stability of the region, we'll begin to utilize it as a tool in the war against theocracy and dictatorship which is exactly what it is. >> do you want to add to that? >> well, yeah. i've been writing this for 30 years or something, that there is a real identity. i think david put it exactly right. this is an identity between moral imperatives and strategic comparatives. it's rare that you find such a perfect fit of one to the other, and the degree to which the myth of rouhani has been created along the same lines as the myth

of gorbachev is a real throwback for me because i remember back in those days as one soviet dictator after another emerged, they always had their loveable human aspects. they liked jazz. they were yes, they had been head of the kgb but they liked dixieland music so there's a kind of human element to them and so on. i mean, rouhani is a man of the system. he's a pure product of the system. he came of age in it. he worked in it all his life. he's always been a loyal servant of the system itself, and now here he is at the top, and people don't talk much about what he's really all about and what he really wants. why does he take all these different positions? because the maybe game that's being played inside iran right now among the various factions

who are contending among one another is who is going to succeed khomeini? khomeini is believed to be sick. i mean, he should have died long since if he was anywhere near as sick as the stories say he is. but anyway people think he's sick and no one would be surprised, let's put it this way, quietly, carefully, no one would be surprised if he dropped dead. all these characters, they're all maneuvering for the succession. it's what i have called the war of the succession. they're all trying to make sure. rouhani is basically acquiring support everywhere. if you're acquiring support everywhere, that means each individual faction has greater autonomy and has a greater run at its own enemies and so that is why in part, i mean,

rouhani's government is setting records for executions, tortures, censorships, so on and so forth. incomparable than ahmadinejad who was the stereotype of the nasty, vicious hardliner and rouhani who is the stereotype of the angel child mullah is objectively by any measure worse, much worse. so this tells us among other things that there are these fractures inside. i want to make one point about what we know and what we don't know, cliff, since you started with that, about the known unknowns. and in iran there are a lot of known unknowns, and if you just look at our history in anticipating internal develops inside the country, look at the big uprising of 2009 which was bigger than the uprising that

overthrew the shah in 1979. more people in the streets, covered larger parts of the country and so forth and so on. i think it's safe to say that no one inside government saw that coming. no one in serious position either to make policy or affect policy. they were amazed because up until then the conventional wisdom had been there is no opposition of any standing or significance inside iran and even if it existed, they don't have leaders that people are going to follow and so forth. it doesn't matter, just forget about it. there isn't going to be insurrection inside iran. then there was this big insurrection and people said, well, of course, it was there, we knew it was there, it was there all along. you could see it and plblah, bl, blah. and then they added it's irresistible. if you read the press of 2009,

june and onwards, you will see the intelligence committee and the policymaking committee, they were saying we don't have to do anything because these people are irresistible. look at them all. they're going to win. it's a precursor of the assad is going to fall, no, assad is going to win, no, assad is going to fall, no assad is going to win types of conventional wiss doms. so bottom line, we don't know. we didn't know in 2009, and we don't know today. what we do know is that the regime acts as if there was something serious to be afraid of. we can say that. that bespeaks a regime which doesn't think it has control and which is worried, plus whenever more than three people gather on a street corner in any major city in the country, they're

either arrested or broken up or beaten or sent home or whatever. anyway. >> i'm going to ask a couple more questions but if you want to ask a question, just signal me and i will get to you. michael, you talk about record numbers of executions, incarcerations. i guarantee you most people don't know that. most people think that we're in a period post-ahmadinejad of reform and moderation. if you simply read the media as i suggested earlier, i think you would get that impression. maybe if you come to think tanks like fdd you would have a different understanding. does that not suggest, let me start with ali on this, that the regime is doing very well with public relations and perhaps that the media are not doing their job in terms of covering the reality of iran and they're not acknowledging that? >> absolutely. i think that, you know, it's very clear, you know, if you compare mr. rouhani to his predecessor, mr. ahmadinejad, mr. rouhani is a sophisticated

man. he speaks like a lawyer. he's a trained lawyer. mr. ahmadinejad was an engineer but spoke like a truck driver. mr. rouhani is dressed in silk robes. mr. ahmadinejad used to wear a $20 jacket just to seem like a man of the people at the same time that his friends in cabinet were stealing wealth of iran. $22 billion are unaccounted for. these are some of the findings of this government. mr. ahmadinejad managed to isolate iran diplomatically. mr. rouhani, they are in reality bringing iran out of diplomatic isolation. so, yes, they are succeeding and the western media is not paying attention they should. they should to begin with start reading what mr. rouhani has said all over the years. back in 1999 iran, you know, the islamic republic, experienced its most serious political

unrest. that was the tehran university unrest which spread to the entire country. which politician do you think it was who went to the public and supported the revolutionary guards and the police suppression of the students' movement? it was mr. rouhani. mr. rouhani who systematically called the iranian students foreign agents. this was mr. rouhani. it was mr. rouhani who as chairman of the supreme council was banning newspapers and now people are expecting that mr. rouhani of all the people is going to allow freedom of the press? why? why? this is what i believe is the mistake of the western press, that they do not pay attention. they do not take a look at the history of those individuals, and, therefore, they have expectations which is totally immature. some younger people in tehran have this kind of expectations.

this is why they voted for mr. rouhani. but, you know, you cannot blame them. they are young and they are naive. here in washington people are not so young but naive. this is one of the complaints that i have when it comes to u.s. government view of the rouhani cabinet. >> yeah, david? >> i think the regime has succeeded in making 98% of the discourse on the nuclear issue and convinced most of the west that the only issue that's worthy of discussion is how to prevent iran from getting nuclear weapons. with purely conventional arms hundreds of millions of people have been killed in the last 150 years. 200,000 people slaughtered in syria. 800,000 in rwanda in 100 days. tebs of millions in world war ii purely with nonnuclear weapons. i think we need to dramatically and unequivocally restore the focus to the human rights question. when his wife was touring the state diplomat one time in the

'80s she would tell a story there was a huge map on the wall and one of the senior state department officials said with all due respect, you don't really expect us to relegate your husband's release to all of these important geostrategic challenges and she said what you don't understand is those issues won't be resolved until my husband is released. i think we're aware of the information. there are lists of hundreds and even thousands of political prisoners, but many people don't get the link between internal freedom and external peace, and just real quick about the issue of the letters to baghdadi. i think emboldening dissidents and speaking up for human rights also encouraging those movements inside of iran. there's nothing more fearful for a dissident than feeling alone and isolated and not cared about by the rest of the world but we can do an enormous amount to increase the strength of dissident movements inside of authoritarian countries simply by speaking out and supporting them and this gives them the

impetus to rise up against those who throw them in prison. i think that's another issue which the west doesn't understand and i completely agree also with michael about missing what has become conventional wisdom of even the arab spripgs. it's pretty fantastic to look back at the predictions of supposedly smart people in 2009 "newsweek" said the best thing for syria was a wise and charismatic leader named assad and in 2010 john kerry said he was a partner for peace, prosperity, and stability. in 2011, you know, the israeli newspaper said syria was an island of stability. and the economist said about ben ali that his regime was far from over shortly before he fell. and you look at p.j. crowley and the ambassador talking about egypt as a rock of stability and an island of stability and secretary clinton's famous remark on january 25th that our assessment is that the egyptian government is stable. all of these were falsehoods and just dangerously wrong in no

small part because they weren't listening to the dissident movements and they missed the fact that the amount of double thinkers is always bigger than we think and the amount of true believers is typically lower than we think in authoritarian countries and dictatorships. >> the only thing i would push you on a little bit, and i may be misunderstanding. yes, greater emphasis on human rights is called for, but that shouldn't mean less emphasis on the nuclear issue. if this regime should get nuclear weapons, the amount of repreparation and carnage we could see under that nuclear umbrella for the remainder of this century would make what's going on now seem very small. >> no question it would be an infinitely large danger but i think the unfortunate corollary is people underestimate the danger of the regime staying in power and supporting terror throughout the world and funding terrorism and brutally repressing 80 million people for decades. that's an untenable and

unforgivable situation which we need to work faster as you might say to undo. >> we have some questions, again introduce yourself and speak into the microphone if you would. thu. >> i'm mary ann we run an e learning insuit for iranian civil society. my question or comment is about michael ledeen's point that in 2009 american intelligence or policymakers were saying things like these guys are going to win. we really don't need to do much of anything. i question that because president obama in one of the very few things he said when people on the street were chanting for him to do something, say something, the slogan was barack hossein obama, you're either with them, the regime, or you're with us. when he did respond he said, you know, we really don't care if

mousavi begins or ahmadinejad wins, it doesn't make a difference to us. he had taken office and he reportedly had sent a couple letter to ha may ni. if anything i think it was that the green movement was inconvenient and was a wrench in the works of what the incoming admissied administration that yy could achieve with khamenei. a lot of iranians feel a big sense of betrayal from america because of that. i wanted to voice it here. >> i think it's a good point. >> i think everything is true. i agree with everything you said, and, of course, iranians feel betrayed. they were betrayed. they're right to feel betrayed. at the same time the consensus of punditry at that time was that this is a huge thing, the uprising, the june uprising and

it continued and it went on and on and they said they're going to win. so it's not easy to be wrong systematically wrong about everything from beginning to end, but we're trying, and actually in that case we did pretty well. >> this is part of the discussion. it raises a point i'd like to tease out if i could. getting back to what you said about strategic clarity versus moral clarity. there's a view on i would say both on the realist right and the multicultural left that moral clarity is an impediment to strategic clarity. that once we start, and this was a piece that came out on friday in "the new york times" in an op-ed. i'm going to be write being it in my column this week, that if we talk about what's going on including the islamic state in moral terms, in the language of good and evil, we get away from

the possibility of good strategic thinking. i would argue it's just the opposite, that moral clarity is necessary for strategic clarity, but that also means the following. when you're deciding whether to, for example, support the green movement in 2009, when you're deciding three years ago whether to support the nationalists in syria, the equation becomes, well, what can we do? are they just pharmacists who would be given guns and couldn't accomplish very much? the question is being asked right now should we be supporting what's left of the nationalists sort of more or less secular movement in syria or should we not? and that gets to a question of whether we have a moral obligation to support those people who are fighting for values we hold dear even if they may lose as i think was the case we thought in the soviet union years ago or whether we support them only if they've got a good chance to win only if it's clearly utilitarian? do you understand what i'm getting at? >> absolutely. it was said in the end the moral

choice turns out to be the pragmatic choice, too. that op-ed in "the new york times" was outrageous. the dissidents in the soviet union said the single happiest day he had in prison was when the american president called the soviet union evil. finally someone had the audacity to speak the blinding truth about that incredible evil. so, no, i think that too many times today -- what it boils down to is a loss of confidence in our own values and civilization and value. it's not a one to one. there are many differences obviously, but american policymakers like scoop jackson stood up to a num lclear super power which spanned 11 time zones and took on the realists like kissinger who said don't bother with this human rights nonsense. we're trying to contain the soviet union which could start a

nuclear holocaust. you compare that to a iran which doesn't have a fraction of a fraction of the soviet union. people are afraid to confront iran on the human rights issue. when they work out a deal, human rights are not even on the table. that's outrageous on both moral and security and strategic grounds. >> let's go to dana here and then back on the other side. >> dana marshall. thank you, cliff, for organizing this. the question is really more of a challenge to this audience. i think of myself as both sort of a moral view of this and i'm very moved by what you're say being not forgetting the human rights aspect but there's a part of me that really wants to challenge you, what do we do about this? the west has been deploying for decades some pretty severe sanctions towards the islamic republic that -- we can talk a lot about this, but it's had the

affect it seems of starting a negotiation, again good or bad, let's leave that to the side, but it took that. so my question is for those of us who cannot have a colloquy with the foreign minister of iran and for those of us who think a letter or two, how effective is this, let me challenge you what do we need to do? how much do we put on the table? how much do we really put -- i mean, honestly, not just saying, oh, you know, let's put this as the last talking point, but, you know, what do we really pay to move this agenda forward and how likely is it that we will be joined by those areas which are even closer to have more leverage on the islamic republic such as europe? >> well, look at reagan and the soviet empire, and i think you can answer your question just from historical events. when reagan started speaking out

against the soviet empire and saying that its day in history was finished, people yelled and screamed at him, said he was dangerous. when jackson vanek was up for grabs, you cannot imagine how much leaders of various important communities inside the united states came to people who were advocating it and saying don't put the soviet union with its back against the wall. you'll make things worse. things will get worse. exactly the things that people like david hear every day when they speak out against what's going on inside iran, and yet as we now know from all the dissidents, speaking out made life better. support for dissident groups inside the soviet empire eventually was a crucial part in the -- in bringing down the whole soviet system. if we could bring down the soviet empire, how can anybody

doubt that we could bring down this hollow, corrupt regime in tehran? it doesn't begin to compare. and yet whenever we have this discussion, people always talk as if here is, you know, it's big, it's powerful, it's massive, they're brilliant whereas they make mistakes all the time. can i just make one quiet point about iran. keep it in mind. iran on paper should be one of the most successful countries on earth. they have everything. when we sit down and draw up a checklist of what does it take to be a successful, flourishing, booming, democratic country, iran has it all. even an educated middle class, even women with some sort of significant role in society and so on. they've got it all. now go into the streets of the major cities and what do you see? a basket case. record numbers of suicides, drug

addiction, prostitution, you name it. all those indicators of social malaise and failure. the country -- these people brilliant as we invariably think of them have wrecked a country which was very hard to wreck, very hard. it's sort of like venezuela in that regard. venezuela -- when -- in my journalist days a german magazine sent me to venezuela and everybody i talked to said god is venezuela ynvenezuelan. you can't wreck this place. food drops out of the sky. pine trees grow twice as fast, et cetera. so iran is one of these countries where it really takes a lot of work to wreck it. they've wrecked it. >> you know -- >> so support the opposition. what are we waiting for, right? as it was right to support these

others, it's right to support mousavi and all the rest of them. it's morally right. it's strategically right, and it will probably work. no one -- everyone is afraid of them. everybody thinks it's crackpot and crazy. and yet its track record historically is pretty good after all. ask robespierre. sometimes it works. >> i'm happy we have dr. ledeen here. there is a certain generation in american foreign policy making community which has experienced the cold war. they know how the system works and one of the things that some younger people in government have forgotten is the helsinki process. a process which began as an arms agreement and then it proliferated to also encompass human rights issues. the helsinki process helped intellectuals and political dissidents in the soviet union.

most unfortunately, those brilliant people who are in government right now in the united states did not think of a similar model for the nuclear negotiations with the islamic republic of iran, maybe because it was not a priority, maybe because they had no recollection of how things were done in the cold war period. and that, of course, is very, very unfortunate. i totally agree with dr. ledeen. just look at iranians. iranians are successful in every place in the world except inside iran. and this tells you something about the system which is called the islamic republic. >> i would say briefly there's something that you can do on a personal level and then on the more diplomatic and national level. a few weeks ago my organization advancing human rights relaunched movements.org which links dissidents from dictatorships to people around the world with skills to help them. it's like craigslist for human rights. thousands of dissidents from 92 countries just in the first few weeks have come onto the site asking for something.

some need legal help, some needp r help, some need policy help, some of them want a song written about a dissident in prison. whatever your skill is today you can go to movements.org and find somebody from syria, saudi arabia, russia, china, it's only open to large dictatorship and you can had ep. we have had songs and lawyers connecting with syrian refugees and so on and so forth. the next thing is i think we need to revive the spirit of rabble rousing. i came up with this idea to rename the street in front of the chinese embassy. a bunch of members of congress signed on. drove the chinese government crazy. a bunch of official denunciations and it got in their face. and so the house appropriations committee voted to change the street name in front of the chinese embassy for their imprisoned nobel prize winner. and i think these sorts of initiatives -- i have now

launched another. the fact the foreign minister can claim ignorance about a political prisoner, we can undo that. why is every street in front of every iranian embassy not named for a political prisoner? it's a small step but i think it had some effect on the soviet union and the press covered it massively. it was in every major western newspaper. so suddenly the chinese were put on the defensive and they had to answer once again for this, you know, outrageous violation of human rights. and then on the national level, i think just traditional things like raising the names of these political prisoners in meetings. when you do go negotiate in geneva or vienna, you can't say, well, we'll get to human rights later. that's been true not just of iran but all tlaut. when the president went to saudi arabia, several officials said we're going to raise human rights and then they ran out of time when they went to this theocratic dictatorship. so number one is raise the names.

one man said the fact he was on the cover of the economist saved his life. at first the judge said with this picture you signed your own death warrant. after ten years in prison, he said this picture saved my life. and then linking any improvements in any -- any improvement in the iranian economy to improvement in human rights is a lever that's underappreciated. >> let's go back to the north a little bit. >> i wanted to talk a little bit more about the green movement. i'm a believer that the green movement is not dead and iranians are very smart like boxers, just waiting for the right opportunity to come again to get out into the streets when they feel it's appropriate. but my question is what can the west or the u.s. do this time around when the opportunity comes because i'm 100% sure it will come again. it's just a matter of time. what should they do this time around to support the people? what specific things can they

do? >> so one of the things that the islamic republic cannot control is spontaneous uprisings. they can infiltrate any political organization. they can infiltrate even the smallest cell. the intelligence services have learned all their tricks of spy craft from the kgb, from the shah's secret service. they know what they're doing. they are very good at this but they cannot predict and they cannot control and contain when massive uprisings spontaneously break out. however, massive uprising is in need of communication. amongst those who participate in the uprising but there is also a need for further mobilization of the public for a specific cause. there you need public broadcast systems. the islamic republic television is one of those highly censored

institutions, of course, because it has strategic value for the regime and most foreign broadcasters to iran, they are extremely cautious, extremely cautious in their coverage of the green revolution. so one of the things that could be done and should be done is to provide not only support from the media only when things happen but also prior to it. we do not have a single media, not even voice of america which is trying its best is not providing opportunities for iranians to have political debates, to question authorities within the system. there is no forum for debate and it is something that the regime itself is also trying to prevent very actively. there are a number of other countries all broadcasting to iran, none of them would be willing to provide those kind of services. so i think there's a lot which can be done when it comes to the media. and then we also need to look at ourselves i think.

one of the reasons why the green revolution was defeated, of course, was because of the divide between the leaders of the movement and the followers. chairman mao, and we do not usually quote him at the fdd, but he used to say husband and wife may share a bed. they may share -- sleep in the same bed but they do not necessarily dream the same dreams. that was also the problem between leaders of the green movement and followers of the green movement. leaders of the green movement wanted to reform the system. followers of the green movement wanted to get rid of the system altogether. and that was the big issue. in egypt one of the reasons why the mubarak regime collapsed was because the leaders of the opposition movement said we are going to stay on tahrir square until mubarak steps down. in the green movement the leaders actively urged their own supporters to go home so they could sit and negotiate with mr. cat main ni in the dark of the

night. as soon as the people went home the leaders of the opposition movement had nothing to negotiate with and they became themselves captives of the regime. so i think from the u.s. side and those who are interested in a better development in iran, media and communication. when it comes to us iranians, we really, really need to think hard if this regime is capable of reforming itself. i think that's a valid question to ask and it's something that we need to discuss. >> the main thing is that the leaders of the united states have to stand up and embrace these things. had reagan failed to embrace the dissident movement, it would not have become what it became, and since we now have an administration who does not seem at all interested in ep dorsing, supporting, embracing an anti-regime movement in iran, quite the contrary, all the evidence that i see is that this

administration wants to work very closely with iran and coordinate with iran and have a big deal with iran and so on. as long as that continues, no iranian is going to risk his or her life to bring down this regime hoping or anticipating or expecting that they'll get -- he or she will get american support. that support has to be explicit, outspoken, and continuous, and it has to come from all the top diplomatic and political leaders from the administration starting with the white house. >> let's take a question here. >> director of the iran service based in prague. i would just bring a small position to what mr. alfoneh said about the media out of iran, particularly persian speaking media, we provide such

opportunity to its listeners inside and outside iran for debate and for question and for exchanging ideas. thank you. >> and i thank you. it's a great job which is being done and i think it follows the tradition of providing radio broadcasts to eastern europe. iran is facing similar problem and i think that, you know, a great job is being done in prague. thank you for your service. thank you. >> i'm a consultant to apec. i know this is not the main focus of this particular meeting, but i would very much appreciate hearing from the members of the panel what you think will happen with nuclear talks. >> with nuclear what? >> nuclear talks. >> this thing with the talks, ali, why don't you begin on that? >> unlike many people in

washington, i am not so much concerned that here you have somebody who just lies, you know, who is just deceptive, who just makes promises that this person is not ready to keep. i actually think that there are three different approaches in iran when it comes to nuclear issue. all of them strategically agree that, you know, that the nuclear bomb is desirable. mr. rouhani believes that and his cabinet. that group, they believe that. the supreme leader share this is belief. however, each group has a different approach. they employ different tactics to achieve the strategic goal. mr. rouhani's goal is it to achieve it in the longer term. they believe right now iran is on the verge of bankruptcy. sanction relief is urgently needed in order to keep the system afloat. on the other hand, we have the revolutionary guards. the revolutionary guards wants to get the bomb as fast as

possible and they believe fundamentally that it would end like pakistan's nuclear bomb. iran would be forgiven and sanctions would be removed, exactly because iran at that point would be a nuclear armed state, and no one would like to see an economically bankrupt nuclear power. so that is the argument that the revolutionary guards is making. mr. khomeini is oscillating between the two power centers. every second day he extends support to the line of mr. rouhani, the second day he supports the line of the revolutionary guards and says he does not believe in a positive outcome of the nuclear negotiations which is because i believe he understands the rouhani argument that right now iran needs to give concessions in order to get sanction relief, but on the other hand mr. khomeini cannot afford to lose the revolutionary guards because next time 3 million people like in 2009, he needs the support of

the revolutionary guards in order to suppress the public, the dissidents. so this is why we see him oscillating. the difference between these three groups is not so much strategic but tactical. how to achieve it. and, therefore, i believe that as soon as the worst sanctions are removed, as soon as iran's economy has stabilized, then we will see tendencies where mr. khamenei is backing the line of the revolutionary guards. so iran would walk away from the table, would not live up to its obligations, and things would change. these are some of the expectations that i have right now. which is very pessimistic. >> i'm going to say just a word on this even though it's out of my role as a moderator because i'm friendly with the study of this that's being done by a number of people here at fdd. i think that one of the things we have to worry about at this point in the negotiations is that rouhani will -- well, two

things. one is that rouhani will pretend to have made significant concessions and the obama administration will pretend to believe him. and one way this might happen is through what's being talked about by some as the sunset provisio provisions. the idea you would say you will not have a nuclear capability during the life of this administration but the next administration is not going to be our problem. one hopes that those who are thinking about running for office in 2016 are well aware of this. the sunset provisions would essentially tie -- correct me if you think i'm wrong -- would tie iran's hands or at least make the breakout period reasonably long, i mean no more than a year, but only for the next few years, and at that point everything comes off, there would be no more restrictions on iran than there are on japan.

that seems like a plausible and distressing narrative that we could see unfold as early as this november where this agreement that holds us off for this administration is spun as a good deal, a deal we should all applaud, and, in fact, we're just opening. the one thing that might stop it and i think ali has made mention of this, is the iran revolutionary guard corps who is in a rush and probably supreme leader khamenei who as michael said is not young and is not healthy. he may have a different time frame. he may think i don't want to wait. i want this now and i don't see any reason why we can't have it. i just throw that out for your discussion or the discussion of the panel if you think i'm wrong, please say so. we're happy to disagree in this forum. >> just bring down the regime and then you don't have to worry about these details. >> next question?

yes, go ahead. >> it may very well be that what's being played in iran is simply good cop/bad cop but the goal is exactly the same. and this administration and many other western administrations play along whether it's for the reasons that let's just kick the can down the road a little bit and then we don't have to worry about it or we are not going to change anything anyway. one of those two things are going to play, but the goal is the same. the iranians are moving forward with the nuclear -- with a nuclear plan. in fact, i think they're even holding it back just for strategic reasons but they're a lot further ahead than what you think. that's the problem with that.

my question though is on this side we have the useful idiots. we have the people who really want to see america being reduced and having less influence in the world but the press is a much more amorphous kind of a thing, and they have been playing along all along with this game. what will wake the press up? this is i think our only way out of it from the point of view of what we can do. you know, the government is whatever the government is, but we as organizations, individuals, the only anger from my point of view is somehow the press has to be involved. what would that be? >> well, the first thing is to be realistic about what a journalist can or cannot do inside a totalitarian regime and

survive. years ago i went to granada on the first anniversary of the american invasion of granada and i went with a tv news crew, and the correspondent, we were walking in the hills outside a big city in granada and you came across some man and they obviously knew each other and they embraced and he said so good to see you, how are things? and the local person said, great, now they're not going to torture me anymore and the correspondent said what do you mean torture? and you could see the scars on his back, and the correspondent said, well, how long have we known each other, five years, ten years, i have been talking to you, you never mentioned this. why did you never mention it? and the guy looked at him like he was a mad man, right?

and you cannot expect that journalists inside countries where people are routinely tortured, killed, locked away and so forth are going to have reliable sources who are going to tell them the truth about what's really going on in that country. it can't happen. [ inaudible ]. >> it is this country that is completely sold on the way things are and they have to be changed. >> but that takes us to an even bigger problem which is the educational system which is we have -- i mean, when you look at the people talking about the world right now, your heart sinks, right? because they don't know anything about anything. and the words they use to talk about the world show you that they don't know, and they don't know because they have been dumbed down by an educational system which doesn't -- which only teaches them certain kinds

of doctrine rather than information so that they can think through by themselves and arrive at their own conclusions. i mean, when the candidate for president of the united states talks about 57 states and you say, well, ha ha, that was just a slip of the tongue. and then you go on to all the other things that that same person has said over the last six-plus years, and it's just astonishing. and it becomes the characteristics of a whole generation. excuse me if i vent on this. when i was in the white house, when a draft of reagan's speech started to circulate all of us eagerly jumped on it. first because if you get input into a presidential speech, that's policy. that's what policy is, a presidential speech. and secondly, we didn't want him saying some stupid, ignorant, misguided thing. obama, never mind policy, obama

says so many wrong things, false facts as my kids used to say, gets so many things wrong about the world just as a matter of simple respect, people are obviously not doing that for him. that's not happening. and there are two possible reasons for it not happening. one is he's made it clear he doesn't want it to happen. he's going to write his own damn speech and if you don't like it, shut up or get yourself elected. and the second is they don't know. so they don't know that when the president goes to cairo and says muslims brought printing to the middle east, that it's three times wrong. not just wrong, but wrong -- trebly wrong. the chinese brought it. they sold it to the middle east and they didn't want it and then portuguese jews brought it to egypt. the first printing press was

1492 when portuguese jews brought it to cairo. totally wrong. wrong, wrong, and then wrong. so when you ask the question, here we have these journalists who talk about the world in ways that alarm you and alarm me obviously, if you want to fix that, you're going to have to fix the schools, and that's a really big undertaking. >> bring a microphone so we can hear it. a quick follow-up and comment. >> [ inaudible ] but the press is a distribution of people. there are some very -- they talk to a lot of people but there are some who know and choose not to call whether it's a president or the policy or any of those things, and somehow that is a part of the press that has to be

influenced. the ones who know and are quiet and that's a question of really -- i don't know if you can resolve it but that's what i was trying to get at. >> briefly, there's so much information that's out there already. i mean, every minute there's a new youtube video of a slaughter in syria by assad's forces. we cece saar, this guy who came with the hood and showed tens of thousands of photographs of people starved and tortured and killed and it doesn't move policy seemingly. for a lot of reasons, fatigue, isis is worse and so on and so forth. so i think it requires -- we all write op-eds frequently and i'm often frustrated at the little impact an op-ed has, even in "the new york times." it's gone often the next day or a few hours and people forget about it. it requires a whole new way of thinking about how to use information to push it and to

impact people who can make policy decisions but i'm not sure that it's just, you know, we need a bunch more journalists covering good thing because even when we do know we often fail to act and that's a spiritual and a moral failure more than a lack of information, and it's, i guess, a much tougher thing to, you know, broach. >> i would just say -- one thing, and that is it's in a way worse because anyone who you hear on npr saying i have been to iran 12 times in the last 5 years, you know that means they have not done anything to seriously offend the regime in all those times, and, therefore, as brave as they may be, you have to take with a grain of salt what they're saying. nobody at this table can say i want to find out for real what's going on, i'm going to apply for a visa, get some notebooks and go to tehran and fill them up and find out what's going on. journalism is in a crisis today, a total crisis today in terms of what can be reported, what can

be said, and it's also coincided with the crisis in that there's no business model for journalism really anymore and this is really a subject for another panel or many more panels but it's very -- there's there is really a lot of noise and very little signal. >> an ambassador in vienna, the atomic agency and more. i know what the game is. the negotiations. but i believe the corner stone of democratic states are free and fair elections. without that we are not going to solve anything. going to have an atomic bomb or not. that's a tactical issue. you have pakistan, industry yarks china, russia who has it.

what's going to happen with the regime. how realistic is it that we have free and fair elections. that freed up the democratic government. then you can sit and negotiate. democracies don't go to war against each other. >> thank you. your country has gone through very, very harsh historical times. just like ours. arguably you experienced greater harshness in many ways. most unfortunately many of the intellectuals in my country draw the wrong lessons from what happened in central and eastern europe.

many still live in the world of utopia. those who are in power now believe in an establishment and continuation of an iz almostist ideological regime and power. some parts are deceiving themselves. there could be a calmness, utopia at the end of the rainbow where they can find peace and prosperity. this is very, very unfortunate and eyde lonl call experiences in your part of the world show us that this is certainly not the path iran should follow. concerning the helsinki process and how realistic it is, i think some parts would be imposed. takes spread of democracy. propagation as a model. tied to the negotiations. this is not the case. this is one of the issues that we really need to talk even more

with obama about. we need to make leaders in iran and understand that a democratic transition, a slow democratic transition would be in their own interests. because a violent turnover of the regime and assistant would be worse for the system, for the country and for the current ruling elites. we are witnessing a gradual maturity. large parts of the opposition. particularly in the united states. even those who are victims of the regime's abuse of human rights. former political prisoners. those who lost family members, they don't want revenge. we want justice. justice is different. there are those who genuinely are talking about south africa. those who say to keep all the

money you have stolen. keep it. open it up. pressure. from the domestic opposition says justice for us is more important than revenge. we career more about the brighter future than about correcting the injustice of the past and external pressure. also pay attention to the plight of the iranian public that i feel would be a combination. we certainly do need to learn from your experience, mr. ambassador. >> i want to follow up with david. the agreement with regard to human rights isn't widely shared now this the sense that the obama administration has not made human rights a priority. rand paul, a leading priority doesn't think human rights internationally should be a priority.

the u.n. human rights council has become a forum for human rights violators. that's accepted by most of the world. major transnational organizations. also selective about rights. your organization came into being. this is a challenging time to make the case for you. the arab spring has not become -- we have not seen human rights flowering from the soil as some hoped. this is a particularly challenging time to promote human rights as a moral -- with moral claritier or as a strategic imperative. >> no doubt. you have the heart of the challenge they face every day on capitol hill and in the state department. it's too frequent to hear. you blab on about the democracy stuff. better c.c. than the brotherhood. better eassad than isis. you go down the list.

better king abdullah than what's waiting in the wings. i think people in policy-making circles, even amongst the general public don't understand what tyranny does to increase radicalism. they don't ask where the strength came from. in no small parts, 30 years of corrupt and brutal dictatorship which decimated any political discourse which wrecked the economy. that helped give rise to the muslim brotherhood. isis in syria is in no small part a consequence of the brutal dictatorship for the last decade and a half and western inaction to stop it. the quicker we understand that opening these societies is absolutely critical to the fight against islamic radicalism, the sooner we'll act on the human rights issue as well.

that's not to negate the importance of simultaneously combatting liberalism in the middle east, fighting on all levels. the issues, when you poll egyptians, jordanians and ask if someone leaves islam and 80 to 90% say you must die that requires cultural, social re-education. that's in no small part coming from within the societies. identifying true moderates, not fake moderates. supporting dissidents, liberals and moderates is crucial to our own safety. until that link is recognized we'll keep the vicious cycle alive where the west supports a brutal dictator who represses his own people. the only part is your mosque where you rant against the jews and the protocols on every street corner.

radicalismfesters and grows. then instability increases. i think we are repeating the same mistakes of the past. read the case for democracy. it's in there. >> the other thing is modesty. as we judge our own ability to see what's coming next and forecast what's happening and what david said about the brotherhood reminded me of that one. i don't know anything about the brotherhood. i don't do those countries, but in any case when they came to power, i asked all the experts on the brotherhood, okay, what's happening now? what should we expect? almost all of them said this is it. they are in for x generations -- two, three, four -- because they have been preparing for this for 80 years. they're ready. they are organized.

well, as we know, they failed in two, three, four months, something like that. i mean they failed almost at once. these were the great experts who told us that brothers were going to rule generation after generation. we are not very good at figuring out what's going to happen next. it's not easy. the experts on the brothers had the advantage of knowing at least what the brothers wanted and intended which is a big part of good intelligence. but for heaven sake don't think that anyone has a reliable crystal ball or even a good magnifying glass. you have to keep fighting. you have to keep at it. that's why policies of the sort we are talking about here which combine moral and strategic

wisdom are so valuable, so important. it's discouraging to me as we get national leaders who don't appreciate that, who run from it in the name of false realism which is based on this conceit that we can see the future when we can't. >> to give you a precise example, ask yourself. people say, there are no liberals in egypt or saudi arabia. ask yourself a question. where might liberals be if they had been the recipients of tens offal billions of support going back decades. rather than funding these tyrants imagine if a fraction of the support went to dissidents. small in number as they may be, it would help them grow. help the ideas spread faster. mubarak got over $50 billion in military aid and we got

instability, coup, muslim brotherhood. another $10 billion would not have kept him in place. the same is true for saudi arabia. the president spent $60 billion in arms to a country which kills you if you bring in a krorksz bible. what message does it send? does it strengthen lig ralism, give hope to democratic dissidents or cut out the rug from under them and simultaneously keep in power the dictators which help foster instability in society. >> we have another question. take the microphone. >> we were talking earlier about the spiritual and moral failures that we can't control here about the media in particular. one thing nobody wants to hear about is we have a spiritual, moral failure.

sometimes it's real. sometimes it's manipulated. all these people who had to leave the country because of a lack of freedom are now being sold this lie, this association that the best thing we could do for the homeland is to not support sanctions, not talk about human rights, political prisoners. that it's all a game. that it's meant to create war and bring suffering to the iranian people. when we talk about moral and spiritual failure we as iranian-americans aren't doing our part. i would wager more than half of iranian americans are falling prey to this propaganda that's being developed right here in america. >> i spent a week in london just meeting with iranian dissidents

and had the opposition. i would ask each one and say, i met with so and so. to a person they bad mouthed it. they said, he takes money from shady sources. he has no influence inside of iran. he's a joke. or number three he's connected to the regime. i was flabbergasted. only worked with dissidents in the middle east. it matters all of the undercutting, back stabbing and in-fighting. when they were fighting for jewish dissidents they got 250,000 people on the mall in washington. that made a difference in terms of political power and what people responded to. i'm just an outsider. i pretend to be iranian because i grew up in l.a. but it's difficult. >> you may want to address this. the iranian government is very

adept at causing fractures and splits among iranians outside the country. groups like nayak are the more unified voice. it ooh es not hard to cause suspicions among a community if you're clever about it. >> when i was in copenhagen, i finished university, spoke in public about politics. i would deliver a public lecture. never ask a question. no exchange. i'm just bored. i went over to him and said helloment very, very polite exchange of words. could you please tell me how many spies you have in denmark? he looked and said we don't need

spies. we don't have the capacity. there is truth in it o cf1 o unfortunately. it's part of our problem as an iranian community that we dislike each other and forgive the big enemy. that's a big issue. >> there is system attic when you organize a poetry reading. anyone in europe. somebody is going to stab you with a knife. of course if you and your wife, girlfriend or fiancee, you don't expect somebody to be stabbed by a knife. the mosque is also organizing a competing poetry reading at which there are body guards, armed people who are taking care of the situation and nobody get s stabbed. the regime is for cultural

activities for the iranian community. to even make things more spe "tju)urjz movements. it is the intelligence ministry itself controlling the opposition. these people have been reading well. that's one of our problems. as a community we have to be stronger. we have to forgive even if somebody we believe is working for the regime. that person our family member. it might be a distant family member. this is why we need to beat this regime. because we are better. >> i will ask everybody to spend one minute to sum up -- state if you can the one policy change or legislative initiative that would be most helpful in regard to the situation we have been

discussing today. do you want to start with that? >> tied to nuclear negotiations with the human rights issue in iran. that's the one policy negotiation i hope president obama and the administration coming after the administration is going to take up for consideration. >> does that mean unless you get agreement for concessions on the nuclear portfolio and the human rights portfolio sanctions will be increased and the pain will be greater for tñe regime and for the people. >> that's correct. unfortunately that's one of the side effects of sanctions. in the longer term the iranian public would benefit. >> just want to be specific on that. >> speaking out vociferously about human rights and making a oal ending the hts and making a regime, not keeping it in place with the nuclear weapons. even if it comes about it is profoundly dangerous, not just for iranians but for the world.

>> supporting dissidents and freedom movements inside iran. start at the top from the president on down. every spokesman for the american government and go to international meetings, whatever they may be about, whether it's olympic games, nuclear negotiations with lists of political prisoners and demand their release and keep at it. >> let me ask you all to thank our panel. and thank you all for coming. we'll be in touch for anq) session before long. thanks again. today live coverage of remarks by freshry secretary jack lew at the hamilton

project. he'll participate in a discussion about the economic effects of climate change on the eve of the climate summit in new york city which will be attended by president obama. live coverage of secretary lew's remarks at 4:00 p.m. eastern on c-span. at 5:00 live on c-span 2, a preview of the upcoming supreme court term that begins in october including the racial gerrymadonnaering of districts, and are religious liberals of next representatives from the public and private sector talk about how to make the health care system ft taster, cheaper and more efficient. hhs secretary sylvia burrwell, dr. francis collins and fda commissioner dr. margaret hamburg testified at a house hearing about the ongoing efforts in the medical community to improve and develop treatments and cures.

>> today, this morning we'll continue our efforts on the 21st century cures initiative with this round table to discuss ideas received this the last couple of months and look to more specifics about the steps we can take to accelerate the cycle of cures, embrace technology advances and th rise of personalized medicine and keep america the innovation capital of the world. there were round tables to hear about how american innovation is ndout how american innovation is creating jobs.

the initiative affects every american as they, their families and friends have been affected by disease. hard work continues for cures and treatments for 95% of diseases without cures. we have seen an outpouring of support inside and outside washington to work together and achieve this common goal. today we brought together truly another all star round table. joining us, we have sylvia burrwell, hhs. dr. francis collins, michael milkin of the institute. dean kayman of dk research and

development. mr. bill par fit from mpi research from michigan. and dr. dan tier derks scu from the colorado cancer center. we need to hear from participants as much as possible. i know my colleagues agree that the participants are the experts and this is an opportunity to learn. we want to keep our talking to a minimum. i want to keep the conversation moving knowing we have a hard stop at noon. we appreciate the thoughtful contributions of everyday americans. we expect a discussion draft in

january, 2015. we'll look to swiftly move the legislation early many the next congress so if you want your idea considered, send it to cures at mail.house.gov. so now i want to turn to my colleague, diana degette from the state of colorado. >> thank you very much, chairman.

thank you for convening this last round table. i want to welcome everybody here today. i see the chairman today, in whose shadow we toil. i'm glad he's here. i want to thank secretary burwell for coming. i know she has a very busy day and, of course, my homie, dr. theodorescu, thank you for coming all the way out here. as fred said, we've been working together to hold a big series of round tables and hearings on the 21st century cures initiative and have taken many white papers. we've had a lot of suggestions, but i think we will both agree that we have a lot of commonality in the themes that we're hearing and we're eager to sit down and actually start drafting legislation. the round table that we had in denver over the break, we talked about personalized medicine. and we had active engagement and interest from the audience. we heard from the nih, the fda. we've heard from local universities and health centers and private investors, industry and researchers and we really are beginning to hone in on some areas that we can think about how we streamline the process so that we can get from the lab to the clinic. and that's very important to all of us. one of the things we talked about, for example, was the potential time and cost savings of a central irb process, which

is something i have been working on for a long time. we also talked about the importance of sharing data and information among clinical registries. and these are just some of the topics that fall under this. today, what we're doing is we're looking for feedback from participants on what we've learned so far and where we could go. and i'm really happy to see so many members here. some of the common topics that we've seen are modernizing clinical trials, facilitating data sharing, insentivizing drug research, incorporating the patient perspective into the research and regulatory process and developing young, emerging scientists as well as making sure we have adequate and stable funding for biomedical research in this country. and so i'm looking forward to hear from our experts and our colleagues today about how we can make a positive difference.

i just want to echo your thanks for all of the members, all of the participants who have wozked so diligently on this. it just really shows that there's a need. i want to leave you with one thought. i went around my district in august and some of you might know, just as happens every two years, in election year, colorado's a purple state. so we have shock and awe of campaigning going on there right now. and every time i talk to somebody, democrat, republican or unaffiliated about 21st century cures, their eyes lit up. they were so excited about the prospect of bipartisan legislation, where we would actually be working together in congress to do something, but even more to do something big about how we can get those cures to the patients. i called a group last night. the big risk is it falls of its own weight. we can't let that happen. we have to work together to make it happen.

and so i just really appreciate this effort. thank you, mr. chairman. >> we'll start with secretary burwell. >> thank you, chairman upton and representi degette for convening this round table and having me here today. i am looking forward to working with all of you. while i'm sorry i won't be able to stay, dr. collins and dr. hamburg, two of our best at hhs will ably represent us. i wanted to become of what you both have said. the importance -- i'm here today because we want to be your partner in making something go forward. i'm a big believer that if we're going to deliver, in fact, we need to start by building those strong relationships. that means listening to the experts we have and listening together and being responsive as we work together for meaningful solutions. i first want to thank you, also,

for what you all did in terms of bringing everyone together but this committee has also done important work previously in this space with fda and our user fee legislation. these round tables are an excellent way to continue making some of the progress that we've already made. when we watch a loved one who is taken by alzheimer's or als, we all want the same things, the most effective treatments, the groundbreaking cures and the best medical care possible. and so we take at hhs that very seriously and we're committed to keeping us on that cutting edge of innovation, science and technology. and nih has supported most every significant advance of biomedical research in the last 50 years. from the human genome project and attempting right now to unlock those secrets of the most complex, mysterious things like the brain. and dr. collins and his team walk the line, i think, some days between science and science fiction in terms of whether it's robotic, exoskeletons, nanotechnology developments or

personalized medicine and what that can mean. this work isn't just improving our health care system. it's hopefully going to transform it. these advancements allow us to shift from keeping up with illnesses to getting ahead of illnesses and they empower patients to engage in their own health care like never before. and new biomedical science and technologies create high-paying jobs and strengthen our economy, another important part of what this work is about. in fact, we have estimates that say for every dollar of nih funding, it generates over a dollar in local economic growth. so, at a time when the world is vigorously forging ahead, we must protect our competitive edge and make sure that we are a global leader and not falling behind. with that said, we have a crucial equilibrium to maintain with the oversight that keeps us safe as a nation. dr. hamburg will be speaking to

those issues. fda is committed to reducing the length and soft of medical development. we've shortened the high-risk device review times by a third since 2009, also working to strengthen and improve the medical product process. we've expanding accelerated development pathways. with review times as short as 4 1/2 months. over the last years we've made great progress with support and we appreciate that. we also know there's a lot more to be done in that space and we want to focus on that as part of this conversation. we're committed to partnering with you while committed to maintain a safe and accurate product data and information for people. with that, we look forward to working with you all. this kind of session where a conversation can occur, i think, is an important part to moving forward. and the committee process, which

we want to engage in support. so, thank you for having me. >> i just want to say that you and i talked about this, literally, the first week you became secretary of hhs. and you indicated then you would be very supportive. we're delighted for your participation today and all the way down the line. so, we really appreciate you being here, knowing that you still have to leave a little bit early. but thank you. >> thank you. >> peggy, do you want to say something? >> sure. well, thank you so much for including me in this discussion and importantly for the leadership that chairman upton and congressman degette have brought to this 21st century cures and all of you on the committee. and it is true, as secretary burwell said, this committee has done great work to support science and the advance of biomedical product innovation and most recently with the passage of fadaz, i think we really accomplished something that's important and in a bipartisan way.

this goes to the heart of what matters to us at the fda. our mission is to deliver on the promise of science for the public, to do our part not just in assuring the most streamlined review times, but also in helping to support the most effective and efficient research and development pathways for promising new products, and to be able to provide information and oversight throughout the lifespan of a product, not justify in the development and review stage but also when it's in the marketplace, being used by people when we have the opportunity to learn more about what works and for whom and why. and, you know, we think that the discussion so far has been enormously productive. in the identification of some of the critical area that is congresswoman degette noted very

much align with our priorities and perceived needs. we want to work with all of you, to continue to reduce the length and cost of medical product development, to improve medical product review. of course, improving business processes and systems but also to bring new tools and perspectives to bear. more advance science and technology, patient perspectives and, of course, increasing the predictability and transparency and partnership in what we do. we think that there are a lot of lessons to be learned from the work that's been going on with accelerated development, including the breakthrough designation that we were able to move forward with, with the passage of fadazia. the more the fda engages with

stakeholders and more importantly with companies as they develop products to make sure that the right studies are done, we can reduce the time for research and development. we can certainly dramatically decrease the time for review. and, most importantly, we can give the american people the products that they want and need, recognizing that the ability to really advance biomedical product innovation is essential for the health of families but it's also vital to the health of our health care system and the health of our economy and the continuing preeminence of our great country in this important sector. so, i'm really delighted to be part of this and look forward to moving to the next stage of really translating all these good ideas into action. >> great. bill? >> thank you, fred. and i'm very pleased to be here. i'll take a few minutes to give my background. not too impressed. i'm humbled by how little i know but to share with you where i'm coming from as we have these discussions today.

i'm 67 years old. i'm proud of it. and for the last 50 years, i have been developing drugs. i worked at the up john company for 20 years. we do business for small bioteches, many of whom just have three months of cash flow and six employees. as we know today, they've been very effective and productive in bringing new products to the market. and i also served as chairman of stryker corporation, a device company located in our district. i'm humbled by what i don't know, but excited about what we can do here today as the legislation moves forward.

i hope during the two hours that we have here today, what i consider to be the critical success factors for our success going forward, talking about such things as a collaborative role between private sector, industry and government, including regulations that are required and can be a real companion to what we're doing, including the changing role of the patient. we have to have a changing role for the patient, including the consequences of risk, which are sometimes becoming so ownerous that risk takers don't want to step up to the plate with really innovative ideas and also looking at the role of government in terms of helping out some of these smaller biotech that is have great ideas but don't have the funding sources and finally making sure we can energize our young people to be rigorous scientists. we clearly are the best -- we have the best health care system in the world. we have the best ability to innovate in this world and we want to unleash, unshackle some of the impediments that, over time, have allowed us to be the best we can possibly be. i'm pleased to be here and thank you for the opportunity. >> i'm dean kamen. i'm not 67, but i spent a

lifetime designing and building medical equipment over the last few decades, as everybody in this room is aware. i'm concerned that the pace at which technology is developing is increasing. we're in the 21st century and accelerating, the pace at which the systems around us are moving makes us feel like we're trapped in a 19th century model trying to deal with 21st century opportunities. over the next few hours, i would like to talk about a few of them. but a list of things that i think should be noncontroversial that should help things go better since, as michael milken has said more than once, the

whole issue is time and money. we have to shorten the time and reduce the cost. if cms, fda and all the other agencies that are part of the chain of events could work together so that we could, for instance, in parallel do all the work we need to do in this industry to deal with cms and reimbursement at the same time as we go through the fda process, things would get faster and simpler and cheaper. another issue that i hope is noncontroversial, no business i know could run if it lost 25% of its people every year. we have had multiple projects come through the fda and the reviewer changes. one of our most recent projects, the reviewer changed four times. each time you sought to do a restart. it's expensive, takes time and costs money. we have to find a better way to keep continuity on the government side of this process. the third, and i'm glad that the congresswoman brought it up, is irbs. you go it you a pretty detailed,

extensive process of getting an internal review board to approve it. that's a necessary thing. it affects the people and the company. you have to do it in three or four medical centers and have to go through each and every one separately. that's crazy. we should find a way to make it more universal. international competition. it's not just that they compete sort of in the marketplace. these days, most of my major partners, the biggest companies in the world that want to take our products out, look at the situation and because of the lack of certainty in how long it will take to get a product approved or the lack of certainty of what the reimbursement will be for it, almost -- almost universally now, we transition to a world where our biggest clients would prefer to go and launch a

product in europe or japan than in the united states. and that hurts on many levels. it makes the product less accessible in the united states. it has a lot of bad implications. we should be competing to be the most favorable place to attract innovation. finally -- and maybe it's just a small one to some of you. the device tax, which does nothing but make things more expensive -- but it's really kind of a slap in the face to this industry. you could say it's only a few percent. but a few percent is a pretty big number to people that are trying to make a new product. and particularly because it's uniquely a medical device tax, as a matter of public policy, we learn that you tax tobacco, alcohol, have luxury taxes. there's certain taxes that the government puts out trying to encourage or discourage certain behavior. i don't know why people trying to make life-saving equipment should be taxed the way you tax industries that you're trying to say it's a luxury or it's a sin tax.

i don't like to be lumped with that crowd. and i think it's bad policy. >> thank you. dr. theodorescu? >> close, and the green light on. >> it's a privilege to be here. and a little bit about myself. i'm director of the university of colorado comprehensive cancer center. in that role, i am charged to the synergies of cancer research at the university of colorado, a consortium cancer center, which means we encompass three universities as part of our consortium. i also have a very vibrant

laboratory that's funded by the federal government with multiple nih grants. and our area of interest is doing personalized medicine, establishing genomic tests to assign therapeutics as well as doing drug discovery. in addition, because of my role as cancer center director, i'm involved directly or indirectly with clinic trials and i also get a lot of positive and complaints from our membership regarding the access and process of global trials. so, i think i bring a perspective of both the user and also somebody that's recipient of feedback from my colleagues. you know, i think this is a -- this enterprise by medicine is basically bringing upon it a defining moment for this country because this is something that is going to be the future. personized precision medicine. how we do it is in our moment in time.

thanks to dr. collins division, it's built an incredible genomic system intestine fra structure and resulted in technology to really push forward molecular. biotechnology and medicine. it would be a shame not to capitalize on that. and maintain our international and national leadership in the area. we have a great opportunity. this initiative is fundamentally important, i think both from a health perspective and doing right and doing good by our citizens, but our international leadership and also for the economy. and we have discussed the numbers of things about the irbs, et cetera. there are tangible things that we can do. one of them, for example, is aligning the reimbursement process with the regulatory process for biomarkers, really the part and parcel companions to targeted agents. they work hand in hand. we need to establish the

guidelines for biomarket development. biomarket sphere is reimbursed less than drug development. yet it's fundamental to precision medicine. we could really think how we have parallel tracks so companies, small bioteches, small businesses can really develop biomarkers and have a possibility, an expectation of return on investment to grow this economy. the other sort of vignette that i like to bring out is in trying to protect our patients, patients are basically the heart and soul of translational medicine. we rely on them.

when we have consent forms for drug trials 40 pages long, even though they're written at the eighth grade level, perhaps my children, in eighth grade, were not as smart. i can tell you, they were really not prepared to read 40 pages. i think we need to visit those n trying to protect people, we are actually dissuading them from participating and hurting them. we really need to rethink that. that's a vignette of a practical thing we could do to the central irbs and supporting our young investigators. that support can be in the form of facilitating the translation. people who want to do translational research have to have a clear career path and spending their time with forward motion, getting trials done, getting patients on trial. if the barriers to p((áur'g patients on clinical trials are so high, we'll get progressively fewer young investigators wanting to embark on those

careers. it's not a money thing. it's basically trying to overcome obstacles. after a while, you just get tired and you go and do other things. we need to remove those barriers and that will promote our young investigators and also the entire translational infrastructure of clinical trials. thank you. >> thank you, mr. chairman. i commend the work you and and representative degette have done in those efforts. i am here today not as the chairman of the milken institute. i'm here today not as the chairman founder of faster cures. i'm here today not as the chairman and founder of the prostate cancer foundation. i'm here today not as one of the founders of melanoma research alliance or adviser to the focus ultrasound foundation.

i'm here today as an american who lost ten relatives to cancer and representative of the men and women in america, one in two men, and one in three women, that will be diagnosed with cancer. and i am the happiest person to be with you today, mr. chairman in that they gave me 12 to 18 months to live when i was diagnosed with cancer 21 years ago. and i'm here to remind the committee that 50% of all economic growth in the last 200 years has come from bioscience and public health. that the greatest achievement in the history of the world has been the increase in worldwide life expectancy from 31 years of age in 1900 to over 70 today. it took millions of years for average life expectancy to go from 20 to 31.

and a little more than a century we've risen average life expectancy from 31 to 70. i'm here today to remind all of us that it was 20 years ago that a woman had more than a 90% chance of passing hiv or aids on to her children. and today with modern science, it's easy to understand economic growth when in subsahara, life expectancy has increased 50% in a generation with two-thirds of everyone living with hiv or aids. living in subsahara africa today and it's no surprise as a result that today six or seven of the fastest growing economies in the world in this century are in subsahara africa due to the great benefits of u.s. medical science, possibly the greatest contribution of the united states to the world has been the benefits of this medical science

that is available to so many people today. those countries that lead in the biosciences will lead the world in this century. we're not just talking about health. we're talking about agriculture, environment, energy, air, water, et cetera. and so we're of the dawn of the golden age, this enormous investment that the american public has made with the leadership both in the administration and the senate and the house, approving in '98 an increase in funding, which now exceeds over 200 billion. we're about to reap those benefits. whether those benefits will accrue to the united states of america or to some other country will be determined by the leadership and the commitment of this committee and others today.

there are five easy lessons we could talk about today. one, putting the patients at the center of discovery, development and delivery process, more efficient clinical trials, meaningful working relationships between patients and disease specific organizations. one of the greatest advancements of the past two decades has been the strengthening of the research group. two, incentivize collaboration across the r & d process, public, private partnership. look at history books and see those partnerships between ford and kaiser and the government that allowed us to have victory in world war ii as we moved our for-profit industrial companies

quickly to produce ships and other products we needed during world war ii. three, change the risk return ratio. as an example, mr. chairman aushlgs we have to do is look at acid rain. a major issue in the latter part of the 1980s in america. movies, public hearings, et cetera, the loss of life to acid rain. the creation of a financial market for sulfur index, to reduce emissions, to buy credits, eliminated 95% of all the acid rain in america. strengthening the basic translational research infrastructure depended heavily on the next generation of young

scientists. stem education is the rage for men and women, boys and girls in america. after 15 years of studying phds, mds, internships, residency, we have little to promise them in the future. and today, america is losing our best and brightest students to the rest of the world and we run the risk of losing generations of young scientists either to other countries or to other fields in the world today. fifth, assure sustainable and predictable funding for our science agencies, nih, fda, nci, cbc, cms, et cetera. it's impossible to build an organization or recruit the talents you need when, on a year-to-year basis you don't know if you can fund them. the probability of a young

scientist today being funded is the lowest it's been in more than four decades. this golden age is in front of us. we think about the cost and to do no harm. in many ways by length time, we are losing lives. by not providing access to the state of the art treatments today, by not incorporating science. in many ways, science today is running in the 21st century.

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position to distribute rapidly tens of thousands of places in collaboration with the colleagues of this vaccine, how much difference would this be? how many lives would have been saved. the consequences are not just that it has been tough. it damaged our ability to take advantage of the growth that would have happened. that's not being saved, but could have been. that's the greater chance to be a part of it. >> we have experts in the fields and i didn't mention at the beginning that not only is this community united and working on

this together, but we also have the commitment of leadership on both sides. testified that first day back on may 6th and kevin mccarthy, our new majority leader is on board as well. let's open it up for discussion. i want to say to both you and diana how valuable i think these round tables have been. i think it was only a week or two weeks ago that the chairman in his hometown in lancaster, pennsylvania i thought was very good. from my district it was the

hydro sev lis foundation. i wanted to talk more about that and how we can engage patients and referencing that i know with the user feed bill, we had a provision that allows patients to be a part of the advisory panels. that would be maybe one example and maybe to talk about that specifically. it's just the idea of engaging patients. a lot of times the initiatives in terms of legislation that you pass on the floor some of the bills we did last night on the floor actually come from these patient groups who were so grass roots and involved. they spent a lot of their life on some of these foundations like that. if you can elaborate more and mention something about the

advisory participation. >> thank you. it's such an important question. this is a critical time as we are rethinking not just more broadly about how to put patients at the center of what we are doing and really include the patient perspective and reflect the patient needs in the work we put in. it goes far beyond engagement so you can sit down with the patients in groups in a systematic way to better understand their experience and their perspective and the products they are using whether drugs or medical devices and what they actually need to better understand how they are experiencing their disease and what are the critical symptoms of their disease that they want

addressed and what are the underlying needs and how can we actually incorporate that into the product development and review. for example, biomarketers are mentioned with respect to personalize medicine with the genetic trades and linking it to therapy. we want to be able to use patient reported the outcomes like biomarkers in order to make sure that we are assessing both the right measures of whether a product is having an impact and use the measures in a more fundamental way to define success. i think that is important. to look in these various philanthropies and organizations in the area, but the role of patient-specific philanthropies and organizations that they work with them as well as with the

community and product sponsors. to really identify the critical needs and opportunities and together think about how the shape and in particular the clinical trials that need to be done. and the research and development with be as accelerated as possible. one good example is the work that was done with the scientific community and the cystic fibrosis foundation. a new drug which was for a subsection of patients that was cystic fibrosis that have a particular genetic marker. it was the first drug that treats the underlying cause and not just the symptoms with the devastating and this has been

transform of a and provides the patients and the cystic fibrosis foundation made this work possible because they helped to create the patient kmund necessary to move into the trial to get the tissue as well as the patients that could create a foundation for understanding the opportunity and moving forward quickly on it. that's to conduct the critical resources and the patients and the dollars to help move it forward so there is a lot in this area. i think we need to look at what's being done and it's incredible success and importance and build on it.

>> thank you. >> thank you, chairman. that won't be one of the test objects. you objected on each criteria and that was discrimination on your part. >> i had to object myself. >> i still stand ready to offer my services. we had a good with manhattan institute, we had a good and that was part of that. i have been in boston. the clinical trials. the funts once it's approved, they are