jen alluded to, which is prevention, was the area where there was the most action because there have been the most new studies and trials out. a couple of things to highlight there. first of all, the new w.h.o. guidelines on prevention, treatment and care for key affected populations were released just before the conference and then we had sessions on them. i should say that i co-chaired that guideline process. fantastic. those guidelines really made one of the strong recommendations based on quality of evidence was for consideration of the use of preexposure prophylaxis, that is prep for men who have sex with men as an additional prevention option. some of you will have seen that this got very misconstrued in

the media. very inflammatory headlines. w.h.o. says all gay men should be on prep. nobody said that. read the guidelines there. i think a real advance. in addition to the recommendation, there's an important recommendation for community distribution to reduce overdose deaths, which have actually in countries where there's good coverage of arbs, overdose death has been begun to replace hiv as the leading cause of death win people who inject opia opiates. there was good news on prep, which was the results released -- the clinical trial came out in 2011. bob grant was the lead investigator. this is the open label extension. so this is really the question of the effectiveness of the prep when it's not a placebo trial,

when people know what they are taking. the good news is the effectiveness was higher than in the trial. about 50% overall. but looking at blood levels and at people who actually took the drug, it turns out, first of all, that the efficacy was 100% as measured in people who took it every day. it really works if you take it. but it was just as good as six times a week, five times a week and four times a week. so while that's a difficult message to put out there and we're not backing away from daily prep at this point, because we don't have the data to do that, adherence doesn't have to be perfect. that's a real advance. the other thing that really emerged from the study which very important is that people had a good sense of their own risk. taking the drug daily was much more common among people who actually had high risk exposures and less common among men and

transgender women who didn't. so that isn't surprising. people are smart and they know what kind of behavior they are engaging in. nevertheless, important. the other thing that's critical is there's been all kinds of concern about risk compensation. if people are on this drug, they will use condoms less. the same concern raised by the way in using treatment as prevention. lots of science around this. it's a theoretical, not a real world concern. condom use is better in couples who are -- one of whom is being treated and who are using treatment as prevention for prevention. there was great data on that. no evidence of behavioral disinhibition. there wasn't great condom use but it didn't decline. there was encouraging news on voluntary male circumcision. the most important data are the first real impeer cal findings from the french group that did the first trial of the benefits

for hiv prevention for women and lower rates of hiv and syphilis in women whose partner was circumcised. it really is very encouraging. i would say on track d, which is our human rights policy and the law, there was an enormous amount of work. michael kirby, led us off with the theme. there were a number of presentations on human rights policy and the law. also some impeer cal data from a special issue of the lancet. this one was on hiv and sex work and sex workers. i would encourage you to read it. i edited that. full disclosure. it's a wonderful group of young investigators who led the papers. really excited about the science. but there's strong human rights

evidence there for, for example, the potential benefits of reducing police violence on hiv incidents. modelled outcome and on decriminalization as an hiv prevention approach. finally, in track e, which is the implementation science track now has the largest number of abstract submission. so for those of you who work for implementers out there, you are an enormous sector in this field and doing lots of work. there was great science. some very encouraging outcomes. also one or two warnings. i would just highlight a couple of things. one was, good news that earlier disclosure to adolescents turns out to improve their adherence on therapy. that's an important finding, because the cohort of kids born with hiv is now in adolescents in young adults. in africa, many of those kids are surviving. earlier disclosure to them matters.

a challenging issue with plan b, putting all pregnant women living with hiv on therapy, which looks like their retention and care is not as good as we had hoped post partum. that's an important challenge ahead. i would say finally from track e, the other thing that really emerged was how much more granular -- gran ou emerged was how much more granular -- gran olar was a big word. strategic use of data. the importance of really targeting resources to where the virus is, where people need treatment, where transmission is ongoing. given what the global funding climate looks like and given the fact that we are beginning now to really bare down on this epidemic. >> i have to thank you. i was at many of those sessions and i read so much that's come

out of the conference. that was the best summary of everything that happened. so you got best summary right here. >> thanks, jen. thanks to kaiser and craig for hosting us and for this paster inship. congratulations, chris, for your ascent into being the president for next two years. it's very exciting. we will talk about that. i, too, was struck by the convergence of opinion just in sitting and listening to deborah birx, to celine, to mark, to tony, to michelle. the degree to which there is a very mature and advanced consensus around what needs to help is remarkable. this is not a community beset by deep controversy and division. i was at times a little

irritated that there was not more debate. but this was really a science of success, i think. and there was an embedded within that was a palpable realism and focus upon result and implementation. there was a spirit of constructive forward looking progress to this. and a sense of advancement and a sense of realism that all came together around those five or six key things that need to happen. and i didn't fully appreciate the degree to which that convergence had happened. it's a real testimony, the maturity of the leadership and the continuity of leadership. when you look at the people that were up and eloquently making the case and you realized how long they have been in leadership positions in pushing this forward. it's a very unusual group that we have. i'm going to say a few words about the implications of the

mh-17. i think this was truly extraordinary. i will explain a bit about that. we have heard some about this. i think we need to tease out a little bit of the implications from it. first of all, we have never had a conference in which a geopolitical global crisis sucked the conference in and sucked the host country. australia suffered the loss of 28 citizens and eight permanent residents, 18 citizens from victorian state died. this became a geo strategic top priority, pressing, urgent matter for the australian government. as it did become a pressing and urgent human matter for the organizers of the international aids conference. there was no escaping the

reality that this was going to become a dominant factor going through the week and beyond. so thinking about what that means in the immediate and longer term i think is important. one is, the mh tragedy will become a signature frame for thinking about this. i think in the future as we talk about this conference. secondly is, it triggered a massive spike of media coverage. bare in mind, going off to melbourne was to pushing the aids conference off into the periphery and lowering the numbers and lowering the media presence and in a world in which the media -- the global media is shrinking in terms of its willingness to deploy to these kinds of conferences, the media presence was a lot lighter than it was two years ago. that tragedy spiked the media coverage in a period. the story line was not the substance. the story line was the human

tragedy and the impact there and what that meant. far less was the coverage, as there has been in the past, of the developments that chris and deborah have summarized. i do agree the immediate impact was a slightly disorienting and dulling affect upon the population for the first couple of days. there was a somberness that hung over the opening ceremony. the delegates themselves individually and the early panels and events. but what was interesting was that there was a rebound affect that began soon thereafter in which you saw a community that had an unusual resilience to it. it had an unusual capacity to absorb and process this tragedy. and some of that has to do with the historical legacy of hiv/aids. it has to do with this is a

community that is familiar with loss. tease familiar with irrational violence and cruelty. it has the 1998 precedent of jonathanm mann and his wife dieing on an aircraft. there was a reconciliation that began to happen slowly and move people out of this dull and disorienting initial reaction. and then i think one of the key moments -- i would like to hear from jen, deb and chris on this. i thought one of the key turning point was president clinton on wednesday at midday. and this was not a conference that attracted a lot of big celebrities. it attracts bob geldorf as a foe celebrity. it attracted bill clinton, a real celebrity.

clinton came in, and the media attention intensified again. and he really was quite defendandeft at lifting the spirits of the conference. and he was humble and eloquent. he talked about mh-17 emanating from the dark spirit s -- dark forces. he reminded everyone to not -- not to weaken their resolve in the face of this. he supported the dutch and the australian and american positions that there was no excuse, that this was a crime and there was no excuse. and then he segued to talking about the vital point that -- of appealing to the assembled community that it had an obligation to honor the service and lives of those who were lost and the children we lost.

the people we lost gave their lives. this was the kind of engagement and speech that was quite historic, i thought, and quite unusual. and obviously, driven by this tragedy. two other points about the impact. one is the australian government. the australian government was an exceptional host. they were gracious, well prepared, they were generous, they were cordial. it was very well organized on their side. this was a national tragedy for them. i think it completely consumed this government in a way stole any serious high level engagement away from it. because they were absorbed in security council, getting the forensic teams into the crash site. they were rallying and mourning and grieving their own population. during the conference on thursday in the early afternoon,

1,200 opinion leaders from australia gathered at st. paul's cathedral, across the river. so that was an important thing to remind ourselves, that in the midst of this conference was this other larger drama unfolding. the last thing i will say, which chris can add more to, which has to do with putin's actions regarding hiv/aids. this mh-17 tragedy aggravated and further worsened what was already a trend line in which putin's seizure of cry mere ya, the confront indication over ukraine and the battle to regain dominant shares over the baltics and elsewhere, which has grave public health implications, was driven into the next stage. and we need to think about that. we need to think about that. i'm not sure there's any

near-term solutions to this. but it was another one of those dark and implicit implications for this terrible tragedy. thank you. >> thanks. i want to pick up on one thing you said and come to a couple of you as well around some of the turning points. i agree, that speech that president clinton made was extraordinary. i'm not sure everyone -- it got the attention it needed given how extraordinary it was. the other thing i wanted to say is that the ias itself in the way the ias responded was also pretty phenomenal. there had been a few calls for, should we go on with the conference? the ias came out immediately and said, we are going on, that we have to go on. that really, i think, just gave a lot of energy to people that people needed. and the way you adjusted to the opening ceremony was very admirable. thank you for that. there's a lot to pick up on. i'm just going to go to a couple places. i don't know, chris, if you want

to say anything in reaction to some of the pieces that steve mentioned on the conference. one thing that would be great to hear a little bit about is the melbourne declaration. maybe those things it. then we will come back to you, debbie. >> maybe start with the melbourne declaration. one of the core ideas that we had for australia is, countries now 30 years and more into the epidemic, each have their own story and their own national response and what's happening. part of the story with australia is very early implementation, one of the first countries to take needle exchange to scale with a big injection problem and heading hiv off at the pass and having a low rate of infection, although ticking up in young gay men is happening virtually everywhere.

so this was always going to be part of the story, that australia is a place to talk about key effective populations. we are in the asia pacific region where that is the driver of most of the epidemics and not so much the key affected populations but the poor public health policies and programs around them and the restrictive environments. that certainly is the case with central asia. and the increasing russian influence on public health programs in that region. so we focused on the melbourne declaration to say non-discrimination is totally unacceptable at this point and that if we cannot do a better job of delivering safe and effective programming with dignity and human rights for everybody who needs it, we're not going to be able to succeed in the hiv response. so the melbourne declaration became all too real and alive

during this conference, i have to say. the issue with the russians, we wanted very much to try and have the russians engage in this conference and have central asian governments engage as well. in the asia pacific we try to really -- an outreach there. organized a special session on the region, which we invite ed russian participation in. they agreed. ten days before the conference, they pulled out and said, we're not coming. russian government is not participating. we invited them to put in a report. they didn't do it. on the day of that session, which was on the thursday, they sent a letter to the international aids society and to the media protesting the russian exclusion from participation. very unhelpful to say the least. and put us in a very challenging position. we tried to respond with the evidence. we laid out what actually had

transpired. as steve said, what is really distressing about this is first of all that their own public health programs have markedly deteriorated. the quality of the data and evidence is such that i really don't think anyone knows what is happening with new hiv infections in that enormous country, honestly. in addition to that, there are also aggressively promoting these policies and practices, blocking home reduction, pressing harm on anti homosexuality legislation in their region of influence. the best example of that is the occupation of crimea. they announced the cessation of the methadone program. ukraine has methadone. on the first day of their occupation of crimea. that gives you a feel for where this sits in their priority. you occupy somebody's country, there's a long list of things you need to do.

most people would not put methadone on the day one list. nevertheless -- we really do have an enormous challenge ahead. >> thanks. debbie, to come back to you. then we will open it up, unless steve wants to say another comment. two other things that have come up. one is around this -- i think we all felt around the global consensus about where we need to go, whether geographic, the goals, how we get there, how we use existing resources. i was wondering how -- they put themselves into it the dialogue and relate to the dialogue. a follow-up related to the africa summit. i know it consumed all of your time until probably right before you arrived here. what's your readout on that for us? >> this particular meeting, the ias was really helpful for me personally because it was the intersection of the new gap report really illustrating where

we have done well and really recognizing that. but also recognizing where we haven't done well and then immediately be able to look at the posters and planners and see who has got something that we can bring back and try to implement in the areas. we looked through everything. where do we have gaps? tb-hiv. we have parents getting therapy, being dying notiiagnosed, not g treatment. we have a gap there. we have to figure that out. that one should be pretty simple, because we see the patients. we're paying for them to come to the clinics. the we need to really redouble that effort and really use, again, data for decision making and understand that situation. the other big gap that was clear is pediatric treatment. so we really tried to respond to that immediately. we sat down with pete mcdermott.

he shares my concern of children not accessing children. only a third of treatment who should be on treatment are on treatment. this is country by country. even in countries that have been successful in getting adults on treatment where you have adult rates on treatment of 80%, 90% and children of 30%. the big announcement at the african summit yesterday, i think it's an exciting time not only because what it stands for bus but it recognizes they are working together on the issues. i think we haven't really had that kind of alliance with europe during this time. they feel strongly about the global fund. we do, too. we're the largest contributor. having that technical dialogue really helps us to have that broader dialogue. we're very excited about that. that's a gap i think we can all address. i think the bubble diagram was

very importance. to make it very clear that the vulnerable population in africa is young women. 7,000 young women infected every week. if you add up all the our bubbles of the vulnerable populati populations, they fit within the woman's circle. the size of that group that is vulnerable and at risk. if you walk around to the posters, a lot of people have ideas. young women, like young men, have their own agenda and their own endeavors and their own belief systems that we have to really discuss with young women. it takes us back to, we have to understand what's driving young women's decision making. do they feel empowered? do they have all the information to make their own decisions? are we giving it to them? are we giving them the correct services in a friendly way? where an adolescent feels like they can get advice without

someone going, why are you here, you are having sex? we know that happens. if happened in our household. i think it's happening in others. they are 27 and 31 now. it was a vulnerable and difficult time. i recognize it as a mom. i think all of us struggle with this. we struggle to figure out the best way to resonate with young women. we have to figure that out. it was a great time to really look where we still need to do better and then see if that can connect with science that gives us a road map. we're excited about those pieces coming together. we're excited about the opportunity to translate gaps immediately into response. we want your ideas. you know we put all of our data up on the website. you can go to it. you will see our budgets, all of our results by country. all of our investment strategies by country. send information back to us and say, i'm there. i have looked at this.

this doesn't make sense. you can't -- don't try to hold back. we want to really hear where you think we could do a better job. we're committed to putting additional data as we receive it. we're going down to the site level and site level quality data so you can look at our performance and tell us how to do a better job. we're all in this together. we're there together. i want to leave with one last thing. you didn't mention it and i'm sure it's on everybody's mind, ebola. it's a very big contrast in how the united states has worked effectively in partnership with countries. because the last five or six ebola outbreaks you haven't heard about. you haven't heard about them because scientists and clinicians in the countries had the infrastructure, the knowledge base so when those patients came in, they were immediately isolated. the labs diagnosed them.

there was one case in uganda. another one or two cases in uganda. i think all of us should feel guilty in a way that sieree si own didn't have the ability to identify that. it speaks to the laboratories that have been built, have been critical to the health system. sometimes we ignore the laboratory and we shouldn't because it's critical. i'm going to -- one more gap. long act two -- long acting prep would be amazing. we have vulnerable young women who may not have the ability to take a pill every day regularly. i see a lot of birth control pills on my counters where there are pills and not all pushed out. it worries me. yes, it worries me. prep is important. i think a long acting treatment

option so that people get monthly injections, long acting prep could be a bridge for young women. i think good tasting pediatric formulations. i don't understand this, frankly. we made other drugs taste good. we have gummy vitamins. we can't make pediatric treatments taste good. a mother cannot hold their child down every day to give them a dose of medicine. it's horrifying. if your child is already sick and you are trying to do this, it's horrifying. we have some technical gaps that we need help for in a global way. if you are working in any of those areas, please work harder. please work harder. >> i have one other thing that hasn't come up that was talked about at the conference, which is the question of resources going forward. and where they will come from. part of it, there was a big emphasis on using existing pool of funding that we have and using it wisely, which is

incumbent upon everybody. but going forward, we know there's these gaps and needs. we released a report showing donor government commitments are going down. so that was an issue. there's other sectors that can help. that's something we can get into if it comes up. steve, i will see if you want to add anything else before we open it up. >> just a couple quick points. the melbourne declaration, michael kirby, the australian jourist, came across as remarkably eloquent and powerful at multiple points, from the beginning, then there was a session on criminalization that was a very dramatic session. and the u.s. ambassador showed up at that and kicked that session off. and in his presentation turned the view back upon the united

states in terms of the body of law at the state, federal or local level that impedes a sensible, rational approach on reaching certain populations that need to be reached. and it was a very, i thought, refreshing -- a very refreshing self-critical way. and it opened the discussion quite nicely. michael kirby came in and joined it as well. that was quite amazing. it was less clear to me what was supposed to be done. i mean, it was less clear to me after all of the pronouncements. i mean, the melbourne declaration was great. the appeals that were made, kirby's opening address on opening night. but it hasn't yet gelled into a fairly clear set of priority actions that are supposed to happen to address this surge of

homophobia and proliferation of bad laws that we confront. i put that out. another problem area that emerged was the fact that there were no serious high-level asian leaders that showed up. the president of fiji showed up, which was nice of him to do. that was great. there were ministers there. there were ministers there. but there was not a surge of -- there was not evidence of broad-gauged high-level political interest from the asia pacific region. i was disappointed to see that. the world bank had a test run, a study of the financing across the asia pacific, a pain they're wi -- a paper that will be published. it shows that there -- in this case, the response is overwhelmingly dependent upon government commitments. but is very flat and very deficient.

so that's something. we did a session that chris was very instrumental in helping us organize, a regional session which the deputy minister from myanmar came and presented. it was a day brebut. the government had overcome its sense of embarrassment or discomfort at talking publically about its programs. it came forward in a very candid, comprehensive, honest and forthright way. and that was so refreshing to see. and the response was great. i mean, you had dozens of myanmar folks come and those from the region and the indonesias and thai experts join in the effort. i was delighted to see that. thank you. >> so let's open it up to questions or thoughts. we will take three at a time. just introduce yourself. there's mikes i think on both sides. i will try to facilitate this

by -- anybody have any? this is not a shy group. you have somebody over there. over here and over here. say who you are. >> hello. i'm suzanne from u.s. aid. my question is for dr. morrison. you mentioned that there was near consensus at the conference on the five or six things that need to be done to turn the tide of hiv. i'm wondering if could you just review those quickly. >> next question. >> mary lynn with creative associates international. i have the same question for stephen. i think consensus at an aids conference is frightening. i wondered what you wanted to see more debate about. i also wondered, what is the explanatory dialogue going on about low treatment for pediatrics? i worked as a pediatric aids adviser to a child health

project. and i never thought it was the lack of reagents or formulations. mothers in communities did not know anything about what could be done for their children and the stigma around the discussion of parents being positive were much more the barriers. what would be the response? what kind of interventions are being looked for? >> i'm edward green. i'm the u.n. secretary-general special envoy for hiv in the caribbean. i happened to be at the conference. i share the sentiments of the head table. in fact, i want to congratulate you for making the content, the context so vivid for the audience. i, however, want to add a more optimistic take away.

for me, when i reflect on the conference, there was a take away which was a resolve to end hiv/aids in brackets by 2030. i believe that this is a momentous opportunity for health and development. one reason is that i think it was embellished by the u.n. aids ex executive director. are you as optimistic about that? secondly, an implication as we go forward, where it is we position aids in the post-2050 agenda. one of the take aways and the results from the conference is ensuring that aids is positioned in the -- post-2050 agenda. i think we were all clear on that. but less clear was whether or not we embrace it within the

convergence of health. and that's what i was not sure about. i think that we have to discuss that strategy as we move towards the u.n. general assembly in september and beyond. >> thank you. we had a few questions here. one on con ssensus and what it s about. another one around pediatric low access and what's going on and this last around -- thank you very much. were we as optimistic and hard questions i think about post-2015 agenda, are we really going to get there? do you want to start? >> sure. we have heard from deborah in particular about the fundamentals of the consensus. i would say they are really about making full use of an expanding and very promising set of prevention tools, including treatment.

to prevent and prep. that there's a sense that in the last several years, there's been dramatic improvement in expansion of tools and those become central in moving forward. a sense of the need to systematically retool approaches from the general to more targeted investments at local and sub-regional areas, where the epidemic is most intense, and that includes geographic as well as targeted populations. dramatically the need -- the imperative to improve the use of imper cal data to track impacts that will guide future investments. the shared common view around girls, rur areal girls in south africa. i would also put as the broad

frame of this a shared optimism, a pragmatic approach, a forward looking approach, a data driven approach -- i was being only if a shee shout shoif a shee shous there was not an active debate. the last thing on this the question around criminalization, surge of homophobia, proliferation of bad laws. that was a prominent portion of all arguments across the board. i think those are the major elements. >> i want to come back to the community piece. it's not only relates to the children. it relates to all of the mothers and fathers in these difficult countries being further

stigmatized, being afraid that they will be -- when the perception is that hiv/aids is only in the vulnerable populations, then it becomes finger pointing. we had it in the u.s. we have to make sure that our responses are comprehensive at community level so that the x p community understands there's a compassion that needs to go with public health. but there has to be a sense that all of us are vulnerable and all of us need access to services and no one should be stigmatized. what has happened in uganda, in nigeria, what's happened at isolated cases in tanzania, kenya, very difficult and will only drive people away from services, because no one wants to feel like their life is in danger while you are seeking life-saving services. people believe their lives are in danger. and they are. this has to be addressed.

it's a matter of criminalization. but it's a matter of the community accepting that criminalization and actually even turning each other in. so we can't and we need to work in that more comprehensive way. i do believe that there are mothers, both mothers accessing option b and b plus and mothers who are not bringing their children in to the clinic for diagnosis for the very reason that mothers found it so difficult when we only had single dose therapy where we asked mothers to come out of their communities and out of their villages and identify themselves as hiv positive to save their child when there was nothing for them. and i think in a way we didn't have any other options then. but imagine the break of trust with that mother when there was nothing for the mother. so i think option b and b plus are going to help us there where mothers feel like they are being cared for, where they feel like their children are being cared for. we have to overcome the 10% or 15% that we know are throwing away their pills on their way

home because they can't confront stigma in the community. involving the churches are an important fabric of the community, involving the community leaders, involving the local chiefs to make sure that no one is turned away from services and becomes more vulnerable to disease because of what we're doing ourselves. you are right, the community piece is essential and remains a barrier for both mothers and babies. >> a last question on optimism. also a little bit about the post-2015 agenda. to start it off, i actually -- anyone who heard me speak, i'm an optimist. i approach it off the mystically. i do think this in general that was a feeling at the conference. if we didn't convey that, i think we felt -- most of us felt it. what's changed from my perspective is in the last four

or five years we can actually say we know what to do and the fact that there's more of a con -- is a consensus on those things. a few years ago we didn't necessarily have all of the evidence and the tools. we did a lot but not all of it that we have now. there wasn't this consensus around doing those things. those are two things that have come together at this moment that i hope will get carried forward in the next few years to really reach those goals. anyone want to add on optimism or post-2015? >> let me just say that i -- in my incoming address at the close of the conference also tried to share in that optimism but also back away a little bit from putting ourselves in a position where our concerns are 2030 and saying really what do we want to do by -- two years from now. if we just kind of keep the pace that we're going at, we should

add at least 4 million or so more people on to treatment between now and then. that would be actually where we are plus a little better. and it seems to me that what we need to do with this every two-year global convening is to use it more as an accountability tool and really to use it more as a formal way to measure where we are and what we have achieved. i feel for myself that the new goals, the 90, 90, 90 makes sense. it's a long way off. i think we -- we are at a place where we have, i think, the community that cares about hiv, this consensus that you heard about about now we really know so much more about what to do. probably the single biggest change in that is the recognition that treatment is prevention and that by getting

folks on therapy we really are impacting the dynamics. but there are notes of caution there for me. one is key populations, the wave of homophobia, the bad laws that go in the opposite direction. the second is degrageographic. we know the epidemic is expanding given what little data we have. it's a very, very tough challenge. i will say that one bright note of optimism there is that, my co-chair for the 2016 conference, is south africa's representative to the think tank on the bricks and is working very closely with the bricks. that is, of course, brazil, russia, india, china and sou africa. maybe there is some hope that that forum, which will not include us, the u.s., maybe is a place where the hiv issues and

the global health issues and public health practices can really be brought to the fore in a different and new way that will be different. we have discussed that in detail. i think that's a stay tuned. ? >> if you look in the gap report, there's this great diagram that shows if we continue to do what we're doing today at the rate at which we're doing it today, the number of new infections creep up. what's missing in that is where you end up at 2030 is 80 million people infect and a treatment gap of $31 billion -- $31 billion every year. there is this imperative to

accelerate that in the programs. treading water gets us to twice as many people infected. by 2020, it gets us to another five or six or seven million people infected. but an $8 billion treatment gap. these are not numbers that we can make up. they're not numbers that any number can make up, that global fund can make up. but look at the diagram and count out the number of new infections there are per year. and realize the cost of only doing what we're doing. we're doing a lot. but we're not going to be on the right line unless we do more. and i think that's call of action to all of us that somehow we have to do more with what we have. and we have do it before. maybe we will get some additional funding. but we can't wait for that. we have to figure out now how we can get more control now rather than just doing more of what we are currently doing at the rate that we're doing it.

i think that diagram to me is one of the most telling diagrams in the gap report. and i think we should always look at it and study it and understand it and understand what those differences in lines really mean, how you have one case maybe 43 million total infections and another you have 80. we can't afford another 80. we have had 75. to put on top of that over 100 million, 150 million people that have been infected with hiv, it's too many. one is too many. that is truly too many. >> let's go to some more questions. someone is back there. you have somebody back there? okay. and over here. >> thank you. my name is sister veronica. i worked in tanzania for many, many years. i worked for 12 years hiv/aids program. and we were very grateful when

pepfar began in the early 2000s. what is happening today, i have received two e-mails today, one from kenya and one from t tanzania. they say because pepfar is being lessened, their funding in kenya and the funding in tanzania now will go down quite a bit, i understand. they are saying, who can we pressure? how can we start to get that funding back again to a level? because now the incidents they're afraid the incidents will rise again. so thank you. >> over there. >> i'm julia from enterprise service. i spoke with ambassador birx earlier about this. i would like to ask the question to the rest of the panel.

which is about especially in terms of educating these populations about the need to seek treatment and diagnosis and whatnot. i'm wondering how -- if and how you utilize the expansion of social media and the internet and mobile technology to help raise awareness and about proper treatment and correcting misinformation about hiv/aids. thank you. >> my name is anna. i'm an independent consultant working on woman and hiv prevention. i wanted to thank you for a helpful discussion. i wanted to thank you, dr. beyrer for editing the series on sex workers and hiv. it's a brilliant issue. and it seems to me as though the data that we have in that issue particularly in study by kay and

her colleagues, is sort of equivalent -- the data is showing the connection between dekrimization of sex work and reduction in hiv is sort of equivalent to the data tipping point that we reached in 1996 with syringe exchange, where it really became irrefutable that these two things were connected and that we couldn't achieve hiv reduction in the way we want to without syringe exchange in the one case and decriminalization of sex work in the other. what kind of political response can we expect to see based on this data? and even more specifically, how much we can expect the research community to step up and use its political clout to advocate for decriminalization. we saw with syringe exchange after the 1996 data came out there was increased pressure not

only from the advocacy community, but the research community for syringe exchange to reduce hiv. now we have canada on the verge of changing and decriminalizing its sex worker laws, or possibly not and the south african aids council pushing to decriminalize sex work. i'm sure the issue is coming up stronger in other countries. how much can we expect these communities to step up and make an issue out of what we now know is true? >> thank you, great questions. one was around funding concerns focusing on tanzania and kenya, but i think it was a larger question. and the last very important question is what's the role of science now in the political sphere on the issue of sex work and the relationship with incidents and criminalization. would you like to start? >> i can talk briefly about the budget. i think we had tanzania come back for a week of discussions

with us last week. a very important discussion, because we're not cutting the budget in tanzania. the budget hasn't been cut. and the budget isn't being cut in kenya. their total funding envelope is the same. it's the mix of how it's old and new money and creating that total funding envelope. but i think what your question is is do you have enough resources? and so what we're doing right now is trying to look at how to get to 90/90/90, and there are places that don't have hiv but there is service provision there that we may not be able to support any longer so that we can move that human capacity and the funding to where hiv-positive patients are, where they can be found and to the communities that surround those patients. so we are looking very carefully at the geographic analysis and using data down to the site level of every single site, showing how many positives they have for every six months based

on the number tested. so we're going down to a very granule level so we can make decisions based on the funding level that we have. once we do all that and see what can be done, i think your question begs that bigger question of do the countries have enough resources between pepfar, the host country and the global fund to meet the demands of controlling the global pandemic? that's the question on the table. when he says there's consensus, there's enormous working relationship between ambassador diebold, michelle sidibe and godfrey and myself since we knew each other since we were babies. we've grown up together. we've done nothing like this. we've only done hiv/aids. we're passionate about turning the tide of this pandemic. so i think there is consensus of how we utilize every dollar we have collectively to have the biggest impact. so, i'm reassured by that. i have one social media thing

that i'll do quickly. i saw this incredible work coming out of i think cambodia, i'm not sure, different internet communications strategies that resonate not only with different age groups, different sexual practice, so everybody can click on a site and find the voice that resonates with them and gives them the knowledge that they need. so i think it was just incredible. they had 40 or 50 different individuals talking and you could click through them and decide what voice resonates with you based on some profile that was done anonymously. and i just found that so incredibly powerful. and if we could figure out how to do that and how to get broadband through sub-saharan africa, it would be terrific. i'm sure you saw more though. >> i was on a conference call

with our tanzanian colleagues today. of course they dropped off. and all the connectivity problems right just remains a reality that we all have to deal with. i think there's a lot going on in terms of innovations in technology and not only in mobile technology and internet-based technology, but also in some other domains like self-testing, home testing, getting testing out of clinics, getting it to people. so lots of effort around that. point of care, cd4 and other point of care diagnostics, where now the technology is moving to a place where there are much more local kinds of facilities that can actually do staging. you don't have these big problems with people waiting forever to get a cd4 and then being told to go somewhere else and all those challenges. that area, which broadly is in the implementation science arena is, as i said, now the largest area of scientific endeavors. it's really very striking, at

least for what we see coming to the conferences. and i think, you know, part of what we're learning is one size doesn't fit all with these innovations. it turns out, for example, there are several studies on this looking at interactive supports for treatment and for prep adherence and use, that they're very age-dependent differences even among one population, men who have sex with men. men under 25 really like interactive sms messages and want to be notified all the time. older men, no, thank you, leave me alone. so very age specific. we're going to have to get that right. i would just say as something of a plea, i think one sector that hasn't engaged very much in hiv has been the social media sector, facebook, google, all of that silicon valley and we need them. and we would love them to be way more engaged than they are. >> on the special issues?

>> on the sex work question. when we do one of these comprehensive reviews and really try to look at the field, you have an army of graduate students harvesting publications. you know, one of the things that really is striking is that basically for the last ten years of innovation in hiv prevention and other domains of hiv, sex workers have not been a part of the research agenda. none of the trials, prevention trials in men, women or transgender people have enough strata of sex workers in them to be able to do independent analyses the way. the way -- that sex work is assessed in the research agenda is inconsistent and unhelpful. there's a lot of confusion about what is transactional sex, what is survival sex, what is sex work. sex workers themselves have been

reluctant, many of the organizations, to engage because of feelings of mistrust and concerns around coercion. and the whole issue of the legal and policy environment that's been seen, quite rightly, as hostile to their interests and needs. one of the things that came out of this series -- and we hope this will really resonate with the research community is that, you know, we need to be doing, prevention research studies with this community very much in a new way of engaging, or communities, that includes them in meaningful. right now, we don't haven't right now, we don't haven't an assessment for women who sell sex. and that in 2014 is a real gap. we sincerely hope that that happens.

i have to say that in terms of the issue of decriminalization, that will have to be a government by government, country by country issue. but the cbos, ngos really have embraced this data. they're taking and running with it. as a researcher, that's what you always hope, that people will find what you do useful and go with it. with it. i think you'll see, hopefully, a lot more evidence based activism now that the evidence base is better. >> i think we'll take two more quick questions because then i want the panelists to talk -- sort of look forward on durban a little bit and what that means, and we'll just have to wrap it up. now i see a lot of hands, of course. one over here and one in the back.

>> all set? and a third over here. make it quick, please. >> i'm andrew forsythe with the office that's charged with implementing the new strategy. one of the things we've learned is that to make the most of the dollars means we have to reallocate to maximize those dollars and that means that we won't be able to do everything. part of our decisionmaking depends on the cost effectiveness of interventions and the efficacy of them. can you say a word or two about how that process is informing what you think is going to need to take place through pepfar and other international donors? what will not continue to be or able to be supported in order to have the greatest impacts on home testing or whatever those new innovations are? >> thanks. second? >> hi. i'm angeli and i'm from intrahealth international.

you mentioned that a central consideration in the future global hiv/aids agenda include ensuring treatment, follow diagnosis, advancing technology, like therapy and long-acting prep, et cetera. how can we know having a well staffed work force is essential to delivering these services and with the current enormous shortage of global health workers, even if new treatment and prevention options were developed, many countries would lack the capacity to administer these services. so i wonder where health work force strengthening fits specifically within this global hiv strategy in the future? >> and our last question? >> my name is mike. i'm a fellow with the international gay and lesbian rights association. my first question is during the conference, we had the youth faction. i'm looking at how pepfar and

global fund is looking to engage the data that was released. and regarding the aids conference, we had several panels on discrimination and criminalization in africa. and one of the key at risk populations is transgenders. i'm looking at how having programs to address this population. >> anyone want to address those? then you all have the last word. steve? >> well, so thank you, michael, for that question. i'll just say that you know, happily, we now have an adolescent trials network that's expanding its footprint in trying to do meaningful research and is going to look at adolescent key populations. the other i think really encouraging things is, again, relates to the w.h.o. guidelines.

the w.h.o. guidelines, for the first time, they address adolescent key populations, really included them in all the recommendations. and in some countries, w.h.o. guidelines don't necessarily mean so much, but for many, they play an informative role that allows for all kinds of activities to occur and people that want to do more of this critical work with adolescents, including lgbt and adolescents selling sex and using drugs. they are empowered by using those guidelines and being able to say this is w.h.o. standard of care now. we have to do this. >> let me just quickly address the strategy and the great work you've done realigning and congratulate usaid on their line of programs to really have a bigger impact on maternal and child mortality. extraordinary work. we're learning from those groups.

that's why we have these 12 countries coming back emergently before we release the '14 money. we know we can't do everything everywhere, but what can we do in certain places? what are the right things and the right place at the right time? and getting that right will be absolutely key to either going on this line or this line. and we feel such a strong moral imperative to do the hard work that you did and do the hard work that usaid did, we're running as fast as we can. i discussed those gaps. it's not only a matter of doing what we have been doing but doing that cheaper so we can address young women so we can deal with issues of stigma and discrimination, training at the community level. there's all of those pieces that we feel like we have to respond to at the same time that we're trying to focus the programs, both geographically and in this core areas to control the pandemic.

it's an exciting time. it linked to that and we've started an entire program of high level and hrh and systems strategies. we've gone to every one of the agencies where we know there's incredible talent and we've said, give us your talent. every agency has come forward with five to ten additional people to work on these core strategies. we've gotten janice timberlake and the team really helping us, looking at the hrh strategy. task shifting has worked extraordinarily well. the nurse previbers in botswana are among the best physicians we've seen. and we need to bring them to the children's world, too. we know they're all interconnected. but the human rights piece is such an important piece to us also. and we're trying to weave that through this whole health care worker piece because that's where patients come and that's often where they first get stigma and discriminated

against. so, we have to ensure that our training also cover those areas and make sure we've funded that adequately. >> great. we only have a few more minutes. and i would love to hear from each of you your just concluding thoughts on durban, which is where the next big conference will take place. the every two year conference going back to durban after being there in 2,000 which for those of us who were there was quite a turning point. what are your hopes for getting us there? and, chris, i'm going to end with you since you're really the person who is going to take us forward. you can use this opportunity to solicit input. steve, i'll start with you and get your thoughts, then to deb. >> okay. i think coming back to durban, coming back to the epicenter of the global pandemic, coming back in partnership with olive and

celine and others in south africa, that's just an exciting and buoyant sort of opportunity for us. and the memory of 2000 will be very much there. i'd say a couple of things could be done that have been problems to address recurrent problems. one is to work to recover really aciduously to recover high-level african leadership into this. that if you go into durban and you don't have them, it will be yet another sort of sense that the leadership has walked. second is to figure out in practical real political terms how to address the homophobia and the surge of bad laws and who needs to be there that was

not there this time, who needs to be there that is credible and can be empowered and can come out of the woods and talk about these problems and not feel threatened and be able to put forward a concrete agenda. i think if you do those two things, you will have advanced the agenda very dramatically. south africa's transition, of course, many of those people that need to be brought on treatment that both chris and deb referred to are going to be south africans. and the u.s. will also be in the midst of its own transition towards lowering its support and handing that off to south africans, according to current plan. so trying to highlight some of that. the fact that we're coming into a zone where our own programmatic achievements and engagements and partnerships are so rich and so deep gives us all sorts of opportunities to be so much more creative, i think, in the way the conference is used

to build congressional support, to get other people excited. it's just so much -- it's a very promising set of opportunities, thank you. >> i love the way you talked about the road to durban as a way to really mark our progress. and i think if we reflect back to 2000 and that very difficult time between then and about 2007 in south africa, where there was difficulty with even awareness of hiv/aids, as the agent causing aids, putting road marks down about each of these things, about stigma and discrimination, the legal framework, south africa has some of the most important laws. and working with our south african colleagues to say let's in these next 24 months work with other countries on the african continent to move towards your vision and really accelerate south africa's leadership in this area and celebrate their leadership and investment in hiv/aids.

they've stood up like botswana and are investing the billions of dollars that it's going to take to control the pandemic in their country. and they've identified the young women issues. so i think getting them to have that discussion now so that that leadership exists in the role up to durban will make it such a much more vibrant conference on where it is a report card, did we deal with the issues in melbourne and did as a continent we move together. so exciting. chris. >> well, thanks, for those -- very helpful. believe me, all three of you are going to be part of this effort, so please, please, your engagement really matters in a big way. i'll say a couple of things. one is, of course, we have not had or won't have had an international aids conference in africa in 16 years. so it's been a very long time.

and, of course, south africa's story and trajectory from 2000 to now is just a sea change, an extraordinary transformation. that would be a huge part of this story. we always try to have the conferences in places that we hope will make a difference. people don't know this, but steve does, when the president lifted the hiv travel ban and we could, in fact, come back to the united states, many of you were there in d.c. in 2012, we'd make the decision to come back to the u.s. and we had to choose cities and we ended up choosing washington because it was the highest prevalence city in the country, sadly. kwazila natal is truly ground zero for women and girls in the united states, the highest rates for women.

we'll truly be in the epicenter of that component of the epidemic and that's the critical part of all that we need to do human rights and stigma. so for those reasons, it's the right place. the head of the human sciences research council and been one of the architects of the national health system is really a leader in how you integrate hiv into a health system. that's one of the reasons why we asked her to do this. she will be the first woman in history, first woman from africa, to chair an international aids conference. so we're very excited about that. when i brought this up to her and said that to her and said, of course, we're going to focus on women and girls. she said, well, i think it's really important that we focus on human rights and key populations and men who have sex with men in africa. so i said, you're on. we're going to do both of those.

finally i would say the nis is a member organization. i hope all of you are members. if you're not, please join us. you actually do have quite a lot of input. it's an elected representation. your new regional representative for north america on our executive committee is ken mayer, fenway health center, a real leader in the field. and so please go on to the is website. join if you're not a member or get involved. we think that durban is probably, we hope, going to be the same landmark as in 2000, but in a very different way. there we were trying to prove a point, a rather simple one, that

hiv is the cause of aids. this time we're really going to be, we hope, at a real turning point where we can start to say, all right, we have the measures, we have the deliverables, how are we actually doing on this promise? and that will be the key. yes, july -- the third week of july. it's always during that time. it comes out to 22 but 27, 2016. >> we're here to help you, for sure. >> wonderful. >> please join me in thanking our panelists. thank you, everybody, for joining us. tonight on c-span3, programs

on campaigning and voting. we will hear about the latest innovations in social media, a recent debate on campaign finance laws and an event focusing on voter i.d. laws. it all starts at 8 p.m. eastern. our campaign 2014 coverage continues with a week full of debates. on c-span today at 7 eastern, live coverage of the florida governor's debate between incumbent governor, republican rick scott and former governor, democrat charlie crist and at 8, live coverage of the kansas u.s. senate debate between incumbent senator pat roberts and independent, greg orman. live on c-span 2, the delaware u.s. senate debate win couple bentsen tore democrat, chris coons and republican, kevin wade and thursday at 8 p.m. eastern on c-span, live coverage of the third and final iowa senate debate between u.s. representative democrat bruce braley and state senator republican joni earnst. friday night, live at 9 eastern,

the wisconsin governor's debate between incumbent governor, republican scott walker and democrat, mary burke. c-span campaign 2014, more than 100 debates for the control of congress. >> just a reminder that tonight's kansas senate debate between incumbent pat roberts and independent greg orman begins live at 8 p.m. eastern on c-span. here's some recent ads from the campaign campaign. i'm pat roberts and i approve this message. >> trillions in new debt. obamacare. nearly 10 million americans unemployed. now, barack obama says -- >> i'm not on the ballot this fall. but make no mistake, these policies are on the ballot. every single one of them. >> obama's candidate for senate in kansas? greg orman a vet for greg orman is a vote for the obama agenda. >> make no mistake, these policies are on the ballot. >> pat roberts is attacking me

and that's exactly what's wrong with washington today. they rather attack opponents than the problems we face. i tried both parties and like many can sans i have been disappointed with both. as an independent, i won't answer to either party, i will answer only to the people of kansas. i will stand up for the idea, regardless of who thought of it. i'm greg orman and i approve this message because while they attack and try to label me, our country's problems only get worse. >> hello, everyone. in case you've forgotten, i'm bob dole. and i want to talk about my good friend, pat roberts. pat's a fourth generation can san who shares our values and fights for kansas every day, from protecting our national security to creating thousands of new jobs, pat roberts is a workhorse in the senate. the stakes are high, the choice is clear. we need to keep pat roberts in the senate. >> i'm pat roberts and i approve

this message. >> pat roberts first got to washington, there were under 1 million illegal immigrants in america. 47 years later, the problem's only gotten worse. today there are 11 million illegal immigrants. instead of working on a solution, roberts has come back to kansas to lie about greg orman. the truth, orman opposes amnesty, he will secure the bored we are a plan that's tough, practical and fair to taxpayers. >> i'm greg orman and i approve this message because while they attack and try to label me, our country's problems only get worse. >> the kansas senate race at one time considered to be solid republican, but then democrat chad taylor left the race, leaving independent greg orman as senator roberts' sole challenger. recent polling has found kansas to be a tossup. see tonight's debate live at 8 p.m. eastern on c-span. now august senate panel looks at universal health care systems in country countries.

the discussion includes the high cost of pharmaceuticals in the u.s. compared to other industrialized nations. this senate health subcommittee hearing is about an hour 40 minutes. the chair is senator bernie sanders of vermont. [ gavel bangs ] >> let's get to work and thank you all very much for being here. we want to thank c-span for covering this important hearing. and i especially want to thank our witnesses, some of whom have traveled from very long distances from around the world to be with us today and we very much appreciate your being here.

the united states states has, i think, a very effective form of government in the sense that we are a federalist system of which means that we have 50 separate states and it is very common that one state learns from what another state is doing. every day in north carolina, vermont, somebody is.coming up with an idea or program it works, other people steal those ideas, learn from those ideas and that's, i think, a pretty effective way of going forward. i do not believe we utilize that practice as much as we should internationally. the united states is not the only country on earth there are other countries that are doing very positive, interesting things and we should be learn willing from them n a sense that's what this hearing is about, is to see what we can

learn from other from other countries around the world in terms of health care and in my view, in fact, we have a whole lot to learn. because at the end of the day r, its united states spends far more per ka.ka.capita on health care, twice as much per person on health care, yet many millions of people who are uninsured and our health care outcome outcom outcomes compared to other countries are not particularly good. that is my starting premise, why is that and what can we learn from other countries who, in many ways aring about debtor than we can? let me start off with a couple of basic facts with both american health care system. while it is absolutely true that some americans, often those with a lot of money receive some of

the best cutting edge health care in the world it is also true that for millions of low and moderate income americans, they have little or no access to even the most basic health care services. later on as part of the questions or answers, we will show a photograph many of you have seen of in virginia or california people lining up in fields to get basic health care and get their teeth, rotted teeth extracted, photographs that would remind you of a third world country. the reality is today the united states is the only major country on earth that does not guarantee health care as a right and that is a basic philosophical debate that we have to have. should all americans, regardless

of income, have access to health care as a right or not? the united states is the only nation in the industrialized world that says, no, you're not entitled to health care as a right. in 2012, more than 15% of our population, nearly 48 million americans, were uninsured, but that's only half the story. many people who had insurance also had high deductibles and high co-payments and those payments created situations where people hesitated to go to the doctor when they should. not to mention, other people leaving the hospital deeply in debt and going bankrupt. is that something that we are proud of? here's another important point to be made. we talk about rationing and so forth. of course, in the united states, health care is rationed but it is rationed by ability to pay, by income.

according to a harvard study published in "health affairs" 2009 and "health affairs" in 2014, some 45,000 americans die every year because of lack of access to health care. and i have talked to doctors, i don't know if my colleagues in their states have talked to doctors. i have talked to doctors who say yeah, people walk in the door and they are now terminally ill, and the doctors say why didn't you come in here six months ago or a year ago and people said, i didn't have any health insurance. i didn't want any charity. i thought i would get better. we're losing some 45,000 people a year because they don't get to a doctor when they should. there are, furthermore, communities around this country. i know senator roberts of kansas mentioned this in a hearing we had a while back. there are no doctors and no doctors in the area at all. people do not have access to basic primary care. now, despite all of that, the

united states, as i mentioned a moment ago, spends almost twice as much per capita on health care as does any other country. we are spending about 18% of the gross domestic product on health care compared to 11 to 12% in france, germany and denmark and canada. 9% in the u.k., australia and norway and less than 8% in taiwan. and israel. and we're going to hear a representative from taiwan in a few minutes. in terms of efficiency, are we an efficient system? compared to the huge amount of money that we're spending, are we getting good value? in august 2013, bloomberg, a respected business source, ranked the united states health care system 46th of 48 countries based on efficiency. now what about outcomes?

if i'm spending $100,000 on a car and somebody is spending $20,000 on a car, we would assume that my car runs better. i'm getting better value, i'm getting value for what i pay for. well, the united states pays almost twice as much per person for health care, but in terms of our health care outcomes, we do not do particularly well compared to other countries around the world. among oecd countries, the united states ranks 26th in terms of life expectancy. residents of italy, spain, france and norway, and the list goes on, will live two to three years longer than americans. so in terms of our outcomes, they are not particularly good. what about prescription drugs? clearly, when we go to the doctor's, very often, the therapy is medicine. i recall talking to a doctor in northern vermont who told me

that about 25% of the patients that she sees and she writes prescriptions for are unable to fill those prescriptions because they are just too expensive. the fact of the matter is the pharmaceutical industry in this country earns huge profits and charges our people the highest prices in the world for prescription drugs. there's a lot more to be said but let me end my remarks with those comments and i look forward to hearing the testimony of our esteemed panelists. senator byrd. >> thank you, mr. chairman, thank you for calling this hearing. i truly thank our witnesses

today for their knowledge and for their willingness to be here to share with us their information and about two weeks our nation will mark the fourth anniversary of the enactment of the affordable care act. better known to most as obama care. today's hearing will inform what direction we will next take health care in america by examining access to care and cost associated with health care systems overseas. as we examine single payer systems in other countries and what we can learn from their experiences, it seems fitting that we also take stock of where things stand in the american health care system today. at the time obama care was being debateded in this very committee, i warned it was the wrong direction for our country. health care was broken before obama care but four years later, the american people are experiences firsthand how the new law has made things worse. that's why americans view the law unfavorably.

and that's why they are understandably weary of still more government involvement in health care. the president promised if you like your plan, you get to keep it under obama care. the federal government mandates that americans -- that americans buy health care coverage and not just any coverage but the coverage that federal government says it good enough. sadly, millions of americans have lost their health care plans and health plans they liked and wanted to keep despite the promises and continued delays of the administration. obama care expanded medicare an unsustainable health entitlement program on which 40% of physicians on average do not even agree to see medicaid patients. i believe the experiences of other countries will reinforce what many medicaid patients already know. their coverage does not always translate into timely access to care. today's hearing will also examine costs. while the president promised that obamacare would bring down premiums by $2500, premiums have

actually gone up by an average of 41% in the individual market due to the law's mandates, how do they attempt to control costs? for starters it established the independent payment advisory board on unelected board of 15 bureaucrats empowered to make cuts to the medicare program most likely in the form of cuts to doctors, which will impact again, senior's access to care. today's hearing will be informative as to the direction we take health care in this country. will we repeal obama kaur and replace it with reforms that lower health care costs and put our nation's entitlement programs on a sustainable path and empower patients in decision-making to find plans that best meet their individual needs? or will we continue on the current course of unprecedented government involvement in health care and unsustainable cost? what do we have to learn from a single payer system overseas and what have other countries reforms meant for their

patients. what would such a course mean for our nation standing as a global leader in medical innovation and for american patients seeking access to quality and affordable coverage and care that meets their individual health care needs. i do want to thank chairman sanders for holding this hearing because it will inform many of us on these important questions. i think today's hearing represents an important admission that obama care is not working, that such an admission takes place within the very committee that the act was written in is a huge step and i commend the committee in taking it. i continue to work with my colleagues to advance patient centered reforms that will lower health care costs and increase access to quality affordable health care. i thank the chair. >> thank you, senator burr. did you want to make a statement? okay, thank you. we have seven very knowledgeable panelists and we look forward to their testimony. we're going to ask you to keep your remarks to five minutes and

then we will follow-up with some questions. our first witness is may ching a health policy reseasrch analyst at the woodrow wilson affairs in princeton university. she is adviser to the china national health development research center and we very much appreciate her being with us today. please speak right into the microphone so everybody can hear you.

>> it's already started counting. >> get close to that mic. >> good morning, mr. chairman, senator sanders ranking member burr and senator enzee. my name is sue mae cheng, research analyst at the woodrow wilson school of international affairs, princeton university. thank you for inviting me to testify. i have been asked to give an overview of single payer system and my written testimony into a few salient points. an overarching point in my testimony is that single payer systems are notes same as socialized medicine or socialism so often assumed in this country. in socialized medicine, government owns and operates the health care delivery system and finances it. the health system americans reserve for their military

veterans and va system is purely socialized medicine. single payer systems are typically just social insurance, like the social security system, under social health insurance, the government merely organizes the financing of health care but the health care delivery system typically is private and can include for profit entities. medicaid, for example, the social insurance, it is social insurance but not socialized medicine. the main characteristics of single payer systems are the following. they are ideal platform for equity and access to health care because everyone has the same insurance coverage and providers are paid the same fees regardless of the social economic status of the patient. single payer systems typically are financed on the basis of ability to pay. rather than on pt basis of health status of the insured. single payer systems typically give patients free choice of doctors and hospitals. in single payer systems providers of care do not compete on price but they must compete

on quality of care, including patient satisfaction. in a single payer health insurance system, health insurance is not tied to a job. instead it is fully portable from job to job when people lose their job and in a retirement. does not go away. therefore there's no job lock in these systems over health insurance. because all funds to providers of health care in a single payer system flow from one payer, it is relatively easy to control total health spending in such systems. the international data i cite in my written testimony made that clear. now, some single payer systems like u.k. and canada, may put constraints on the physical capacity of their health system like number of hospitals and mri scanners as part of their effort to control total health spending including waste create by excess capacity. this constraint may lead to rationing by the queue. the alternative to rationing by search administrative measures is rationing by price and

ability to pay. something that we see in the u.s. health care system, the argument that health care is not rationed in the u.s. is not supported by the data. a single payer system is an ideal platform for modern i.t. with common gnomen clay tour. it can be done electronically and yields enormous savings in administrative costs. and because such i.t. system conveniently captures data and information on all health care transactions, these systems provide data base that can know spending in real time and is in the case of taiwan and it is a base for use for quality measurement monitoring and improvement. and public satisfaction of a single payer systems is generally high. denmark, for example, is ranked the number two highest in the european union in consumer satisfaction. in taiwan public satisfaction is also very high with a national health insurance program. ranging in the 70s to 80%. in canada, a 2013 international survey of 11 countries found that 42% of canadian surveyed

said that their health care system works well and need only minor changes compared to just 25% of americans who said that. 75% of americans said -- american health care system needs fundamental changes or completely rebuilt. lastly, survey research has shown that single payer medicare is very popular in the u.s. a final point is that every health system has its flaws which can be highlighted with anecdotes, therefore there's now

a brisk medical tourism worldwide, for example, canadians come to the u.s. for health care but it is also true that americans go to canada, mexico and thailand and taiwan for lower cost health care. thank you very much.

>> thank you. we're going to go to do rodwin, a professor of health professor of wagner school of public service and work the his entire career on studying health care system as broad with a special focus on france. he head the fullbright distinguished chair at the university of paris in 2010. doctor, thanks very much for being with us. >> thank you, senator sanders and distinguished members of the committee. good morning to all of you watching on c-span. my name is victor rodwin. i will speak on the french health care system. that system is a model of national health insurance that provides health care coverage to all legal residents residing in france. it is not, i repeat it is not an example of socialized medicine like cuba. it is also not a national health service as in united kingdom. it is also not an instance of a

government-run health system like our excellent veterans health administration. french national health insurance in contrast is an example of public social security and private health care financing combined with a die verse public/private mix in the provision of health care services. the french health care system reflects three political values embraced by americans. liberalism in the sense of giving patients free choice of any doctor or any hospital they care to go to with no networks and no restrictions. second, pluralism, everybody has a die verse choice, they can go to fee for service or group practices or outpatient health centers or emergency rooms or go to public hospitals or private hospitals or outpatient consultations with specialists in public hospitals. the third value is solidarity in the sense of having those with greater wealth and better tellth and finance services for those in poorer health. in terms of population health, the french outdo us and i'm

embarrassed to say that, hands down. look at any indicator you like, life expectancy at birth, infant mortality, they better than we do. female life expectancy at 65. they outlive us. female life expectancy at 80 years of age where medical care matters, they outdo us. disabiblt adjusted life expectancy, they outdo us. years of life lost, we have more years of life lost. this is not a re-republican or democratic debate, these are the facts. but that's not the way to judge a health care system entirely. surely a health care system reflects these indicators but not just the health care system. my colleagues at nyu would still say we have the best health care system in the world in spite of these indicators and would argue these indicators reflect other things for which they assume no responsibility. social securities, inequality of income, family policies which are very strong in france. maternal and child health programs which explain why they have better population health

than we do. we have to look at other indicators and one person indicator of health system performance is called avoidable mortality. in a good health care system women should not die in childbirth. people should not tie of tuberculosis and not die of he schemic heart disease or cancers that can be cured. when we look at that, i'm embarrassed to say we come out at 19 and french come out as number 1. i repeat, number one. that is a fact that cannot be ignored. it must be addressed.

it was written up in "health affairs," a reputable journal, and confirms with different measures by the oecd and not received, in my judgment, sufficient discussion. another indicator of how well a system is doing and theme of this subcommittee that i know is dear to chairman sanders, is access to primary care. you can talk about primary care until you're blue in the face, but let's look at the consequences of whether you receive primary care or not in different health care systems. we have a very established measure of primary care access. it's very direct. if people end up in the hospital for conditions for which you should not have exacerbations if you have access to primary care, that's called avoidable hospitalization. on that criterion, avoidable hospitalization, the rates of avoidable hospitalization are twice as high in the united states as they are in france. that's an unfortunate statistic from the point of view of an

american, but that's the way it is. lessons that we can draw. i believe that health systems cannot be transplanted from one country to another. but we can talk about some issues, and i'll just tick them off. i'll go over 30 seconds, if you'll allow me, mr. chairman. in france, there's no choice of insurance plan. everybody is in the same plan for the standardized benefits, but there's a complete choice of hospital or doctor. in france, all insurers, and there are more than one, pay the same price according to nationally set rates. you don't have a lower price for medicaid, a higher price for medicare and higher price for commercials. in france, there are no physician gatekeepers. everybody can go where they like.

no one is telling them what work they can or cannot go in. they have to call their insurance company to get authorization. there's extensive co-insurance, small, but there's a voluntary -- >> we'll have to learn more about france in a few minutes. senator murphy, did you want a brief opening remark? all right let's go to dr. yeah, a professor at the school of public health, university in taiwan and we appreciate you're being with us today. speak closely into that microphone and tell us what goes on in taiwan. >> chairman sanders, senator byrd and distinguished members of the committee, thank you for inviting me to testify here. i'm the professor at the tzu-chi university, but i was the founding ceo of our national health insurance administration in 1995 to 1998. 19 years ago. and i was the minister of health in taiwan. and taiwan established the universal national health

insurance in 1995. currently, 99.6% of population enroll in this program. the other .4% is -- they have citizenship, but stay abroad. they are not covered. taiwan's nhi program is a single-payer system and has a large single-risk pool. before that, we have 12 different social program, strong and weak program, and we merge into one single pool. that's enabled us to have close subsidation among the rich and poor, the well and sick. studies show that the premium contribution compared to the health resources utilized are favorable to the low and mid to low income.

having a single-payer system is the main reason for our sufficient services and how at the low prices of our health care we can achieve. we have a private not for profit and very highly competitive providers enable us to have efficient service. we contract 100% of the hospital in taiwan and 93.5% of the private practitioner, and if they have the card, they can go anywhere, any hospital, any practitioner and seek their advice. that's enabled us easy and equal access to the system.

and single insurance administration have the benefit of very low administrative costs, which is only 1.15% of the total nhi spending. and people enjoy complete free choice of provider. and provider in taiwan must be mindful of their patient's demand to stay competitive. also, the effective rate is up to two years of the implementation, only 70 to 80%. we have a national fee schedule, uniform fee schedule. the cost of the hospital and the provider can only compete on quality instead of price competition.

and we -- a patient carry their insurance card can go to any provider if they are not satisfied with their quality of services. basically, there are no waiting lists at all except for a few well-known medical institutes or well-known doctors. and rationing is solved by provider competition and efficiency of our services. in 2012, our expectancy and infant mortality and maternal mortality and the some indicator we are much better than u.s., although we spend only 1/6 of the u.s. dollar. if ppp adjusted, it is one fourth of the u.s. dollar we spend, but we are doing better than u.s. and lastthing i wish to mention is our i.t. system.

health information system. subm. so in the -- in the, on the way to develop a emr. in the next few years. i think my time is up. thank you. >> thank you very much. >> no, sir, in the interest of time i do have a question of the witnesses. >> okay. we'll get to that. thank you very much. senator burr, you have a panelist you want to introduce. >> thank you, mr. chairman. and i thank my colleagues.

i have the pleasure of introducing to you today miss sally pipes in health care studies at the pacific research institute in san francisco, california. sally, thanks for joining us today. to explore what we might learn from other countries around the world to improve our health care system here at home. as a native canadian, she has a unique understanding of how sing singlepayer systems actually operate. congratulations on becoming an american citizen. we're ploeased to welcome you ad look forward to hearing about your personal experiences and professional analysis. >> thank you, chairman sanders and ranking member burr for inviting me to testify today. i'm sally pipes, president of the pacific research institute, a think tank based in san francisco that's dedicated to advancing opportunity for all

through market-based solutions. i'm going to focus. a system with which i'm extremely familiar as i am as senator burr said. as a shining example of advantages of a state-run singlepayer system. canada is, in fact, one of only a handful of countries with a bona fide single payer system. government officials set the budget for what can be spent on health care. every year. provinces administer their own insurance programs with additional funding from the federal government. private insurance is outlawed in many provinces. this is a sort of system that many are calling for here in the united states. they want to abolish private insurance and leave government as the sole source of health coverage. but the canadian system is one that would not be suitable for

america. officials severely restrict patient access to care. and those restrictions saddle patients and their families with massive monetary and nonmonetary costs. or to frame this in terms of the title of this hearing. if you're looking for lessons from health care systems abroad, canada shows us exactly what not to do. let's start with wait times. according to canada's frazier institute, the average canadian has to wait over 18 weeks from seeing a primary care doctor to getting treatment by a specialist. and wait times are only growing. the 18-week delay today plaguing canadians is 91% higher than it was in 1993. at any given time, 17% of the

canadian population, 5 million out of 35 million are on a waiting list to get primary care. there's also a severe shortage of essential medical equipment. for instance, canada ranks 14th out of 23 oecd countries in mri machines per million people with an average wait time at just over 8 weeks. these lengthy waits have profound consequences not just for patients who are suffering, but the rest of society. when people aren't treated in a timely fashion, their conditions worsen and their health deteriorates. their productivity drops and they may have to stop work entirely. and they often end up requiring significantly more expensive and extensive treatments which are costly for the entire system. one estimate from the center for spatial economics found that wait times for just four key

procedures, mri scans and surgeries for joint replacement, cataracts and coronary artery bypass graphs cost patients $14.8 billion every year in excess medical cost and lost productivity. once canadian patients finally receive medical treatment, it is far from free. about 68 cents out of every dollar in government revenue goes to health care spending. but the typical canadian family spends about $11,300 in taxes every year to finance the public system. technically, every canadian has access to needed health care services. in 2005, madame chief justice beverlily maclaughlin of the canadian supreme court ruled in favor of overturning the ban on private health coverage in quebec. she wrote that access to a waiting list is not access to health care. those canadians who can afford

to opt out often come to the united states about 42,000 canadians come every year to this country. to pay out of pocket. danny williams, former premier of newfoundland in 2010 flew to florida for heart valve surgery. when questioned by the press about that decision, he said it's my heart, my health, my choice. i did not sign away the right to get the best possible health care for myself when i entered politics. brian day, an orthopedic surgeon said, a person can get a heart -- a hip replacement for their dog in less than a week for a canadian it's over two years. my own mother died from colon cancer because she had to wait. she could not get a colonoscopy. she entered the hospital, had a colonoscopy, died two weeks later from colon cancer. how much longer could we have had my mother if she had prompt

treatment. there are -- there is an example in the u.s. of a singlepayer system, it's the v. v.a. and dissatisfaction with waiting lists. no way for us to run a health care system. a singlepayer system. we need a new way to inject genuine market competition and choice into our health care system. we need to scale top down controls by government. thank you and i look forward to your questions. >> well, thank you very much, ms. pipes. turns out we have another canadian with us, as well. dr. danielle martin, a primary care family physician actively involved in practice at women's college hospital in toronto, canada, where she also holds administrative leadership position as vice president of medical affairs and health systems solutions. dr. martin, thank you very much for being with us. >> chairman, sanders, ranking member burr, distinguished committee members, thank you for inviting me to address you today.

my name is danielle martin. >> i have daily firsthand experience. in addition to my clinical training, i hold a masters in public policy from the university of toronto where i'm an assistant professor. i do not presume to claim the canadian system is perfect or we do not face significant challenges. the evidence is clear. the evidence is clear. those challenges do not stem from the singlepayer nature of our system. quite the contrary. working within a public insurance structure helps us to better tackle many of the challenges shared by all developed nations in health c e care, including rise in costs, variations in quality, and inequities of access. i would like to highlight for you three major benefits of the single payer model. the first is equity. poll after poll has demonstrated a strong consensus among canadians that access to health care should be based on need, not ability to pay.

while of course, it is worth emphasizing that at substantially lower cost than in the u.s. all canadians have insurance that covers doctor and hospital care. we do not have uninsured residen residents. we do not have an industry working to try to carve out different niches of the work pool. as we watch the debate unfold, we are reminded daily of its significance. one of the big challenges in the multipayer system is the question of how to achieve policy reform with so many players in the game. in the single payer framework if governors and providers identify a challenge in the health care system, they can work together at the bargaining table to align financial incentives to advance their shared policy objectives. an example upon which i elaborate in my written submission is the way in which

ontario's government and physicians worked together to increase the number choosing primary care and to work in rural underserviced communities. finally, one cannot speak about single payer without the issue of administrative costs. the total estimated savings here would be 27.6 billion per year. we spend our gdp on health care in canada. canadians enjoy the same or better than others. and when we look at outcomes for a range of acute and chronic illnesses. in fact, a recent scientific system review.