highlights the need to enforce bertha guidelines on management of pain need to be enforced in better ways. there's a study that evaluated the extent that physicians are following guidelines by the main medical organizations as relates to management of pain. that's an area where there needs to be an aggressive increase in education and enforcement of guidelines. >> thank you. i am out of time. i ask unanimous consent to submit for the record. >> thank you, mr. chairman. doctor, as i mentioned in opening statement, you're one of the world's top experts on the issue of treating addiction. briefly, what does the body of scientific evidence show regarding effect i haveness of met doen and buprenorphine in

treatment of opioid abuse disorders? >> the research has shown, has shown it not just for methadone and buprenorphine, and naloxone, as part of a comprehensive program for treatment of opioid addiction are quite effective and significantly improve outcomes of individuals being able to stay on one hand ab stinent from the drug or to decrease likelihood of relapsing, also protects them against adverse outcome such as overdose. >> so in light of those studies you also said in your testimony that existing evidence based prevention and treatment strategies are highly underutilized across the united states, and last week we had an expert tell the panel that very few patients with opioid addiction today receive treatments that have been proven most effective. he was talking about the rapid

detox, followed by abstinence based treatment. i wonder if you can help understand this. why do we have a situation where people are not getting evidence based treatment? >> it is a complex problem. there are many reasons they're not getting correct treatment, including the fact of education of proper management of substance abuse disorder including the health care system. then you have an infrastructure because addiction is sigma advertised, therefore likelihood of people accessing that care is much lower, then of course there's a difference between states in the way they implement treatment, so all of these factors account for the current situation. >> dr. frank do you have anything to add to that? >> yes i do. i think one thing that's very important to remember is that overall we treat 10% of the

people with these disorders. so it is not surprising that people aren't getting evidence based treatment because they're not getting treatment period. second part is why aren't they getting evidence based treatment among those that do, and i think that there are insurance dynamics that hopefully we are fixing. there are access to trained professionals who are trained in these things and then in a sense trying to kind of get the systems and infrastructures aligned to support the best practices. >> and doctor, several of our witnesses, including you mentioned that role of the states in this. can you talk about that for a minute? >> absolutely. i think states have different populations, different issues, different prescription drug

monitoring programs and so tailoring for states, so they can identify state medicaid program or other high risk patients, that's why the program at cdc is helpful, we are a higher level view to work across states. >> and do you think the states have work to do in terms of implementing these programs that are science based and that work? >> you know, i think we are starting to do that. like our program itself has only been in existence for six months but we are seeing great progress. if you look at policies states are implementing we are seeing reductions in doctor shopping patients going to different doctors because of utilizing prescription drug monitoring program. although it is early in the stage, i am optimistic we are making progress in the states. >> doctor, i want to come back to you. another expert last week said patients and their families need to know detox i have indication and drug free counseling are associated with a very high risk

of relapse. i am wondering if you can tell us what the science shows. is this type of treatment generally effective or less effect sniff what is does the research show? >> the research has shown that in general it is associated with increased mortality. this reflects the fact that addiction is a chronic disease, changes in the brain persist months, years after you stop taking the drug. what they do is remove the physical dependence and assume the addiction is cured and these are two independent processes. as a result, the patient feels they're safe and then they relapse because they're still addicted addicted. >> thank you. thank you very much, mr. chairman. >> recognize mr. collins for five minutes. >> thank you, mr. chairman.

this is truly a fascinating topic we are discussing and it is obvious there's no easy solution. we heard it is a chronic disease, 10% are seeking treatment. i guess my question for miss hyde and samhsa is certainly with pregnant women that may have young kids at home, inpatient treatment might be the preferred, we just can't let perfect be the enemy of good. what other options are you looking at for people that aren't going to enter inpatient they may be part of 90% not getting treatment at all. some treatment better than no treatment, as frustrating as that might be? what are your comments to the young mother that's got kids at home, she's pregnant and dependent and just can't go into an inpatient center. what do we do for that patient? >> thank you for the question. the issue of pregnant and

parenting women is a big one in our field. we have a small program to address your issue, but you're right, it is a residentially based program. we are increasingly looking for ways to take what we learned in the program about the best way to treat pregnant and parenting women and take it to other settings, whether it is opioid treatment programs or the training we do for physicians who are using medication assisted treatment to deal with pregnant and parenting women so we are trying in every way we can to make those services available to those women. >> so again, with pregnant women, looking at other treatments, whether that's buprenorphine or methadone, are there studies that show whether that has an impact on the fetus and baby? >> you're right to be concerned about the child. what we see is that this prevents death it prevents

addiction of the baby prevents a lot of other issues that come with allowing the young woman to continue with the prescription drug abuse or opioid misuse. providing treatment helps both the woman and the child. >> now, you've counselled these women. what kind of reaction are you getting? are they recognizing, you would think genuine concern for the baby, very much a complicated balancing act going on here. what kind of reactions are you getting from the women acknowledging the problem and wanting to treat it? >> you know, most pregnant and parenting women really want to do the best thing for their babies and they want to do the best thing for themselves, but as you've heard addiction is a chronic disease, it is difficult. changes the brain changes the

ability to make decisions. the women in the programs we provide support for find it a helpful program with the kind of supports because we provide a range of programs and we have recently introduced medication assisted treatment into the programs as well. >> so are these women finding you on their own or are there physicians guiding them to you? >> the women that come to our programs come from a variety of places, some from correctional system, some from physicians some from family some from self referral. so they come from a number of places and we don't make a distinction between where they come from in terms of providing care. >> now, something this committee is very concerned with, and again, mr. chairman, thank you for holding this hearing and for all of your testimony. i wish there was an easy solution there just doesn't appear to be one. so this will have to be addressed on a lot of fronts. with that, i yield back.

>> thank you, mr. chairman. let me welcome the connelly family to the hearing and let me compliment michael bod which he ee for having the roots origins in the 20th congressional district of new york. welcome all. one of the biggest concerns i hear from families struggling with addiction is difficulty they have accessing treatment. with the mental health parody and addiction equity act as well as with the the affordable care act, millions more gained access to mental health and substance abuse services. however, recent reports lay bare the fact that these new treatments as options sometimes exist on paper only. so my question first to assistant director frank dr. frank, what is hhs planning to do to increase public disclosure of the medicaid management practices insurers use both on the commercial side and on medicaid and chip so that

consumers can truly evaluate their health plans to ensure they're in compliance. >> thank you for the question. we too, view the mental health parody act as an incredibly important opportunity to increase the use of evidence based practice and access to treatment. we are doing a number of things. we work with both the department of labor on the erisa side of commercial health insurance side. we trained the erisa investigators in how to detect deviation from parody arrangements within insurance, and so they're out there fully trained now working on these issues. we have a group within hhs who regularly provides technical assistance to state insurance commissioners and works with them to resolve complaints as

they arise and we've done continuing series of forms and technical assistance around the country. we are working with stakeholders, some in the room today, to improve our ability to ask for disclosure and to offer up consumers the opportunity to really make that evaluation that you referred to. >> thank you, assistant secretary. director bod which he ee would like to talk about another barrier for treatment to patients. press accounts suggest that some states are denying patients access to drug courts if they're receiving medication assisted treatments or mats. i understand this is a problem in kentucky, according to some press accounts. so director can you explain what's going on here, given the important of mats, why are some attempting to cut patients off medicines that can help them recover? >> thank you congressman.

as many of my colleagues talked about today, increasing access to medication assisted treatment along with other behavioral therapies is the best course of treatment for people with opioid use disorders. one of the accesses we find in addition to issues around payment have been particularly lack of access within the criminal justice system and we know that many people with opioid use disorders end up in our system. some drug courts haven't adapted policies that national association of drug court professionals endorse in terms of ensuring people who have an opioid use disorder get access to those medications as well as not predicating participation that they get off the medications. part of what we have been doing on the federal level is using our federal contracting standards to ensure people with opioid use disorders, whether in drug court or treatment program or other venues are offered access to medication assisted treatment and are not denied

participation based on the fact that they are on physician prescribed medication. >> doctor volkow, on that issue do you agree with the ai assessment? >> i agree and developing opportunities that are more amenable, like prison and jail there's no reason they shouldn't get access to medication. >> another barrier that patients face is lack of available treatment providers who can prescribe mats. director, can you comment on this derth of providers that can prescribe buprenorphine, for example? what are the reasons for the shortage, what can we do to address it? >> one of the other opportunities we have is ensuring all of our treatment programs either -- low

percentage of them incorporated medication assisted therapy into their programs. some of this, congressman quite honestly, has been by myth and misunderstanding and this divide between abstinence based care and medication assisted treatment which i think is really unfortunate that we have here. we really want to make sure if a client is entering a treatment program that has particularly federal funding, needs to offer by way of its own offering or through referral medication assisted treatment. >> all right. thank you very much. and thank you to the entire panel for guiding us on this. >> i want to ask as clarification for the question on drug courts and use of medication assisted treatment, you're recommending medication assisted treatment as part of an option package, although you say obviously we want to get people free from drugs all together.

does it require recommended practice from your agencies to get drug courts to do that? does it require regulatory changes from one of the agencies or legislative solution from us to do that? >> we have been doing that as condition of their federal drug court language. you know again we want this to be decided by an expert in addiction services in consultation with the patient, but didn't want categorical denial. >> are you adding to that? >> i did mention in consultation with ondcp and with department of justice we changed the language in request for applications for drug courts so that they can't require someone get off of or not be on medication assisted treatment, if it is prescribed appropriately by physician or certified program. >> so i just wanted to add though, what you can do you can make federal funding contingent

on full programs but we can't force the states or whatever regulatory agency setting up the drug courts to offer this, they just can't get federal money if they don't offer it. >> going to be talking at state level as former state administrator, states play a crucial role. there are many many programs out there that don't receive federal funding or drug courts that don't receive federal funding. we hope our policies and procedures are adopted by those nonfederally funded programs, but states play a key role in licensing treatment programs. >> thank you. >> and they i think can look at the opportunities of increasing or ensuring that state license of treatment programs also have the same kind of language. >> thank you. speaking of states, the gentleman from west virginia. >> thank you very much, mr. chairman, and thank you for the hearings on this topic.

as an engineer, i need to see things in perspective. so been following this the last four years in congress and on this committee, trying to look at this issue. i think one of the last meetings we just had, i tried to put it in perspective by saying -- you said there were 44,000 overdose deaths. i want people to understand, that's more than died in vietnam in combat. i don't know that the american public understands that and every day on the news nbc or whatever, they had body counts and had that and people were outraged over that. i am not getting the sense of outrage over every year we are lose as many to drug overdose as in a ten year war in vietnam. i am concerned when i had affirmed in west virginia one in five babies born in west

virginia and may be 1 in 4 in other states, but 1 in 5 have been effected with drugs. i keep things in perspective saying in europe overdose rate is 21 per million. in america it is 7 to 10 times that amount. i get on the verge of outrage, father of four, grandfather of six. these are what we are giving our kids, this is what the future is. i hear this testimony from this panel of seven and seven before that and seven before that. quite frankly, i get confused. i don't know what the priority is. for the business community and you all here in washington everyone loves to plan. but they don't carry out. that may be insulting, and i

don't mean it in insulting fashion, but we have 44000 more people that will die between now and next year. i would like to think we could come up with one way at least one, prioritize it, what's one thing, and then put everything we have into it. that manhattan project go after that one solution and see if that doesn't start the ball rolling in the right way. then we can do two, three, four with it. but a focus. i don't see a focus. i didn't see a focus from you. i heard seven or eight ways we might be able to approach this problem because the plan everyone loves the plan but implementation falls short. so since you're meeting on a regular basis couldn't you come up with one idea to where we ought to begin? the metrics, the optics, we can dig into that and then we can have plan b, c and d, but let's achieve one instead of continuing to meltdown like

this. i don't want to see another statistic of 44,000 more people died of overdose. i hesitate to ask, can you come up with an idea today in the time frame? is there one, just one idea we should focus on? what's the best way? is that in the drug use is that in real time, on purchasing prescription drugs that it is a national database? is that the number one thing we should do? my god the federal government just changed sentencing guidelines for her oh in. if you're caught with 50 hits of heroin you get probation. what are we doing? are we fighting heroin or not? i am really frustrated with this. give me more guidance on plan one. >> i appreciate your attention to this and you know myself and many of our colleagues have been

doing this work a long time, i think are filled with a sense of tragedy in terms of where we are and know that we can do better and work with congress. you asked for one. i think there are three areas in the secretary's plan that we have to do. we have to change prescribing patterns, we are prescribing way too much medication. and that's starting the trajectory. we need to increase capacity to treat the disease so people that go down that path have adequate access. the third, that we need to focus on reducing overdose deaths. those are three areas we can work with congress onto look at how do we increase our efforts. >> let me add onto that. seems that people from west virginia think alike that way and our secretary who is -- shares the same experience you do pushed us to focus and take action in those three areas. you know with it this year we

more than quadrupled funding in those areas and we're going to triple that again if our plan goes through and these are in those three focused area because that's where the evidence says we should be doubling down. that's what is guiding us. >> thank you. is the secretary asking for legislation on this then to facilitate the answer to that question? >> there are some legislative proposals and some of it is just increasing some of the use of discretionary funds and we got some additional appropriations this year, and then in the president's budget we have some legislative proposals. >> let the committee know if there's any language to address that question. miss clark from new york you're recognized five minutes. >> thank you very much, mr. chairman, and ranking member. thank you to all of our witnesses for giving the committee the benefit of your expertise and experience. i would like to focus on the

prevention side of the equation, how do we prevent opioid addiction in the first place. dr. volkow picking up on a point made just a moment ago about way too many prescriptions, this is to you. why are so many prescriptions being written for opioids? are physicians not getting the appropriate level of training and education in pain management? responsible opioid prescribing practices? what would you say? >> they're both. actually what happened is we have to recognize that there's another epidemic of chronic pain in our country, estimated 100 million people according to the institute of medicine. as a result of pressure of need to go address this problem the joint accreditation required that hospitals and physicians in hospitals ask questions about pain and treat them. this was in 2000. the problem was that that was

not aso atd with the education required to properly screen pain but also to manage it and to manage it and use opioid medications adequately. there was a pick up between need to implement better treatment for pain, but inadequate education of that system. so that's a major problem. in terms of prevention we have to recognize two aspects on this epidemic different from the others. one, we have individual start diverting and get medication, they want to get high. then there's the other element as important of individuals that are properly prescribed the medication because they have pain. in the past it was believed you got an opioid and had pain, you will never become addicted. data shows that's not correct. the range goes enormously from none to something like 40 60 we have no idea. that's why i highlighted the

notion of if we need to be very aggressive in education of health care providers on screening and management of pain but also be very aggressive on treatment of health care providers for recognition of substance abuse disorder to determine who is vulnerable. when a person is properly treated, to transition and how to treat. >> director do they believe the federal government should mandate continuing medical education on responsible opioid prescribing practices as a precondition of dea registration to prescribe controlled substances? can you elaborate on how that would work if that's the case? >> sure. we support mandatory prescriber education for all of the evidence that you heard today, it is clear that if we want to prevent prescription drug misuse heroin use and overdose,

we need to stop prescribing these so liberally. there was a recent gao report that showed physicians get little to no pain prescribing, veterinarians get more pain prescribing than physicians in the united states. so we don't think it is overly burdensome to require physicians in this epidemic to have education. i think if you talked about it, we would have to work with legislature to look at changes to controlled substances act to ensure that a certified continuing medical education program would be linked to the dea licensure or relicensure process and that we would monitor both -- oversee those courses we believe have core competencies we think are important and monitor who takes those. >> very well. thank you very much. manufacturers of opioid pain relievers are currently required to offer free voluntary

education to physicians or responsible opioid prescribing practices. however, as i understand it physician participation rates for the voluntary education courses are fairly low. is that correct? >> we do have those programs in place. they were put into place about 18 months ago and so the initial year was spent putting into place a process to allow the education to be available prescribers to make use of it. during that time we saw about 20,000 prescribers that are using extended release, long acting opioids sign up for one course. 20,000 out of 320,000 prescribers that prescribe the medicines is not a large fraction. it is progress. we hope in the second year that ends july this year, we will see a larger increase in terms of uptake and use of this education. we have been working with the continuing education community to make better use of it, make

it more available. we are optimistic. we hope we will see more use. it is one of two pillars of education from our perspective, combined with mandatory education that he just spoke about, we believe both of these provide important opportunities to educate prescribers. >> very well. i yield back. thank you very much. >> thank you. miss brooks of indiana five minutes. >> thank you, mr. chairman, for continuing the focus on this critical subject for our country. i want to start with you, dr. volkow. we talked about how the opioid addiction facing the country is in large part due to chronic pain. you mentioned 100 million people suffer from chronic pain. one in i heard up to one in three americans possibly suffer from chronic pain. one of the goals of this hearing is to focus on evidence based treatment and new treatments, try to find out what is working and obviously one treatment doesn't work for everyone as we

heard. but there is, i learned about in the course of examining this that there are technologies that are new, not completely new, one being -- i was told about spinal cord stimulation which targets nerves with electrical impulses rather than drugs. clinical studies show it to be safe, 4,000 patients received the stimulator, so it obviously is a device, a technology that can actually stop that stimulation, it can help hopefully end that addiction yet nih hasn't included it in the draft pain strategy didn't mention technologies like scs. can you talk at all about why it wouldn't be promoting this fda approved type of technology and are there other technologies we ought to be talking about other than medication for chronic pain? >> thanks for the question. indeed, this is an area that is

rapidly evolving, and if it is not mentioned it is because many of the findings are too recent. the one that you're commenting in terms of stimulation is one of the strategies we are promoting research, and the same strategy can be utilized to be able to actually inhibit the emotional centers of the brain that react to pain. so researchers are utilizing a wide variety of tools and technologies that have a goal of the initiative to understand the brain, that again highlights, but brings up something that i think that is facing us in this epidemic the need that we have to develop better strategies for the management of chronic pain because the physicians are forced, patients in great suffering, they don't know what to do and give an opioid even though the evidence does not show us that they're very effective for the management of chronic pain but there are not many out there.

so recognizing this is an area where we require to invest resources for patients with chronic pain is an important part of address zblg how would you recommend we increase patient access and educate more physicians about this type of technology? >> well, this is new technology, some of them, actually the evidence is just emerging. it will have to be submitted to the fda for approval then physicians as part of training should be exposed to them. i would say just highlighting in the notion because michael bod which he ee delynn latd it is important medical students as part of basic training have understanding of these technologies. pain is part of every medical condition, almost of every medical condition. >> thank you very much. i would like to ask you, my state, state of indiana, recently passed a law allowing

physicians to prescribe the naloxone to parents and others and friends giving them greater access to the reversal heroin drug. would you speak as to what's known about the impact of those programs and whether you have concerns about whether naloxone might encourage more risk taking because i met with law enforcement who said they had given people naloxone, saved their lives and a couple weeks later saved their life again with naloxone. and so i am somewhat concerned. i want to absolutely save lives and we must, but yet -- and we know there aren't enough treatments, this is a huge problem, but might that encourage an addict if they knew their mom, dad or friend had the save right there can you talk to us about these naloxone programs? >> so to the first question obviously naloxone distribution

by people who have the potential to win this and overdose law enforcement in counties play a key role in that effort. i will tell you by way of when i was in massachusetts, we significantly increased access to naloxone and did a peer reviewed study that showed when you introduced naloxone into a community, overdose rates go down. and the more naloxone you introduce, the better the scale effect. one of the pieces we are concerned about but no evidence to show that naloxone distribution increases drug use, some of the issues that you mentioned become critically important that overdoses are often seen as a significant motivator for people to seek care, but having treatment on demand is a particular issue. treatment on demand particularly in rural communities, is particularly an

issue. interventions at emergency departments to get people into care are critically important. while we know addiction is a chronic disease, and some people continue to use when you have adverse events, but we also need a comprehensive response. >> i agree. i hope the results in indiana prove to be the same as in your state. i yield back. >> thank you, mr. chairman. before i get to some questions, i have a follow-up question for miss hyde. last time that you were in front of this committee which i really appreciate you coming back we discussed your websites and if they were an effective use of taxpayer dollars. at that time you stated that you were in the process of evaluating that. have you finished that process yet? >> that process continues. thank you for asking the

follow-up question. the process continues. i think the website that you indicated most concerns about was one of the websites we were in the process of reviewing. it was originally developed based on data and knowledge from nida. >> that was for the three to six-year-olds for suicide prevention. have you finished that one yet? >> yes building blocks i think is the one you were concerned about. >> right. >> we have worked with our colleagues at nida and determined the website hadn't been updated needed to be updated, and we are in the process of updating that. >> could you give me progress reports so i can know where you are at? we want to be sure taxpayer dollars are being used in an effective way. >> certainly. >> to get to questions simple yes or no, does the fda recommend methadone be used as first line of therapy for chronic pain? >> methadone is approved for use for pain, yes.

>> but specifically speaking to the first line, for first line of defense basically? >> it is one of the medications that we've have approved for pain. if you look at methadone, the labeling for methadone it calls it out as far as a product that has particular characteristics that make it challenging to use for pain. >> that would be a no for the first line. >> our recommendation is prescribers think carefully before using methadone. there are things that make it a challenging product to use. it is approved for use in that setting but i hope doctors think carefully before they do it. >> well the fda put out a warning about the drug safety and basically said that you guys, that insurers should not, should not be referred as preferred therapy unless special instructions in education was put onto it. so i would take that as the fda would by this statement it would be a no, that you wouldn't

recommend it unless there's a lot of consideration taken? >> personally what i just said is where i would be. i would need to look at the statement and get back with you about specifics of it. it is a drug that has a long half life that's variable patient to patient. has unique cardiac toxicity. there are other drugs useful for pain that don't have those characteristics. >> all i am looking for is yes or no. i am trying to get to another further down the line of questions. i appreciate you being here. i like the last name, my sister's last name. >> good last name. >> i have three beautiful nieces. the spelling is usually messed up. doctor, what about the cdc? do you guys consider this methadone as being first line of defense for pain? >> at cdc we focus on primary prevention, not as much as care. i would defer to sister agencies

on that. >> which would be. >> the panelists here fda. >> he gave his personal opinion, the statement of fda you heard about. would you follow the statement i am assuming? >> i would follow his statement. i don't have a person opinion on methadone for pain, it is not something i did in my prior practice. >> dr. conway, by the way i am always jealous when people have their family with them. i have five wonderful kids. if you ever want to see me cry, that's about the only thing will make me cry, i miss them. >> how are your kids doing? >> thanks, i appreciate that. >> i'll take a deep breath, wipe the tear away. are you aware that methadone accounts for 30% of overdose deaths while only accounting for 2% of prescriptions prescribed for chronic pain? >> i am aware it is a higher percentage of deaths compared to

prescriptions because of the long half life and risks described. >> would you personally recommend it as a first line of defense for pain? >> i am a practicing physician, i do not as a practicing physician typically use methadone as first defense. however, i think it depends on the individual patient characteristics and would defer to the physician's judgment with that individual patient. >> according to the pew research, they put out a deal that said methadone is available in low cost generic form, considered preferred drug in many states by their medicaid programs, despite fda warnings about the drug safety and statements by american academy of pain medicine that insurers should not be referred this therapy unless specially educated and provided to the individual. i just kind of wonder if overall i would think we're considering it not being there, why is this still listed as a first line

with medicaid when we are seeing so many deaths. it almost makes you think is the cost of a life not more valuable than the cost of a low drug? >> i would make a few points. statutorily, medicaid programs have the ability to set their preferred drug list. however, we have taken a couple of actions to try to address this issue. one, working with samhsa and others on the panel put an informational bulletin to medicaid programs talking about this issue and complete array of pain both on the medication side risks of methadone and the other options and importantly as others have said the importance of behavioral treatment and medication treatment. i also call out that our medicaid innovation accelerator program, the first area we are working on is substance abuse disorders. we have over 30 states involved and they're taking a comprehensive approach to the

medicaid program to appropriate substance abuse treatment, including appropriate use of medications and other therapies. >> appreciate it. mr. chairman, i yield back. >> a follow up and i do to. >> one of the questions or statistics i was giving in talking about perspective is the model or the situation that they're facing in europe. the average is 21 per million. i was just looking. that's the average? italy, italy is below that. belgium, greece france, poland, bulgaria czech republic slovakia turkey, romania all have less than that, significantly less. what are they doing right what are they doing differently in

europe than we are in america? are we learning anything from them? >> there's something we are doing very differently. you pick up exactly on the point. if you look at united states from some of the medications we may be consuming 95% of total production in the world. the question is are we a nation that is so much in pain that we require these massive amounts of opioid medications or is there something that we are doing in terms of their access to them that it is inadequate. i want again to reiterate the notion that yes, we are overprescribing opioid medications on the one hand, but at the same time not exclusionary, sometimes we are undertreating patients with pain. so we are in a situation that we have it bad in both ways. we overprescribe making these drugs available which then can be easily diverted and prescribing to those that deent need them can also result in

adverse consequences. you don't see that level of prescriptions in none of the european countries. >> so what's the why not? what are they doing? are their doctors more sensitive than doctors in america? are they concerned about trial lawyers? what's the difference between it? 10 to 15 times more dying in america than europe something is wrong. they're doing something differently. i would like to know what it is. >> and that's exactly the way i said, we have to aggressively institute education of the health care providers on proper screening and management of pain. that's a crucial component while also educating them about the adverse effects as relates to substance disorders. and need to face the fact that we need to also provide with

alternative treatments for the management of chronic pain that are effective. >> thank you very much. >> miss collins, you have a quick question. miss brooks. where am i going. >> thank you. this is actually i realize he mentioned it in his opening i wanted to have an unrelated follow-up, if i might, mr. chairman. you mentioned we are having a crisis in indiana with respect in scott county a community of 4300 people an outbreak of hiv due to needle exchange, and would i simply like and i hope many of you have been following what's been happening and the number of citizens in indiana who now have contracted hiv because of their in all likelihood heroin addiction right, or prescription drug addiction, and possibly heroin

addiction as well. i am very curious since i have this incredible panel of experts here what you might say to our state and to the health professionals who are dealing with this crisis to our state and local government officials, what advice and thoughts do you have for our state. truly, if we could this is a crisis in our state that could be in any state in the country. >> so first of all just about staff from all of the agencies on this table coordinate on a daily basis in tight coordination with indiana health department to give scott county the resources to do that. >> i am sure dr. adams appreciates that. >> you're right. i think we are over 145 cases of hiv. one of the consequences nationally is increases in viral

hepatitis as relates to sharing needles. and i think it also points to some issues that we need to include about access to treatment services. what's happening in indiana and scott count is emblematic of potential we could see in other parts of the country, but point to some issues we have been talking about today in terms of making sure that people have access to good care, both infectious disease and substance abuse. have adequate access to clean syringes so they're not increasing infection in this most poignant case of what we need, and that they're having timely access to treatment services, all areas to do that. we will continue to engage with folks in scott county to make sure that whatever we can do on the federal side can help alleviate the situation. >> i would like to add to that i am proud of all the efforts cdc is doing on the ground in indiana in conjunction with agencies here. i agree completely with the director about access to

medication assisted treatment and hiv therapy. the other thing i would add is indiana is number nine in the nation for prescribing. there's a lot can be done when you look at trying to stop the epidemic before it happens. looking at again using prescription drug monitoring programs, having better prescribing guidelines, so people don't get addicted to opioids. that's the third component we need to add. >> maybe dr. volkow and floor hyde. >> there's another, i mean, we got caught by surprise with the indiana epidemic of hiv. i heard tom frieden say it is the fastest growing incidence of hiv cases since hiv entered the united states. but there's been extraordinary advance on hiv that emerged in the past two three years, which is that if you initiate someone on anti-retro viral therapy not only are you improving their

outcomes but you're going to dramatically decrease infect infectivity. when you see a case, you immediately treat with antiviral therapy. they'll do better and this is another aspect which relates to the issue, giving care to -- good infectious disease care jointly with intervention for substance abuse treatment. thank you. >> so i wanted to add, we are working collectively on this issue and we understand there may be legal barriers that we have been talking to indiana about in terms of developing opioid treatment programs and there's not a lot of waivered physicians able to provide buprenorphine. the closest treatment program is 40 miles away. there may be transportation barriers, cost barriers and other so we're collectively working

with the state to try to develop alternatives. >> thank you for allowing me to speak out of voice. >> first, ms. hyde, last week the subcommittee heard testimony from the program director of the stand ford university addiction medicine program that the 42 cfr part ii is an artifact of the past. two doctors seek to treat the same patient for opiate addiction can't community kate with each other. the rule was based upon a 1982 law and reyat havoc in the records. so she strongly recommended that we change that so we are not over prescribing people. and a fen can know who is in treatment. now my understanding is they're contemplating new part 2 rules. i want to know if you're committed to the rules that reflect the concerns that have

been repeatedly voiced by so many in the medical community who want nothing more than to make sure patients aren't given double dozes. is that what samson is going to be working on? >> really appreciate that question because it is a complex issue. and you're right, the laws and regs are decades old bf we had electronic records and other things we're now considering part of practice. we a couple of years ago put some some regulatory guidance to help the issue. but that wasn't sufficient. last year we held a listening session for stakeholders and have taken those pieces of input and are trying to balance the privacy concerns with the need for access to data. we hope that we will have something available for public input yet this year to try to address some of these issues. >> please let the committee know. thank you. and i wanted to follow up on this kentucky drug court issue.

could the drug court decisions relate to the diversion? we heard testimony that the mills are popping up in kentucky and west virginia. and when entering the drug court system it's hard to determine whether it's from an illicit source or prescribed by a doctor. could this part of an issue that the drug courts could work and have some flexibility to deal with this on a case-by-case basis basis? >> i think there are a number of issues. the national association did a survey of drug courts in the united states. and for those drug courts that were not referring, it was actually more about judicial bias than fear of diversion that kept people from doing that. i think the second piece that any treatment whether it's medication assisted treatment or residential treatment requires a level of collaboration and relationship between the court and the provider to ensure that koushts who are referring to treatment are referring to high

quality treatment. you know we do need to pay attention to diversion and drug courts i think in combination with treatment programs with ensure that these are appropriately prescribed and appropriately monitored medications. and they need to make sure that they're partnering with physicians who have prescribing medication in a quality way. >> i just got an article that was talking about in some of the courts they're using viv troll. and for people in and out of incarceration, trying to keep them off by maintaining viv troll. they want to keep these people released from prison drug free. could you please clarify. are you saying that unless they have some synthetic opiates they're going to have federal funding cut or they can still maintain federal funding and vif troll would be acceptable as another part of that program?

>> so we don't dictate to drug courts what medication. that should be a decision between the treatment provider and the patient. our work was to make sure there weren't cat goirl classifications to not offer the medical assisted therapies. and if someone was on a recommended course of treatment, that they not have to get off the medication to do that. we actually don't dictate what medications courts use to be able to do that. i think like any treatment you want to have an arsenal of medications. >> dr. frank, could you respond to the viv troll question too? i'm wondering if that is an option for states as a diversion to be using viv troll that that could be part of what we could be -- microphone please. >> i think that we are trying to have the full armor available to

the treating providers, trying not to get between the provider and the patient as long as there's the opportunities to offer the most richest menu of evidence based treatments that are available. >> follow-up? >> mr. mckinley asked the witnesses what one thing you would recommend that we could do to try to start reversing this epidemic and this problem. he got as far as dr. frank when he ran out of time. so i just ask unanimous consent if we can ask each one of the other witnesses to supplement their testimony. they don't have to say it right now. >> get back to us. >> get back to us with that recommendation. we recognize there's a problem and we're really struggling with the issue of what we do as a congress to remedy it. thank you. >> and i think what you're also talking about, a partnership with the states says we should be looking at kentucky and others indiana. >> indiana. >> colorado courts and see what

else is going on. i want to thank this panel. we'll follow up with the questions. we will ask for more clarifications of this. i want to thank you. as i said last time, too, you know, if this was about a single airplane crash the room would be filled with media. but we've had more people die in the last year from drug overdose deaths than the come pi nation of every airplane crash in north america from 19 75 a to the present. this is a serious crisis whether it's education of physicians. we want to make sure that fade rale funding is going to right direction. i'll remind members they have ten business day to submit questions for the record and i ask that all of the witnesses agree to respond promptly to the questions. with that, this committee is adjourned. thank you.

on the next washington journal, a look at the riots and protests in baltimore and how the death of freddie gray is brings attention to race. the founder director of the center of race and democracy and editor an publisher crystal wright will join us. also smith college economics professor on the nfl's recent decision to voluntarily give up its tax exempt status. we'll be looking for your phone calls and your comments via facebook and twitter. washington journal lye every day

at 7:00 a.m. eastern on c-span. she embraced the role of first lady and wore the finest fashions and looked like a queen, hosting afternoon party frs politician to help her husband's political agenda. and during the war of 1812 when british troops invaded the capitol, she's credited for saving a portrait of george washington and other valuables from the white house. dolly padson sunday night at 8:00 p.m. eastern on "first ladies, influence and image" examining the public and private lives of the first lady from martha washington to michelle obama, sundays on american history tv on c-span3. as a compliment to the series c-span's new book is now available "first ladies." providing lively stories of these fascinating women creating

an illuminateing interstaining and inspiring read. it's available as a hard cover or e book through your favorite bookstore store or online book seller. snow part of a day long event looking at changes for women in the military since the 2013 repeal of the defense department's ground combat exclusion policy. experts and military officials focus on unit cohesion in the mill tear and how it excludes women in combat. the reserve officers association and no exceptions. and it runs an hour. thank you, everybody. and welcome back. we have a thrilling panel coming

up. i think this next discussion gets right at the heart of everything we're talking about, to a great extent. my name is mike, the executive director of the truman center. we are proud to say no exceptions is an initiative and led by a remarkable group of women, including combat leaders from our organization, and supported by a larger number of men in the truman project and center for national policy who also have combat experience. myself included. i served a combat arms officer in iraq and afghanistan. to me, i don't know when this issue was settled for me, probably i'm supposed to be an objective moderator, but to put my cards on the table, my sister is currently serving with distinction as a detective in the gang unit in the new york police department. she can kick my ass. i can tell you that for sure. you know, over two years on the sharp end, on the battlefield, i've seen more than enough examples of women distinguishing

themselves, including in the close fight, providing the fire support, whether it's from a cockpit or another platform we desperately needed at various times, defending their convoys when they came under attack. i mean i think for very many of us who have seen this movie out on the ground, this is a debate that was over a long time ago. so those are my cards, and they're on the table. any pretense of objectivity, i will abandon now. out of curiosity, how many currently serving or former members of the military, u.s. or otherwise, do you have in the audience today? okay. i should have asked how many civilians were in the audience. yes, excellent. it is no exaggeration to say that there is a wealth of knowledge and experience in this room, and that's why we're going to try to make this more of a conversation than a series of presentations. we're looking forward to that. this discussion is really about the central question of unit cohesion and leadership. in the battlefield, especially in the close fight.

we have with us four people that i think provide a great perspective on that across the board. dr. megan mckenzie from the university of sydney. she's a senior lecturer in the government. the center for international security at the university of sydney. research crosses gender studies and international development. she's published in top journals, including security studies. her first book, "female soldiers in sierra leone, sex power and post conflict" and the newest book, beyond the military and myth women can't fight, debunks the belief that women can't fight. it is one of my favorite mini series, but i'm willing to see that happen.

we have dr. robert egnol, a visiting professor and director of teaching with the security studies program, as well as a senior faculty adviser for the georgetown institute for women, peace and security. he's currently on leave from a position as associate professor at the swedish national defense college. he's the founding director of the stockholm center for strategic studies a think tank created in response for non-governmental research and policy advice in the swedish and international context. we're joined by my friend, captain john rodriguez of the u.s. army national guard. he's a 2015 herbert peace fellow who works with me at the center for national policy. served six years as an army infantry officer, including a combat deployment to afghanistan. if that place and name don't mean anything to you perhaps it will. look it up. i had the privilege of spending time there at a different time. john provides an incredible experience.

that sort of infantry unit in a daily grind fight. high intensity and that's a perspective that's needed in this conversation. we're happy to have him. he's a member of the maryland national guard and has worked as a national security intern, focused on human rights complaints and security policy. we're joined by mary beth brigamen. i should have asked you how to pronounce your last name. >> you got it. >> graduated in 1999 and commissioned to the marine corps. she had a deployment to iraq as a company commander. she was combat arms. is a combat engineer. after transitioning from duty, she developed robots to marines. she's the executive director for the southeast region of the mission continues. this is a great panel. i'm going to start it by turning

to dr. mckenzie and asking her to replace me at the podium. if you could tell us about this question that lends its name to the panel. what did you find as you were researching the book on the question of band of brothers, and what does it mean for the combat integration? >> thank you. yes, so i am the outsider in the room. i'm a researcher, and spent years researching the topic of women in combat. i started my research in sierra lee leeone interviewing women there. what was interesting is i found some of the arguments, so there was a high percentage of women who participated in the conflict. even though i present, women said they weren't really soldiers. they were just following. i found some of the arguments

were similar in the debates happening around the combat exclusion for women in the united states. that's how i made that shift. i spent the last three years really sifting through all the research i could find on physical standards, cohesion and women in combat. so i'll talk about that. first of all, i want to say thank you for inviting me. it's a real honor to be here. so focusing on cohesion, one of the most common arguments used to justify the combat exclusion in the u.s. and elsewhere has been the position that women undermine the types of bonding necessary for combat troops to operate efficiently. so the cohesion hypothesis, as i call it, presumes that all male combat units are more cohesive and, therefore, more effective than mixed gender units. this became the dominant argument, along with physical requirements, for excluding women from combat up to the

decision to remove the decision. it remains the main argument used by other militaries across the world to retain the combat exclusion. so today i would really like to talk about the role of myth, emotion and gender bias in shaping the debates around combat cohesion. two points i'd like to make. first, there is an extensive amount of research on women and cohesion. the question of women's impact on cohesion is addressed in actually a staggering amount of well-funded studies, conducted both within the u.s. and abroad. at present, there is a greater need to reflect on the results of these findings, which i'll get to in a minute, rather than call for another study on cohesion. second, in my book, i argue that all male units have been central to military identity and national identity in the u.s. for a long time. there are deeply embedded assumptions associated with the band of brothers.

from my perspective, cohesion arguments, rather than simply focusing on mission effectiveness, can sometimes be code for preserving the band of brothers. while cohesion is often treated as a group dynamic that can be objectively measured, much of the debate around cohesion is driven by emotion and stereotypes that serve to reinforce the perception that camaraderie and bonding is exclusive to men. let's start with the evidence related to combat cohesion. the first point to note is studies show the need to disaggregate between social and task cohesion. social cohesion is the bonds, feelings of trust and camaraderie. by contrast, task cohesion is defined as the commitment of a group towards a shared mission or objectives. put another way, social cohesion refers to whether the group members like one another. task cohesion is whether they can work well together.

despite the important distinctions between task cohesion and social cohesion, researchers often ignore the difference and measure them together. this is important because indicates show women impact social cohesion. this makes sense. many types of workplace studies have found that we tend to want to work with people who are similar to us in terms of race gender, class and ideology. so to learn that men tend to feel more socially bonded to male colleagues in the military is no surprise. but those studies that isolate social and task cohesion have found that task cohesion is linked to mission effectively than social cohesion. in fact, one major study concluded simply, quote, military performance depends on whether service members are committed to the same professional goals, not whether or not they like one another. knowing the task cohesion is a greater indicator of true effectively is significant. when we focus on task cohesion, women are not a factor.

leadership is. here, there's room to learn from other militaries that have integrated women into combat. for example, research on the israeli defense forces found that cohesion can be inspired through shared commitment to a mission, irrespective of previous social or personal interactions. a canadian report on gender and diversity determined the cohesion of a mixed gender combat units was primarily a leadership challenge. in turn, research that puts these together overemphasizes the social dynamics and underestimates the role of leadership and training and they lead to flawed conclusions about women and cohesion. now, getting to the heart of the matter, there's actually quite a few studies that indicate that -- that have been conducted both domestically and internationally that find little relationship between the integration of women and various

understandings of cohesion. as early as the 1970s, the u.s. military conducted tests that determined that women did not have a significant effect on operational capabilities. 1970s. we're still having similar conversations. these conclusions were supported by a 1993 report that found that gender was not listed by focus participants as a requirement for effective unit cohesion. a couple of excellent studies found in the 1990s, that the real cohesion story was one of leadership. so something that is often overlooked here is the fact that similar cohesion arguments were used and then put to rest when it came to african-american troops and gay and lesbian service members. also, we tend to ignore the potential negative effects of social cohesion. in various workplace settings, including the military, overly cohesive or homogeneous groups

have been associated with group think, and diverse groups have been found to have enhanced intelligence and problem-solving and decision making skills. moving on to my broader point about gender and cohesion, i think there's two main indicators that there may be gender bias in relation to discussions on cohesion. first is that cohesion is often referred to implicitly or explicitly as male bonding. second, evidence indicates that the main impediment to cohesion may be men's attitudes, not women themselves or their ability to perform. this first point, cohesion is male bonding. when we're looking at the public debates and the broader literature around cohesion, some descriptions tend to assume that cohesion requires segregation. it is the masculine nature, not the bonding itself that's essential.

so anthony king acknowledges that sociologists prefer informal masculine rituals in sustaining social cohesion. similarlily, kingsly brown, a former u.s. supreme court clerk made the following observation. quote, men fight for many reasons. but probably the most powerful one is the bonding. male bonding with their comrades. perhaps for a fundamental reasons, women don't invoke the follower ship and bond ship that men do. linking national security to all male units makes it very difficult for those trying to integrate women into combat units. defining military cohesion and troop effectiveness by masculine rituals or masculinity places

women as outsiders as their nature irrespective of their performance. and this perspective can't be countered with more research. it requires a change in perspective. this is why attitudes matter. going to the second indicator. i mentioned research earlier that shows little correlation between women and reduced cohesion. but there are some studies that actually show that find the contrary. but if you dig deeper into these studies, you can find some quite interesting conclusions. let me explain. one study found that units with higher numbers of women may report lower levels of cohesion because women as a group tend to report lower levels of cohesion. the more women you have the lower levels of cohesion was women report lower levels. another study found that women did negatively impact also found that men's acceptance of women impacted cohesion. the more accepting men were of women, the higher the rate of cohesion in the group. here you have a separate factor. attitudes that are -- actually

impacting cohesion. and this has been reproduced in international studies on mixed gender units, which have found that men's acceptance of women positively correlated with horizontal cohesion and combat readiness. this is really important because it means that men's attitudes towards women and their acceptance of women, not women themselves, might be the key factor in levels of cohesion. it's also important because it seems that irrespective of women's roles, negative attitudes about their place in the military persist and impact how a group describes its cohesion. just a couple of weeks ago, the results of a survey given to the american special operations forces were reported. and this was a survey just to gauge apprehensions that troops may have in relation to women in combat in order to preemptively address them. and the results did show several misgivings and concerns, including concerns about sexual assault. so we need to understand how these types of misgivings and

reactions to women in combat might impact group dynamics and reported levels of cohesion. we also need to acknowledge that sexual assault is not a gender integration or cohesion problem. it's a sexual assault problem. again what these studies show is the main issue may be men's attitudes and perceptions. we may want to focus on cultural change rather than future studies on cohesion. debates around women and cohesion, particularly those focused on women in combat leave several important questions unanswered, including why does there seem to be more concern regarding women and cohesion with regard to combat units? do women only hinder cohesion for combat troops? do combat units require different types of cohesion from other units?

are we suggesting that the training and military leadership are unable to foster task and social cohesion amongst the soldiers? i would argue that come bags cohesion is not a gender neutral concept. an essential element of the band of brothers myth is the unexplainable or indescribable bonds of the all male group. this representation of cohesion can make it really a moving target that's impossible to pin down and measure. and therefore it's very difficult to counter with research. irrespective of the vast research indicating that women don't impact cohesion, ideals associated with the sacred or special bonding between all male units are all too often treated as fact rather than narrative. i think this characterization sells both our male and female troops short. it implies that men cannot be professional and serve alongside

fellow service members ir irrespective of their gender. and it assumes that women are not as trustworthy or dependable comrades as the male counterparts. evidence indicates these claims simply aren't true. the idea of men on the front lines and women staying behind in support roles are over. stories like ashley's war are stories i'm hearing over and over again not only in the u.s., canada, and new zealand. women are on the front lines and play a major part in modern warfare. speculation about cohesion can actually reinforce myth rather than make women's jobs easier. i think we need to move forward when it comes to combat cohesion and we have the research we need to do so. now we need to address the attitudes about women and consider how the military culture needs to catch up with the reality of women's participation in the war.

thank you. >> thank you very much. [ applause ] >> thank you for that overview of the landscape and the research behind it. robert, can i turn to you and ask you the straightforward question. based on your experience, your research, do you feel that the evidence and the experience of international military supports the idea that introducing women into combat units will degrade performance? or do you not feel that way? >> we'll see. i'll come to the answer at the end of this. first of all, thanks for a brilliant presentation there. i was desperately flicking through my notes wondering what i could possibly add. i'd like to go back to the quote by general dempsey that was up here in support of this earlier on. i'm an academic. well, i'm slightly -- and i'm a foreigner, i don't have to be nice to anyone in here. so he said, we will extend opportunities to women in a way

that maintains readiness, morale and unit cohesion. we'll preserve our war fighting capability to defend the nation. and that sounds good, but when i unpack that, there's a lot of really problematic assumptions and negativity baked into that one. it's about maintenance, about preservation of the existing order. that, to me, is an assumption that the existing organization is perfect. and whatever we do to change it can only have negative or no impact if it's done really, really well. that, to me, is the wrong starting point when it comes to the inclusion of women in combat. i just wanted to put that out there. i think it's horrible to join an organization and feel that the only way i can impact it is negatively or not at all. let's think of this more in terms of increase combat effectiveness or maximize combat effectiveness.

i also think, on the other hand, that military effectiveness unit performance, et cetera those are the right measures. those are the right topics to talk about. we have military organizations for those -- for very specific purposes. the army calls it fighting and winning the nation's war in order to defend the nation. i should probably add that military units do a lot more than just fight the nation's wars, or that fighting the nation's wars these days entails a whole host of very complex tasks beyond tactical level engagement with the enemy. but physical fitness and unit cohesion, those are two traditionally very important aspects of military effectiveness. it's absolutely right we're focusing on those things. that's where you hear most of the complaints or the fears about integration of women. so we have to tackle them on their home court, if you will. i think we've done a pretty good

job of the physical fitness. and at this point, i would just say, get over with it. just do it. let women compete with the existing standards but then also work with those standards to make sure that they are not only gender neutral, because that's a term that quite often hides gender blindness. we assume that just because it's the same for everyone, they're neutral while actually they're part of a highly masculine tradition, highly masculine view of what war is and it means and how it's conducted, et cetera, and tradition, also part of a masculine such. so we have to be aware there and create gender aware standards for all rather mos than gender neutral or slash blind. i also think we should be aware of this argument about

effectiveness since we have not exactly come out of 15 years of almost continuous war with great success and glory. there's been tremendous mistakes, most of them at the strategic level, but also at the tactical level. there's all reasons to try to improve the way we fight. the way we train and organize. and i think we should view this issue as part of that ambition to always try and improve and maximize the effectiveness of the armed forces. something really interesting that came out of iraq and afghanistan are a number of organizational innovations. we have the lioness teams were the early versions. the female engagement teams, gender field advice, gender focal points, cultural support teams, et cetera, et cetera.

lots of interesting innovations going on. those were not ordered from the political level and imposed on the organization. they were attempts at dealing with tactical level challenges our units were facing in the field. again, let's not just look at this in terms of maintaining effectiveness. let's look at it as a way of improving it. these were necessary measures. and i'm going to come back to them in terms of what are the most appropriate ways of integrating women or creating female engagement teams, et cetera, et cetera. but, remember that they were responses to tactical challenges, not imposed on units. there's a number of fields of research. and megan did a great job of covering them. you often hear this argument. we need more evidence, and there is quite a lot of evidence out there. the challenge is that we are up against what is considered common sense within the armed forces. a feeling that what we have

really works. and we know how to train a good infantry unit. we've done it for centuries in the same roughly way. and our drill sergeants know exactly how to push our recruits very hard, and they know that they should encourage the weekend activities that men do, as well, quite often hard drinking and wooing the ladies down at the local pub, et cetera. those are all ways that we know work. and we're comfortable with it because we assume that it is the way we do things. and it, you know, if it worked for centuries, why should we change it? but there's also quite a lot of research highlights that these types of masculine social cohesion units, or sort of constructions, if you will, can quite often lead to some extreme and very problematic cases of

hypermasculinity, abuse. now i don't know if it's directly related to sexual violence within the armed forces, for example, but it seems to me a pretty obvious connection. there's also the link to toxic leadership that we quite often consider quite acceptable because they are usually quite effective. they create the kind of units that perform according to the standards at the end of the day. why should we fire them if they're effective as officers. while actually they are producing unit cultures that in the end may become really problematic. in all kinds of ways. and there are some, again, some experiences with the worst cases of units misbehavior leading to crimes -- or war crimes, for example. we have the business literature,

the civilian literature out there supporting us more and more. that doesn't mean so much, though. because, again, we are looking at combat that doesn't apply because warfare is something completely different. you can always dismiss that. that's very clear, though. we are seeing the same thing within diplomacy and negotiations and humanitarian affairs that if you have gender lenses, if you conduct gender desegregated analysis, you'll do it more effectively. one might assume that applies to the military affairs and intelligence gathering, as well. unless it's so unique that it doesn't, again, right? we can also obviously look at the impact on noncombat units. and that's most of the studies we have from the past. there's no serious indicators that it ruins it. if there were -- and sometimes you hear this. that we all know that it doesn't work.

you can't mix men and women. and we all know what happens, sex and love and what have you. so it ruins unit cohesion effectiveness, et cetera. now, we've had decades of integrated units. if they have performed so poorly and no one said anything, that would be -- you know, shouldn't they be on trial for misleading the country in such an important way. we are talking about direct combat support units who are absolutely crucial to those fighting on the front lines. and, by the way, that distinction these days in modern warfare is pretty ridiculous anyway. we have plenty of experience of integration of combat units internationally, as well. so far, and megan would know much more about this than me. but what i'm seeing in my own research is what would be referred to or dismissed as anecdotal these days because we don't have enough cases to make it really quantitative.

but we're seeing very little negativity in those studies. what you hear, first of all, is usually it's an absolute non-issue. it doesn't matter at all. she performed the job great, became one of the guys. i don't see why sex or gender has anything to do with it. now, that's the first reaction. but when you prod them a little bit, they will actually acknowledge that it is an issue. that it had an impact on the unit, that you had to resolve certain issues. love, sex, again, it happened. but those are not the worst things that can happen to a unit and a good leader can tackle those issues just as any other challenge that many of these units come up with. so it is an issue. and i think we should, again, be aware. rather than being gender blind, let's be gender aware. let's adjust leadership so we

can tackle those issues that might arise. you also hear really interesting stories of improved effectiveness from inclusivity or gender integration. one being that men overperform when there's women around. so they get better when there's women around. they don't want to lose to women, for example. more importantly, you hear stories about a matured culture within the unit. and again, we have the diversity dimension that with more backgrounds, more experiences, you become more effective problem-solving unit avoiding the group thing. so there's -- it's a bit of a mixed bag. but it's looking very positive. and as i always highlight, you very seldomly hear from this anecdotal evidence the opposite, that i served with women and it really didn't work.

it ruined the unit, et cetera. you hear it from the people who have never served in a military unit but are very vocal about how military units should function because they've seen it in movies. but also the people within the organization who have never actually served with women, or with women in combat. and again, of course, that's pretty rare. but there's a staggering amount of people who have served with women. and you would think that those stories would seep out more than in the angry commentator fields and in the professional journals, that some of them would step up for the sake of the country, for the sake of the organization if it's such an important issue to defend the existing effective organization. but we don't have that. and that to me is very encouraging. men's attitudes towards women as a key factor. i thought that was absolutely

astonishing and in so many ways provocative and also, i would say, accurate. it was a way of saying what i've been trying to get for a long time. that also raises issues about bigger consequences, perhaps, of integration, as well. it's not just a nonissue. it's not just about preserving the existing culture and order. it might be something more fundamental, that it has an impact when you mix men and women. but it can be an incredibly positive and rewarding force for our armed forces. and let's study that, as well. let's try and study the improved impact as carefully as we try and find the negative impact these days. and i'll stop there. there's so much i'm sure john and mary will cover as well. >> thank you, robert.

that advances the discussion beautifully. it does indicate that too often we ask the wrong question. frequently we ask, how do we avoid hurting the force by doing this. and that's implied sometimes as much as it is explicit. and the real question we ought to be asking ourselves is how do we improve the force. i think it's fair to say there's an endeavor that has not benefitted from extending the opportunity to join in that endeavor to all of those are qualified, regardless of gender or any other characteristic. this feels to me like a case like that. and you're suggesting that it is. but you raise a couple of important questions, both of you do. and i want to turn to john and mary beth about those questions. and john, i think, you can speak to this with great credibility. is combat, as robert asked, so different from every other sphere of human endeavor that these rules don't apply? john, you had the experience of -- you're a ranger qualified infantry officer.

you had the experience of leading, really training and leading almost new combat formation into some of the heaviest and most sustained combat the army's experienced since the vietnam war. so of all of the folks who can talk about this, you know, i think you're certainly one of them. from your perspective, given that experience, do you feel that having access to a talent pool of women for your unit would've improved your performance? would you have some concerns as a line leader about that? how do you think it might have improved your performance in the close fight? >> yeah. so first off, i want to say that my views here today are my own, don't represent the department of defense or the maryland national guard. but to answer your question -- >> thanks. i should have said that up front. >> you know, there i was, fall of 2008, deploying to afghanistan with my rifle

platoon to the valley, to the most kinetic company sector in the war or terror. and my platoon was at 75% strength. so when you ask, would my platoon have benefitted if we had opened up a greater pool of talent to draw from? i think the answer is yes. so why was my platoon under strength. we trained up for a year before deploying and we lost people. we lost people because of injuries, we lost people because of, you know drugs discipline issues. and as many recruits as we would get into the unit as we were building up strength, we would continue to lose folks. and so we never got 100% strength and then we're sent in to this crucible. and so we kicked out some folks and didn't bring them with us,

there were some folks we took overseas that maybe i kind of regret taking them with us. they weren't necessarily physically fit enough to do the job. to be an infantry man in the army, you need to be a male and pass, you know, the bare minimum of the pt test. that's a standard across the board. and it's not differentiated whether you're a light infantry man in the mountains of afghanistan or a cyber guy or gal here at ft. mead. and so when i think about the, you know, the women that are competing or going through, you know, ranger school right now. you know, made it through. you know, i don't think that 42% of my platoon could've made it through rap week that i deployed with. that's pretty tough challenge. and so to open up the field to have like the best people possible i think would have been a value added.

because going to the point that, robert, you were making about, you know, we idealize the band of brothers and unit cohesion. you know, certainly i serve with a lot of outstanding human beings. and i thought that our unit overall performed at a very high level. but, you know, not every infantry man is, you know, john rambo, right? you have folks like that out there. and i served with individuals who were heroes. but there's other folks that, you know, are just kind of barely skating by. and so when we think about, you know, bringing in, you know, women into an infantry unit like that, i think in the popular debate, it's always, we're thinking, oh, you're going to replace, you know, john rambo with jill rambo or whatever. and she could never, you know, keep up. but that's simply not the case. right?

i think that a lot of women would be able to perform at that same level. at least certainly well enough to have been a value add overseas. getting to some of that discussion about cohesion and what did it take to build cohesion. we dead focus in my unit on task driven cohesion as much as possible. you're leading a bunch of 18-year-old, 19-year-old kids and you try to make being squared away, you know, doing your job, make that what it is to be cool, right? so these young soldiers emulating their squad leaders, looking up to them, they're role models for them. and you make being physically fit, competent at your job, what it means to be a good soldier. and those young soldiers want to emulate their elders and follow in their path. and i think we worked at a really high level. now, going to the idea that is

combat different than working in a business environment. i do think that at least the stress that my unit was put under in afghanistan was much higher than the stress you'd find in, you know, civilian occupation. and so we were really tested. and, you know, there are times when individuals weren't able to kind of keep up. we had a number of soldiers that would go home on r & r and they wouldn't come back because they were, you know, scared. they were suffering from ptsd. there was, you know, a lot of issues. and you had other soldiers who were suffering but, you know, were toughing it out and kind of did not seek care because they knew that their friends were out there. that if they left, you know, we'd all be a soldier down. so that level of stress and the level of cohesion you need to

maintain kind of -- just maintain in the face of level of adversity is much greater than what i've found now. but most of my experience in the military was not, you know, the valley. right? and there were times in afghanistan that, you know, weren't necessarily hell. so, yeah, you want the most cohesive unit possible when you're going into high-intensive combat like that. but i think that most of the techniques and leadership skills that you would use in the civilian sector and the way you can kind of have a broad base of support and reach out to a broad community of people works in the military, as well. >> thank, john. and to that question, i think, too, mary beth, you led a company of marines on certainly not an office retreat.

the invasion of iraq in 2003. can you speak to what that experience was like for you and some of the leadership challenges you may or may not have had? and i think also possibly speak to this larger question of -- i'm continuously fascinated by the way we look at this as if we're diving into an unknown world that we have not in any way experienced in terms of having women in direct fire combat. does that strike you as accurate? or maybe something's been going on for the last 15 years? >> yeah. for sure. it is interesting that we approach this as though this is the first time we're dealing with this issue. when i see so many faces in this audience, some of them familiar to me. we've been doing this for an awfully long time. the difference, i hope, between my experience on active duty and the experience of the young women i see in the audience is i hope you won't have to fight so hard to get there. when i was on active duty and i served from '99 to 2007 as a

combat engineer officer, i was in a field that was open to women, but there were a number of units within the combat engineer field that were not open to women. so i could only do 2/3 of my job. i was barred from training in a whole third of my occupational specialty. i wasn't allowed into that part. so we fought everywhere we went. we fought to train. and i'll actually say. i may say "i" while i'm talking here, i was, actually, the only woman in my combat engineer platoon. so it was very much me fighting as a woman to get these training opportunities. but everywhere i went, i had things closed to me. because i was a woman and closed to my platoon because i was a woman and i wasn't allowed to lead them to certain places. so, you know, one example, i had an opportunity to take my platoon to bridgeport, the mountain warfare training center with a company of combat -- a combat engineer company which was closed to women. there were no women there. i had an opportunity to train with them with my platoon for a month and do the mountain

warfare training package. i was told no by a number of people. fortunately, my commanding officer was not one of them. i'll come back to the common theme as i go through. i had some pretty amazing leaders. despite being told no by several people, i did it anyways. and everybody survived, we did great. and the nice thing was, you know, being able to compete with the men up there -- and i wasn't in competition with them. being able to keep up with them and excel on that mountain, it said something. and the 200 men that walked away from the experience, having seen a woman complete those tasks, left having a different idea about women. for the first couple of days, i was a distraction to them. i can't deny that. they were fascinated by me. like i was some weird alien creature. what is she going to do next? how is she going to do this? i'll have to watch and find out. they were really, really fascinated by me. but they got over it really fast and the rest of the month went extremely smoothly. and i built some incredible bonds, amazing relationships through that experience.

fast forward a little while to a combined arms exercise in 29 palms where i was an engineer platoon commander. and we were organized at that time. they were trying a wonderful experiment where they organized all the engineers into a pool, male, female, no matter what part of the engineer field we were in, they put us in a common pool and farmed us out. i was essentially detached from my parent unit and put into an engineer pool to be used wherever engineers were needed. well, when they tasked out my platoon, they forgot i was the platoon commander and tasked me to a reconnaissance company headed out to the field for a week into, you know, to practice to train for combat. so i showed up all bright eyed and cheery with my platoon of all men. and immediately, the platoon sergeant for the lar company said, you can't come with us. i mean, there's -- i wouldn't want you to get in trouble. you know, there's this combat exclusion rule says that women can't train with combat units.

and i said, wow, no kidding. what time do we go? because i'm what you've got and i'm here and this is my platoon and i'm coming with you. and again, for the first couple of days i was out there with them, i'll admit, i think i was a distraction to those guys, but they got over it so quickly. and we went on to have an amazing week in the field, built lifelong relationships with those guys and some great laughs about it over a few beers at the club afterwards. just them getting over that process. so fast forward a little bit more to kind of the culmination of my career, i think, which was the invasion of iraq. i was a company commander. we were in kuwait ready to cross the border with the third infantry division. the first units that went across. and the days before, all of a sudden, a colonel who will remain unnamed realized that i was a woman and thought this is going to be a problem. and he told me i would not be able to take my company across

the border and i would be replaced after being a company commander for nine months and training my company and doing all the prep work that needed to be done and being extremely well bonded with them and my platoon commanders. two days before the invasion of iraq, i was told i couldn't go. i was being pulled out of my unit and i'd be replaced by someone these marines had never seen. again, fortunately, i was surrounded by amazing leaders and one of those leaders was my commanding officer. and he kind of did the -- you know. and at this time, the fog of war worked for me. and they forgot. and i did it anyways. and it was great. and obviously me being a female did not hold me back from that mission at all. and so, you know, crossing the border was by far one of my proudest moments. second only to bringing everybody home and crossing the border back into kuwait safely afterwards. so, yes, absolutely. this was -- this was 12 years ago now. this is not a new argument. women have been doing this for a long time and doing it extremely successfully, extremely proudly.

i am so proud to be counted among them and among you in the audience here. the ones who have gone before me. and juliette snuck out, but i owe a special thanks to her. she busted through that glass ceiling and made a nice neat hole for me to climb through with my compatriots. i appreciate that. the key was great leadership all along the way. the key was not whether or not i was strong enough to do it. i was. that helped me. but the key was always that i had terrific leaders who trusted in me and trusted in my ability to lead my marines and that was all that mattered. i love what john said earlier, just kind of listening, he didn't say this explicitly, but just kind of listening, we've broken this down now over the course of the day to being so much about the physical standard. and truthfully, and not to discredit the research here, but -- or draw attention away from it, but i'd like to keep the focus on that. because i honestly think that's the only thing holding us back anymore.

and it's not going to hold us back very much longer for women. women have figured it out for a long time. and once the standards are thoughtfully made. maybe they're there now. once they're thoughtfully made, women are going to figure out a way to do that. and that needs to be the last barrier. because the talk about any other surrounding issues is gone. we've proved that. my generation proved that many years ago, and the generation, i mean, i've got two rangers sitting in the audience. female rangers. women who went through the ranger course sitting with me. and it's amazing. sorry. i don't know the exact term there. but we've done amazing things. women have done amazing things. and i think that the focus should be on what the true barriers are left. which aren't many. >> thank you. that's a really, really inspiring story. and you talk about decisions made on the basis of what's good for an organization. as you were telling your story, john and i were sort of sharing a look like, i can't think of anything dumber than switching out a high-performing line combat leader two days before the invasion of iraq because of

gender? >> right. >> i mean, my god. so i think your company's very, very lucky that didn't happen. at this point, i think we want to open it up to a conversation with the room. i'm sure there's plenty to discuss. would anyone like to jump in? we have microphones orbiting positions. >> army national guard. i had a question that mary just actually touched on. as we were -- as i was talking to -- do you -- and the researchers, too. do you see it more as a generational gap that as we continue on in generations, those things will kind of go -- not go away, but kind of allow it? like she said, when she was in the class with the lieutenants. wasn't worried about, oh, you're a female. maybe it's more of a generation, as you said, generations before. i think i graduated the same year as you. i saw different things and year you.

i saw different things than the lieutenants coming out today. that's the question. is there research done with maybe a generational gap as far as cultural, and i believe it's leadership's ability to change that and make a difference. >> anyone want to take a crack at the research about the questions? >> i think there is research that indicates there is a cultural gap and with don't ask, don't tell, there's the saim indication. the problem is that often leadership is part of the generation that may be stuck in the old culture we're talking about. it may take some time for cultural change, and so, yeah, i think that the attitudes among new recruits, there is indication that especially around issues of gender don't ask, don't tell, were very different. >> i think just to add quickly, i think military historically is not great at quick culture

change. it takes some time to come along, and while i do see huge differences between the generations of my parents and myself and the young men and women here in the audience, i think that's not good enough, and i think for us to be able to push it gently in the right way in a thoughtful fashion is extremely important, and that's why these panels and discussions are really important to happen on its own, but not in enough time. >> to echo that i've been in so many conversations with different level of command as well where the younger generation will say, with all due respect sir, to generals that they are everywhere. performing everywhere my wife flies the helicopters where we go in, et cetera et cetera there's something tremendous happening in terms of generational shifts. >> yeah. >> so my name is jessica tant

professor at the school of international service at american university here in d.c., and big shoutout to the georgetown colleagues. i want to speak to the point about generational and cultural shifts, and so it was brought up the israeli defense forces and they have historically had women integrated into their operations, but in pushing through their removals of gender base combat exclusions, there's a difficult time. for example, women who operate unmanned drones are allowed to deploy in theater but not with infantry units. they are only allowed to stay back with artillery units. there is still, among the most advanced countries in overcoming hurdles, hurdle remain. i think it's a little bit naive to think all the issues are going to go away immediately, and in part because a lot of the developments are tactically driven, and i'm excited that that came up as a point of conversation.

my own research deals primarily with rebel groups, et cetera, insurgencies, and we see developments in developing world, military for example the sri lanka military has an all-women unit in response to the high female participation and so the degree to which these developments are being external externally driven versus internally driven through changes in american culture or perceptions of the role of women in the work force et cetera, something that i would like to see you speak on because there does seem to be this tension in a conversation of the panel, and whether it's about manpower and shortages and getting the full staffing levels or if it's about, you know, acknowledging as was said earlier that we're all people and we're all equal, and we should all be able to

participate in the same rules, so your view on whether this is an externally or internally driven development would be helpful. >> interesting question. >> anyone want to take a crack at it? >> i can start perhaps. it is a great question, but your opening pandora's books here as well. the short is it's both. we have not talked at all about u.n. security counsel resolution 1325 the u.s. national action plan on women, peace and security, which are -- you could say a more right spaced argument that this is the right thing to do empower women, gender equality, et cetera, but at the same time those come from an understanding that the existing order is not working, and that we can improve the way we create peace, development humanitarian affairs by high representativeness of women. even there it's a combination.

operational experience from the last decade is hugely important. we've learned a lot of lessons there. they all combine. the way i try to avoid that issue of deciding whether it's the right thing to do or the smart thing to do is to say that there's a difference between that sorpt of very difficult fundamental chicken and egg discussion versus how we sell this. to a highly reluctant organization. the arguments, to me, simply do not work. they acknowledge it is really important with gender equality and improved opportunities for women, but you know, we're in the business of wars, so we can't deal with that within the military, and that's the response you get, but if you do explain it with examples, se yar scenarios where it impacts

operational effectiveness you have their ear for a while and crack a door or gain access to the organization and explain yourself. i find that argument gets their attention at least when you focus on operational effectively. do that. not because it's the real reason, but most effective in terms of organizational change, which is what we are approaching. you're touching upon a number of how questions. how do we go about the disprocess? you asked a good question to the last panel, female engagement, support systems, et cetera, necessary capabilities. i think most would agree with that these days, we're never going to fight a war where those capabilities are irrelevant. how do we do that? now, we can create female moss. we can create female engagement teams with those specific functions that fills the gaps of

the existing organization, but this is the panel on unit cohesion. we all agree that unit cohesion is a very important thing for military effectiveness and military performance, so if you have ad hoc solutions, if you bring in a woman to special operators or add a female engagement team to an existing platoon out on control, that's a liability because they will not be as cohesive and trained together as they will be if that platoon has those functions baked into it. i would always say first of all get women in the units if they need them rather than an add-on to the unit. apart from the fact of female moss, et cetera will always create risk of -- feelings of different standards, for example. if you have a range platoon

where you have hip thetically have standards that no women have so far passed, and you add a few women because they need it, it's going ton seen as a second rate ranger even though they might be performing extreme extremely well. i would avoid that. again, that's the highlighted in the last panel we have to look at all of these standards and rethink them. >> unfortunately, we have to wrap up the conversations so we can move on with the program. i encourage everyone to continue it outside where the cliff bars and coca-cola are but thank you very much to the panelists for joining us, and thank you to all of you for being a part of the conversation. >> thank you. [ applause ] >> this week, the cities tour partnered with cost communications to learn about topeka topeka, kansas. >> when the kansas-nebraska act was signed in 1854 the very act of signing it of just signing

that piece of paper, was viewed by missouri as an act of war. so when northerners decided that if popular sovereignty decides the state of kansas, we send people to settle that was viewed as an act of war by missouri who just assumed this would be theirs. there were raids back and forth across the kansas border, almost immediately. and in may of 1856 john brown his sons and a couple other followers, dragged five men from their cabins along the mosquito and poth wattmy creeks, and they are shot and hacked to death with swords. that cleared the area of southern settlers. >> here in topeka, if you looked at the schools standing outside you're hard pressed to determine whether white students or african-american students attended because the school

board really did provide all of the same materials that the white schools offered. and what is even more interesting for most people when they visit is they find out that after graduating from elementary school, african-american students attended integrated middle and high schools while they certainly were no supporters of segregation and obviously saw injustice of having to attend separate elementary schools, the african-american community also was very proud of their schools because these were excellent facilities, so while there was support for the idea of integration, there was resistance, especially from the teachers and the local chapter of the naacp who feared the loss of the institutions and the loss of those jobs. watch all events from topeka saturday at noon eastern on c-span2 book tv and sunday at 10:00 on