and it was difficult. now why is it that in rwanda and mozambique you've come out of a conflict -- terrible conflicts in both countries, and instituted such strong gender equality in the constitutions, et cetera? null may still be challenges, but in both cases i think rwanda and mozambique stand out. how did that happen? was it because women were pushing at it and demanding it? did they play a particular role in the conflict and situation? or was it just enlightenment? either one, perhaps. >> thank you. let me add another dimension, which is the elections, the participation of women in the election processes. i feel that this is very important. when women participate in this

electoral processes, they are part they prepared the processes and they campaign to be voted or to elect other women to their positions. power positions. and in mozambique we have the experience which is successful, the quota system. i know that in other parts the quota system is not applied because there are people who think that that is a kind of man's marginalization. but in mozambique, it works and it has worked. that's why we have reached such total of women enrolled in decision positions. yes, women participant. we have conflict.

and since women are the most affected, they are much more easily are able -- it's true, not always are they seated at the table the decision table, to solve the conflicts or even after the conflicts. but they are there, and they are the grassroots organizations. and they help build the society. and they help to sustain the societies. so i think that we have to work much more in terms of empowering women to be able themselves to defend themselves, to defend their rights in the society. >> thank you. madam ambassador? your thoughts on -- >> there are a few things, if i can say why it's happening. and you mentioned the history also. >> yeah.

>> you have a very tiny country with a million people dying in three months. and you either die or you resurrect. so what happened was that the first thing that was able to revive our country and also comprehensively include women is that we needed to harness all of the efforts of everybody in the country to be alive. and women had -- are the ones who kept the fabric of the country going. given the incredible challenges when you are looking at people whose society society to death has been reduced to ashes. but so there are three things. one is leadership. you have to set a vision that this is what you want. you have to have intentionality. there's intention. and then you really have to marry policy and practices. so it means that in our particular situation, we created

what we call homegrown initiatives. socioeconomic initiatives give toward empowerment of women. so for instance we say, like what does it mean to give a cow to poor women so they are able to organize themselves. or community work, cooperatives, where they put people together, they are able to get microfinance and they can start a business. so i'm talking about intention. intention has to be there. principles have to be translated into practices. so you really have to create that kind of pathway and that's what we did. thank you. >> i'm going to open it up now to the audience. but you know, i once asked a revolutionary leader in africa who had come to power but i was raising with him a problem of gender discrimination in parts

of the country. and he said well, then the women just have to organize and fight for what they want. now, it was a little bit self-serving comment, but there's some truth to it it seems to me that it's not just organization. it's willingness to demand inclusion and rights. i assume that that was also part of the experience in your country. i don't know, kamissa, you've worked with a lot of organizations. >> i worked with a lot of organizations. and really, and i've said it during my short presentation, is that you have these grassroots women leaders who have nobody to look up to. there's nobody in the government who will actually represent them and who will make sure that their voices are heard or that their interests are served in the government at the national level and at the regional level.

and maybe because we're talking about the au here, i wonder how we can talk about women's leadership in african when the au has never, ever sent a woman as an international mediator. in africa over the past -- i don't know, i would say over the past ten years, for example, in west africa, we've had conflicts in liberia, in mali, in sierra leone, and not even once was there a woman who was sent as a mediator. it was only this long-serving presidents. i'm sure there are qualified women out there. so when you said marrying policy and practices, i like it. it's really -- that's the issue. so it's nice to be talking about women's participation. but how do we make it happen? >> good comment. i think you've provoked a good set of questions. i think people should go to the

microphone and then we'll take them in order. please. >> good afternoon. my name is allison shapira. i teach public speaking and presentation skills with a special focus on helping women around the world find their voice and their courage to speak up. and so my question for the panel is, what specific skills do you think women need to learn in the process of being empowered in order to drive the region forward? thank you. >> jacqui you work a lot on that. do you want to start on that? >> you know, i -- confidence isn't a skill but it is confidence that's needed most. i've actually never liked the word "empowerment." to me it's the idea that someone can give you power. i think what we see is that women have power if they choose to use it and to exercise it. so we do a lot of work with

women leaders. our premise is always you know what you need and you know what your community needs, and all we need to do is work on packaging how you say it. i think that's the biggest issue. the single biggest issue holding women back is that their knowledge or their experiences are somehow less than those of their male colleagues. constantly we're in workshops where people say, you know, we're too illiterate. we're not literate enough. we need to make sure that maybe next generation or in ten or 20 years we can read, then we'll be able to run for office or something. the most important answer is do you have a vision for your community? do you know what the issues are? do you know what you want to change? if so, then go for it and the rest -- it's not like all of your male colleagues have all of these skills. women have a perception that everyone else has the skills and they don't. we're often getting requests from women -- we need capacity building, capacity building. our answer is often, no, you don't. you actually don't.

you have everything you need. we'll work with you to maybe shorten your responses or you throw in some lingo or some jargon that will make international policymakers think you know exactly what you are talking about. but it's really confidence and the assertiveness and belief that you belong there as opposed to the skills. >> anybody else want to comment on that question? >> i think that while women have to be -- have to have access. for instance, for technology tools. we see that in many parts of africa where women have access to cell phone. a simple cell phone. that is a very powerful tool. she can use for whatever she needs to connect. and also to improve their life, her life, and her family life. that is a skill. >> good point. go here. gentleman there.

>> my name is pierre from national endowment for democracy. i want to thank everyone for all the presentation. i really -- one thing that struck me was i didn't hear about the participation of women in the media. the media is one of the most important institution in terms of development or democracy or post-conflict building, whatever you want to call it. >> women's participation -- >> in the media. in the media. yes. what can be done or what is being done in the countries present of the other panelists, what is being done to address that? and my second question -- kamissa touched a little on it when she was talking about grassroots women leaders who don't have anyone to look up to in the government. what can be done so that a lot of these women in those countries that meet the quotas, a lot of them are just the daughters of, or wife of. what can be done to make sure

that that representation is key for women or what is being done to make sure grassroots women leaders can access those positions where they can actually make a change? thank you. >> i'm going to take two or three questions because we have a lot and want to make sure people get them on. that one on the media and grassroots. then the woman right here. >> yes. thank you very much. my name is corneli weis. this is directed to madam ambassador from rwanda but would be delighted to hear from any of you. you had said a threat to anywhere affects everywhere. and i ask you to think about the situation right now in burundi. right now it is in the midst of needing conflict prevention. just recently, i understand, that the great mother marguerite

bartisi, that she has gone into hiding. and so there was a discussion that the au's never sent a woman as an international mediator. there are talks right now about you need elders to go back in there just like years ago. and so i'm asking i'm asking the women here to stand up and to be leaders, and i think rwanda, if anywhere knows what can happen. and i ask you to stand up. and i'd like to hear what you plan to do. thank you. >> okay. let's take those two. we have one on media, and one specifically on the problems -- crisis in burundi. you want to take that one first? >> maybe i -- because you ask the question specifically for me -- >> yeah, sure. >> of course, what is happening in burundi is we are trying to see how we can do it originally but also on a country basis.

we are being not only following the situation but also helping the situation. as you are aware of, there are many refugees. in my country, i think -- i haven't looked at the numbers but there are hundreds -- tens of thousands of refugees coming from burundi coming to rwanda. so that means that all the mechanism of treating people, women specifically, is part of tfwup)e doing. so we are expanding even our resources to try to accommodate the people coming to us. understanding also is something that peace -- and you know, we are a part of the people who are trying to bring peace and stability in the region for this specific time. we are not -- in burundi, we are standing with the international community but also regional and local communities to try to see how the people can come together

and talk and not encourage any violence. so locally for what rwanda has done on policy -- not policy level, but hoe they have expanded themselves in burundi, the situation now, but also dealing with the immediate and very challenging issues like people's rights. you have heard, for instance, that some people are dying from cholera in large numbers among refugees who are living in burundi. it means that all of the mechanism have put together for our own people. in the last couple of years, 20 years, also to the service of the people who coming in especially in terms of health. so we can maintain the lives of people who have found safe asylum. but as you were saying i agree with you, that everyone should look and see how we can address or help the situation in burundi.

as it evolves. there are quite a few american organizations. i heard about an institute i know they have extended themselves in terms of relief and so on and so forth. so i don't know if i'm answering the question. the question is how do we address it beyond that? >> i think this is a perfect opportunity for women's leadership in conflict prevention. you're a woman leader. and to be there with the council of elders to help try to solve this. >> and this -- we use ourselves, you know, we are still on a long journey of reconciliation and building. we have achieved some mighty stones and we'll put whatever we have on the service of burundi. you know, one thing -- i cannot for instance when i work for peacekeeping and we are one of the largest for africa, we don't

do just peacekeeping, we do peace building. if you went to south sudan, you'd find the same type of programs that we have in terms of reconciliation. central after, republic, they have one program. this is what we are intending also to do when it comes to burundi. >> i think, madame ambassador the suggestion is that you go -- >> me? >> -- as a mediator in burundi. >> individually yes. >> no on behalf of the au. we have a question -- we had a yes earlier on the role of immediate, yeah the role of women in the media.

>> my name is ida. i'm from south africa. and i thank you all for everything from what i have heard. when we are talking about peace and development, i think the first thing that comes to my mind is food, agriculture. i didn't hear that. from the two -- and the other thing i would like to know is, maybe from the organizers, how they came up with who represented out of all 54 regions of africa. are we talking about international african. but i see with the money that

was intended. the other thing is -- we can't have everybody have too many questions. >> well this is -- maybe this is the last one. >> okay, quickly. >> yes. the participants, we heard about the conflicts going on in rwanda. and if -- i would like to read something here very brief which i think would be part of the solution about what's going on for us in africa. where i come from. and this is about two americans. i read it from a geographic book written by jack mcclinton. they say that the ship of africa the size, the ship and the

composition of today's african countries have very little to do -- have very little in relation to the cultures or geography of that continent. they were created by europeans for their convenience and after a look of haggling during which no african was represented at a conference in berlin in 1894. the europeans simply chopped africa into pieces and handed it out, splitting tribal -- >> okay. i apologize. i think we got -- we'll take the question but i want to open it up to more. but i understand the question. >> so we have to find solution. i think that's what we should address first. >> right. thank you. we'll come here. >> good afternoon, ladies and gentlemen. ambassador, your excellency. my name is rosemary, i'm the president of hope for tomorrow. we focus on conflicts and violence prevention. i come from kenya.

i want to say thank you so much. many times we have never had the ambassador women speak about conflicts of women. conflicts and women, because at the u.s.-african summit, i wrote an executive summary to president obama. i was part of the event on peace security and women and agriculture. now, the women empowerment, let me tell you where it started. do you know where it started? nairobi. in 1985. that was when we met empowerment, before beijing. beijing is on the top, africa is down. and the african women are the ones suffering. i focus on the rural areas. now that we are here together. i'm talking as a woman born and raised in africa. if we don't take this ourselves from you today, help the rural area african women, who, you know rwanda, the ice cream ladies, they really make me proud. so we africans who are born and raised in africa we need to be

on the forefront as the young ladies say, we need to be on the table of peacekeeping. if we don't the women in congo have been wrecked. now burundi, in rwanda. you know what came out of it now that women are leading because they knew women are coming out and we are on the table now. 50%, 61%. women in parliament. no men can say something about abusing them or say something -- so i really appreciate the president of rwanda and the women of rwanda. so now that we are here this day talking about women, we can eat, sleep and talk and tomorrow and again we wait until next year, to 2016 and women are suffering. what can you tell us from this point of level, from this place of peace and security, u.s. institute, what are we going to do to the common woman in the rural area of africa until tomorrow and today, though my organization called hope for tomorrow. we want a change in african women. >> okay. >> we want to do it as african

women. born and raised in africa. >> i apologize -- >> not on television, not in radio, not in newspapers. there has to be a change from today. you will be seeing me knock on your offices. and don't close your door. thank you. >> okay. i'm going to try -- [ applause ] >> i'm going to try to take another question here before time runs out. i apologize if -- we've got to move along. >> your excellencies, thank you for this opportunity. i'm university of california student. i'm currently at the african women's leadership. this organization invests in women professionally and through leadership and through networking. and i want to ask, in what other means can disposterior ra individuals and groups outside of africa be invested in so they can help enhance this mission of

women empowerment that was just established in 015. >> let's try to address some of those and i'll try and get back to as many as we can. we had a question about the whole historical issues of borders and whether that is contributing to the problems. we have the question around rural women, in particular. then this last question. so i'll let any of you address any of those that you wish. >> go ahead. >> let me address about diaspora. the participation of diaspora. we have many people coming from africa either living -- born from africans, living here, coming from africa. and what we used to do is to work with them and ask them to organize themselves in

associations. so that they can first help each other and also be able to strategize how to connect with their home countries. we have many people from mozambique who are here. they have different associations in different places where they live. and what normally they do, they connect with the country through the embassy or themselves. they collect some kind of support to the fellow mozambiquens who are in country, who are in need from cloth, from different tools, from educational material, and other kinds. but also they organize themselves to rebuild their

lives in mozambique because they know, they understand that at end of the day, their families are in mozambique. they are there. their roots are there. so i think that it's very important to have diasporas. we used to say that they are how ambassadors here in the united states and elsewhere. and we immediate with them, we organize them, we help them organize themselves. and they're our base. we come and we go. as embassies. they're here. they live here. they know how this country works. they are enjoying the hospitality of the united states of america and they have always to reconnect with the country. so it is important to work with the diaspora and have them grow in this country. >> i would think it's also

important in a conflict situation that the diaspora does not contribute to the conflict, because sometimes in some cases the same divisions in the country are reflected in the diaspora and i think that's something that has to be addressed. did anybody want to comment on the rural women issue and the importance? >> what i can say is that you can't really develop anything without inclusive development. i'm using your words. but the rural development, you were talking about food and agriculture. the majority of our women work in agricultural industry. in a traditional agriculture. it means that at the same time they -- like 90%. 90% live in rural areas. so you can't talk about any country development without developing the rural areas. and i think that in the agenda

2063, we set out to modernize agriculture because that's where the majority of the people are. but at the same time also you find a strong correlation between development in -- also development of the agriculture sector where most of the women are. so that's how i can answer the question. the other thing, there was a question that was asked about representation. by all means, here our voices might be weak, but all of the 50 countries can't come to this forum and start presenting. just we selected the best support who was chairing the africa group for this particular month or next month. then we selected ambassador from mozambique. but it is not -- i hope that we are -- even though we might be giving examples of one particular country, it is because we know it very well for discussion purposes, but here i am representing all the african ambassadors. so blame it on me if we are weak

enough to represent today but we can't really bring all the people to come and represent so i had to mention that. but definitely significant for all of us around the questions if you want to ask general questions on africa, you should also come to us. the last thing i want to mention. someone was talking about colonialism and the rules of what was -- our agenda was set by colonial powers. yes, they were. and also that some of the difficulties we have we would be remiss if we can't attribute it to the fact that africa is young. africa is a young nation. when you talk about a nation with 50 years of history, it is nothing. that's yesterday. so actually the milestones that africa has achieved are incredible when you look at where we came from. a country can't develop if you can't make your own diplomacy, if you can't make your own mistakes and learn from them. for africa, for almost 100

years, we couldn't do that. so it means that we are still on baby steps but we are really going in the right direction. so i have to tell you that all the major advances we've underscored are showing where africa can be. because we have all the potential. we have resources. we have the people. we have young people who can drive the economy. we have our women who are pretty much have been in many challenges that if you talk about women's liberation, they come from africa. so i have to state that particular thing because when you discuss africa, also have to look at context. africa as a continent is young. so we are still sometimes trying to find ourselves, sometimes we are doing this and that. but at the same time, understanding that the course we have set for ourselves is slowly, but surely working. not everywhere the same way, but it is coming along.

so maybe that will address the other part of your question that you didn't finish when you were talking about colonial roots and son on and so forth. thank you. >> now i think -- i don't know if our c-span friends can stay with us. we've reached the 4:30 time. but if you have a few more minutes, we could take a few more questions. is the panel okay? if c-span can stay with us, that's wonderful. if not, thank you very much. don't forget the hashtag i mentioned. #africaday2015. there we go. for all you tweeters. so, let's take a few more questions, because people have been -- we'll start here.ai >> my name is mindy riser. i'm a vice president of an ngo called global peace services 2r

resourceful mothers who support the families, who do amazing things with modest resources, they need to see other life possibilities. they need to think about being biologists and engineers and chemists and physicists and anthropologists. please talk a little bit about what your countries are doing particularly in the rural areas where teachers often do not want to come because of many life challenges. how you are encouraging good experienced teachers, men and women, to go there. and how you are trying to craft curricula that invite young girls to consider the broader world in africa, in larger regions as well. and how they can find a place there. >> the woman right there, please? >> thank you so much, panelists. in fact, i don't know how

coincident it was for me to be here from the first person who just spoke and we have the same question. so my question is actually in terms of leadership from the grassroot, in as far as young girls are concerned. my first question goes to miss susan. in sudan where you're dealing with women are you considering young women so that they can can be trained that in a way when they come up, they're not going to be here talking about leadership. instead, they'll be leaders from the classrooms to universities so that when they come here they are now coming with solutions to problems. not here to learn how to solve problems. thank you so much. >> let's take another question there from the gentleman. >> my name is nector. i'm the ambassador from malawi. i should indicate that i'm the

new kid on the block. i'm only three weeks old in d.c. you'll excuse me if i speak out of turn. but two things i would like to relate to. first of all, the lady ambassador from mozambique and rwanda are representing africa. what you have said is something that most african countries relate to. it's an issue that most african countries are having to deal with, and therefore, we are with you and you have represented africa very well. >> thank you. >> thank you so much. [ applause ] >> the second thing i would like to say is, i would like to talk about malawi. malawi is making some headway in issues relating to women's empowerment.

i would like to cite an example of a law that was passed in february of this year on women's empowerment. you can find it on the internet if you would like to do that. but in the case, the role of law in ensuring women's empowerment in modern days. having said that, i should also say that malawi has been one of the luckiest countries on the african continent that has enjoyed peace and has not had conflict since independence. in that regard perhaps on the point -- >> i'm going to have to ask you to be fairly brief. we're going to take the last few words. >> i would like to relate the point i'm making to the point the lady made about peace time situations. perhaps malawi could learn some

lessons, malawi could be a case study for how women's empowerment has happened in peace times. sometimes i worry that we tend to throw the baby out with the bath water with african customs. is there -- can we learn something from african customs and practices on women's empowerment because sometimes we tend to think that african customs don't have systems for african empowerment. perhaps you could think along those lines. thank you. >> i'm going to just ask the remaining people to very briefly put their issues down because i know people have to leave. so we'll ask you to be very brief. just the ones who are up already. >> good afternoon. my name is matilda banga. i'm originally see earierra leone.

i just want buttress on what the gentleman said about the media and the effect of media in politics and how it empowers people. because i walked with the late president and we were some of the women that changed our names to be on radio and i know how effective that medium was to bring information and change to sierra leone. but as far as today, my question is to jackie. what security reform initiatives do you have as far as west africa or sierra leone? please. thank you. >> okay. tat gentleman there. very brief, please. >> good afternoon, your excellences. i'm from nigeria. i want to react to what the panelist said when she said building african elite may lead us in a time of peace. what is a solution to reach? i want to suggest some lugss.

i think the women of africa -- >> i can't take any my people, sorry. just the ones up before. >> in a sense they need to repackage and restrat guides because in the place of power and politic sxlgs leadership, strategy's important. packaging is important. african women have to think with new mind sets to be able to gantin the leverage they are looking for because so many factors are already working against them. secondly, african women tend to be very, very, very blunt with use of power. case study of nigeria, you know.)?!

the nigerian government was able to raise the profile of women participation to 35% currently. but we can see that the economy of nigeria nosedived within this period when women particularly running the economy. check -- >> oh, man. >> yes. >> you know what, i think our time has run out. i'm going to let -- i'm going to let the panelists make some final comments. everybody's been here for a long time. so, thank you all very much. and i apologize for those who are up there. but i'll let you commented on any one of those. jackie i'm going to go with kamissa. we have a number of questions about leadership and education but any other final comments you want to make. >> all right perfect one of the confess related to me was about young women. it's especially relevant.

my first experience in africa was working at afad university for women in sudan. it was one of the maces most transformational in my life because uz saw a generation of young sudanese women who wanted a voice in their future who were studying, were serious, and really seeking a life for themselves in their future an inclusive future for their country. capacities there again in the groups of women we are work with, they challenge many of the groups in the united states and elsewhere face this generational challenge between some of the older women who think the younger women don't appreciate the path they ready to or the younger women who think the older women aren't adapting enough, aren't quick enough. one area this comes about most is technology. some of the younger women we work with talk often is what app -- it's like a diplomat tool in africa like what's app and using what app and twitter and

facebook to mobile idz campaign where a number of the other colleagues we work with want to do traditional diplomacy, et cetera. there's very healthy generational tensions in africa and other parts of the world when it comes to women's advocacy. first of all, it's a wonderful dress you're wearing. we'll have to get our photo taken afterwards. women's involvement in security sector reform. sector reform in west africa, we've worked with the geneva initiative for the democratic force and created available online, women's guide to security sector reform. we created-n guide because we were often involved in conversation about security sector reform and found this gap. women in communities who knew what they wanted from police, knew what the security priors were, knew what they wanted and needed but didn't know how to access institutions or how to speak the language of the security sector. so we created a women's guide to security sector reform, meant for women in civil society to break apart and demystify all

the things that the border patrol does, the custom sdshgs the military does, your defense oversight committee in parliament does and to provide some suggestions for advocacy. we've been rolling that out through a series of workshops in west africa. i'll tell you more about it but it's available to anyone online. >> ambassador, final comments, thoughts? >> brief comments on education? >> yes. >> we talk about women advancing without education. once again, it's intentional to put women -- there was a huge gap between women and men education in the past. so initially for us to be able to put them on the table we had to create programs to almost like call affirmative action so women can be there and compete. now that we've also opened the doors or the push for women to be in all sectors of education, including science, technology,

so on and so forth, as we speak, we have many women who are in the military. you have to open the doors of inclusiveness whenever we are talking about education. education is actually the foundation for whatever we are talking about. we can't separate advancement without education. the second thing i wanted to maybe say the ambassador talked about was about maybe using women from african traditions, quite frankly, i can tell you, without what we call the homegrown initiatives we couldn't get anywhere. whatever you bring, you don't find -- you were talking about the different environments talking about different cultures, different context. so it's very important that we don't get -- african type of programs don't reject other ones. it means we just include what is

needed so you can create very powerful program that can empower people. i think i'll leave it for now. thank you. >> thank you. kamissa. >> so there were two questions about women's empowerment in peace times. i think that we need to remember that it's women who have changed the history of women over time. so the grassroots initiatives that come up have to be supported by gender sensitive policies at the national level and i think that's what the countries like malawi should be doing so when you have these women's groups or women's movements that come from the bottom they are supported and they're sustainable. our nigerian friend, are you serious? okay. all right.

[ applause ] >> and i can tell you, if we had some nigerian women on the panel, they would have answered that very strongly. >> your excellency. >> yes, thank you. thank you very much again. let me also stress about education. what is important, too, based on the culture set -- the mind set in mozambique where the government has instituted incentives for families who send their girls to school and maintain them until they graduate. why? because in some places it's not a priority to send girls to

school. and families need to have this kind of incentive. besides that it's important also to increase infrastructures network so that girls and the young women who live in the rural areas can get access, close to the places where they live. it's difficult for some of them to live the village, to go to town, to have schools, because of different difficulties that they can face. so it's important. that's what is being done. to increase access of education in terms also of building much more infrastructures, close to places, to the villages where the population live. >> thank you. i want to thank you all for being so patient and staying with us. above all i want to thank this

wonderful panel that's given us a lot to work with. thank you so much. [ applause ] >> thank you all. and today some of the gop presidential candidates have been making remarks at a meeting of religious activists in washington, d.c. commenting on the shootings at the church in south carolina this week, saying they were an attack on faith. you can watch our coverage of the faith and freedom coalition online, c-span's video library, c-span.org. 21-year-old dylann roof allegedly killed nine people at the church in charleston south carolina, wednesday night.

he's been charged with nine counts of murder. c-span was at the church a few years ago for a look at its history and its cultural significance. denmark vesey was a quintessential charleston man because he represented the majority of the population here which was a black population and an enslaved population. and he -- through his actions, in an effort to organize a conspiracy, spoke to the aspirations of african people in this city, in this state, and indeed throughout the south in the early 19th century. he was a member of what was then known as the african church in charleston. and the african church in charleston was an independent african-american denomination in the city affiliated with the ame

church or the african methodist episcopal church that had been founded in philadelphia in 1816. this is a significant development and a significant point in history because the black charlestonians who started this church, affiliated with the ame church in philadelphia were essentially dealing with an abolitionist church. as you might imagine that african church and its leaders and vesey were one of the members. the leaders came in for persecution. the lead rz were arrested. the church was closed down on more than one occasion. and we think that it was probably the persecution of this church as well as denmark

vesey's personal satisfaction with his inability to enjoy all the full fruits of freedom in a slave-holding society as a free black. and then his inability to obtain freedom for his freedom for his children. he was not able to purchase their freedom. and it may have been the convergence of all of those factors that then led him to begin to organize a conspiracy of slaves in 1822. and let me tell you about the plan. the plan was to organize slaves in the city of charleston and for them to arm themselves set fires strategically to a number of locations around the city and then to call in slaves from the surrounding area to occupy the city. as it turns out word would leak out and there were some informants. slaves themselves informed on the conspiracy.

and denmark and others were arrest ed arrested. they would be tried. and of course a trial on these kinds of accusations virtually always led to a conviction and execution. and so indeed in the summer of 1822 denmark vesey along with 34 others were executed by hanging on the outskirts of the city. and 37 other people convicted of participanting in the conspiracy in one way or another. now, today we're standing right in front of emanuel ame church in downtown charleston on calhoun street. and this church is symbolically and substantially important because of the connection to denmark vesey. the builder the original builder for this church in 1865 was denmark vesey's son.

and the members of the original african church that remained in charleston really comprised the knew clees for this congregation and for this place of worship when the african church or the ame church was in effect reorganized and re-established in the city of charleston in 1865. >> nine people were shot and killed at emanuel ame church wednesday night. a 21-year-old suspect hack charge charged. the controversy of the confederate flag has resurfaced since the shootings, become a presidential campaign issue. south carolina senator and gop candidate for president lindsey graham says the flag is part of his state's heritage. even though some people choose to use it in a racist way. and south carolina congressman james cleburne tweeted removing the confederate flag from the dome of the state house and placing it in front of the state

capitol gave it the appearance of sovereignty. coming up today live coverage of president obama's remarks in california. he'll be speaking to the u.s. conference of mayors in san francisco talking about the economic health of u.s. cities. we'll take you there live at 5:15 p.m. eastern time. over on our companion network cspan. here are some of our featured programs this weekend on the cspan networks. on cspan saturday night at 8:00 eastern, supreme court justist ruth bader ginsburg on national issues like gay rights, race relations in america and the production of a new movie about her life and career. and sunday night at 6:35 a profile interview with presidential candidate texas senator ted cruz. on book tv on cspan2 saturday morning at 10:00 eastern we're live for the annual roosevelt reading festival at the fdr presidential library and museum. authors include christopher o

sullivan sheila cull lins and her book when government helped. and molly lyy guptill manning. on sunday night at 9:00 on "afterwards," mona on the need of a sexual revolution in the middle east. and this weekend on american history tv on cspan3, we're live from the gettysburg college civil war institute annual summer conference on the civil war's end and aftermath saturday morning beginning at 8:30 eastern with university of california los angeles history professor joan wau on general grant and apmatics and at 11:00 with author harold holzer on abraham lincoln and the press. on sunday morning we continue our live conchverage beginning at 8:30 with gregory downs on the consequences of the civil war. and later at 11:00 a discussion about treason and loyalty during the civil war with penn state university history professor william blare. get our complete schedule at

cspan.org. next a look at the growing industry of online medicine. also known as telemedicine and the barriers of regulation and licensing, the role of state boards, coverage and reimbursement of services and policy concerns. the discussion was hosted by the cato institute. they talked for about an hour and a half. good afternoon everybody. my name is simon lester. i'm a trade policy analyst at the herbert center for trade policy studies here at the cato institute. thank you all for coming out today. thanks to those watching on the internet and also i understand cspan 2. we have what i think will be a very interesting and informative policy forum for you today on removing online barriers to

medical care. this is sometimes referred to as telemedicine or telehealth. i expect to learn a lot from this forum myself. i have only written about a narrow aspect, about how international trade agreements address it. basically what happened i was following the canada-eu trade negotiations and i saw in legal text germany had explicitly ex excluded telemedicine, we're not going to liberalize in this area. as a trader this offended me and i wrote a paper sort of in response saying actually in trade negotiations governments should affirmatively try to liberalize cross border trade in medical services. but i realize that if i were to hold a policy forum just on the trade aspect of it it would be hard to fill my own office much less this big auditorium. so i decided to broaden the topic and talk about telemedicine more genuinely and invite some real experts on the issue, the gentlemen to the left

and right of me. i think we'll all benefit from their knowledge. this is a new topic for many people. i think it's best to start with the basics and get into the nuances as we go along. here's the issue at its most basic form. for most people medical care is still something that always takes place in a doctor's office or in a hospital. we've all had this experience go to the doctor's office wait a bit have these 1970s era paper forms, fill those out wait more and take you to another room and wait again. it's pretty annoying. but what if instead of that you could just take out your smartphone and place a skype call to a doctor, go do some other things, get some lunch, maybe go to a policy forum and when the doctor's available you have your online consultation over the phone. obviously i'm not talking about surgery here but just routine consultations. it sounds very convenient. but it's actually being done although i haven't done it myself. the problem is in the highly regulated area of medical care there are lots of regulatory hurdles that get in the way.

and there are a number of start-up companies that are trying to break them down. but it's not easy. and it's been a struggle. our first panelist is going to give us an overview of this emerging industry the regulatory barriers that they face and ongoing efforts to address these barriers. renae is a senior council focusing on health care policy. i came across his name when i was reading an economist article about these issues where he was quote ed quoted quoted. i feel you're doing something right when the economist quotes you. jeff rose at the end senior attorney for justice which does a lot of great work. jeff is bringing a fascinating case on behalf of a texas veterinarian who was fined by his state's medical board for offering veterinarian advice online. among other things this case involves important issues of free speech. and although it involves a veterinarian, it potentially has larger implications for the

practice of medicine more generally on human beings. jeff is going to give us the background of this case tell us about its current status and its prospects. and then finally we have josh an actual doctor. nice to have one of those on our panel talking about health issues. but he's not just a doctor, he's also a policy wonk and a former high ranking government official dealing with health care matters. he is currently an associate dean and professor at the john hop kins school of public health. before that deputy commissioner at the fda and secretary of health for the state of maryland. josh i suspect although i don't know exactly what he'll say may be the voice of caution here. hold on here you free market loving libertarians, we can't throw out all regulations. we need some regulations in place. so each of our panelists will speak for about 12 to 15 minutes and then open it to the audience for questions. one thing to mention is if anyone has cell phones please turn them off. with that let me turn it over now to renae who will get us

started. >> thank you very much. by way of disclosure even though -- yeah. even though simon did introduce me, i do represent a lot of telemedicine stake holders hospitals, health systems health plans, some of the leading te le medicine company. some of my comments may be skewed in that direction. i have a quick powerpoint we're going to go through here. one of the things i always start with is definitional. tel,medicine, telehealth used interchangeably interchangeably. medicare has a very restrictive definition of -- they use the word telehealth, which involves two-way realtime interactive communication. so no forward has to be audio, visual. i put this up there just to show you that we can't even agree on a deaf nation of what we're

talking about. we can't even agree on the terms. i see somebody here from the american telemedicine association. they use the term telemedicine, they use telehealth. for me i look at it very broadly. to me it's just the delivery of health-related care, services education and information via telecommunications technology. that's it. very simple for me. these are some of the usages of telemedicine. you can see we'll get into some of this later during the question and answer session. these are really the sort of three telemedicine modalities. some folks will tell you or say remote location monitoring is separate and apart. i think gary and i've talked about this before. but i just wanted to give you a flavor that there's a complexity here that we really need to pay attention to. we've talked about realtime. there's store and forward where digital images and audio files

are stored sent to a provider wlo can look at them at some later point. there's really no interactive communication between patient and doctor. remote patient monitoring is exactly what it sounds like. you monitor patients digitally across distances and providers get information and can intercede at any point during that process. so what is driving the issue? what is driving the discussion of telehealth and telemedicine? i will tell you i've been practicing law for 17 years and this is i think for the last two years, the first time where i feel as if telemedicine and telehealth have arrived. what's driving some of this? part of this is the aging population. we're supposed to age almost 327 million people by 2030, but i think more important than that is the percentage of those folks 65 and older almost a fifth of the population. ofblg the older you are, the older your population the more

health-related issues you're going to have. do we have the capacity to take care of our aging populations in addition to all the other things we need to do in this system? this is also coupled with the fact that a lot of folks are predicting a shortage of physicians. you see here almost 65000 by next year's going to double by 2025. so you've got increasing population, increasing share of aging population, plus you've got this shortfall of physicians. you also have a health care system that's really in a transition from a fee for service environment where payers pay for service to one that i will call income for outcome. where your payment, your reimbursement is really based on health care outcomes, quality, metrics. we're in that transitional phase right now with all the attendant problems everybody's read about. and also technology. the sophistication of a lot of

health technology that exists today is incredible, incredible. and the question is can our health care system absorb pay for and adequately manage the risk of all this new technology? that's part of the reason we're here. now, in terms of the telehealth market overview these numbers are all over the map. but what i can tell you is most financial researchers, most economists are very bullish on this market. bcc research predicts that the global telehealth market is going to reach 28 billion by 2017. global health data does one better and says it's going to be about 33 billion by 2018. burgen site estimates we're going to be at 22 billion by 2020. and ihs predicts in the united states we're going to be in the neighborhood of about 500 million by next year. towers watson, which is one of the leading employer benefits

firms says the use of telehealth could result in $6 billion a year in health savings across the board for u.s. companies. just to give you a flavor of what's happening. we've already talked a little bit about the landscape that's changing. we've talked about the transition from a fee for service environment to one in which we're really really paying attention to outcome. the benefits of telemedicine. so what are some of the legal and regulatory issues we face? i think the first one we always talk about is license. i think it's an important issue. i think there are some ready-made issues some folks are attempting. the other thing too we tend to look at it from the physician perspective, but there are a lot of mid level and other providers. we also have to consider scope of practice which i'll talk about very briefly and how physician-patient relationships

are established. and why those requirements may be a barrier though some states are taking care of that in their own way. coverage and reimbursement, it runs the gamut from very restrictive payment approaches by medicare to a mixed bag in medicaid to a better overall picture for private payers. we probably won't touch on the rest of this given my limited time. so let's just talk about license sure. licensure follows the patient. govern what constitutes the practice of medicine. if somebody's practicing medicine, they need to be licensed in the state. what state do they need to be licensed in if you've got a physician in one location and a patient who's out of state? in the united states it's where the patient is located. so you can see how this impacts telemedicine if you've got a dually licensed physician in pennsylvania, for example who's

providing online care or tele telecare to somebody in north dakota. they need to be licensed in north dakota unless they meet a number of exceptions. we're going to talk about some of these solutions that have been developed recently. this has been a long standing barrier. and one of the reasons i think it vexes people is that if you really think about about health care in the united states, i think for the most part a lot of the core requirements are the same across the board. the doctors practicing in california, doctors practicing in florida especially if you're practicing in urban areas, is there really a difference between the practice of medicine in miami, los angeles, new york chicago? that's a question that needs to be addressed. there are some exceptions to obtaining a full regular license. i talk about some of these, a consultation license as well which we don't need to get into.

but those exceptions usually don't resolve the overall issue of having to obtain liecensure. the organization that represents 70 state and osteo pathic medical boards across the country has come up with a medical licensure compact that only applies to physicians basically it's a system in which licensure portability is made easier depending on whether or not a state is part of the compact. so for all states part of the compact, being licensed in one compact state makes it easier to get a license in another compact state so you can practice. problem here is you still have to apply. it's not like the nurse licensure compact where you're deemed licensed. so far i think six states have signed on officially to the compact and are part of the compact. according to the federation of state medical boards they need

seven to make this work. so we're almost there. i think another 15 have bills in various stages of the legislative process. so you could see 10 to 11 states and members of the come back-to-back by the end of this year. so you'll get this going. so this is one stakeholder's attempt to address a licensure issue. the other big issue i see -- before we go on i should talk about nonphysician licensure. nurses already have the compact which i think 24 states are a member of, but interestingly enough for the nurse licensure compact the big states are not members, texas california they're not members. it limits the utility of the nurse licensure compact. the other issue to touch on is scope of practice. how do a physician-patient relationship is established?

the one thing here i want to emphasize is that in order for a physician-patient relationship to be established among other things, most states require some kind of examination of the patient. what institutes an examination varies from state to state. in a lot of states an in-person examination of that patient is required. as you can imagine in the telemedicine that may be difficult. some states have seen fit to pass statutes which allow that examination to occur by telemedicine. meaning if you can get the same information that you can get in a telemedicine encounter as in-person encounter, that's fine. the problem is we have not yet developed enough peripheral and diagnostic technology to make those examinations -- to facilitate those kinds of examinations yet. so what we see a lot of or what

i see a lot of is folks providing telemedicine services without actually doing any examination. there's a video connection with that particular patient. and a lot of folks are concluded that that's enough. that really doesn't constitute an examination by telemedicine. now, the federation of state medical boards again came up with a model policy for the appropriate use of telemedicine technologies that sought to loosen some of the restrictions involved in the practice of telemedicine. one of the things they talked about was the examination issue and really leaving that up to the physician. let the physician decide whether or not they have enough information to continue their relationship to diagnose and treat. unfortunately unlike the nurse licensure compact the model exists in the ether. i think some state medical

boards have sought fit to adopt some or all of this but there's really not a lot of energy behind passage of the fsnb model policy. i will say a lot of other stakeholders have developed incredible protocols. i know the american telemedicine association has an accreditation program for direct to consumer care, the medical american association is developing their own set of protocols. so there's a lot of activity in this space that's occurring right now. the other thing i want to talk about before i leave is reimbursement. this is a particularly vexing issue at the federal level. i should tell you that under the medicare telehealth benefit i think just a little under $14 million was paid out last year, last calendar year. this is out of $615 billion in reimbursed -- total reimbursements last year. i think that represents 0.0023% of the total. so basically medicare doesn't really pay for telehealth.

there are a number of reasons for this. the first being that the approach taken by medicare is that this is really for people in most rural of counties in the united states. that's the first restriction. there are only certain kinds of providers that can be paid under this benefit. a patient has to be presented at a certain kind of facility, the patient cannot be at home and receive services and have professionals be paid under this. last thing is only certain codes are paid for. so if you look at the codes there seems to be a trend towards assessment and evaluation and psychological and psychiatric services, there seems to be a trend towards having those kinds of services reimbursed as opposed to others. obviously there's a bias that telemedicine is really not suited or suitable for nonurgent primary care purposes. medicaid's a little different. most medicaid programs as you know medicaid has more flexibility to decide what services they will and will not

cover. medicaid -- most services are coffered in some form but requirements vary state by state. some follow medicare very restrictive rules. some are more liberal on the issue. a few cover remote patient monitoring a few cover store and forward. there's no uniformity. really there's no logic to what states can and will cover. i think this could change especially as medicaid programs come under increasing fiscal pressure. private payers, the private payer world is probably in a better spot. a number of states, and gary you can correct me if i'm wrong, almost half the states now have statutes in place that require private payers to pay for telemedicine services if those same services are covered if provided in person. so basically states are forcing private payers to cover +n telehealth and telemedicine.

the definition and what is covered varies state by state. also they don't mandate the same reimbursement levels, i should caution you on that. but the private payer approach i think, is a little better than you have with the public payers. the other thing too is even in states that don't have these statutes in place what we find is a lot of private payers see a benefit in providing these services. whether they're required or not. and have listed here some plans that -- none of them are clients. some plans that are known as being progressive about telehealth and telemedicine services. i'll leave you with that. i will finish up by saying that the one other aspect to really, really pay attention to in the coming years is employers. a lot of employers are very encouraged by what they see and the value they see in telehealth and telemedicine. there's the impending cadillac tax coming in 2018.

we could talk about that at some point maybe during q & a, but employers seem to be incentivized and look at telehealth and telemedicine as a way to control the costs of their employees. >> thanks rene, that's a great introduction. we turn over to jeff who will take us through what happens when you actually provide telemedicine services online. >> thanks, renee. so one of the reasons why telemedicine presents such a challenge is because medicine is a vivid illustration of a peculiar reality in america which is everything is forbidden unless it is expressly permitted. so this amazing interesting fresh innovation comes along and all the medical boards say, you can't do that. we need to write 10000 regulations to be able to do it. we have to completely subdue it with a regulatory process because after all this is america. if we don't have a telemedicine statute, you can be certain of one thing, you better not be doing it.

in part that's because we have a 19th century or early 20th century regulatory model. we have fifty different states each with their own regulatory boards and doesn't even take into account the fact that americans can now talk to people all over the world. there are billions of people who would benefit from the expertise of well-educated americans. and it's completely unclear whether or not they can get it. now, the thing about telemedicine is that at bottom it's just two people talking to each other. that's it. people are talking to each other. one person wants some knowledge that another person has and they want to share it. now, at least by reputation we live in a free country so what does the first amendment the free speech clause in particular have to say about that? this turns out to be a really interesting and one of the most important unsettled questions in constitutional law. so let me begin by telling you a story. imagine -- and this is a true story. imagine a group of scottish missionaries go to rural nigeria. and a married couple finds a

stray cat. and they think we're going to adopt this stray cat. but there are no veterinarians in rural nigeria there's no pet food in rural nigeria but one thing they have is a cell phone tower. so these missionaries can get on the internet. now, go all the way around the planet and you'll find ron hines. he's a retired physically disabled texas licensed veterinarian. he has a ph.d. in biology. he spent his career working with exotic animals at a research facility here in maryland. he worked at sea world. he was in private practice. he's just an amazing veterinarian who after he retired because his disabilities made it impossible for him to continue to work, he still wanted to be able to help animals. so one day he and the missionaries in rural nigeria start writing e-mails to each other about what to do about the cat. how should we feed the cat? how can we make sure this cat stays healthy? it was a stray cat, what should we be looking out for? so ron and the missionaries are exchanging e-mails. and ron starts doing this with

some other people too, mostly for free although occasionally he would charge people a flat fee of a couple of bucks. to help him cover the cost of keeping his website going. he never made any money doing it. so what has just transpired? a disabled 70-year-old man in texas writes an e-mail to a scottish missionary about a cat in nigeria. that's a crime. and ron hines had his veterinarian license suspended, he was fined, he was forced to retake a portion of the veterinary licensinge inging exam, and he had to shut down his website and stop doing it. why is that? because under texas law you have to physically examine the animal before you can offer any opinion about it. so this house-bound physically disabled veterinarian was supposed to get on an airplane and fly to nigeria before he could offer an opinion of any kind about this cat. never mind there would be no veterinarians that the cat would

be completely out care without ron. he wasn't prescribing medications, wasn't sending drugs, he was offering an opinion. that's it. two people talking to each other. what does the first amendment have to say about that? because after all the first amendment is supposed to protect the right of americans of which ron hines is an american. and indeed anybody subject to the american jurisdiction generally speaking to be able to have useful conversations about the world. well, we brought a first amendment lawsuit. and the trial court the federal trial court said you know what, you're right. the first amendment applies. the state of texas tried to get it dismissed on the ground that when two people talk to each other, if that conversation is subject to occupational licensing, the conversation is by definition physical conduct. so if ron hines writes an e-mail that says you know, you should try to maybe feed your cat some shredded pork or something like that, the law treats that as though ron hines is taking a skal scalpal and cutting.

it's not that first amendment applies and you happen to lose under whatever first amendment balancing test there is. it's that it doesn't apply at all. so the federal trial court said the first amendment applies to this. after all it's just two people speaking. so then the state of texas asked for a special kind of appeal and we went to the federal court of appeals. and in march the federal court of appeals reversed. and they said you know what, we disagree with the trial court. we are going to call that conduct. if you are speaking and you are giving someone individualized personal advice, we're going to call that conduct. so what's going on? well, what's going on here is the collision between two venerable constitutional doctrines. one is that state governments have broad authority to license occupations. that is well established in the law. we challenge it all the time. at i.j. it leads to all kinds of rational barriers to entry. one of the reasons why medicine and other kinds of professions are expensive and hard to get in

to because lobbyists and others create all kinds of occupational barriers. set that aside states have broad latitude. the supreme court has also said that the protections of the first amendment are broad. so what happens when those two things intersect? there was a case a few years ago about advice to foreign terrorists. and some american doctors and physicians were providing individualized technical advice to foreign terrorist groups about how to resolve their grievances nonviolently. one was the kurdish liberation movement and another one was the tamil liberation movement in sli lan dlsh sri lanka. the federal government considered to be material support to terrorist groups. and so the question that went up to the supreme court was, is individualized advice the

consistent of speech, no money or guns or bombs or anything, you're just talking about the law. is that something protected by the first amendment? and the supreme court said, yes the first amendment applies. turns out the federal government has a huge interest in suppressing advice to terrorists because it's just kind of fungible. that just frees up resources for terrorists to do other things. but the first amendment applies. so we actually tried to take that precedent and we said to the federal court in the fifth circuit, we said look, if the first amendment at least applies to individualized technical advice to murderous foreign terrorists surely it applies to this utterly harmless disabled veterinarian in texas who's just talking to somebody about a cat? and the court said no. no. here's another interesting case about the first amendment. that's also from a few years ago. u.s. v stevens which vovred animal crush videos. there are people out there, perhaps, you know, probably not anybody in this room, but there are people out there who like to

exchange videos about animals getting tortured and that provides them with sexual titillation. so the question the supreme court addressed whether or not the first amendment applies to a statute that restricts communication in the form of animal crush videos. and the supreme court said you know what, this is america. this might be repugnant speech but the first amendment applies to repugnant speech. the first amendment applies to animal crush videos. so what does this mean for ron hines, the veterinarian in texas? what it means is, if he decided he wanted to talk to kurdish terrorists about how to, like, let's say they have a herd of cattle or something like that and they're using that herd of cattle to support their fighters or something, he could talk to them about that, and the first amendment would apply to that conversation if he were to be prosecuted by the federal government for providing material support to terrorists. now, if ron hines also wanted to exchange animal crush videos with scottish missionaries in rural nigeria, the first amendment would apply to animal

crush videos. according to the fifth circuit, the first amendment doesn't apply if ron hines is actually just trying to help an animal. so if he wants to help terrorists, or he wants to trade fetish videos, no problem. but if he just actually wants to sit down and talk to somebody to help their animal, no, no first amendment protection. so this is actually a big issue. the federal courts of appeal disagree about the extent to which the first amendment applies. so we have a case from the early 2000s in california, that involved medical marijuana. and this was before -- california at that point i think had said that medical marijuana would be okay, physicians could prescribe it. as it is now it's still illegal under federal law. so doctors have a controlled substance license from the drug enforcement agency to be able to prescribe drugs. and it turned out there are a group of doctors who wanted to be able to say to their patients, look, i'm not going to prescribe marijuana for you. i can't do that.

but i'm going to tell you that actually in your case, i think there is a valid medical reason for using marijuana. so a conversation between a doctor and patient. the u.s. court of appeals for the ninth circuit said the first amendment protects that conversation and the drug enforcement agency can't pull your controlled substances license just because you're a doctor having a conversation with a patient about medical marijuana. as long as you're not illegally prescribing it. because the first amendment applies even to doctor-patient communications. that should have been a good case for us. we cited it extensively in the fifth circuit. on the other end of the country, in the 11th circuit, there is a case going on right now sometimes called the glocks versus docs case about guns. and some gun rights activists got a law passed in florida that forbade physicians from asking whether they own guns. as part of a checkup they might say are you wearing seatbelt, because accidental gun

discharges and suicide by gun, those are legitimate public health issues. so anyway, the gun lobby didn't like the fact some doctors were asking people about guns and they thought it was an invasion of privacy so they got a law passed that said doctors aren't allowed to ask people about guns. so, of course, a group of doctors brought a lawsuit and said, look, the first amendment protects my right to have a conversation with a patient. and that just because we're in a doctor-patient relationship doesn't mean we have completely surrendered our free speech rights and the government can tell us to do and say whatever we want. the 11th court of appeals said no, even if it's just a conversation, you're not touching them, doing anything, that is conduct to which the first amendment doesn't apply. you may notice that the medical marijuana issue is kind of a liberal issue, right? and the ninth circuit court of appeals on the west coast, kind of a liberal court. and on that liberal issue, the liberal court decided the first amendment applied. the 11th circuit is kind of a

conservative court. and this was like a pro gun thing. and wow, coincidentally, the kind of conservative court decided the first amendment didn't apply when it was a conservative issue. but we have a square disagreement among the federal courts of appeal, a disagreement that was exacerbated by the decision in the vet speech case that just came down so the supreme court actually has to step in. and the supreme court is going to have to decide whether or not the first amendment applies when there is a conflict between occupational licensing and free speech. and so we're in the process right now of writing our petition to the supreme court in the vet speech case. and this is actually the perfect case. because what's going on here is you have ron hines, talking to people generally speaking on the other side of the world about animals. that's it. they're exchanging e-mails about animals. so this isn't even the most intense telemedicine context you can imagine. this is right at the edge. so if the first amendment is ever going to apply to protect the free speech rights of

licensed professionals and their clients, then it is going to apply in the context of ron hines' case. and this is the perfect clean case for the supreme court to take. the other thing too, there are some cases making their way through the court system right now that have to do with what's called repairitive therapy, providing psychological counseling generally speaking to minors who are gay or say they're gay and their parents don't like it and send them usually to christian-based psychologists. and there is a movement that says the first amendment should protect the right of therapists to engage in gay conversion therapy. now, one of the great things about the ron hines case is it is just about people talking about animals. it's not about gay rights, not about guns, not about medical marijuana, not the hot button cultural issues. it presents the case perfectly in a benign context, where the supreme court can address the first amendment issue without worrying about making collateral statements that might have

ramifications in other areas of the law. so fingers crossed, we'll try to get the supreme court to take the case and perhaps this time next year we'll get a decision that will tell us to what extent the first amendment applies to occupational licensing and this will have implications far beyond the practice of veterinary medicine, scholarly, law, all things that can be done as a result of the internet. so thank you. >> thank you very much, jeff. it's fascinating case, and i will keep following it, and i wish you the best of luck with it. >> thank you. >> i'm hoping for a supreme court decision to -- hoping it goes a certain way. even if it doesn't, something fun to talk about. so let's go to our last speaker now. josh sharfstein and i'll turn it over to josh. >> thanks so much. i really appreciate the chance to be here. i appreciate the invitation from simon. and i thought both presentations were terrific. really interesting. i'm a little bit in the sesame

street segment, where they say which one doesn't belong and you're supposed to pick it out. that's me a little bit in this panel. i'm a physician, not a lawyer, like the other three panelists. i've been appointed to city, state and federal positions, by democrats. and so i'm coming from a slightly different perspective. i do appreciate that cato's internet password is obamacare saves lives. i'm just kidding. that's not true. i thought that was changed yesterday. now it's just a little joke there. so i -- i actually started reading simon's paper and i was like, i don't think there's going to be a thing in here that i find attractive. and i just found the paper absolutely fascinating and interesting and provocative. and i thought that both of these presentations were also very interesting. and there's a lot to agree with about the points that have been made. and let me just say that for me, telemedicine kind of struck home when i was visiting a rural hospital and they showed me a ward where the patients were

being entirely managed by a remote team of physicians. so there were -- it was intensive monitoring. it wasn't like your phone calling a doctor and showing them your rash. it was a hospitalized -- you know, situation. and i never had seen anything like that before. and they go, well, actually, there's a doctor watching all of the monitors. and we have one nurse or a couple nurses here that will get a call from that doctor if there is an issue to check on. it's better if there were a doctor asleep down the hall. and i thought is this a good thing, is this not a good thing? i couldn't get my head around it and what's the best way to regulate it. i think when it comes to telemedicine, it's a similar question as a lot of things, xr which is what is regulation. is regulation sort of red tape protectionism that hurts consumers, and just keeps things from happening that would save áó ñ lives, or is regulation necessary to prevent exploitation of patients and

consumers and protect the public health.$?í and the answer oftentimes, +rf'?çç having worked with different levels of government, is yes. it's both. and there's no simple one or the other, and it depends how well it's done. and the key is figuring out how to strike the right balance. in this case i would say you see with professional boards, there absolutely is protectionism out my last job, i was responsible for more than 20 professional boards of different kinds. and i was called on to mediate when the doctors and nurses fought or the nurses and the dentists. there was a huge fight in maryland between the physical therapists and the acupuncturists over dry needling. dry needling is what physical therapists want to do, but acupuncturists say that's unlicensed practice of acupuncture. and i decided at one point to do a public comment period. and usually we do 100 comments. it's a lot. and i got over 1,000 comments on all sides of the issue.

very revved up. i picked up my 8-year-old from school, and he's like, you know, dad, what's dry needling? and i said why do you ask that isaac? and he said well, because my gym teacher gave me this letter to give to you. so just -- i used to say that it's not a safe place to be between the dry needlers and the acupuncturists. and at one point i proposed legislation in the state of maryland that would take these scope of practice disputes out of the medical boards and all the litigation, give them to a -- give the ability for the legislature, just the ability for the legislature to appoint a committee to resolve it in the public interest. and the line out the door of all the lobbyists who were testifying against that bill was an image i will keep in my mind. nobody wanted that. they just wanted to battle it out. so i do -- i absolutely concur that there are -- you cannot assume that just because the medical board or dental board or

a different board has a particular policy it's going to be the right thing for the public interest. the flip side is, they do provide very important public health protections. and particularly when people are sick, they're not your economics 10 well-informed consumers. people who are sick are very vulnerable. there is an unbelievable record in the united states of people getting taken advantage of when they're most vulnerable, when they're sick, fraudulent cures, things that hurt them. and it is very much the case that medical boards, for example, protect the public for -- against physicians who are quite dangerous. as do the other boards. and i used to interview -- i interviewed all the medical board candidates and we set up a process for interviewing the other candidates and i was like i have only two questions. number one, will you put the public interest first, even if

it's about people -- if there are people out there who shouldn't be practicing, it is your job to get them out of circulation and to make sure you're protecting the public. and number two, be reasonable on scope of practice issues. because you know, the fights that happened were just totally all-consuming when they happened. so how do you draw the balance when you have regulation like this? you know, if you're not going to be someone who just thinks all regulation is wrong and if you're not going to be someone who thinks all regulation is right and some things that make sense and some things that don't. how do you do it? how do you maximize the benefit and minimize the risk of a regulatory approach? and the answer is, you have to set up an approach, a process, that has the public interest as j the bottom line. and i don't think that the boards themselves can really play an effective role in that. i think there are some state models that bring in external people to think those things through. that those are good models, as you're thinking about global

models, figuring out what would -- where are the opportunities to do things that really are in the public interest to get the -- you know, it's not just, i think, what simon is putting on the table isn't just that they're u.s. health professionals treating people around the world, but people in the united states could log on and get a consultation somewhere else. well, that may well make sense for certain things.:ñ[ú

groups say they'd thought we'd done a fair job. and that was because we tried to strike a balance and we were1 i think that in general my view is that it should be the public interest that's the real north pole that the compass isç÷/ aligned to. it should not+++$ñ

and i do understand the fact that there are speech considerations. i think that if there were a way to say that -- you know, what is the balancing test. so i think jeff may be focused on getting the first amendment to apply because that's a threshold issue for him. i'm more interested in what's the balancing test you apply. what is the balance between state regulatory agency and individuals in this regard, and i think that the balance has got to be some assessment of the public interest, whether it makes sense. i would make the case, as a pediatrician, and along with my professional association, that it can be very important to ask about gun safety for the very reasons that jeff said. and that there could be -- the standard that would be applied is not just are they words coming out of someone's mouth, but does it make sense. on the other hand, on a therapy that has been totally discredited by the profession, that it -- such as reparative therapy, which has essentially no support within organized and %í evidence-based medicine, that the public interest would --

would favor a regulation in that area. so for me, i could see that there is a yardstick that could be done that it's not so much whether the first amendment applies or not, but then how you would apply an appropriate test so you get regulation that maximizes the benefits to the public and minimizes the risks. and i think probably if we were all to sit down, even though we may come from different ideological parts of the spectrum, we probably could work out that it's totally reasonable for someone to be sending cat advice to someplace in the world to help cats, and something else might not be reasonable at all. and how do we draw that balance or what would be the process that could draw lines that would lead to better health, lower costs and a interesting progress as technology evolves in health care. thank you. >> thank you, jeff. those are all great presentations and give us a lot to think about. i want to open up to questions now. let me take an opportunity to ask a first one so start getting yours ready.

i think this question and i don't mean to put you on the spot, rene, and others feel free to answer, too. i think this question may be most for you, rene. i don't know what extent you've thought about this. i think both josh and jeff alluded to, there are international aspects about this and that's what i wrote about as well. and i'm just wondering, as we all know, the united states is not the only country in the world. other countries are aware of this too and doing things too. rene, do you know, you know, are there other examples of what the european union is doing, what china is doing? what are other countries doing with this? it seems to me, eventually someone is going to be trading these services internationally. if the u.s. is going to put up barriers, we're going to be the only ones. everyone else is going to go ahead with this in some way. do you have a sense of what the rest of the world is doing with this right now? >> yeah, a little bit. i think we're all sort of in thef same boat. a lot of this is new. or we're wrestling with a lot of clinical, political and other issues as well. i will say, for example, in the eu, licensure follows where the

physician is located which makes sense and which facilitates the greater access to care, obviously. because physicians don't have to worry about being licensed where the patient is located. but a lot of other areas have not yet had the sort of fully developed regulatory approach the united states has. now, one thing i will say is that sometimes i tell my clients, have you thought about starting this somewhere else outside the united states where you have fewer regulations to worry about, where you have fewer political considerations. i mean, we heard about the board, and i think dr. sharfstein, you alluded to this. there is some protectionist bent for these boards as well. so i think we're generally all in the same boat, but i would say that given the way our laws are -- the way our laws are enacted, the way regulations are promulgated, the federal and

sub regulatory guidance we have both at the federal and state level, all the various boards you have to deal with if you have a regional and national network you have in mind and want to develop. it's hard to do in the united states. >> let me open it up to questions now. so a couple instructions. please wait to be called on. raise your hand if you have a question, wait to be called on, wait for the microphone so everyone in the room and audience can watch your question. and announce your affiliation. with that, any -- any questions? >> my name is lee young. my question now is how are you going to do -- or what should be done in the medical sector or in the public citizens. onnxp ike hacking or i"hd

manipulation of equipment or internet or some kind of obstruction, basically. okay. and then you have a regulation, but currently there is also a wzv# trend -- as i say, maybe more related to the fraud operation. and they are now promoting occupation without examination. what they call it now is a competency, which is very strongly worded and maybe very subjective.xpp and then if the people complain to the government agencies and they ignore the complaint, really, and what they say is they are not in the best interests of the public. so how are you going to regulate government agencies rather than

professional health care?ms >> go ahead, josh. >> so i -- to your first point about security, i think that's extremely important. and i think that is a potential role for regulatory standard, because even if you could work it all out that there is a great dermatologist in germany who is perfect for your kind of rash, and everybody believes it's appropriate to do over -- but suddenly, you know, you're -- you know, www.simonsrash.com shows up on the internet and there's all your pictures because that's been stolen, that's not a good outcome at all. so i do think one of the things that is important is to have strong security standards and enforcement of the standards so everybody is participating is at least able to have some level of competence about privacy. i think that's a really good í9oj point.1

jobs are very hard. and boards in general, jobs are very hard. because some of the things are bh7'-jç very easy. there is something that has been horribly done horribly wrong and needs to be clear discipline or r even someone losing their license. but a lot of them are in a gray area. and it's very important for zú boards to be as prompt as possible, be able to at least, you know, as -- at a certain level, be transparent about its approach to different issues. and then usually there's recourse to the courts if boards don't do -- for both the provider and for the patient, and in the case of a totally egregious decision, occasionally the courts will pick that up. but there is enormous authority. and i have seen very unhappy practitioners who felt they were being treated unfairly by the board, and very unhappy patients who felt like they were mistreated and the board didn't really listen to them.

you have to try. in this case you have to think about the board being run well as well as there being some opportunity in certain circumstances for appeals. >> do you know anything about the security issues, rene? >> no. i think security is very important, but we have other laws. the e.u. has an incredibly efficient+++ír

through simon's work. when i was doing research on this, a lot of the biggest challenge seemed to be licensing within states to practice medicine. my question's open to the panel. if the day comes in which, you know licensing is eliminated per states across state laws, do you see this phenomenon spilling over to other industries. what i'm thinking is the practicing of law right now doing research on mobile banking in africa and there are similar regulations prohibiting, i guess, the flow of commerce between countries and even between banks. so i just wanted to get your thoughts on that. thanks. >> so does this set a precedent for other industries? >> yes. if the first amendment applies to occupational speech which it should, then it will be a precedent that applies outside the context of medicine. but as josh was suggesting how

it applies will be a little bit different. and, you know, the particular tests that we would use in the first amendment likely although i don't know it would be something like the test for commercial speech which recognizes there's a substantial interest constitutional interest that should be protected but maybe not as big constitutional interest as in other contexts for example pure political speech. what would this mean? in the context of medicine you would expect there to be reasonably robust protections because appendicitis in florida is the same as appendicitis in alaska. but on the other hand florida and alaska actually have some different laws and might have different banking laws that are peculiar or real estate laws that are different for whatever reason. so the kind of teleoccupational regulation that will exist, even in a context in which the first amendment applies, will allow for the kind of flexibility that josh is describing, i think. but it should apply to just about everything. like financial services seems huge.

the practice of law frankly is something that's big. psychology and maybe life coaching, and diet and nutrition. those are the kinds of things people can actually do from a distance and they can do much more cheaply, much more conveniently if conveniently if it were possible to do it across state lines. >> let me just clarify that i do support medical licensure by state. and the reason is there's a strong history of medical licensure by state. in maryland we did a lot to improve function of the medical board. there's some terrific doctors who are serving on it and they did a great job clearing a backlog and taking much more rapid action while they were expanding procedural safeguards for doctors. it's a really hard thing. it goes to my previous question. and i think that it has credibility in part because it's relatively local. we have experts from the university of maryland who's on the chair of the board, johns hopkins. so if you're taking someone's license away, you're doing something like that it helps for there to be an internal

credibility within the community about the fact that it's the medical profession doing it. it's not some external national global board of doctors. it's actually a local board so i think getting the boards right is correct. what the relationship between boards are and the compacts that renee talked about and expansion, i think that would be the right area to pursue. i would say as you think about limiting -- how you approach policy judgments i would afford a lot of importance in the need for the people to be licensed for where they are taking care of patients. and i see this different a little bit than the case of the veterinarian, because the case of the veterinarian is about sort of the definition of how to practice. you know, you should have to do a visit before you do something. i mean, those sorts of things i think are like trying to regulate the practice within a place that you're doing it.

whether or not i think there's an appropriate role for a first amendment or other things to say actually you don't need to get licensed in this other state anyway, i would probably have much more of a concern about it because i think there's a huge public health value to having well-run medical boards in -- at the state level. but i see that as a little different than the case of what is under the jurisdiction of the board and how the board may be going about its work within a state. >> that's true. but as a quick response, as a constitutional lawyer, the mere fact that free speech rights are inconvenient to the government is not a justification for ignoring them. like, the constitutional is the foundational document and our free speech rights are foundational. and even if they create what might be a suboptimal regulatory state, that may be what a free country tolerates. >> and i appreciate that. as a pediatrician -- [ laughter ] as a pediatrician i would say -- i gave a speech at one point in the law school where i said i'm familiar with the argument that

the bill of rights is not a suicide pact when it comes to terrorism. i would say the first amendment is not a suicide pact when it comes to public health. >> do you want to weigh in on that? >> the only sort of talking about the boards, aren't most boards complaint-driven, doctor? number one. a lot of boards are underfunded, number two so the question i always have is are the boards the best way to regulate the practice of medicine given those two thing i've just mentioned? >> you know i -- i think that the question is certainly there are fwhoordsboards that are underfunded and you could look at a lot of front-page stories that say they're not doing as good a job, a number of them, as they could do. it's complicated to think of how you would do better other than to improve boards like we were able to do, i feel like, in

maryland and other places. for because of the local nature of medicine and the history of their care -- i guess in this respect i'm the more conservative personal only the panel in that i would be careful about tloinghrowing out more than a century of regulation at the state level unless you had a sense of what you would do. do people really want want group hearing all these cases within -- and it is true, though, that there are local standards of care for certain things. and so you know, i -- >> but aren't those -- not to interrupt you but aren't those disappearing over time? >> that's probably a debatable proposition. i think there are people who would like to see some of those differences disappear, but it may be that, you know if you have a board that has their group of experts in a particular field from one part of the country, they don't realize that there's a unique different kind

of disease or history or treatment or wariness or something that's going on somewhere else. and, you know, i think that it's -- i have written about the medical boards so i'm not in any way trying to defend them. on the other hand it's not that easy to think of a national medical board that would be able to do that much better. >> let's open up to other questions. i see a couple in the back there. maybe the guy closest to you then the one in front of him. >> steve chisolm with the chisolm group. thanks to the cato institute great work. my question may not be particularly jermaine. i was thinking about the v.a. medical system and they're trying to talk about telemedicine and doing some things that would be at the federal level but obviously would affect the first amendment, and i'll admit to being an attorney. but it will also be done at the local level, particularly with rural veterans.

it's a major issue in the country right now. i wondered if the panel may opine that. >> anyone know anything about that issue? >> i think that there are parts of the country that are in desperate need of access to care. veterans are particularly in need of mental health care and services that aren't available in all places. and one of the things that comes up, for example, in the military medicine and veterans administration is whether it makes sense to -- you know you have both huge gaps in access to care and quality problems at certain places and can you -- is there a strategy that involve mrs. telemedicine that can address both of those at once? >> and i think those are very fair policy questions. in the end, the question is are people healthier and can you design something to serve the needs of veterans? that should be the litmus test not some arbitrary measure of speech but are veterans getting

healthier? >> and i think this brings up another issue which is sometimes i think we take a one-size-fits-all approach it's just telemedicine. but i think we can all agree for example, in telemental health care you don't really need to lay hands on patients to be effective. it's really about communication. i would think that for subspecialties like that telemedicine is a great fit. and ought we not to treat that differently than telecardiology or something else? so maybe we ought to start thinking about this in a more sophisticated way as opposed to this one sized fits all and everything fits under this umbrella of telemedicine. >> it's certainly true that doctors can say things to patients short of an actual diagnosis and implementation of treatment. so ron heinz one of the things he did is people would write him and say "i have been to two different veterinarians, they've given me two different diagnosis and can you look at the file, help me make a decision?" because i have to make a decision and ron is the kind of

person who has a great deal of experience and can help out. with respect to people in rural areas, one of the things that ron got in trouble for is that there was an impoverished double amputee in maine who was living by himself and the only thing he had was his beloved dog and his dog was sick and his dog was dying and ron was talking this guy through certain things to help alleviate his dog's suffering and eventually ron found a veterinarian in maine who would treat the dog for free for this amputee and another veterinarian heard about that that ron heinz in texas has been providing some initial hope the this over the phone and reported ron heinz for doing that. and this is, like cure economic protectionism. no rational person would say that this impoverished double amputee who's not going to a veterinarian who's getting some free help from a guy in texas that that should be stopped. it's ludicrous. but that's one of the things that happens and one of the reasons why we need to have a

rational telemedicine regime. >> another question right there. >> hi pat mike frls kayechaels from cato. this probably goes to dr. sharstein and it has to go with the complexity of the ultimate regulatory regime we're going to have. i can see -- to maybe differ with you on the remote cardio -- if you put a heart monitor on a person and they showed some frank arrhythmia, some remote physician can read that and make a reasonable diagnosis and proper prescription without seeing the person. however, if you show up with some kind of maybe substantial skeletal pain symptom to an orthopedic person, you're going to have to be examined because you can't remotely do the manipulations that are required in order to come to a reasonable perspective diagnosis.

now, where this question is leading is it seems to me given these differential regulatory possibilities that we may wind up with a group of folks having to go through the entire diagnostic code manual to decide which one requires a personal visit and which one does not and that will entail all kinds of special interests getting in on this. howprevent this from becoming 10,000 pages of regulations that nobody understands? >> it sounds like you've seen those regulations on some other issues i'm guessing. >> i'm thinking of a person -- famous person from m.i.t. >> so i think that you're asking a very, very good question which is -- and this is partly about the approach to regulation. how do you strike a balance that's not such a kind of jerry