>> yep. >> okay. >> i don't think this will take language long. >> i don't know. i think there's consultation going on. >> it's rigged. the system is clearly rigged. we can agree on that. >> you guys think you're punching those buttons -- >> it's this -- >> there we go. some modification. >> some modification -- >> one in ten complete elimination, and nobody thinks it's going to change at all. >> all right. >> okay. >> your answer? >> so look, you want what i hope happens or do you want what i -- >> what you hope happens and what you think will happen. >> okay. what i hope happens is that we have some modification. i think that dodd-frank was not tough enough. and donald frank -- donald trump, let's be clear here -- donald trump said -- >> i think they had a different kind of modification in mind. >> this is the rick you run when you modify where does it go. donald trump said that he

support glass-tigueisle. we have -- steegle. we have a strong bill. john mccain, maria cantwell from washington state, it's a well thought-out glass-steeg lethat tsds we're going to separate banking, we're going to make boring banking more boring. if you want to take risks, you can't get access to the guaranteed accounts that we have over in the -- in the traditional banking system. going to separate those two. that's good for small banks, small businesses, it's good for the economy overall, makes it safer. it also has -- i should add it has a lot about the better regulation of the nonbank financial institutions. so it's really about fighting the next war where many of the risks lie with nonbank financial institutions. all i can say is the guy that was just elected president of the united states gave that one

a two thumbs up. as i recall, my want to remember it's in the public platform that this is an official party position to adopt dodd-frank. if you want to ask me about modification, that's the place i'd start with modification. >> it what's your expectation? >> hmm. the expectation is that there's going to be a lot of -- a lot of back and fwoerth this. you know, a lot of republicans have dug in on the notion that we need to roll it all back, or eviscerate whole parts of it. that you raise dollar limits enough that there is no effective regulation. you keep on the books, but it's not there. i think that's going to be a battle that's going to be fought hard, and i think it's going to be one where it will be interesting to see where donald trump goes. but it will also be one -- you think you can't get american people engaged in these economic issues? i think you can. i think the american people get this.

i think the fact that i have people stop me in the grocery store to say go glass-steegle, sounds crazy, but it's true. people get some of these basic economic points, and they understand them. they understand them as markers for the underlying question about who are you running the system for. is the system here just to help a handful of giant banks who rolled over american families in the early 2000s, who traded in these terrible mortgage products, that ultimately blew up our economy? that cost millions of people their homes. that cost millions of people their jobs, that cost millions of people their savings? the american people have not forgotten this. i think one of the big questions still for the american people is how could it b b b b b that nobr

went to jail over that. that we had a savings and loan crisis, and hundreds of people ended up going to jail over the savings and loan crisis. the idea was you couldn't have been running the bank where the books showed this on one day and they showed this on the next day without something being wrong in what you did. and that's ultimately lots and lots of folks. the reason i want to say this -- i'm, is and then i'll quit. is when we open up dodd-frank, we're not going to open up dodd-frank saying, oh it's 2017, a new day, nothing has ever happened before. you know, there's flowers and -- and birds are singing. we're going to open it with the memory of what happened in 2008 and how people took -- how a handful of people took down this economy. and then the part we're going to remember is what happened in the next eight years as they got bailed out by the american taxpayers, got richer than ever,

and left american families behind. that will be the context for reopening dodd-frank. >> one of the things that did happen in the aftermath of that was the creation of the consumer financial protection bureau. you had as much to do with that as anybody. does it survive now, or is it going to die in the next six months? >> again, who do you think you're fighting for out there? let's be clear about the consumer financial protection bureau. it has forced the largest financial institutions in this country to return $11 billion directly to people they cheated. it has now handled more than a million complaints. it's out there doing its job. it's leveling the playing field. it's transparent. you can look up which banks get lots of complaints against them and when banks don't. where the problems are, if they're on student loans or if problems are on credit cards or if they're on payday loans. the consumer financial protection bureau is doing the

people's business. and it has its own fan club out there. it's got the people it's working for -- you try to take the legs out from underneath the consumer financial protection bureau. i think that's not only a problem for donald trump and for the republicans, i think this is something that the american people will say enough, we didn't elect a government once again to try to increase the profits by .1% for giant companies so they can turn around and step on us. the cfpp shows that government can work for the people because it is working for the people. >> let's jump into some questions. i'm going to start with one that was in that -- that just gets back to the question of what next for the republican party. this one asks -- we need to come

togeth together. as a leader, how are you going to make this happen? this is in the context of what now for the democratic party? >> look, i think what coming together means is that we use this government to work for the people. and we do the things that work for the people. you know, let me put this way. you look at the election and say we're a very divided people, and there are issues, we are deeply divided. i understand that. things where half of america feels one way and half of america feels another. those are not economic issues. on these core economic issues, how we build a strong middle class going forward, we have a lot of consensus in this country. let me see how many i can remind everyone. refinancing student loans and bringing down the cost of college. this is something that is keeply supported across america. democrats, republicans, independents, raise the minimum wage, equal pay for equal work.

paid family and medical leave. expand social security, and rein in wall street. those are core economic principles that between two-thirds up to three-quarters of americans say, yeah, that's what i'd be behind. that's what's helpful to my family. that's how we build a strong and robust economy going forward. i'll fight for that every single day. and i'll be blunt here -- i don't care who gets credit for it. what i care is that those are the kinds of changes we make in this country. we need debt-free college in this country. we need it for the families who are struggling to educate their kids. but we need it for our economy. has anyone looked at the numbers on this right now? what student loan debt is doing?

we have $1.3 trillion in outstanding student loan debt right now. and studies coming out of the fed, the department of treasury, the consumer financial protection bureau. they show that young people -- you do this stuff -- they're not buying homes at the rate we expected them to. they're not moving out of mom and dad's house. they're not starting small businesses. we're watching depressied entrepreneurship. and what's the number-one reason behind that? the number-one reason are student loans. we are saddling our kids with debt, and that means they can't get a start in this economy. we're telling temperature that they're 100 yards behind the starting line by the time they get out of college. and it's becoming one more element of how you divide the rich from everyone else. do you realize that today 70% of

young people who graduate from a public university have to borrow money to make it through so that what's happening is -- when i was a kid, my dad was a janitor. my mom worked a minimum wage job at sears. and yet, how did i go to college? i went to college because i went to a commuter college that cost $50 a semester. that was my chance. that was my debt-free college. and that's how i got to be a public school teacher. and from there how i ended up going to a public law school and from there becoming a law professor and from there becoming a united states senator. it was an america of opportunity. and if we don't invest in opportunity, it's not only bad for families and bad for democracy, it's bad for all of us. that's the kind of change we need to make. >> we've got time for one more question from the audience. yes, right in the back here.

richard edelman? >> senator, where are you on the sharing economy? what about benefits for works who are uber or other? >> so look, we have had what is in effect a contract with workers. i use contract as the big meaning of the word. a big social contract with our workers for generations. part of it was about what you got paid by your employer and what your employer provided. part of it was the rest of it. we had social security as the backup. so when you retire, you wouldn't -- you wouldn't have to be in poverty, right. we had unemployment insurance for when you got laid out. but it was all built around a model that just doesn't exist anymore. it was built around the model of the single employer that you had for a long period of time. now we're moving to people putting together multiple -- i'm not sure the word employer is

right anymore. multiple income streams in different ways. and what that means is we have to rewrite that contract. we have to rewrite it, and we have to rewrite, i believe, the public part, as well as the private part. we can't keep dumping all of the obligations, all the things we wanted to see us do, build a social safety net, on the private side. we're going to have to have more creativity here. i'll give one specific example so it doesn't sound totally generic. and that is independent contractors. the independent contractor laws were written for a very different america. the notion that uber drivers, for example, cannot come together and bargain collectively to figure out what their terms, working terms and conditions are going to be, is crazy because what that does is

it forces them into a -- an economic circumstance that just doesn't exist anymore. it hammers them in to a place that leaves them weakened and unable to get together and negotiate something that's going to work for all of them. and look, here's -- here's my last pitch because i know we've got to go. i'm with a bunch of people who iran very successful businesses, and i applaud that. but for -- i assume almost everybody in this room it's really on the premise that everybody needs at least a little chance to succeed. sure some are going to do better, some are going to work harder, some are going to catch a break. but that we build opportunity for everyone, and that we keep running our systems in ways that those who work hard, who play by

the rules, are really going to have a chance to build a future. right now, america's not heading in that direction. and this government has not been a government that helped move it as far nature that direction as it should. and i think this is the true challenge in the 21st century. i think it's the challenge for all of you. i think it's the challenge for the democratic party. i think it's the challenge for all of america. >> senator warren, if there were any doubt, that it's going to be an interesting time in washington, you dispelled it for us. i appreciate very much. thank you very much for coming. >> thank you. thank you, thank you very much. thank you. thank you. later today a memorial service for former cuban leader fidel castro who died last week. his brother, raul, joined other world leaders in the same location where fidel castro delivered his speeches in the years after he seized power in 1959.

that's coming up on c-span at 8:00 p.m. eastern. at 8:00 on c-span2, supreme court oral argument on immigration detention. the court will decide if detained immigrants facing deportation can be held for longer than six months without a bail hearing. a lower court ruled that the government must provide individualized bond hearings to determine their danger and flight risk. the justices heard the case this week. more from this "wall street journal" ceo conference with dr. tom frieden of the centers for disease control and prevention on global health risks and public and private responses. susan desmond helman who heads the bill and melinda gates foundation also participates. [ applause ] >> well, good morning. >> good morning. >> we're going to get right to

the worst case scenario here. i don't know how many of you have seen the movie "contagion," i watched it again recently and got scared. one of the things i wanted to start with is by asking how close are we in the infectious disease world to a scenario like that? i'm going to start with you, dr. frieden. we've seen ebola, we're dealing with zika. there all these new tropical emerging infectious diseases coming out of the swamps. how close are we to something that can't be contained, some biblical plague? >> well, first off, every year on average we identify one new pathogen. and every day on average we at cdc start an investigation that could detect a new pathogen. the contagion scenario is a pandemic influenza. that's, frankly, what worries us most. bill gates has said there are only two things that could kill ten million people around the world, nuclear war and a biological event, either intentional or natural. and if you look back to what's happened, it's happened before. 1918, 1919, 50 million to 100

million people killed around the world. even 1957 influenza pandemic, which most people maybe haven't heard of, cost 3% of the world's gdp. even a relatively small outbreak cost about $30 billion. these are deadly, costly problems. we don't know when the next one will come, where it will come from, or what it will be. we're certain there will be a next one. >> in terms of the gates foundation's interests in this, you've obviously been involved in ebola specifically, in zika. how do you see this in terms of the danger to the world, to the idea that business will be disrupted, that there's looting, fires, and social unrest? >> well, i would say from a gates foundation standpoint, there's three ways we look at this. first, as you heard from tom, we need to be ready for the worst case scenario. the world needs to be ready for pandemic flu being the scariest. but what we learned from ebola is that there's a couple things

that are underutilized and not ready, not fit for use in the world. one is governance. who makes a call which things happen. and the global health security agenda has gotten a lot more attention. and the second thing is having the right tools. >> right. >> the focus on global health research and development, the focus on tool development, those investments in global r&d are a big focus of our foundation. the last thing is even though the world is worried about something really super scary like the movie "contagion," we all saw this last summer, how something like zika that had been thought to be not a big threat spread by mosquitoes was a particularly threat and a particular threat for women who can get pregnant because it causes a catastrophic birth defect. even zika from a business standpoint, i know everyone in this room probably had young people who were going to travel on business, and either men and

women who were completely concerned about their risk should they become pregnant or should their partner become pregnant. so understanding these new pathogens, understanding what we need to do from a governance standpoint, and having the kinds of tools starting with diagnostics so we can spot them are a big focus for us at the foundation. >> obviously there's a new administration. one of the things that has to be funded is things like research and disease control. in terms of this global health security, i think a lot of people think about, you know, homeland security, they think about economic security. i don't know how worried the general public is. you know, we hear about these -- these things that fire up in africa or affect, you know, maybe pregnant women. how many of these things are we able to control with a global health security agenda? what are the components of a global health security agenda? >> fundamentally there are three things that need to be strengthened and one key tool

which is worth people having heard of and knowing about. we have to find things better, stop them faster, and prevent them wherever possible. for each of the three aspects of the global health protection or global health security, there are both institution that's need to be strengthened and new tools that we need. we've got exciting things now where we can do whole genome sequencing with handheld sequencers in the field and figure out what organisms are and how to stop them. the thing that everyone should have heard about is something called the joint external evaluation. currently if you want to start a business or expand a business or see what the risks are in any country in the world and you want to know what are the corruption risks or security risks, you have data bases that will do that. if you want to know is this country ready to deal with an emergency from the health sector, currently there's really no way to do that. what we've done over the past one to two years is get a global consensus on an accountable, independent, objective, transparent, public rating of

all countries that agree to do it. and if a country doesn't agree, they basically can be considered, you know, potentially problematic. and it looks, score of 100, red, yellow, green, core capacity, they ready? that's important because it holds them accountable and the world accountable. if there are poor countries that aren't ready, that puts us all at risk. let's channel assistance to close the gaps because a blind spot anywhere is a vulnerability everywhere. and yes, disease was anywhere can end up here a plane ride away. when it's a drug-resistant material that spreads to hospitals, a new organism, or next hiv. >> in terms of the gates' foundation's involvement in helping to put together public/private partnerships, when it's corporations or institutions, federal agencies, how can it be done in a way that gives rapid response? once you have a structure in place, can you deploy it rapidly for other things? if it's ebola, is there never

that's applicable to, you know, an influenza pandemic, for example? >> what we know is that each epidemic has its own clicks. we can partner with cdc, the world health organization, and others who do help us to understand what we need in the global infrastructure because there's borders and countries' sovereignty. so figuring out that piece of this is essential for us. but on the public/private side, it's one of the aspects of the gates foundation that i think is maybe not -- not well known, and that is that we encourage incumbents, big, multinational companies that have the power and the capability to move quickly in the face of an epidemic. >> it that would be you -- >> that -- everybody in the audience, to invest in these. not only because these are global health security problems that can affect your own business, but one of the tools we like to use is something that we used for market failures. ebola wasn't worked on by

companies because in the first 30 years it existed, less than 3,000 cases and really not any rich countries. so in the case of market failure, we'll make investments. we're happy to take an equity stake to make investments in making sure that these multinational companies can work in these areas that are the subject of market failure. so working on ebola vaccines, diagnostics, therapeutics, and vaccination for any of these pathogens is something we invest in as a foundation and collaborate not just with academia but multinational companies and small biotech companies. >> from the cdc perspective, 25 years ago congress created the cdc foundation to help cdc do more faster. we have a business council in the foundation. when ebola hit, the gates foundation was first to give us resources so that we could act quickly before and in a more flexible way than would be possible within usual government

systems. so we really encourage that collaboration. we were also able to then provide to those individuals and companies realtime information, updates regularly, when on flu or ebola or zika, the next threat. >> the other investment that we should mention is the investment in data. so one of the biggest challenges with the last couple of years, when it's ebola or zika, and it would be a massive challenge if it was the next sars is getting good data. good global data that's believable and just on time. and using things like the ubiquity of smartphones and other information technology so we've invested -- and again, collaborating with when it's cdc, cdc foundation or others, we've invested heavily in better, accurate, and quicker data so that everybody in the world knows what's going on. >> so technology obviously plays a big role. we were talking about one of the

battleground scenes for zika is down in florida where people are very upset, for example, that -- people don't want their neighborhood sprayed with deet, so do you want the risk of zika or deet? they've come up with an interesting approach that's genetically modifyi ining mosquitoes. talk about that. >> there's actually two approaches to what we call in global health virginia techer e it -- vector control, it means we're not thinking about a therapy or vaccine for the human, but we're trying to control the mosquito. milks that transmit dengue fever, zika, this is a bad mosquito. unlike the malaria mosquito, you can't just protect it with bed nets. it bites all day, lives in small bodies of water. vector control can be challenging with this particular mosquito.

importantly, there's two different novel ways of thinking about controlling these mosquitoes. one is further out in time. that's a genetic modification or a gene drive method. that's still at the research stage. there's a nongenetic modifying approach, something called wobachia which i think you should think of more like the mosqui mosquitos' microboime. this is found naturally in insects in the earth but not in the dengue or zika mosquito. we've been investing actually since 2005 in -- scott o'neil, an australian inventor who's invented a new way to infect this mosquito with wobachia which prevents the mosquito from transmitting zika. originally done for dengue which is scarier over history than -- than zika. and that is now being used in

brazil and colombia through a recently announced grant to actually try and release these mosquitoes florida cannot transmit this virus. a really great example of global health research and development, something that seemed very risky, very far out, that's being done with the communities so that in terms of the innovation and the risks, very thoughtfully studied, and very important for all of us to realize when you think about a behavior change intervention, the communities are driving this intervention. but it has a lot of opportunity. we don't know how big it will scale. it's just gotten to populations of 2.5 million in the two most recent studies that are being done. but when you're faced with japanese vectors and concerned about insecticide, a novel based on biology and based on great long-standing research attack on these mosquitoes.

>> well, there is that problem with the public health perception. you know, in puerto rico i know, for example, they had a real problem getting spray. people don't want spray. it's almost like you're taking your chances that you're going to be -- >> the mosquitoes are quite difficult to control, as sue says. they can hatch in a bottlecap full of water. they co-evolve with people. they spread really serious diseases, including zika, dengue, chicken gunia, and they're an urban pest like a cockroach. they're referred to as the cockroach of mosquitoes. we have to do two things. one is mix and match our current tools to control them as well as possible. and there are some new approaches that may minimize the use of insecond sides. none of us like to use inse insecticides and other tools that may in the future be effective. we have to try them if communities choose to try them. what we recommended in the winwood neighborhood of miami-dade was to use an aerial

insecticide and aerial larvicide that kills the larval forms. the result was quite impressive. we saw almost all the mosquitoes killed overnight, and the trap counts, we trapped mosquitoes, going to essentially zero. as the next batch of mosquitoes bred, they then applied the treatment again. after four times, no more mosquitoes basically. and the spread of the disease stopped. so it showed that at least in that environment, it was pofbl to stop an outbreak. something like wobachia or other tools will need to be applied many months before an outbreak starts. once it started, it's too late to do that. we have a fundamental approach in public health, get the data and use it to improve public performance. we don't like to do something because it's always been done that way or because someone told us to do it. let's set up an information system and continuously improve our program. >> there's one other innovation to quickly mention on the zika front, and that is modern family

planning. and so one of the early grants that we made was to cdc foundation and the pan american health organization to get the right communication out there. so that women who were pregnant or who could become pregnant knew what was going on, knew how to prevent zika, knew what the risks were, and we continue to fund research and development to make better, more widely available, more affordable modern contraception that can be used voluntarily by women anywhere in the world when they're faced with such a health threat. >> right. well, the other -- obviously you mentioned earlier, the idea of hospital infections. i know a big crusade of yours has been antibiotic stewardship. the idea that we're using too many antibiotics and breeding resistant superbugs. any one of you who has asked the doctor for a z-pack when you didn't have a cold -- it was a virus and wasn't a bacterial infection, you're all contributing to that. i among them have probably done that. but the question is, how do you

-- are you seeing progress toward this call to stop overusing antibiotics, to prevent the number of people using them who don't need them in hospitals and the community? >> first off, this is a really big problem. i'm an infectious disease specialist. i've cared for patients who can't be treated with any antibiotic we have today. it's a terrible situation. we talk about a pre-antibiotic era and antibiotic era. if we're not careful, we'll number a post antibiotic era. we are for some patients and organisms. the economic impact is enormous. it's not just about infections that you think of like museumia and urinary tract infections, it's about modern medical care. treatment. arthritis, organ transplants, dialysis, chemotherapy. 600,000 americans get chemotherapy a year. in all of those situations, we expect there to be severe infections because we're suppressing the immune system. we expect to be able to treat them. if we can't treat them, we risk undermining much of modern

medicine. we've estimated based on careful analysis of data that between one-third and one-half of all of the antibiotics used in this country with either completely unnecessary or too brad. it could be narrower spectrum. we need to do some things in terms of getting better tools for diagnosis. it would be easier if you could quickly tell, oh, is it a bacteria or virus, a resistant bacteria or not, we don't have that yet. we can do a lot more to be better stewards of the antibiotics we have. we need new antibiotics. we haven't had new antibiotics recently. but we're not going to invent our way out of this. the microbes outnumber us. we have to outsmart them. the way to do that is to steward our antibiotics better. and one of the things that we've done working with the center for medicare and medicaid services is to dwhier every hospital have a steward -- require every hospital to have a stewardship program. globally as agenda work, we're expanding our think of what's out there in terms of drug

resistance. it's broopder issue. we overtreat symptoms and undertreat silent conditions. if you look at things like the flu, common cold, pain, adhd, we may be overusing medication on those. if you look at hypertension or ohio cholesterol, we may be under prescribing. globally we haven't scratched the surface of what's needed to understand and stop drug resistance. i'll never forget, a few years ago i was in india where i worked for many years. i was at the all india institute of medical sciences, really a terrific harvard-quality institution there. i was in the intensive care unit. and this is soon after the -- the new delhi strain of a resistant organism was defined and described, and the head of the icu said i don't know why you're so worried about the new delhi strain of the organism. every patient in my icu has untreatable organisms. >> run out the door. >> try to avoid being in the

hospital if at all possible. >> i will say from a global health standpoint, two things to add to what tom said. first, many of the people we serve in the poorest areas of the world don't have access to antibiotics. we certainly want effective antibiotics to get to where they're needed if you have an antibiotic-sensitive bacterial infection. and that includes -- anti-microbial things like hiv/aids, malaria, and t.b., threats that face resistance. >> right. >> one of the things that is one -- a best approach to anti-microbeular is vaccination. >> vaccines, my next question -- >> vaccine might have preve-pre don't get to the stage where you have a fever or you worry about antibiotics or resistance. we consider vaccines as -- as nearly miracles because they are so profoundly making a dent

already in childhood mortality globally. and any child who can get a vaccine for a vaccine-preventable illness is somebody who won't be subjected to antibiotics and won't cause even more anti-microbial resistance. >> there you've got a huge public health challenge. you have intelligent, educate people in places like, you know, southern educate, in northern california, in seattle, i think vashon island, does anybody vaccinate their children? it's a real problem of resense based on junk science and just, you know, personal belief likey, oh, this isn't natural, i don't want to do it. how do you overcome that? >> there are a few things. we believe that sunlight is the best disinfect ant. we're open with information on vaccine and vaccine-adverse reactions. we put them on the web so people can see them. there has never been a vaccination campaign anywhere where there hasn't been some paranoia conspiracy theory about what it's about. one of the things that the gates foundation and we have worked very closely on is polio

eradati eradati eradicati eradication. we're closer than ever to it, but it's still a challenge. >> they'll kill you in pakistan if you try to -- >> increasingly we're making a big dent in polio prevention in pakistan. >> good. >> good with cdc and w.h.o. -- >> in 1988, 350,000 children were disabled by polio. this year so far, it's been less than 30. we've made a lot of progress. but suspicion is a problem, security is a problem. and with vaccination, these are -- one of the greatest gifts to humanity that there's ever been, but they're in some ways victims of their own success. people in developing countries, poor countries, see people die from measles. they don't doubt that they need a measles vaccine. here it's gotten rare enough that people wonder maybe i can get away without getting vaccinated. part of this has to do with rebuilding the commons. we are all in this together. if everyone said,em with, my kid's safer not being vaccinated, we would see large outbreaks as we saw in southern california last year.

>> is there a policy aol -- i know certain schools will not allow you to have your child in the school unless they're vaccinated so you see more people doing home schooling. are you worried enough, is it more of a global concern do you think -- do you think in the united states we still have the ability to educate people and to get beyond the anti-va kanti-va? >> well over 90% of american kids are vaccinated and vaccinated on time. there's a small vocal group that we're never going to convince, maybe 1%. there's another group that wonders. for them, we ask -- we answer, we answer the concerns, we listen. some parents who statewided not to have their kids vaccinated for flu and their kids died from flu have gone on tv and told the story. each year we lose at least 100 kid from influenza and about 90% are usually not vaccinated. so making clear that these aren't just theoretical risks. this could happen. and it's only by working together and only by taking those preventive measures that

we can protect ourselves and our neighbors. >> so i was interested to read you did a public health piece for the "new england journal of medicine" recently in which you listed all the challenges. 40s, there's infectious disease and chronic diseases. the largest still cause of underlying diseases in the world is tobacco. >> tobacco use continues to kill globally millions of people. in fact, more than infectious diseases combined. and it can be stopped. if you look at countries and communities that as well taken tobacco prevention seriously, they've been able to drastically reduce tobacco use. mike bloomberg and his foundation, the gates foundation -- >> guys are all working together. >> work together to come up with a very concrete set of policies that a country can decide to do or than can drive smoking rates down. in new york city, we help 400,000 people quit smoking in just a few years, saving over 100,000 lives. and extending life expectancy by three years over just a few years. so this is something that we can

make a huge difference in p. and companies have gone smoke free. companies have been supportive of this. sometimes they'll say, you're not pro business. businesses have different interests. if your business is tobacco, you have the interest to sell more cigarettes. if your business is to have a healthy work force, your business is to have fewer workers who smoke. their health care costs may be high her and productivity may be lower. >> profound public health intervention. we've been thrilled to partner with bloomberg foundation in supporting what are proven remedies for tobacco control. it has a positive economic impact to do tobacco control. it is a profoundly positive intervention. the other intervention is nutrition. and globally we see both over nutrition and under nutrition and poor nutrition. so very simple things like exclusive breast-feeding for six months, making sure that mom as

she says pregnant has access to good nutrition, understanding micronutrients and what's needed. so the kinds of things on nutrition and tobacco that we can do as public health and global health interventions are incredibly cost effective, very pro-economic. that magic time. year, first thousand days from conception isn't just important for your stature but is important for your cognitive development. so these are the kinds of things that emerging countries and businesses that are working in those countries are extremely interested in because that's your future work force and your future consumers. >> right. >> and this is very relevant to the issue of health care costs. a nonsmoker costs drastically less to care for than a smoker. and an ex-smoker costs at least $1,000 less to care for each year than a smoker. in the u.s. today, there are ten million fewer smokers than there were in 2009. and if you think of the payoff, how much higher our health care costs would be if that weren't

the case, it's substantial. but in public health, we often have what i call a wrong pocket problem. >> right. >> where you spend money here and that saves the money there. and so it makes it important that there are groups throughout society, when it's vaccination or tobacco control or research on new diagnostics and treatments, that there are groups that are advocating for that which is good for the -- for the society as a whole. including this -- >> the idea of wellness and prevention, i know a lot of companies probably look at their health plans and wonder do we need to offer this or that. and i think you had said that the idea of making wellness a priority, to get ahead of disease, to get -- before you have to spend all the money to prevent it, is that a good invest for ceos to make in their -- >> i think it's a great investment. and just speaking as a ceo with a group of employees, there's nothing better than a group of committed, passionate employees who -- who are not just passionate about the mission, but passionate about their own ability to make an impact. so their own health and well

being, i've always felt it hasn't changed over time that that's the bestmen investment a institution can make. >> any other major public health issues before we turn it over to questions? i know uncontrolled blood pressure is another thing that everyone's like a ticking time bomb walking around with uncontrolled blood pressure. >> if you is ask what other health issues there are, we could keep going. i'll mention that one. hypertension is called the silent killer. in this country, about 70% of people over the age of 65 have high blood pressure. about nearly 30% of our total population has high blood pressure. we don't do a very good job at it. a few years ago, i put in an electronic health record system in new york city. we said, what's the single-most important thing to do. a simple question. if you want to save the most life through hong konealth care should you do? there was no analysis in the medical literature. we had to do the analysis. the answer was clear -- control blood pressure. nothing else could save as many lives as controlling blood

pressure. in fact, globally, it's the only thing that kills more people than tobacco. and controlling it is not hard. once-a-day medications, monitoring. and in the u.s. we get that most important question right 54% of the time. 64% of americans with high blood pressure don't have it under control. as a result, strokes, heart attacks, kidney failure, more cognitive decline. so lots of problems that we could prevent by better treatment and prevention. >> i think if -- all of of this is possible if there's a functioning health system. >> yes. >> so globally and we learn this with the ebola epidemic, a functioning health system is the through line from everything from hypertension, tobacco prevention, good nutrition, vaccination and early readout to rapid response to threat of pandemic. increasingly, our foundation with many, many partners and

governments worldwide is focused on having a functioning healthy, health system for those citizens. >> i would like to throw it open to questions if anybody has any about threats to -- >> yes. >> i'll stand up. >> we'll get a mike for you. >> could you elaborate on the prevention side? doug do vas. nut irs-lite is one of our brands, we're interested in prevention. but could you elaborate on prevention from a policy standpoint? we tend to pay for cure a lot and diagnosis, but the -- from a public policy standpoint, anything on the prevention snide. >> again, you have a few hours? prevention is really underfunded. the -- there are plenty of hospitals that have units named after someone who has cared for -- was care the for in their icu. there is no health department in the country that has a floor

named after a person who prevented many more heart attacks than occurred. on the prevention side, a lot of it is policy, and some of it is clinical. we think of several different venues where you can have prevention. on the policy side, tobacco, it could be smoke-free workplaces, high tobacco taxes, deter use. on the hard-hitting ads, make a big change. and includes cessation measures, prevention could include things like increasing physical activity, the closest thing we have to a wonder drug. it improves everything you'd want to improve from mood to resistance to cancer and infections, and it decreases everything you'd want to decrease including diabetes, even if you don't lose any weight. we think often in public health about what is scaleable. there are very limited or no examples of whole communities becoming much more physically active with people exhorting them and changing things. we're working on that and trying to see where that happens --

>> like making things walkable. >> absolutely. complete streets and other programs. use the stairs instead of the elevator. there are lots of ways that we can tweak the environment to make the healthy choice the default choice. but there are other things that are in the clinical sector, when it's immunizations or control of blood pressure or other things. we know that if we got blood pressure controlled in the u.s. from 54% to 70%, we would prevent hundreds of thousands of heart attacks and strokes. i think we would save money. but at a munn mum, we would change our expenditures from taking care of people who have had strokes and respect in nursing homes or rehabilitation to paying for blood pressure and blood pressure monitoring and medications. >> we're investing in understanding behavior change. particularly investing in what creates sustainable behavior change in the community, and compliance. when you make a big investment, and companies find this, you can for a short term change things.

people wear a device and stop wearing a device. increasingly, what's sticky, what sustains, and how a community drive its own wellness. part of it is incentives. so i think there's a big economic argument, and making that more visible at the community level is something that i think you'll see more of over time. >> other questions? right here? we also have a poll question. before the question, we'll let you ask it right now, but we have a poll question, as well. why don't we bring that up, if we could, danny. and you could be answering this while we're getting the next question. do you have or potentially have business interests that could be impacted by infectious disease threats like zika, yes or no? international is -- how international are you is the question. yes, please? >> i'm going to go back, dominic, i'm going to go back to the question about pandemics. you talked about the jee, the

assessment. individual countries. how do you think about incentives for what is undoubtedly preventive expenditure for those countries who come out with an amber, yellow, or red outcome from a jee? how do we think about incenting them against many other priorities they may have? >> this is something that the world community has to work together on. it has to be important to them. business has to say, you know, we're concerned about this. and globally we have to be committed to trying to fill those gaps. now that we've identified them and they've been honest enough to say, this is our problem, accu-weather it's the world bank or donors, or industry saying okay, we're going to fill in area knowing that in two or four years someone's going to come in objectively, measure it again, and say yes, your investment paid off. it's gone from yelly to green or red to yellow. i think the key is that we move from a world previously before ebola that was nonaccountable

and non-assistance to a world that is accountability and partnership with accountability for what the results of that partnership is. >> i would only add that having been in a number of advocacy discussions with now heads of state or -- or their cabinets, one of the really important things is what bucket do costs go in. and if the costs go in a bucket of economic empowerment, job creation, driving your economic engine, versus a health bucket, that can be a net positive. so making the argument that this is a financially positive economic engine argument can be a much more effective argument. >> other questions? ye yes? >> at davos a couple years ago, you talked about the global readiness for the pandemic. jim kim was playing a large role. how much. that has been hardwired now?

>> we have a lot more work to do. within the u.s., we've done a lot to enhance preparedness. we need a w.h.o. that is it is . we're committed to helping with that. we need more tools. we don't yet have a vaccine that could work against the flu overnight that arose. we have been tweaking our methods so we've been cutting days, weeks, sometimes months off the production process and increasing the ability to produce things that are rapidly deployable. >> talking about global readiness in terms of countries working together at cdc, the world bank, all of that, as opposed to the science. >> there's a lot more collaboration. that's what the global health security agenda is all about. we have more than 20 countries involved. this evaluation process. or 70 countries have signed up for. by next year this time, 70 to 80 will have had these evaluations.

we're having a common vision of what's needed and where we are now. but we need people from outside government pushing to make more progress. >> and w.h.o. is in a transition on the leadership front. so we'll see more from w.h.o. because there is some pushing, but i would only echo the more pushing is helpful. on the science side, many more investments and i think both on the science and on the monitoring side, we're seeing a lot of progress and many investments. >> other questions? >> thank you, doug pederson, sdp global. we've heard a lot about opiates in the u.s. and heroin usage. >> this is a horrible problem. we're an absolute outlier. we use -- we have 80 -- in the u.s., we use more than 80% of the global prescription opiates. what's happened over the past 20 years is the number of opiates prescribed has increased 300% to

400%. and that has been directly correlated with an increase in overdoses and overdose deaths. over the last couple of years, the drug cartels have recognized a new market and we have lower cost heroin and illicitly produced fentanyl. last year more people died from opiate overdose than from car crashes in the u.s. it is a leading cause of death, more than 10 million americans have used opiates. more than 2 million are addicted to them. and we need to address this with a really comprehensive approach that looks at two different population groups. one are people who are currently dependent or addicted. they need better treatment of addiction and better management of pain. cdc last year released or this year rather, released guideline on management of chronic pain. opiates are dangerous drugs. you take just a few too many and you stop breathing. you may be addicted for life after just a few pills. so there are better ways to treat chronic pain.

second, for everyone else who hasn't yet had an opiate, we need to protect them from it because it may be just a few doses until you're addicted. that means greatly improving prescription patterns to prevent this because it's a very serious problem. there are communities in parts of the u.s. where new businesses can't start because not enough people can pass a drug screening. >> but the prescribing habits is a very big part of that. literally, my husband just had his shoulder replaced. he walked out with a prescription for 90 oxycontin. >> this is a huge problem, and it shouldn't happen. >> they say we don't want our patients to be in pain. >> when i witneent to medical sl if you give a patient a medicine with an opiate, they'll not get addicted. totally wrong. >> there has to be a complete e rebooting of pain prescribing and it has to be done with a sense of urgency that isn't

consistent. i'm an oncologist by background. so there are times when you need pain medicine. however, what we've got in the united states today is inconsistent with those times. >> can i ask another drug-related question. a number of states have legalized marijuana. a couple of questions that were sent in. is the science good enough on that? what's your feeling on the safety of increased marijuana use as a result of legalization? >> just two comments. one, it's severely understudied. and needs more research. i'm a data-driven person. tom is a data-driven person. we need more data. there are data on young people and marijuana, though. and that's, from a public health standpoint and from a health standpoint, that's my concern. >> after decade of the grateful dead that -- >> there's a concert and then there's -- >> their brains are gone by the

time they're 15. >> i think there are farms that are known but not well -- not widely known and lots of things we don't know because it hasn't been legal to study. as sue says, we need to know much more but also there are known that aren't widely understood. there's a big difference between legalization and decriminalization. >> yes. would the two of you as medical specialists be advising a state to legalize or decriminalize marijuana use? >> as a physician, i would say decriminalizing, sign me up. legalizing, i want more data. >> and? >> i agree with sue. >> other questions? yes. >> thank you. when we are looking at global health risk from a business standpoint, it has never ceased

to occur to me over the last half decade or so that we've not been very prophylactic. we have by and large been reactive. whether it was ebola, zika. and it occurs to me from a prophylactic standpoint, for instance, i haven't seen enough studies on the consequences of climate change as one of the root cause or certain of the mutations and pathogens that we're talking about. it would seem to be that you -- i would be interested in your thoughts on the prophylactic aspect of it so that we're not constantly fighting the fight trying to climb up the hill. >> i'll let sue comment on the climate issue. in terms of prevention because we don't know what, where or when the next threat will come from, what's most important is to establish systems that can find it when it emerges, understand it and respond rapidly and figure out how to prevent it. that's what global health security is all about. why we establish laboratory

networks so that they can find out what's going on where and when it first emerges. that's why we train disease detectives so they can do the work there. what we need is essentially a -- what we would call a pluriet pluripotent, something that is used every day. if you want to break the glass in an emergency and use some new system, it's not going to work well. if you use it every day to deal with whether it's food poisoning or measles outbreak or other problems you can scale it up if there's an emergency. that's what we have to do to strengthen those systems to make us all safer. >> just a couple quick comments. there's no doubt that deforestation changes in water availability, changes in climate have driven changes in both animal patterns of infection. they've changed patterns of productivity on farms. so one of the great concerns we have is small holder farmer productivity, especially in

sub-saharan africa but really globally as a result of climate change. it's part of our investments at the gates foundation is to invest to enable those small farmers to continue to feed their families despite those changes. we're also interested in pandemic preparedness. how does that change animal health? and what are the implications for human health. >> can i fit in one more 30-second question for the both of you from one of the ceos. what country has the model health care system in your impression? and what makes it so? >> i'll make two comments and then sue can comment. without naming a country, there are scandinavian countries that have sensible models where, quite frankly, the goal is to optimize health. if you look at our health care system, it's not a prominent goal to optimize health. there are lots of other goals but that's not really a prominent one. if you look at low-income countries, i would point to

ethiopia which has had the most success and most impressive system i've seen where they have young women, well trained, well supervi supervised, well supplied all over the country providing care for the most important problem. if you look at a low-income model, that's the most impressive oouf seen. some of the scandinavian models are able to keep costs down with quality up, focussing on the bottom line on health, helping people live longer, more productive lives with less disability at lower costs. >> i'm excited to see what's the government of ethiopia is doing with citizens of ethiopia in a low-cost, front line health care worker using vaccinations, nutrition, well baby care. really classic things that they now have a profound impact and with relatively low education because human resources are a big issue. they have a plan to transform the health in their entire country in a very, very poor area. so people talk about rwanda. it's a small country, and so the

scale of what ethiopia is contemplating has already made progress on and has plans for the future. it's really exciting to see. >> thank you so much. [ applause ] coming up tonight, a briefing from army general john nicholson. an update on health care costs. and a look at the future of health care. c-span's "washington journal" live every day with news and policy issues that impact you. coming up saturday morning, alliance for america manufacturing president scott paul on president-elect trump's campaign promise to keep manufacturing jobs in the u.s. including a recent deal with carrier to keep 1,000 jobs in indiana. also the cato institute's ian vasquez looks at the future of u.s./cuban relations in