have is everyone talks about it being an intelligent breakdown. we know the intelligence community cannot condemn themselves publicly. if this man's fathers went to the embassy to warn us about him? with that not be the state department? it seems we should be looking at people in the state department. why are they not under some kind of question in response to how they handled this? sometimes there is comparisons saying, the same thing happened on 9/11. before 9/11, it was actually illegal in many instances for the cia to share information with the fbi and any information they did share, the fbi was not allowed to use in prosecution. many of the restrictions have been changed legislatively. so this is a different time. that calls for different response. maybe we have not gotten the

practices down yet. why the delay? i think that would be questioned. why do you say you will talk to people at 1:00, 3:00, then 4:30. hopefully, it is because we have eliminated the information we do not want other people to know. that is the only valid information i can come up with. . .

host: what do you think we will hear in just a moment from the homeland security secretary? caller: as the president was leaving the room, a president shattered -- someone shouted a question. she said that the system basically worked. host: in the interview conducted with general jones, he said there is a certain shock that would come out. caller: it was just the accumulation of clues that were not acted on. anyone of several clues that should have prevented him from getting on the plane. host: will the intelligence

silo's be broken down? caller: we have heard a lot about that since the 9/11 attacks. general jones as a lot of promises have been made since 9/11. this is a classic -- this is a case of the benefit of 20/20 hindsight. how could we have this guy's father going to the embassy and raising a red flag not prompt more attention than it did? this is a white house that does not seem to get off its sech. there is a sense that maybe they did not respond quickly enough after the christmas day bomber. the president was on vacation, but they are showing a lot of focus on this now and we have heard very tough language from him at the conclusion of the statement he just completed making. host: we are keeping an eye on the briefing room to hear from

janet napolitano. what did you learn from dianne feinstein about all this? caller: the standard is now too tough to get someone on the no- fly list. in hindsight, it is clear that he should not have been allowed to get on the plane. the president also talked about that, and we will be seeing some changes there. host: how much is it going to cost, over all in the effort that we put forward for all lan security? caller: this is clearly making terrorism and somewhat higher priority for the ministration. that will come at the expense of some other areas. maybe not the economy, but when

it comes to issues like education or immigration. you might find somewhat less focus on that as the administration focuses more on terrorism. host: we are talking to susan page, washington bureau chief. why do you think something like this could still happen? caller: because terrorists are smart and organized. the chairman of the 9/11 commission said we are looking at what happened on christmas day for what went wrong. al qaeda is looking at id and asking what went wrong from their point of view. they will make adjustments in change their strategy. that is the constant challenge when you are trying to address terrorism. host: what did you take away from the demeanor of general jones? caller: it is clear that he takes this seriously. he is a very methodical man, a

former marine general. he has a command focus on this issue at the moment. host: the think anyone will be let go? some are saying it is time for someone to be fired. caller: general john said we have had two strikes, the fort hood shooting and the christmas day bombing. they should have been acted on and were not. he said we do not want to have a third strike. i wonder if the three strikes analogy was a warning to officials in intelligence agencies. host: choctaw has indicated that the white house wanted to dial down the storied -- chuck todd indicated that the white house wanted to dial down the story. caller: that is not a story you

can dial down. host: we were told there would be a two-minute warning. we appreciate you spending a few minutes with us here on c-span. we are still keeping an eye on the briefing room door and will go to get like and show it to you in its entirety. >> good afternoon. i want to apologize for the delay in the events that have occurred over the past couple of hours. you all should have either with you or in your in box two separate documents that were emailed out. the first is a summary of the white house review, which is the

declassified document i spoke up, and secondly a memo signed a little while ago by the president on corrective actions that have been ordered. we will here momentarily from two individuals, secretary napolitano from the department of homeland security and john brennan, assistant to the president for home and security and counterterrorism. after they speak, we will spend about half an hour taking your questions. i know many of you have deadlines, so if you need to sneak out of here, that is certainly a fine to do. we will hear first from john. >> good evening, everyone. as the president said today, following the attempted terrorist attack on christmas day, he directed meet to conduct a review of the watch list system.

he also directed key departments to provide input to this review. i want to commend secretary napolitano and other leaders of the community for their cooperation, kantor, and support. let me say that every department and organization provided the information that was needed. that speaks to the seriousness with which this administration takes what happened on christmas. it also speaks to our urgency and determination to make sure that this does not happen again. the review had three primary goals, to get the facts, find out what happened, to identify the failures and shortcomings of what went wrong, to make recommendations on corrective action so we can fix the problems. i want to address each of these areas. first, the facts. as the president described in his public remarks, the weeks and months leading up to the christmas attack, various components had g -- strategic

informations about the threats posed and the specific plot. it was known that aqap not only meant to strike targets in yemen but also sought to strike the u.s. homeland. indeed, there was a stream of intelligence on this threat. it was known, thanks to the warnings of his father in november, that he had developed extremist views and his father feared he had joined unidentified extremists. there was information about him in association with al qaeda. these are among the fragments of intelligence that were available to the total community on christmas eve before he ever boarded the plane in amsterdam. the essential question is, given the fragments of intelligence we did know, what were they not integrated and pieced together in a way that would have uncovered the plot?

that leads to the second line of inquiry, what went wrong? as the president described, this was not the failure of a single individual or organization. there were some human errors, but they were not the primary or fundamental cause of what happened on december 25. rather it was a systemic failure across agencies and organizations. i want to be very clear about this. there is some confusion out there. it was widely reported that we saw the same bill years before 9/11. after eight years, why has it not been fixed? before 9/11, there was reluctance to share information between agencies. some were denied access to critical information that could have stopped the tragic 9/11 attacks. over the past eight years, those issues have largely been resolved. that is not happen here. this was not a failure to share information. our review found the

intelligence agencies and analysts had the information they needed. no agency or individual was denied access to that information. as the president said, it was not a failure to collect our share intelligence. it was a failure to connect, integrate, and understand the intelligence we had. no one entities, team, our task force was assigned responsibility for doing that follow-up investigation. this contributed to the larger failure to connect the fragments of intelligence that could have revealed the plot. this bed into shortcomings in the watch list system, both -- fed into shortcomings in the watch list system. he was allowed to board the

plane in amsterdam for detroit. while the watch list system was not broken, help the intelligence community needs information into the system needs to be strengthened. how do we fix the problem? today the president is issuing a directive to all agencies on the corrective actions he has decided on. there are more than a dozen corrective steps altogether, each assigned to an agency that is responsible for its implementation. he is directing that our intelligence community immediately begin assigning responsibility for investigating all leads on a high priority threats so that they are pursued and acted upon aggressively and that plots are disrupted. he is directing that we strengthen the analytic process. director of national intelligence blair will take the lead in improving day-to-day

efforts. there will identify and analyze intelligence among the vast universe of intelligence we collect. that challenge, dealing with volumes of information, is growing every day. the president is ordering an immediate effort to strengthen the criteria used to add individuals to the terrorist watch list, especially the no- fly list. the president said he is going to hold all of us accountable for implementing these reforms. the national security staff will monitor their progress. the president directed me to report back in 30 days and on a regular basis after that, and i will do so. we will improve the intelligence community's ability to collect, analyze, and act on intelligence swiftly. in every instance of the past year, the intelligence

community, the homeland security committee, the law enforcement community, has done an absolutely outstanding and stellar job in protecting this homeland and disrupting plots directed against us. it was in this one instance that we did not rise to that same level of opportunity and success. therefore, the president has told us we must do better. i told the president today i let him down. i told him that i will do better, and we will do better as a team. thank you. >> i want to update all of you on the actions of the department of homeland security taken immediately following the failed christmas day attack and the longer-term recommendations that dhs made to the president in our preliminary report. these recommendations lay out

how we will move forward in a number of areas that are critical in our efforts to protect air travel from terrorism. as many have already experienced, we have immediately strengthen to screening retirement rigid requirements for individuals lying to the united states. every individual applying to the united states from anywhere in the world who has an itinerary are passed for from nations that are sponsors of terrorism or countries of interest are in charge go through -- are required to go through enhanced screening. others will go through random threat based enhanced screening. at airports throughout the u.s. we have airport law enforcement officials and security measures but seen and unseen. i want to express our thanks for

the traveling public for their patience with the increased security measures. i want to thank the department of homeland security personnel who have been engaged on a day- to-day basis to implement them since christmas. today i would like to describe to you five of the recommendations that are included in our report to the president. first, there needs to be an evaluation and modification of the criteria and process used to create the terrorist watch list. this will involve the border, and security and other members of the intelligence community. the effort will include evaluating the process by which names are put on the no-fly list. let me pause here a moment to say that the department of homeland security works day in and day out with the fctc and other members of the intelligence community. these are dedicated men and

women. all of them are dedicated to the safety of the united states. as john has indicated, here we simply had a systemic failure. dhs uses the list as the cornerstone of our efforts to prevent suspected terrorists from boarding airplanes bound for the united states. second, we will establish a partnership on aviation screen technology between dhs and the department of energy and its national laboratories. this will allow government to use the expertise of the national labs to develop new and more effective technologies so that we can react not only to known threats but also proactively to anticipate new ways by which terrorists can seat aboard our aircraft. third, we should accelerate the point of advanced imaging

technologies so we have greater capability to detect explosives like the ones used in the christmas day attack. we currently have 40 machines deployed throughout the united states. in 2010 we are scheduled to deploy 300 more, and may deploy more than that. the tsa does not conduct screening overseas. the christmas day incident underscores that the screening procedures at foreign airports are critical to our safety here in the united states. therefore, we have to do all that we can do to encourage foreign authorities to utilize the same enhanced technologies for aviation security. after all, there were passengers from 17 countries aboard flight 253. this is an international issue, not just what about the united states. fourth, we have to strengthen the present capacity of aviation law enforcement on top of the measures we have are ready taken. this includes increasing the

number of federal air marshals, and we will begin by deploying law enforcement officers from across the department of homeland security to help fulfill this important role. fifth, working with the secretary of state, we need to strengthen international security measures and standards for aviation security. security measures abroad affect our security here at home. the deputy secretary of dhs and other top officials from my department have for the last several days been on a multi country, multi continent mission, meeting with top transportation and airport officials, discussing ways to increase cooperation and security. later this month, i will be traveling to spain to meet with my european counterparts for what will be the first in a series of meetings with counterparts that i believe will lead to a broad consensus on new international aviation security standards and procedures. these five recommendations i

have just described are important areas where dhs and other federal agencies are moving quickly to address concerns revealed by the attempted attack. added to the intelligence review also under way that john brennan just described, these are changes that will help prevent another attack from ever advancing as far as the one did on christmas day. thank you. >> the president talked about using advanced technologies. this seat intend to start using it across the country -- does he intend to start using it? >> advance screening technology is the magnetometer with which people are so familiar. it is explosives detection technology. it is increased use of canines. it is increased law enforcement presence, both uniformed and

undercover. it is a series of layers that we will be adding to the security we already have at our domestic airports. >> you said that 300 additional scanners will be deployed in 2010. was that plan before this event? you said more may be deployed on top of that. how many more, and how much will that cost? >> the answer is, it was planned before this. it was already in finding that the congress had appropriated for the tsa. with respect to how many more need to be done, we will be working on that as part of our ongoing review. i would caution you not to focus solely on that technology. as i just explained, this is a series of layers that we deploy and will be enhancing the

deployment of at domestic airports. >> both you and the president mentioned the word accountability and made a point that it was several agencies and not just one person. who is being held accountable now? >> as you heard the president on a number of occasions take responsibility for the system that we have right now, that is what led the president to ask these individuals to come back to earth review and see where we fell down and how we can plug those holes -- ask these individuals to review and see where we fell down and how we can plug those holes. we do not have any other announcements today. as you have heard the president

say, the buck stops with him, but the team understands what john started is a dynamic process. we talked about that yesterday. it will continue over the course of the next 30 days and long after that to ensure that what has been outlined, all these different agencies, in acknowledging their responsibility, they will take the corrective action that is necessary. the billion dollars the president mentioned in his remarks about technology -- >> the president kept referring to the known terrorists. my understanding is he was a known tech -- and on extremists. what was the most shocking thing they you believe came out of the

reviews? >> we knew that he had departed from nigeria and was in yemen associating with extremists. we knew from the stream of information that he was extremists and had those radical tendencies. the rest of the intelligence indicated that this plot was under way. what we knew about him the person as an extremist, and we knew about the plot developing. >> he is an unknown alleged terrorists after the fact, but was a known extremist before. >> it is one of the most lethal and concerning -- the fact that

they had move forward to try to execute this attack against the homeland demonstrated to us -- we did not know they had progressed to a point of actually launching individuals here. we have taken that lesson and now we are on top of it. >> following up on that, not just the determination of al qaeda, but the tactic of using an individual to foment an attack as opposed to a large conspiracy or multi-person conspiracy such as we saw on 9/11, that is something that affects intelligence. emphasizes and the renewed importance on how different intelligence is integrated and analyzed and threat streams are followed through. again, it will impact how we continue to review the need to

include airport security around the world. >> was there an outside contractor used for security in amsterdam? what is lacking, we did not get the motivation of why they want to do us harm. >> the screen at the amsterdam airport was done by dutch authorities. they did the screening that was described to you earlier this afternoon. the passport was checked and he went through a magnetometer. >> what is the motivation? >> al qaeda is an organization that advocates the slaughter of innocents.

they attract individuals and use them for these types of attacks. he was motivated by a sense of religious drive. unfortunately, a al qaeda has deserted islam and has corrected the concept -- has corrupted the concept of islam. al qaeda has an agenda of destruction and death. it uses the banner of religion in a very perverse way. it is determined to carry out attacks against the homeland. >> you have not explained why. >> what was learned while the flight was under way? this new information came to light after the flight took off, that he was going to be

questioned after he arrived. >> his name did not appear on anti-terrorist screen watchlist there, so nothing pinged to keep him off the plane. while in the air, customs in detroit has access to the entire database, the large database that has 500,000 names in it. they knew he had theyping their -- they knew he had a ping there and they were going to question him against the thai database. the terrorist remorseless did not have his name on it. -- terror of screening watch list did not have his name on it.

>> when the incident occurred on christmas day, a number of people came into the offices and focused on it immediately. mike raised with me that he was scheduled to go on leave to meet his son, and asked me whether or not he should cancel the trip. i asked mike about whether he had a full complement of folks in place. i said he deserved the vacation and need to be with his son, so i was the one who told him to go out there. since then, i think we all recognize that the government and the committee has worked extremely well. we were in constant contact with one another throughout that time of the event. >> when did we first know that

aqap had intentions to strike the homeland, how early? >> over the past several years, it has been aspirational. it has said things and promoted a certain view as far as bringing the fight to us, but all the activities we were focused on were happening in yemen. it was aspirational. we saw there was a mounting drumbeat of interest in trying to get individuals to carry out attacks. in hindsight, we saw the blood was developing, but at the time we did not know -- we saw the plot developing, but we did not know there were talking about sending someone to the united states. >> focusing on the high

priorities seems to be the basic -- >> there are a lot of different organizations involved. we are trying to make sure that as these threats develop, and there are so many of them, it is clearly understood who has the lead on it. most times, cia, dhs and others are working it. we want to make sure that each agency has a lead and moves forward. >> you mentioned to the problems with intelligence sharing before 9/11. after the 9/11 commission report came out, it was all about connecting the dots. at that time there was a pledge to do better on connecting the dots. from the post 9/11 commission

standpoint, why the dogs were not connected, and when you say we are going to improve analysis, how is it going to happen this time when it did not happen that time? >> analysis has improved steadily. we have an amazing track record here in the united states intelligence community across the board as far as identifying and disrupting at thwarting these plots. in every instance. we want to make sure we raised that even higher. we had docks in separate databases that work separated from one another -- dots. we have better and better opera ability. more places have access to more of those documents. we are making sure we can leverage the access to the dots and identify all the threats. >> the president mentioned major

investments forthcoming. can we expect more investments beyond the $1 billion? >> it is premature to make those statements right now. that is part of the ongoing review we will undertake in the coming days and weeks. >> with the major investments be more than $1 billion? is there more money that will likely be requested? >> like i said, i think it's premature to put a number on it. we will be making ongoing recommendations to the president, but do not lose sight of the fact, he was agreed at an international airport. it is the international air environment that we also need to work on. that is why we had undertaken this very rapid reach out around the globe to say this is an international issue. it affects the traveling public of people in countries around

the world. the terrorists do not discriminate when they get ready to take down a plane. that is a very important part of the ongoing process as well. >> general jones referred to the fort hood massacre as strike one. can you explain why things that were learned after fort hood, yemen, but cleric with a visible role in educating for terrorism, did not create within the intelligence community a higher sensitivity to the kind of things invisible? how much does that disturb you? will you personally briefed by the press about the possibility of explosives being hidden in garments or clothing?

>> we were very concerned after the fort hood shooting about what else he might be doing here. there was a determined effort after that to tech rick -- to take a look at what he might be attempting to accomplish here in the homeland. there is a seriousness of purpose on the part of al qaeda to carry out attacks here in the united states, whether they are reaching people through the internet work from sending people from abroad. we have taken corrective steps. president obama has directed several reviews of fort hood as well as this. this one has been completed in a preliminary court within two weeks, lightning speed. as far as being able to bring an

issue all the way through and have reports so we can take corrective action as soon as possible, we are doing that here. this is the start of a process. within two weeks time, we have been able to identify, diagnose, and now take steps to ensure that this does dot happen again. i went out to saudi arabia after the attack and was able to work with the prince, see the room where the attacks took place, talk about the attacks -- it was an assassination attempt and we are continuing to work with the saudis. we are trying to stay a step ahead. obviously they are looking at all these different types of techniques. we have to continue to advance and evolve, and that is what we are doing. >> is there concern about

keeping up with the sheer volume of information? >> what the counter-terrorism has been able to do with increasing amounts of information and a collector systems -- a collection systems -- we were able to address the growing threat of al qaeda in yemen because of the tremendous ability to be able to collect information and use it swiftly. the national security establishment is well served by the changes that have taken place in the last half-dozen years, as well as what we are trying to do in this administration to use the information to a -- to address our national security priorities. >> you said one of the most alarming things you found was the strikes of the al qaeda cells in yemen. what other things did your

review find? >> they have taken a number of different paths to try to carry out at attack. a suicide bomber concealed within his close an explosive device similar to the one that was used and prisons. they are carrying out attacks against hard structures like the embassy. there are several hundred al qaeda members within yemen. we have to continue to work closely with our partners to be able to drive al qaeda down in yemen. >> why has this been such a surprise? >> that they were able to bring a person into the execution phase and put them on an airplane coming to the united states. we were not focused enough on

making sure that we were able to identify who ever would be used to carry out the attack. >> have you learned anything that would suggest why they specifically chose detroit, and when the president today talked about the concern about recruits being attracted to al qaeda, he talked about wanting to have special efforts to break that kind of appeal. is there something specifically about southeast michigan that has of barry -- has that population? >> the part of poland's security has had our reach into

communities across the united states over the last year -- it -- the department of homeland security has had out reach into communities. we need to look at strengthening those activities. we also need to look at the whole issue of counter- radicalization. how do we identify someone before they get to the point of being willing to blow themselves up on a plane? how do we work with our allies like the uk on this? it has been a major topic of conversation between us and the u.k. over the prior months. you are right to point out there is a whole related issue here,

how do we get into the process before someone becomes so radicalized that they are willing to commit this kind of attack? >> did you find any reason to suspect at that particular flight was chosen because it was headed to detroit, given the large yemeni and arabic population there? >> i think that would not be appropriate for comment right now. >> focusing on the international issue, human as well as africa -- yemen as well as africa. has anyone approached the white house to talk about this? >> we have been in contact with the yemeni government.

the foreign minister will be coming here. there are a number of interactions with officials. >> the issue of extradition. i understand there is no extradition from yemen. is that an issue, with the breeding of terrorists there. is that on the table with the yemen government, extraditing them back to the united states? on the africa issue, some of the national security community are saying that focuses is going to be placed on the continent of africa. there are breeding grounds in africa and there is a fear that the tentacles will strike from there into northern africa and europe. have -- is africa opprobrious to handle this type of situation --

appropriate to handle this type of situation? >> we have deployed high officials from our department around the globe. they will be going to africa as well. they need to be part of that solution. it is a global travel issue. there is active engagement there. >> there are many groups in africa of concern. we have had an ongoing, robust and dialogue with african countries and leaders. it is an area that al qaeda preys upon. they are looking in africa for recruits. this is something we are very concerned about. >> we are engaging with african countries and leaders to address

this issue. >> is there any information that the government has been able to analyze that you had prior to christmas but has not been analyzed yet? >> there is a lot of information that is being read analyzed and re-evaluated in light of this. any type of incident like this gives us new insights into methods. there is cowering going on -- scourings going on. >> is what was released today to us a great leap redacted version of what was presented to the president -- greatly redacted version of what was presented to the president?

>> is the system already in place [unintelligible] is that one of the things you are talking about? what do you say to people who were squeamish about personal privacy and body searches? >> obviously as we move to strengthen security, we always have this balance to be struck with issues about personal privacy. here in the united states, we

train officers on how to properly conduct a pat down. they do it in other countries around the world as well. part of the initiative we are undertaking is to make sure that kind of training -- there will be increased use of pat downs as well. >> i am confident we have taken a variety of corrective measures that would have allowed us to identify the suspect as someone us concern. the national counter-terrorism center has been working day and night since this december 25 attempted attack and has been scouring all of the databases to make those correlations. i am confident they have done that very thoroughly.

>> the comments of john brennan focusing on counter-terrorism and homeland security. also secretary janet napolitano and robert gibbs shedding more in detail on the president's announcement that took place just over an hour ago, as the white house has now released an unclassified version of the attempt on flight 253. we want to get your comments. you heard john brennan announcing some of the details of what happened and what the administration and intelligence community have learned as a result of the attempted bombing attack.

wesley is joining us from north carolina on the independent line. caller: i think our u.s. government, as well as the person's across the united states need to take deep breaths and think logically about this. making every man, woman, and child in america take off their shoes did not stop this. everything we do is not going to stop this. it seems the only defense we have, perhaps the best thing to do is just give everybody a gun on the airplane.

if we want to take away the desire of these terrorists, perhaps we should stop launching cruise missiles and sending drones into countries and giving them a desire to join these extremist groups. host: does this incident make you more or less worried about flying? caller: there is no way i am going thru airport screening where i will be exposed to x rays that have the potential to give people cancer, take away all personal privacy, and are not going to stop one who is determined to get on an aircraft and do something like this. host: john boehner has issued a statement that is available on his website saying that the president should start reconsidering a series of things that have made us less save. he also says the christmas day bombers should be detained and

tried as an enemy combat and of the united states, not as a common criminal, and the president should reverse his decision to keep guantanamo bay open. that is from the republican leader of the house. from florida on the democrat line, go ahead. can you turn your volume down? caller: i think what needs to happen, in order for us to stop terrorists, we need to learn to stop migration around the world. you do not know who these people are. if the united states wants to

stop terrorists from coming into this country, i think everybody coming into this country needs to be registered with their own country first. they need to identify the reason why they are coming to this country. if you want to stop them abroad, instead of coming here first, and also make sure they have a three-month period before they come here, that is the bottom line. we need to stop them abroad. all people migrating need to be registered with their country. we could stop them. host: thank you for calling. we will go back to linda, joining us from florida. caller: i have a concern.

i used to know somebody who was trained by the military here in dover. why would we trained saudi arabian pilots in the united states? host: is that your comment? caller: yes, i would like to know. i would like to know why we would even think of training pilots to fly planes. i knew somebody that was trained by dover, new jersey as a pilot. host: we will continue the conversation tomorrow morning on "washington journal." one of our guest served in the bush administration.

he will take your calls in more detail into what happened, and also the whole issue of the failure to connect the dots, as you heard from the president. you can read the entire report, available online at c-span.org. doug joins us from virginia. caller: i am trying to figure out why they did not hire competent people to fill these positions in homeland security, why we do not have our own people screening passengers that are getting on flights coming to the united states. if you fly here from the bahamas, you go through an american checkpoint. caller: i have watched c-span for 20 years.

there was an expert named haskell. he did not have any i.d.. did you hear from haskell? they would not even let him on. he had no passport. there are a lot of good people at a lower level. host: thanks for the call. your reaction to the president's comments or what we heard a few moments ago from a homeland security secretary.

caller: i did not hear anything about the borders. our borders are open and we have people running through them all the time. host: what is the solution? caller: lock up the borders. we need to have control. host: how do we do that? how do we control the borders and prevent people from not coming in. what in your caller: mind is the: if you have border controls, it is common sense. we have a lot of military that is out of work. we have the mexican border and the canadian border. we have a clear crossing in parts of canada. there are a lot of people out of work, that would be willing to go take training for that.

i just don't understand why, if you are going to have all this security on the plane, it's so easy to come across the border. host: next on the independent line. caller: i was very surprised's by president's remarks and the remarks of the two individuals who appeared in the news conference. they must be terrified of the next attack, which is obviously going to come. i think it was a cya exercise to prepare and give them cover for what is coming next. this is a disgraceful situation we are in.

let's call it what it is, a war on terrorism. i think president bush is going to look pretty good before all this is over. host: we will go to a viewer in fredericksburg, virginia. caller: i think on 9/11, we were asleep, and so was the government. we got a new administration and they are not getting the job done. i heard the news conference today. they need manpower to get the job done. it seems like the dogs were not connected because they do not know where to connect the dots. host: we are looking at millions of dollars for the top of equipment that airports require. caller: i at think they needed more in the foreign airports

than they do in this country. we saw what happened on christmas day, because somebody is not doing their job. considering what his father did, that did not do any good. i think some heads have to roll. when she came on and said it is working. well, if it was working, that would not have happened. host: the president returned on monday, holding a series of meetings trying to get answers to what happened on board northwest airlines 253 at the detroit airport on christmas day. the president announcing a series of steps and what will change in home and security issues, releasing an

unclassified version of the report, which is on line at c- span.org. we will hear it again those comments in just a moment. our last caller is from miami. . . luckily, the plane did not blow

up they insisted they could respond of passengers. -- thanks to the quick response of passengers. people are not doing their job at this point of time. host: we will continue the conversation tomorrow morning on "washington journal." michael steele is dealt with a new book. he will be among our guests. we also have the deputy security adviser for counter-terrorism. he will talk about what the president outlined today. up next, we want to share with you what the president said about 430 eastern time. -- for 30 p.m. eastern time. he briefed the reporters.

the report is available online at c-span.org. >> good afternoon. i was just briefed on the fighting for recommendations of reform. i think it is important the american people understand the it said -- the attempt to where taking. -- the thames we are taking. we will discuss the review entered the -- into the counter- terrorism unit.

today i want to just briefly summarize our conclusions and the steps that i have ordered to address them. in our ever changing world, america's first line of defense is timely and accurate intelligence that is shared, and integrated, and allies, and act upon quickly and -- analyzed and acted upon quickly. that is what our intelligence community does every day. that is not what happens in the lead up to christmas day. it is clear that sure churnings -- short comings occurred. although our community has learned a great deal about the al qaeda at the eliot in yemen

-- al qaeda in yemen. they were recruiting operatives to do so. the community did not aggressively follow up on and prioritize particular strains of intelligence related to a possible attack against the homeland. second, this contributed to a larger failure of analysis, a failure to connect the dots of the intelligence that existed across our community and which could have revealed that he was planning an attack. third, this went into shortcomings in the system that resulted in this person not being placed on the no-fly list. it allowed him to board that plane in amsterdam for detroit. the u.s. government had the information scattered throughout the system to potentially uncover this plot and disrupt

the attack. rather than a failure to collect our share intelligence, this was a failure to connect and understand the intelligence that we already had. that is why we took swift action in the immediate days following christmas including updating the terror watch list system and adding more individuals to the no-fly list. it also includes current be set informations in warnings with suspected terrorist ties. today i am tracking a series of additional steps across multiple agencies. they fall into four areas. i am directing that our intelligence community began assigning specific responsibilities for investigating all leads on high priority threats. not just most of the time but all of the time. we must follow the lead that we get. we must pursue them.

that means assigning clear lines of responsibility. i am directing that intelligence reports be distributed more rapidly and widely. we cannot sit on information that could protect the american people. i am directing the restrengthen the analytical process, how our analysts process and integrate the intelligence that they receive. my director of national intelligence will take the lead in improving our day-to-day intelligence. we will examine the longer-term challenges of sifting through the vast universe is of data. i am ordering an effort to strengthen the criteria used to add individuals to our terror watch list, especially the no fly less. we must do better in keeping dangerous people of airplanes

while facilitating traffic. these reforms will improve the ability to collect, a share, and a great come analyze, and act on. they will help the intelligence community to do their jobs even better. even the best intelligence cannot identify in advance of every individual who would do us harm. we need the security at our airports, ports, and borders to prevent terrorists from entering america. at the amsterdam airport, abdallah to love was subject to the same screening as others. his carry-on bag was and trade. he passed through a metal detector. a metal detector cannot detect the kind of explosives that were sewn into his clothes.

we will explain how they were used their but not at the checkpoint where he passed through. most airports to die and have these technologies. there is no silver bullet to securing the thousands of flights into america each day. it will require significant investment in thmany areas. that is why we increase investment in aviation security. that includes $1 billion in new systems that we needed to protect our aircraft, or baggage screening, passenger screening, and and and explosive detection capabilities -- and more advanced explosive detection capabilities. as i announced this week, we have taken a whole range of steps to improve aviation

screening including new rules for how we handle pieces of wood in the -- new visas with in the government. i am dreading that the department of homeland security take additional additional steps. we will work aggressively in cooperation with the department of energy to develop and employ the next generation a screening for opportunities. le florthere is no foolproof sos for do our efforts will seek new ways. in the never ending grey's to protect our country, we have to stay one step ahead. that is what the steps are designed to do. we will continue to work with

congress to ensure our intelligence, homeland security, an login source and a -- law enforcement has the resources they need. i ordered these reviews so we did take immediate actions. we will continue a sustained and intensive effort of analysis and assessment that we leave no stone unturned. i have repeatedly made it clear in public and private that i will hold my staff, our agencies, and the people in them accountable when they fail to perform their responsibilities at the highest levels. at this stage in the review process, it appears the incident was not the fault of a single individual or organization but a systemic failure of cross organizations and agencies. that is why in addition to the corrective efforts that i have ordered, i have established

agency head to give accountability reviews and directed my staff to monitor their efforts. we will measure progress. they will report back in 30 days and on a regular basis after that. all of these agencies and their leaders are responsible for implementing these reforms. all will be held accountable if they do not. moreover, i am less interested in passing not blame than i am learning from these mistakes. the buck stops with me. as president, i have a solemn responsibility to protect our nation and people. when the nation fails, it is my responsibility. over the past two weeks, we have been reminded again of the challenge we face of protecting our country against the vote that is bent on their destruction. well politics can obscure the hard work before us, let us be clear about what this moment

demands. we are at war. we are at war against al qaeda. it is a far reaching network of violence that attack is on 9/11 that killed nearly 3000 people and is plotting to strike as again. we will do whatever we can. we have made progress. the leadership has sucker down. we have worked closely with partners to deflect major blows against al qaeda leaders. -- to inflict major blows against al qaeda leaders. when of the vast majority of muslims reject al qaeda. it is clear that al qaeda increasingly seeks to recruit individuals without known terrorist affiliations, not just in the middle east, but in africa and other places to do their business that is why i directed my security team to develop a strategy to address the unique challenges. that is why we must communicate

clearly to muslims around the world that al qaeda offers nothing except misery and death, including the murder of several muslims. the united states stand with those who seek justice and progress for them to advance the progress, we seek new beginning with muslim communities around the world. we will work together to a fill the aspirations of all people. that is what america believes in. that is the vision that is far more powerful than the hatred of thesis violence. at home we will strengthen our defenses, but we will not succumb to a siege on our liberty and values that we cherish. great am proud nations to not hunker down and hide. that is what our adversaries want. as i am president, we will never

hand them that victory. we will define the character of our country. in this cause, everyone of us, every american, every elected official can do our part. instead of giving into cynicism, let's move forward with optimism. now is not a time for partisanship. it is a time for citizenship and it time to come together. it is a purpose that our security demands. that is what it means to be strong in the face of violent extremists. that is how we will prevail in this fight. that is how we will protect our country. we will pass it on as a safer and stronger nation. thank you very much. [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2009]

>> you can see the remarks again tonight at 8:00 eastern. you can also see the third report on our home page at c- span.org. jan an appalling tunnel -- janet nepaapalitino spoke with in the past hour. >> i wanted first apologize for the delay. we wanted to get the documents

right. you all should have two separate documents that were e- mails out. the first is a summary of the white house review, which for the documents i spoke of a second ago. secondly, a memo signed a little while ago by the president on corrective actions. we were here momentarily from the department of homeland security. after they speak, we will spend about half an hour taking your questions. i know many of you have deadlines. if the need to sneak out of here, that is certainly fine to do. >> good evening.

the president said following the attempted attack, he directed me to conduct an immediate review of the system the nation uses to keep terrorists from entering the country. he asked agencies to prepare input to the review. let me say that every department provided the information that was needed that speaks to the series and -- the seriousness we take. it speaks to our urgency and determination to make sure this does not happen again. the review had three primary goals, to find out what happened, it led by the shortcomings of what went wrong. [unintelligible] i want to address each of these areas.

as the president has described, in the weeks leading up to the attack, ferries components had fragments of information about the threats. there is was known that they had [unintelligible] they also sought to strike the u.s. homeland. there is a stream of intelligence on this threat. it was known that he had developed extremist views and his father feared he had joined unidentified extremists. there is information about an individual and his association with al qaeda. these are among the fragments of intelligence we have before christmas eve before he ever boarded an aircraft in amsterdam.

we did know -- did not know why they were not appeased in a way that could be uncovered. that leads to the second line of inquiry. what went wrong? this was not the failure of a single individual or single organization. those errors or not the primary cause of what happened on december 25. this was a systemic failure across agencies and organizations. i want to be very clear. there has been some confusion. it has been reported we saw the same failures before 9/11. after eight years, why has it not been fixed? before 9/11, there was a reluctance for people to share information between agencies. different agencies were at times denied access to the critical into nations that could have stopped -- informations that

could stop the 9/11 attacks. these issues have largely been resolved. that is not what happened. this is not a failure to share information. our review found the agencies had the information they need it. no agency or individual is denied access. as the president has said, this is not a failure to share intelligence. it is a failure to connect to the intelligence we have we cannot prioritize a state of intelligence -- we have a. we did not prioritize the intelligence we had. the intelligence fell through the cracks. if this happens in more than one organization. this contributed to the larger failure to connect the fragments that could have revealed the plots. this the fed into shortcomings

in the system. it resulted in him not being placed on the watch list, thereby allowing him to board a plane in amsterdam for detroit. while the system is not broken, how the intelligence community beat the information needs to be strengthened. from how do we fix the problem? there issuing a directive to all the agencies on the corrective actions. there are more than one dozen steps all together. each is responsible for their implementation. they fall into four broad areas. he is directing that they immediately began assigning responsibility is to investigate all these on a high priority threat. they will be acted upon aggressively. he is treading that intelligence reports, especially those involving threats to the united

states, be distributed more rapidly. he is directing the we strengthen the analytic process. the president's advisory board will examine the longer-term challenge of identifying and analyzing intelligence among the vast universe that we collect. that challenge is growing every day. the president is ordering an effort to strengthen the criteria used to add individuals to our terrorist watch list, especially the no-fly list. the president said he will hold all of us, at the staff and agencies responsible. they are but to monitor the progress. the president has directed me to report back within 30 days. these reforms are going to improve the ability to do the job even better, to collect and

analyze and act on intelligence swiftly and intelligently. in every instance over the past year, the intelligence community has done an absolutely outstanding job in protecting the homeland and stripping plots that have been directed against us. it was in this one instance that we did not rise to the same level of competence and success. the president has told us that we must do better. i told the president today that i let him down. i am the president's assistant for homeland security and counter-terrorism. i told him that i will do better and we will do better as a team. thank you. >> thank you. i want to update all of you on the actions for the department of homeland security that failed

the christmas day attacks in the longer term recommendations that we made to the president in our preliminary report. they lay out how we will move forward in a number of areas that are critical everett's to protect air travel. we have immediately strengthen screening requirements for individuals flying to the united states. every individual flying to the united states or anywhere in the world who has an itinerary or passport from nations that are state sponsors of terrorism is required to go through a screening. the majority of all other passengers will go through random enhanced screening. at airports, we have deployed additional airport law enforcement officials, the detection officers, air

marshals, and canine teams among other security measures, both seen and unseen. i want to express our thanks to the public for their patience with the security measures i want to thank the department of homeland security personnel who have been engaged on a day basis to implement than since christmas. -- them since christmas. there needs to be a re- evaluation and modification of the criteria and process used to create the terrorist watch list. this will involve the department of homeland security and other members of the intelligence community. the effort will include evaluating process by which names are put on the no-fly list. let me pause here moment to say

that the department of homeland security will -- works day in and day out with other members of the intelligence community. these are dedicated men and women. all of them are dedicated to the safety of the united states. we simply had a systemic failure. dhs uses the list as a cornerstone of our efforts to prevent suspected terrorists from boarding airplanes bound for the united states. we will establish a partnership on aviation screening technology between dha and the department of energy and national laboratory. this will allow the government to use the expertise of the national laboratory to develop new and more effective technologies so that we can react not only two known threats but also to proactively

anticipate new ways by which terrorists can aboard our efforts. -- board our airplanes. we will have greater imaging technology to detect explosives like the ones used in the christmas day attack. we currently have 40 machines deployed throughout the united states and 2010 -- and in 2010 we will deploy 300 more. the gsa does not conduct screenings overseas. the christmas day incident underscored the screening procedures at foreign airports are critical to our safety here. we have to do all that we can do to encourage foreign authorities to utilize the same enhanced technologies for aviation security. there were passengers from 17 countries aboard flight 253. this is an international issue, not just one about the united

states. we have to strengthen the present incapacity of aviation law enforcement on top of the measures we have already taken. this includes increasing the number of federal air marshals. we will begin by deploying law enforcement officers to help fill this important role. working with the secretary of state, we need to strengthen international security measures and standards for aviation security. security measures abroad affect our security here at home. the deputy secretary of dhs and other top officials have been on a multi country, multi consonant missinion. later this month, i'll be travelling to spain to meet with my european counterparts for what to be the first in a

series of meetings with counterparts that i believe will lead to a broad consensus on new international aviation security standards and procedures. these recommendations that i just described are important areas importantdhs and other agencies -- -- important areas where dhs and other agencies are working. these are changes that will help us prevent another attack from ever advancing as far as the ones it on christmas day. thank you. >> son used by using enhanced screening technology. are you using the body imaging systems as the primary method of screening? >> we the get security as a system of lasers. -- we look at security as a system securitylayeof layers.

it is behavior detection, it is canines, it is increase law enforcement presence, it is a series of layers that we will be adding to the security we already have at our domestic airports in the wake of this instance. >> you said that 300 additional scanners will be deployed in 2010. was that planned before this event? how much will it cost? >> it was planned before this. there was already finding that the congress had appropriated for the tsa. with respect to how many more, we will be working on that as part of our ongoing review.

i would caution you not to focus solelyñi on that technology. ñithis is a series of layers tht we will be enhancing. >> both of you and the president mentioned the word accountability. all of three he made the point that it was not just the mistake of one person. who is being held accountable now? >> as you heard the president now on a number of occasions, including today, take responsibility for the system that we have,. that is what the president led these individuals to conduct these reviews, to see where we fell donwn, and how we can plug the holes. the focus is on the timely completion of that review and to

implement his corrective action as quickly as possible. we not have any announcement other than that today. the buck stops with the president. the team under stustands that it is a dynamic process. it will continue over the course of the next 30 days to ensure what has been outlined by all these different agencies, acknowledging their responsibility for the attacks. they have a knowledge that they will take the corrective action that is necessary. i would mention the billion dollars the president mentioned was retained in the recovery act. >> the president referred to an unknown terrorists.

from what i understand, he was a known extremist. what was the most stunning thing that you believe came out of the review? >> we knew that he had departed from nigeria and was in yemen. we knew from that jam of the information that he was an extremist and had the tennessees. -- and had those tendencies. [unintelligible] we knew about him. we know about this other plot developing. >> there [inaudible] >> what was the most shocking thing that you found out?

>> that was an extension of al qaeda core. it is one of the most lethal and concerning the d. the fact they have moved forward to attack is on the homeland -- we have a strategic sense of where they are going. yet taken a lesson. -- we are taking that lesson. >> i have been following up on that. the tactic of using an individual to implement an attack as opposed to a large conspiracy or a multi person conspiracy such as we saw on 9/11 -- that is something infects -- affects intelligence and emphasizes a renewed

importance on how different intelligence is integrated and analyzed and streams are follow through. it will impact how we improved airport security around the world. >> was there an outside contract for security enhancement? what it is lacking is that you do not give the motivation of what they want to do it. >> the screening was done by dutch authorities. if they did the screening. the luggage was screened. it was done by dutch authorities. >> what was the motivation? you never hear what you find out about why.

>> al qaeda is an organization that is dedicated to murder and 110 slaughter of innocents. what did they have done over the past decade is to attract individuals and use them for these types of attacks. he was motivated by a sense of religious drive. a guide has deserted is long and has corrected the concept of -- al qaeda has deserted islam and has corrected the concept to their own. >> you are saying it was religion? >> it was because of al qaeda that uses the banner of religion in a perverse way. >> why? >> it is a long issue. >> he still have not explained why. >> let me clear of a couple of things but of what was learned

while this was under way. there are sources suggesting that additional an affirmation came to light after the flight took off -- additional information came to light after the flight took off. >> in stipple, his name did not appear on any terrorist watch list. nothing pinged to keep them off the plane. while in the air, customs in detroit has access to the entire data base but a as we now know, and that is the large mega database that has five and a thousand names in it. -- 500,000 names in it. they were ready when they were landed to question him about that. >> the terrorist watch list did

not have his name on it. >> why was the director about to take leave after the incident? >> when the incident occurred on christmas day, a number of people came into their offices and focused on it immediately. i was in constant contact. [unintelligible] he was scheduled to go on leave to meet his son. he asked me whether not he should cancel the trip. i told them he deserted the vacation. he needs to be a this them. i was the one who told him he should go out there. our review has looked at what inspired the -- happened there. [unintelligible]

we were in constant contact with one another throughout the time. >> when did the first note that aqat had been sentenced to strike the homeland? how early? >> in the intelligence, over the past several years, it has been aspirational. they have said things. it has promoted a certain fview. all the activities were happening in yemen. it was aspirational. we saw there was a mounting interest in trying to get individuals to carry out attacks. in hindsight, it gives you much better opportunity. we saw it developing. at the time, we did not know they were talking about sending

him to the united states. >> your first recommendation is to assign priority to lead. it seems out of the basic premise of any intelligence. i am sure people are thinking, that is the reform? >> we are having judiciary information throughout the communities and increased capabilities. there are different organizations involved. it is clearly understood who has the lead on it. most times the cia and dhs are working it. we want to make sure that each one takes the lead. >> you mentioned intelligence sharing before 9/11. before 9/11, a commission report came out about connecting the dots. there was a pledged then to do

better on connecting the dots i am wondering why from the post- 9/11 commission standpoint why dots were not connected. when you say you will improve analysis. how is it like to happen this time when it did not happen that time? >> analysis has improve steadily. we have an amazing track here in the united states. we are identifying these plots early. we are preventing those types of attacks in every instance. what we want to do is make sure the rates are even higher. in the past, you had dots in separate databases. they were separated from one another and were not connected from a network standpoint. there is better access. more employees have more access to the dots that comment.

that is the challenge, making sure we can leverage the access to those dots. >> the president mentioned a major investments forthcoming. can we expect more investment beyond that billion dollars? how are we going to pay for it? they are talking about raising airline security fees. >> it is premature to make a statement. part of the ongoing review the we will undertake in the coming days will have them. >> there is more money that will likely be requested? >> i think it is premature to put a number on it. iwe will be making recommendations to the president on what needs to be done at domestic airports. he was screened at an international airport. it is the international air environment that we need to work on. that is why we have undertaken

is very rapid reach out around the globe to say this is an international issue. this affects the traveling public and people around the world. these terrorists do not discriminate when they get ready to take down in flames. that is a very important part of the process. >> [inaudible] >> if there is time. >> he referred to the fort hood a massacre. why [inaudible] he is a visible advocate role and advocating for terrorism this is not create a higher sensitivity to the kind of things so visible? how much does that disturb you? were you briefed about the

possibility of explosives being hidden in garments or clothing? >> we were very concerned about what else he might be doing here. that is why they are making an effort after that to take a look at what else he might be trying to accomplish. he was a nigerian that came to yemen and then came over here. it indicates there is a serious sense of purpose and al qaeda. they want to carry out attacks him in the united states. >> are you satisfied that the intelligence community rose up and applied what they learned about ford put it? >> they have already taken those corrective steps. president obama has directed several reviews of instances.

this one has been a preliminary report. as far as being able into bringing in issue all the way through. we have already done that with the fort hood report. we are into taking those changes. we are doing that here. that'll be the start of the process. we will be able to diagnose and take corrective steps so we can make yousure that this doesn't happen. i went to study every after the attack. -- to saudia arabia after the attack. we are continuing to work with thosothers about those techniqu. we are trying to stay a step ahead. they are looking at all these different types of techniques.

what we need to do is continue to advance and involve. that is what they are doing. are you concerned that it is being overcome by the sheer volume? >> [unintelligible] what happens last month in yemen was able to address the growing threat of al qaeda there. i think the national security is an element is well served by the changes that had taken place over the last couple of years as well as what we are trying to do here in this administration to make sure we are able to use the information that exists to suggest the parties.

>> ease of when the most alarming things you found was the -- you it said one of the most alarming things you found was the strength of the al qaeda cell. what else did you find alarming? >> they had taken a number different past to carry out an attack. a suicide bomber can conceal and dispose of advice that is very similar to the one that was used. they are carrying out attacks against hard structures like the embassy. there is diversity and al qaeda members with in in yemen. we need to work closely with our partners to make sure that we are able to drive al qaeda down with a in yemen. it does present a threat here and abroad. >> why should this have been such a surprise? >> the fact they were able to bring a person into the

execution phase and exit with them on an airport. that is one of the failures. we saw this is taking place. we were not focused enough on making sure we were identifying what would be used to carry out the attack. >> have you found anything to suggest the terrorists specifically chose detroit to send a message to large populations? when the president talked about the concern about a loan recruits -- lone recruits, he talked about wanting to have a special effort to break those kinds of appeal. is anything you'll be doing specifically to the muslim populations?

>> the department of homeland security has set an outreach efforts into different populations. we are trying to build bridges of there is a good communication. we need to look at strengthening those activities. we also need to look at the whole issue of what is called counter-radicalization. how do we stop them from being radicalized to the point the one to blow up others on a plan. how do we communicate better american values and so forth? how do we work with our allies

like the uk on this? that has been a major topic of conversation between us and the u.k. over the prior month. you are right to point out there is a bigger issue here, which is, how do we get in the process before somebody become so radicalized that they are ready to commit this kind of attack? >> did you find any reason to suspect that flight was chosen because it was headed to detroit given the large arab american population? >> i think it would not be prepared for comment right now. >> focusing on the international issue, yemen as well as africa, since this attack, has anyone sincfrom them come to the white house to talk to you about this? >> we have been in regular

contact with the yemen government. i spoke to the present after this event took place but the foreign minister is going to be coming here. there will be a number of directions to our people. >> i understand there is no extradition from yemen. is that an issue, particularly with the reading of terrorists there? is that on the table with the government? >> -- if there is a reason to do that, we will do that. >> some of the national security committee claims that the focus needs to be placed on the continent of africa. we talked about some molly. they are breeding them in africa. they are going to somalia. they are going straight from

there into year. have any the talk to the africans? >> let me just say that we have already deployed officials from our department around the globe. they will be going to africa as well. they need to be part of the solution. this is a global travel issue. there is active engagements there. >> there are many different recruits in africa pitt. we have had a robust dialogue with african countries and the leaders. we see that is an area that al qaeda preys upon. they are looking in africa for recruits. this is something that we are very concerned about.

>> it is just one of many elements of the u.s. government. they are engaging with african countries and leaders in a way to address this issue from the standpoint of cooperation and security. >> is there any information that the government has been able to analyze and you have -- had prior to christmas but had not been able to analyze yet? >> there is a lot of information that is being realized and reevaluate. this gives us new insight into methods and other types of things to d. we are pursuing a number of leads. >> is what was released today

redacted version of what was being presented to the president? was that the delay? >> the delay was in declassifying documents. >> is the system already in place [inaudible] was at one of the things you were talking about? [inaudible] >> as we move to strengthen

security, we always had this balance of issues with privacy here in the united states. we train officers on how to properly conduct a pat down. they do it at other countries around the world. parted the initiative is to make sure that that kind of training incapacity is built in continents around the globe. you are right it is likely that there'll be increased use of pat down as well. >> i am confident that we have taken a variety of corrective measures. it would have allowed this to identify him. he was a dignified as a in extremist. we have been working day in and night since this attack to scour

all the databases abroad. we are making those correlations. i am confident they have done that clearly. >> thank you. >> you can see the president talking about the initial report in just over an hour from now at 8:00 eastern. a summary of the report is on their website, c-span.org. the attacker is believed to have worked with al qaeda in in yemen. now an update on how officials are dealing with the war on

terror in the country. first we would like to get an update on what is happening on the ground in yemen. the foreign correspondent here raghavan is with us by phone this morning. he will tell us what he has been observing. guest: good morning. host: how long have you been there? guest: 43 weeks. host: tell us about the changes you have observed? guest: the biggest was last year with the attempted bombing. -- i have been here for three weeks. we have had to deal with those who have arrived this week. what we are seeing now is the intensified crackdown on suspected al qaeda militants.

there have been two major air strikes backed by the u.s. on suspected hideouts. there have also been several raids in recentñr days been of e government is taking a proactive role in trying to tackle them. host: are you able to judge any reaction to them on the street to the intensity of an increased presence of the police and other actions? guest: not really in the capital. it is life as normal. last year the u.s. embassy was attacked with a car bomb. there has always been a good enough -- a security here in the capital. it cannot tell much difference. host: there must be some conversation having in coffee shops. any idea what the public sentiment is?

guest: most are focused on the civil war in the north or the secessionist movement in the south. that is more the topic of discussion then what has happened in detroit or four could. host: i'm asking because our papers here in the states have a number of articles suggesting the challenges to can you add any credence to that theory? caller: vick is a sense -- there is a sense that the u.s. is reading a little too much in yemen. they are concerned about capita there has always been a heavy dose of anti-u.s. cementhis sentiment. yemen is a country that has sent

thousands of fighters to afghanistan and iraq. there is a good amount of this to american policies here. they do not want to be perceived as being too weak to have al qaeda on its own. the government is trying to publicly contemplates this relationship into the united states. today i was in a press conference with a doctor who is the did the prime minister in charge of security and defense. he clearly sends a message that yemen does not want to see any u.s. troops on his territory. host: i know this is a situation of an influx.

we appreciate your opinion. thank you for your on the ground reporting. we will look to you more in the weeks ahead. guest: thank you. . . cspanvideo.org. >> "washington journal" continues.

host: we will introduce you to our final guest, dr. atul gawande, a surgeon, and has been involved in the policy on health care for a decade and have now. he has written a number of books, and his latest book is called "the checklist manifesto." will talk to him about all that this morning. during the clinton years, he served as a senior health policy adviser during the campaign and in the white house from 1992 to 1993, and you can reach him on a fairly regular basis in "the new yorker." when did you make the decision that in addition to practicing, you would also be involved in health care policy? guest: i tried to avoid being a doctor for awhile. the son of two indian doctors, you will naturally become a doctor yourself, and i wanted to push against my own inevitable path. during that time, i did a master's in politics and policy

and came to washington and work for jim cooper, a conservative democrat from tennessee. i worked on the al gore campaign for president way back in 1988. in 1992, i came back from medical school, which was the thing i kept falling back to, because i did not like depending on working for other people to figure out how to -- what i really think and how i can contribute. host: let's get to the 30,000- foot in view of health care in the united states. will you give us your view of what kind of health care the american public has right now, and then let's talk about some of the -- how much it costs us to get, and how many people don't have access. guest: in many ways, we have amazing, cutting edge of health care. we have access to unbelievable technologies, unbelievably well trained people. the same time, you can find some really abysmal health care,

with a lack of access in poor communities, cities and neighborhoods, and that is a stark contrast and a major problem we are struggling with. the second major problem we are struggling with is that the pieces don't fit together for any of us. the thing we are struggling with in health reform -- we have focused on the insurance hassles and insurance organization, but we've missed the point that the deepest struggle is with the complexity. science has given us 13,000 diagnoses that we have identified as problems that the human body can sustain, 13,000 ways that the human body can fail, and out of the last century, 6000 drugs, 4000 medical and surgical procedures. try to deploy it city by city, optimally, in the right time and my place for people. -- and right place for people. host: is there a big fix that is

possible? guest: coverage, providing insurance to the white population of people who are missing dead, 45 million -- wide population of people who are missing it, 45 million, we have been battling over a period is a public coverage, a private coverage? which ever way, there actually is a solution. when it comes to quality and cost, this is more a management problem. you never fix it all at once. we have had this great frustration about the health care bill -- where is the master plan for solving costs once and for all? the reality is that in order to organize care more effectively, we know we had a fundamental problems. doctors don't work together. we are fragmented. the incentive system where we are paid piecemeal, fee-for- service, has led to be small care -- to piecemeal care, has

led to overtreatment in certain sectors, undertreatment and others, and his treatment, mistakes and a carrot that happens all 2 ft. -- mistreatement, mistakes and get that happens all too frequently. host: have you come to a conclusion about what is moving along the track on capitol hill? guest: you know, might litmus test is are there tools here -- we have clinicians working with patients, be able to use to make the care better for our local communities. the 15% of our patients who come in the door and don't have coverage -- that is a constant clinical battle. i'm a cancer surgeon. . i spent years struggling with what we are going to do with chemotherapy or radiation treatments for people who cannot afford them.

when massachusetts passed this plan a couple of years ago, it suddenly disappeared as an issue. we still have our struggles with some cost aspects for the patient, but the coverage part is there. the second part is that we really have not as a community of clinicians worked on how to make care more consistent, more reliable, and less wasteful. for the first time, i'm hearing people in our conventions, our meetings, and in our hospital organizations trying to figure out -- if the bill passes, there is a lot in here to push us in the right direction. i'm hearing discussions i have never heard before about what we should do to get our costs down. host: we would like to invite you to take part in this conversation. many of you involved in health care debate. we have been talking about it is not here. as congress goes back to work, and opportunity for you to

get engaged in discussion with dr. atul gawande. one last question before calls -- let me ask you to tell us your views about the implications of the aging baby boomer generation, both on the kinds of care people will be seeking, and the countries ability to pay for it. guest: the one we people are voicing about the health care bill is that covering the 45 million people, where are you going to get a primary-care doctors? the larger issue is that over the next 15 years or so, the population over 65 is going to double, which means that the number of breast cancers, calling cancers, heart attacks are going to nearly double. our work force for managing this problem is not going to get bigger. we have not been thinking through how we organize ourselves to handle a larger population of people with more complex needs and not as many people in the system. we are thinking, let us hire more, spend more, and there is

every sign that we can make it safer, higher-quality care and organize themselves better in ways that we can handle that problem without expecting 50% of americans to become doctors. host: how does that get implemented? how does that break into the system as an idea? guest: let me give you a small example. assthma care -- asthma care -- i was at a children's hospital recently, and they implemented checklists, a counter intuitive idea for experts. if out about a half a dozen things that the major happen for each patient, and they found that you tackle things like having calls to keep them on inhalers and so on. the rates fell over 80% to guess what their number one revenue source was? asthma admissions for children's hospitals.

under reform, you say, but let us take for a package of care will be paid for results, rather than just extra money every time you bring a kid into a hospital. we are seeing hospitals talk about how to organize care so that we actually become more efficient, and get better results for people. it is going to be a real turn in how we think about ourselves as doctors and nurses and others working on problems. it is the kinds of experiments that we have to be taking seriously. host: buffalo, missouri, the democrats' line, you are on the air. caller: good morning, susan . doc, what i want to talk to about, and susan, too -- senator coburn was on your show about a month or two ago, and he was

talking about running all of these tests that he knew was unnecessary, but he had to do it for his liability, whatever. now, is that not waste, fraud, and abuse? if i would do something like that, i would be in jail. i know of doctors that do this. i am 63, i am in the va system. they control my blood pressure and everything. it is not cost me a dime. i could be on medicare, but i chose not to do it. i've been with the va since i got out of the service in 1971. but why are all of these tests being run? and i know it costs money. host: thank you. in fact, testing has been a regular theme of your story here is 1 "new yorker" article with the headline, "testing,

testing." guest: your caller hit the button on one of the issues driving the process, the malpractice system, which is driven in ways -- let me give you an example -- headaches. one community tried to look at how many ct scans and cedar rapids, iowa, they were doing for people. they did 50,000 cds dance for a population of 300,000 people a year. all of us know this is not necessary. 10,000 of them were for had ct scans, and only a tiny number of some of it was fear of malpractice suits. more significant part of it is that we have not really established what our process is, our appropriate guideline for care for handling the headaches

so we can do it the right way, so we have tens of thousands of unnecessary ct scans causing more harm because we have radiation exposure and we're seeing increases in cancer, likely to appear over the next 10 to 15 years. this situation is not going to be solved entirely by malpractice reform, but it is important to look at numbers and find ways to drive down the use of scans and we found communities that are doing it even without malpractice. they're able to drive higher quality, lower cost care and begin avoiding lower treatment. >> is malpractice the primary driver, or sit that they make money off the tests if? guest: i wrote an article for "the new yorker," i lked at

two communities in texas where there was malpractice reform and there's not been a damping down of the costs. then you compare two communities two counties on the border that have similar public health populations. one community spent twice as much for health care as the other. what you saw is there's no incentives and home care agencyings and others that have cropped up to take advantage of the insurance system. and you saw really fragmented, disor organized care where doctors -- disorganized care where doctors had not organized to make sure you took good care of primary care up front. even more, you saw two to three times as much surgery in that population. as a surgeon, we're rarely doing surgery to protect ourselves from malpractice suits. you have gray zones. you have a patient with

gallbladder attack, do you watch it and see if there are more attacks or wait to see -- or take it out on the first attack. textbooks say wait. when you make no money watching and you make some money for the surgery, there's a tension. we see it playing out in different ways across the united states. host: scott on the independent line. caller: i have a question about efficiency and automation. is it possible that we could -- i know that there's a lot of advancements in the surgery and things and is it possible that we could have a loss of jobs because our medical system gets so efficient, like what happened in industry, working class

people, you know, fabric, automotive, and things like that? is that a possibility that could happen? >> it is. it's actually -- the move toward being more efficient, we can have lots of people digging ditches and we can hire more people to dig ditches and fill them up again, but if they're not providing value, it doesn't help our economy. in a similar way in health care, if we are moving more and more of the labor force into that sector of our economy, it means we're not able to grow many other parts of the economy. the places we're going, weir far from a world where we are about -- one of the striking things is in this recession, health care is one industry where it has continued to grow in employment. we've expanded spending and

health care over 130% over the last 10 years and a lot of it has been in middlemen in the system, without necessarily getting you more time with your doctor. that's one of the bizarre parts here. it's why, in my unexpectedly, to me, i ended up writing a book about checklists in health care. solving these problems is about saying, we're going to be more disciplined and organized about how we provide care. i designed with my team a surgical checklist that's a two-minute check to make sure there are 19 things we get right in every cases. i was surprised by how often patients had one of those missing. and when we introduced it, we reduced the major complication rates by 35%. the savings from this program,

which we deployed in eight cities is massively more than anything we invest in it. but we don't work on these organizational problems in medicine, partly because the incentive hasn't been there and partly because we don't think of them as needing work. caller: first, i want to chastise most of the colors. seems like all of them call you up and ask, how are you feeling this morning? you know, you answer it wants at 6:00 in the morning and you don't have to answer any more, i don't think. anyway, the reason we have the best health care and the world is that we spend so much on it, and we spend it the wrong way. what we should do is specialized -- when i need a gallon of milk, i go buy a gallon of milk at the best price for my money. when i break my leg, you know, i

don't know what is the best value i can go for my money. what we need to do is promote the capitalism in health care and get it away from the insurance model. i'm so tired of everybody saying we need to have coverage. well, and no, we don't need coverage. what we need to do is no where to go -- that is to know where to go to get quality care at the best price for our money. host: let me interrupt for a second and poke around the edges of your analogy. with the milk, you want milk. but you don't necessarily know you of broken your leg when you of fallen. the first step is getting the diagnosis. caller: exactly. we have got the internet. i'm actually writing a book on how to fix all of this, and i know how to fix the health care system in the country, and in a

way, is it completely opposite of what they're doing in congress. it is to unleash the specialization -- several economic principles -- specialization, supply and demand -- we need to have the supply of health care professionals much greater, train them in a free or nearly free clinics, where people are means tested and have a copiague, electronic medical records for every american -- several points to be killed to go into here. -- too detailed to go into here. guest: he is onto something that is right. we have a figure to be really transparent about where the choices are in men -- a failure to be really transparent about where the choices are in medicine. one of the fascinating about the bill is efforts to create and use for this.

i think until towards of competition here is that we want organizations -- i think the real choice of competition here is that what organizations to be accountable for the standard of your health care and deployment, whether it is vertically integrated models of health care that we're seeing in places like the mayo clinic -- i am part of a system that is trying to move in this direction in boston. but the systems are about is saying to people that we will provide the full package of services, even the complications, and we will work to ensure that they are higher quality at lower cost. the bill offers a world where we will have competing insurers in exchanges that are driving in the direction of giving people more choices like these. but the second part of it is that we have not been willing to be as transparent about our results, or the work on these organizational problems.

and so might sense of the here is -- my sense of it here is that what is a desire to sweep away the old system, drop a new one on everyone, but the reality is that we have to build from where we are today, and it is taking steps forward, including the ideas of really driving our reform process in the direction we have got. half of the 2000-page bill is about coverage and insurance plans, but the other half are experiments and changing the way we a for health care and make it more transparent. host: the doctors latest book is available right now, and you also have a web site. guest: www.gawande.com. host: what will people find there? guest: two things. information about the books, but also the research we do with the world health organization,

deploying these to surgery and childbirth and beyond. host: our next call, patricia. caller: hi, susan, dr. gawande. . i'm retiring nurse. i want to mention two issues that i find would be helpful for reforming the health-care system. one of them is -- you had a guest on -- susan, i don't know if you are the moderator at the time -- but it was either from johns hopkins or the mayo clinic, and he confessed that there were no standards of practice for high-risk surgeries in hospitals. that astounded me. i feel that that really, you know, is a tremendous race

towards tort reform. i think it is necessary to have standards of practice in hospitals where they perform high-risk surgeries. it is the fault of the physician and hospital, they should pay out a patient who suffered -- the family of the patient who died, or the patient that has long term negative results. this would reduce tort reform immensely, as far as i'm concerned. secondly, i want to talk about primary-care physicians. i know that president obama is pushing for a primary-care physicians to increase the help in rural areas, especially. however, i go to a primary-care physician, and i like him very much -- however, i had an experience with the drug they put me on when i was under chemo, and that increased my

blood pressure. host: patricia, with all apologies, we have a lot of colors. -- callers. caller: i'm sorry. when they found out my kidney tests will become the primary care physician did not listen to me. host: what is the point about primary-care physicians? caller: the point is that i was sent to other physicians, and multiple tests were done, and this to me was a waste, and medicare and private insurance had to pay for all this waste. all i am trying to say is that if you are going to put primary- care physicians in, you have to teach them to know what they are doing rather than to rely on specialists to get the answers. host: great, thank you. we have a la -- a lot of callers waiting. guest: what she is describing is

the world. struggling with in edmonson. -- had the world we are struggling with in madison. we cannot know it all. we have been unwilling to admit that. we've been trained to get the idea that it is all going to be in our head, and we have not developed the systems in the place that can change that. it is why i ended up writing on something as mundane as developing a checklist across madison. we look at the aviation world and how they handle themselves, the skyscraper world, and we found the the first principle of successful conditions of complexity is for experts to admit to themselves that they are fallible, that they will fail at times, it will not remember everything, and then to build in those standards of practice, the checks on the half-dozen things that we should just never forget, that we check before you even go out the door.

it runs against our expert in stings. becoming expert is about the idea that we don't use checklist 30 am smart enough to know that -- that we do not use checklists. i'm smart enough to know what i do, that is for low status people. but as they use them, saving errors over and over, i started using checklists. i thought that at harvard, you know, we know we're doing. i have not gotten through a week without finding that our checks are catching problems of the sort that she is describing. complexity has gone beyond our individual capabilities, but we have tools that can improve our quality while saving our costs. host: california, mark, independent life. -- line. caller: i'm wondering what his

views are on how the media has covered the medical malpractice issue, and unnecessary surgeries that are being done, unnecessary tests. constantly, the press is representing this and repeating statements from some of those involved, which implies to the public that these are tests or surgeries that are done because of the risk of medical malpractice, when in fact performed the surgery is probably the most risky thing you can do. it is absurd to make this claim to the public on a regular basis. the press, of course, is getting at enormous amounts of advertising -- you can see these full-page advertisements from hospitals, and when you get hit by a car on the street, you are going to go to the hospital. you do not need to see full page advertisements in your newspaper. but $70,000 cash money coming to the newspaper every day, every day at the full-page advertisement appears in the newspaper for lasik surgery,

different kinds of advertising, different methods of pumping money into the news media to corrupt the news media, and the bribes paid -- host: we get the point, thank you. guest: it is hard for me to lay the blame at the news media ' here. i did research on what the malpractice cost drivers are, and it is about 3% of our increased cost coming from malpractice. see how much money is coming from the practice system? others are pointing out that it is only a small part of our overall cost drivers here. there are multiple drivers. the striking thing is that it has to do with -- yes, someone hears about the practice, it bought about our disorganization in our care, a lot about the way we pay for care on a piecemeal basis. it has to do with the sheer complexity and technology of our

care, and wanting to be sure that we have access to the right technologies. here is a heartening thing i would point out -- that we have about 1/3 of our communities that are providing higher-than- average quality with lower-than- average costs. moving our communities to embrace what those kinds of practices are at the medical front lines is likely to be the place where we will get the most bang for the buck and actually make a difference. with our economy struggling because our wages are being diverted over to the health-care benefit costs, we all have run into this wall, and it is why reform keeps pushing ahead, even though it is so complex and gives us all these headaches and worry about where it can go. it is because if we do not act, we -- will find well, we are already finding ourselves in deep trouble. it is hard for me to blame the news media on that one.

host: we are having a discussion on health care and the delivery mechanisms in this country with atul gawande. next call is from alabama, linda on the republicans' line. caller: good morning. i have two questions and i will try to make them brief. he sounds like a very nice doctor that i am listening to. the first question is, my husband and was rushed to the emergency room in 2009. my son said that he had no strength, could not stand. after nine and a half hours in the er, the doctor came in and its stated, "i believe your father has suffered a stroke, there is nothing we can do for him." my son says, "what can i do? i cannot get him home. my father is greatly il." he said, "if you want a question my diagnosis, i have a form you can fill out to take a

discharge and go of my recommendation." my son to get rid -- my son did that. my entire family from central kentucky drove seven hours to get to birmingham. they did nothing to it did not come into the room, -- they did nothing. they did not come into the room. he needed to go to the bathroom, and we assisted him. three weeks later, the same scenario. my son called me, and i said, " you called 911, you call them now." they got there, my husband, since august 19, has been in birmingham, alabama, and they did not do a simple test on him. he had pneumoniae. it turned into respiratory failure. at dr. -- that dr. got in my

face and my son's face saying, "it will not dispute what i as a medical professional have told you." we had come to realize that there were two deaths last year in the hospital from pneumonia undiagnosed. he got a bill for that one day, $18,000. guest: the kind of story you are telling gets at the heart of many issues we are struggling with. look, first of all, if you have a stroke, you don't necessarily know, but with slurred speech and not moving one side of your body, a family member needs to called 911 right away. 60% of the strokes in our country are treated in completely or inappropriately in our hospitals. we want to say is that hospital or that dr.. for the most part, what i find

is that unbelievably hard working people, unbelievably trained, but pushed against the limits of the complexity of delivering -- things i say we are fooled by penicillin, where we thought that most medical treatment in the 21st century, an injection that would make an infection go away, make a stroke away, make a cardiac problem go away. the reality is that it has been much more complex than that. the pneumoniae you talk about -- 40% of newmont yet in our hospital -- of pneumonia in our hospitals are treated it incomplete or inappropriately. not because people are not smart, but we are fragmented in our care. you experienced a drop in communication between one person coming on shift it and the next person where we have not gone forward is embracing ideas that are, in some other industries -- as professionals, we see mistakes by lawyers, we

see mistakes in foreign intelligence failures. the common issue is what the public feels about what the philosophers called ineptitude. our biggest struggles are no blogger with ignorance, although there are areas of scientific -- no longer with a difference, although there are areas of scientific ignorance. the solutions will come with doing ourselves from focusing on individual experts to thinking of ourselves as teams that have to have discipline, standards, and most critically, effective kinds of checks on ourselves that can aid the expert to be more effective than they were. host: taxes come mark on the democrats' line. -- texas, a month on the democrats' line. caller: i think doctors prescribed pharmaceutical drugs way to much. the to be the last option. -- i think it to be the last

option. second, i want a public health care option. i'm self-employed and i have had terrible health insurance my whole life. and i am healthy, so i am lucky on that. those are my questions. host: let's start with prescribing too many drugs. guest: we have a clear areas of undertreatment, and clear areas of overtreatment and mistreatment. drugs are often not given a four key conditions, especially preventive care, drugs liked saturn's for people who who have high coronary at risk, not offered as consistently as they should read it in other instances we are -- as they should. in other instances we are over- prescribing drugs. do we have complete let the

experts locally run things without any sense of feedback or information on it? we are on the way to carving a path between these two. of course we do not want on manned control. what we want ouare tools, better statistics and information about how well we're doing with the producing overtreatment and undertreatment, having that information --with reduecing or overtreatment and undertreatment, having that information available by county. that information is critically needed. and then what comes in behind that is the sense that doctors will check for themselves. i had a patient who led an onset of depression and went to her

doctor, and they tried and i to present medication after its anti-depressant medication to -- they tried anti-depressant medication after an anti- depressant medication. they realized years later that they had forgotten to check a hormone levels. the problem was not too many or too little drugs. the problem was that they missed the basic check along the way once she got the thyroid -- along the way. once she got the thyroid hormone, within two weeks she was better. host: how'd you feel about drug advertisement? guest: i'm conflicted. i feel they are largely unproductive spending. the reason they spend money on the advertisements is that the surveys show that 80 percent of the time, when they come up with the advertisement, they get the drug prescribed to them. trying to argue out of it just takes too long.

what we really need, though -- i have no idea concerning the legal issues -- what it reflects is that we have a value to the payment for things, drugs, tests, things that i do, without valuing the time that the doctors spent with people, where you can talk through what is the best problem here and how to best take care of it. doctors time is actually now cheaper than many of the technologies we have, and we have undervalued that critical he main component. it is not just doctors treated as respect -- not just doctors. it is nurse practitioners, people who can get the right care in the right time in the right ways. host: kentucky, good morning to you. caller: this bombardment of high-profile drugs and things like that -- you have a lot

patients who go to the doctors it or something they have seen on tv, and is not necessarily something that they really suffer from, because they had one of the symptoms. also, what about the drugs for minor afflictions -- with a lot of the drugs from one of the actions, they have severe side effects. is something that the -- with a lot of the drug some minor afflictions, they have severe side effects. it is something that the fda is getting on top of. guest: when a patient comes to see me with a particular treatment they want, they want to surgery potentially or a drug. if it is completely unindicated, that is an easy call. the hard part is that when people are responding to an advertisement or just when a

patient comes in and has a fever for one day, and the temptation is to prescribe an antibiotic when in certain circumstances, a cold is much more likely. over-prescription has led to massive resistance to the antibiotics that we are using. we want to be able to push back and say that in this circumstance, we should not use an antibiotic. but under the temperatures and the production model of the medical world, it is often easier for physicians just not to battle writing a prescription or an mri scan or sometimes during an operation. understanding how we can make systems that recognize -- we don't even measure how much overtreatment there is, identifying the places where we can work on it, and working with communities towards making sure that the mix of care patients get is much more suited to what their problems are and what

their needs are. host: this message here -- how challenging has it been to incorporate that into use in major practices and hospitals and that sort of thing? guest: on the one hand, we have pockets where we have done it and we have seen improvements each time we have done it, but it really has to be clinicians who are willing to embrace it. there is a huge difference between good checklist approaches and that checklists are purchased -- bad checklist approach is. if they are poorly designed and they take way too long, a doctor cannot use them at the bedside, or find them on helpful. when we put in our approach for surgical care we found a greater than 1/3 reduction in publications -- in complications

-- the u.s. has only had a 20% of hospitals moving with this idea. partly it is because we are all working as solo agents and are not used to getting together as an organization. host: with a national health- care system where that is easier to implement -- guest: that is right. people are more organized in many ways. the other component of it is that everywhere, experts are resistant to these kinds of ideas but we don't like having checks. when we surveyed teams after the implemented the checklist, in the beginning, they did not like at the end, 80% like it, but we still at 20% who hated it, said it was excess paperwork, too much time, "i hate this." then we ask, if you work the

patient in the operation, but would you want the checklist to be part of the care? over 90% said yes. host: next call. caller: doctor, when you do surgery on someone, you get compensated for your costs, and rightfully so. as the materials surrounding the surgery, gauze and whatever medical supplies you need, at today's surpass what you charge for surgery? and lobbyists in congress -- to what is the hospital administrator obligated to buy these products at high cost that really influenced the way out insurance pays off and the way the patient pays off? have a wonderful day, folks. guest: thank you for the

question. under the current structure, i get paid one fee, the anesthesiologist gets paid one fee. at a hospital gets paid a fee, including what incorporate the cost of the gauze and everything else. an interesting phenomenon is that the person who decides whether we use the disposable equipment, the $1,000 item, is the surgeon. i remember going into a case just a couple of weeks ago where we found that we had wasted about five dozen dollars worth of stock. first of all, -- about $5,000 worth of stock to first call, i tried to find out how much that's tough cost. -- that stuff costs. the second thing is that i did not really notice it until i started writing about these issues. each of us are so separated in responsibility is that we never

looked at the whole system of care where we say, let's do this operation in the most efficient way possible with the best quality results, working together as a team. we do that at my hospital in the sense of organizing ourselves, taking ideas from other places, trying interesting things, thinking of ourselves as that kind of organization, moving in that direction. that is new to us. that is something of a surprise, but it is the way we have to move in the future. the fascinating thing to me is that as the incentives of the health reform package are moving through an materializing and people are seeing what they are, for the first time i'm hearing that the conversations in our conference rooms in meetings where we say, ok, how could we as large groups of people, surgeons working with anesthesiologists, primary physicians and others, make it so that we have a package of care that is smarter and less

costly? host: i want to show you a few of the headlines regarding healthcare in the morning newspapers today. from "the washington times," "pelosi sees democrats close on health care." stories about the use of the excise tax on high-cost insurance, the difference between the house and senate. and "the new york times," "obama urges excise tax on high-cost insurance." in "the washington post," "experts remain skeptical of taxing health benefits." finally come in "the wall street journal," it david wessel writes about the lessons of medicare part d. finally, from a local perspective, this goes back to

the discussion about access. "the miami herald" as a story about "the jackson halts dialysis of poor patients." they cannot afford it anymore. guest: the striking thing to me is that we are becoming aware of these kinds of situations. it has been a common at -- it is fascinating to me that it that is finally a front-page piece of news, because the point at which we have been turning people away from care, struggling to figure out how to get coverage for people when they have dialysis, cancer troubles, has been an underlying current in our experience for a while. host: the chief executive of the jackson held system -- health system is quoted as

saying that the decision was not taken lightly. but they can get the treatment in the emergency room. guest: a way that happens is that when you have a kidney failure, you can function for all while, and then after a week or two, you become so sick that you were at death's door, you go to the emergency room and get emergency dialysis, but what you really need is dialysis in two or three-time-per-week basis in order to survive. it is an appalling kind of situation for a country like ours, which has, as one of the callers noted, amazing capability and technology and care. but the fundamental commitment is one at that, if pelosi is right and we are as close to changing that as possible, we underestimate the ways that that

represents a significant change for the health of the country. host: minneapolis, you are on. caller: i have a question for dr. -- host: gawande. caller: what is your take on people who are living with hiv and aids, and health care -- you know, how they plan on cutting -- i hear they plan on cutting medicare part d are doing something with medicare part d. hiv and aids have come a long way since the 1980's. but now that they are cutting medicare part d, what is your

take on that? thank you. guest: the h.i.v.-aids patient care is a nice microcosm for thinking about what is happening in corporate medicare part -- what is happening in care. but why wouldn't hiv or aids patient qualify for medicare -- would and hiv or aids patient qualify for medicare, given that they are on disability for the most part? we have turned into a deadly illness into a chronic one -- turned it from a deadly all this into a chronic one that people can live with and be healthy with. but getting insurance coverage, if you are self-employed or needing individual coverage, the pre-existing conditions make it said these patients cannot get coverage -- so that these patients cannot get coverage.

the only way they get coverage is if they filed disability and no longer work anymore because of their illness. they don't get treatment, they get ill, they file for disability, and we're in this town about where we lose the productivity of a significant part -- of the in this round about where we is the productivity of a significant -- lose the productivity of a significant part of the population. we could have a larger population of people that could really moved back into being productive in the lives as possible and have the advantages of the science so that they can also help contribute to economic recovery. host: just a few minutes left with dr. atul gawande pre confine him on the internet, and his book about -- with dr. atul gawande. you can find him on the internet, and his book is in stores. caller: good morning, susan, and

dr. gawande how will health-care reform might affect the time i spend with my doctor? will they be able to check on the basic things, or will this be quicker than normal? secondly, correct me if i'm wrong, but is malpractice insurance driving our costs up, or is it just a red herring? guest: let me ask a question about physicians and then come to the second one. -- answer the question about physicians and then come to the second one. two years ago, massachusetts took an approach similar to the new reform package, offering it for people who do not have access to insurance or for whom insurance is too expensive. if your income is very low, it can even be free. it has capped the cost at about 8% of income, and it has allowed

people a choice of plans. we had 12% of those who have insurance, only 2% who have insurance. the striking thing is, for most of us in the clinical world, for all of our other patients, we have not noticed a difference at all. i am a cancer surgeon, and i have not seen a patient with insurance coverage problems like we used have in two years. it has been an amazing thing. it can affect physicians in the sense that we are starting to embark with this package on experiments to deal with how we deal with costs. that means struggle at the local level, but for us to be thinking about what can i offer a package, can i join with colleagues in the hospital so that we can change the way we organize our care? it is an opportunity, and it is also one that we will find hard. malpractice reform i have

been in favor of. i am not in favor of taps, but instead moving towards a kind of no fault of practice insurance system. but as a driver of costs, it is one, but it is about 3% of the increase in costs from the studies that i've been part of and that others have been able to do. it falls in between. it is not quite a red herring to talk about malpractice reform, because it is available to us, and as long as we are being fair and accounting for the costs for patients who we harm. at the same time, it is far from the be-all and an ego-a -- and end-all. texas had a strong malpractice reform in this, and did not improve the cost structure there. host: next call. caller: good morning, susan, and

dr.. the doctor seems like eight very common sensical kind of fellow. is it necessary to achieve all the reforms we talking about, to create an entirely new branch of the federal government to compensate for this? guest: it i don't have the easy answer to that question. there is a bunch of the functions we have to have agreed although i am someone who would have liked to have seen a government insurance option as a backstop around the country, and the plan does not have that. the private insurance plans that would be offered -- even there, resorting to a world where we want to have private insurance, we want to have a structure of insurance exchanges that can make it so that you have a panel of options available to you. if you have no insurance or

access to insurance through an employer. it feels like, yes, in order to have reform, there are new rules for government, and new rules to get rid of preexisting conditions, which means enforcement of those rules. then we had a substantial number of programs trying to improve, for example, health care statistics. we don't have timely information on what the costs we are, we do not know county by county how well we're doing with pneumoniae and surgical complications and that kind of information has to be more readily available. although i am pretty much in agreement that creating more government is a place where we can find ourselves hamstrung by bureaucracy, at the same time, we are in a place where the

leading the system to itself -- where leaving the system to itself, we are watching it collapse, people o ought not ony by a lack of care, b >> the new c-span video library is a digital archive from c-span's programming from barack obama to ronald reagan and everyone in between. over 100 hours available now, it's fast and free at c-span.org. >> saturday, president obama's ambassador at large for global women's issues talks about supreme court justice ruth bader ginsburg and the rights of women around the world at 7:00 eastern on c-span's "america and the courts." >> i'm always concerned about the potential for unintended

consequences in deregulations. regulations of any kind act as a tax and when you tax or regulate something, you tend to get less of it. you tend to diminish it. >> this weekend on the communicators, republican f.c.c. commissioner robert mcdowell on efforts to create a national broad band plan, net neutral di, saturday at 6:30 p.m. eastern on c-span. >> up next on c-span, the white house releases a report on the christmas day attempted bombing of northwest airlines flight 253. we'll hear from president obecause mand -- obama and homeland security secretary janet in a poll ta noah. -- napolitano. later, we'll hear about the u.s.'s role in