c-span anytime anywhere with the freeze c-span radio app. you get streaming audio 24/7. you can listen to our interview programs including two in a, "newsmakers", "the communicators" and afterwards. >> now, a forum on the future of pakistan. from the brookings institution, this is two hours. [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2011] >> good afternoon.

i am would wrecking's, and i want to welcome you this afternoon for the american launch of the future of pakistan. there will be another edition. i do not know if there will be launched as there. >> the book had its origins about 1.5 years ago. is this ok? is this better? it is the outcome of a project that had its origins shortly after i finished a book called "the idea of pakistan" in 2004. it was clear that pakistan was not dealing effectively with a number of economic, political, and other problems. one of the many paradoxes of pakistan is that there are more than enough opportunities in a repressive country. i did not think mr. ref -- mushareff was affected. there were also strained relations with india and the united states.

pakistan is important because of its size, resources, islamic identity, quarrels with neighbors, nuclear program, and status as a sponsor and victim of terrorism. the project that led to this one was an attempt to look beyond the immediate crisis. i have written that pakistan has been marinated in crisis. we wanted to take in medium- range view of pakistan. we assembled an expert group of pakistan is, americans, europeans, and indians. some were former government officials. there were some young scholars

as well. a post two questions to each. -- i posed two questions to each. what were the key field -- factors that might shape pakistan's future? the answers are in the book. we want to thank the carnegie and rockefeller foundations, the u.s. institute of peace, and several individuals for their support. ellen hughes was the editor of the brookings press. i want to thank the institute. we're fortunate to have several contributors with us and several have recently written their own books on pakistan.

they vault recently published excellent books on pakistan. there are others we could have invited but we did not have the time or resources. we decided to make this a longer than usual book launch with two panels. if you paid money, you get two to the price of one. i will ask the panelists to stay in a recent events may change their judgment about the future of pakistan. i will give them an opportunity to reassess what they wrote a year ago. before we go to the first panel, let me ask one of the contributors to say if you words in memory of one of the participants who was the source of wisdom. >> hillary was a dear friend of mine from the time we served together in pakistan, before

9/11. we know look back on those as halcyon years of our relationship. they were not that great then. is that better? when i think of hillary, i think of several words. stoicism, rectitude, pragmatism, insight, candor. he was a private person until you got to know him. then he was a very warm person. he was multi-talented. he started life as a naval engineer who served in submarines. he then decided to surface in the diplomatic corps. after serving in europe, he became one of the foreign

office's leading officials and experts on south asia. he found his home in the diplomatic corps. he served in india, pakistan. he was head of the fco office in south asia. his last position took him way out of his line of endeavor and was his -- probably the worst time of his professional life. for six months, he was the head of the british administration in basrah starting in 2003 after the iraq conflict had wound down. he wrote about this in a book called "bad things in basrah."

it was not a good appreciation of our effort or the british effort. for a year or so afterwards, he remained rather bitter about the experience. he also wrote two books about south asia. one was about the advent of nuclear is asian -- nuclearization in asia. both pakistan and india. the last book was on the transformation of pakistan. it is a very optimistic book about what could be the future of pakistan.

he did not dodge trying to tell the truth about pakistan's deficits. steve has written this in the forward to the book that we are launching. i thought he showed his insights by using a term i have not heard before. he said many people think it is either a glass half full or in the on pakistan. he said he thought it was a glass to large -- too large. that was based on the idea that pakistan may have set out in life with more condition than it had resources to fulfil. i want to talk about our final communications. i saw him a lot in the last few years. last june, only a few months ago, when i arrived in england, i sent him an e-mail saying that

i was there. for the first time i got an e- mail back saying he could not meet with me but hope my visit went well. we had two or three more exchanges of the notes -- e- mails. he was always very upbeat. i told him i was writing a paper on public opinion of pakistan. he said he would love to see it as soon as he got out of the hospital. he was literally on his deathbed when he wrote those things. i think his last writing for publication was about five paragraphs on foreign policy. i think the title was "be angry about pakistan's treachery but do not go nuts." this is a bit long, but it is my memorial to a dear friend. he reflected the constant

service of the antique world where people serve for duty. he was not for the fashion of our times. thank you. >> thank you, bill. [applause] >> it was sir hillary that warned me off the idea that we are a delphi panel. he pointed out that the oracle of delphi was a woman and her predictions often lead a person to disaster. we scratched the idea of adelphi panel. a d -- a delphi panel. let me turn the panel over. we have about an hour for the panel presentation and discussion.

panel appeared to conclude the >> thank you for inviting me to participate. i still remember with some regret you are inviting me to participate earlier. i am getting desert without having had the main course. thank you for the lovely remarks about sir hillary. he certainly was a decent, thoughtful, and created public servant of the sort that one does not see that many of. it is my pleasant duty to introduce my fellow panelists. before i do so, i want to give you some thoughts to frame the discussion. i encourage each of the panelists to focus on things their particular chapters brought in that were unique to them or are under-discussed issues. if i were going to be a

panelist, i would have focused on pakistani relations that are going through an awful time at the moment. the central thesis of the book i wrote with my husband is the pakistan's prime negotiating tactic with the united states is what one might call the art of the guilt trip. one of my more elegant pakistani friends referred to as playing the victimization card. that does not necessarily mean that the trip is an appropriate or the in victimization card misplaced.

it is a way of dealing with the relationship that has been difficult for both sides and is that a high point of difficulty for both sides now. i assume this will form some of the backdrop of the presentations. let me introduce the panelists. i will introduce each of them as they come up. the first one is to my immediate left. that is dr. christine fair from the georgetown university school of foreign service who has a distinguished career in political science, data analysis, and embarrassingly long list of distinguished books. the one i do not see on this otherwise splendid bio is the "cuisines of the access of evil." you can talk about cuisine or something else.

the floor is yours for the next five minutes. >> pakistan is in the book. it was the finest book ever. i get paid $15,000 to write it. it was fabulous. pakistan, israel, and india are all included in the book. the dinner -- pakistan chapter is called "dinner with the taliban." it is a real cookbook. i actually cut my finger off, so do not drink and blend. when steve asked me to come on board, it was difficult in 2009 to be optimistic about pakistan and it's foundationalin the wake

of recent events, it is even more difficult to be less pessimistic than i was. in the chapters are wrote, i laid out a number of foundational challenges. there is a tendency to look at the pakistani problem set of the day. there is the democracy problem, the army problem, the terrorism problem. when i look at the pakistan problem set, it largely reduces to what i think is a fundamental failure of constitutionalism. fatah is a failure of constitutionalism. that was the optic i had for the chapter. the specific issue of like to focus on today is the source of terrorism. i do not want to rehash what we know. pakistan uses its nuclear umbrella with impunity such

that it can use jihad as a primary institute of coercion. many of its proxy's have turned against the state. when i look at the literature of the militant groups, and like to draw your attention to a trend that is less obvious. the sufi shrines have been under attack. this is new in the history of pakistan. we talk about violence. we're really talking about one perpetrator. that is a group of militants. they are a network of groups that overlap. it is a disturbing trend in pakistan, the ability of these groups who remain a minority in numbers to declare who is or is not mujahideen and then prosecute them with deadly violence.

this is new. it has seen the slaughtering of shia. idea that a minority has given to itself the right to say who is or is not a muslim is new. one thing that has depressed me as someone who has had a long time relationship with pakistan is that there is no ownership of the problem and how it arose. if there is no ownership, there can be no solution. i do not think there is a silent majority. for those of us who are in pakistan, people we had known for decades justified the killing of him for being a blasphemer. for those of us who have been in pakistan during times of crisis, it is shocking to find what the silent majority would say.

i went to the old city where i had been a student to talk to folks i had known for decades. in their assessment, it was the indians that did it. tearing the fabric of the state apart. the tendency is not to diagnose the problem, the reliance on militants under the expanding nuclear umbrella, but rather to externalize a problem anywhere and everywhere it can. following the recent debacle in u.s.-pakistan relations, you will find people saying what is wrong with jihad when you have imperialism? this is an issue we can debate, perhaps over a lubricating beverage.

the fact that it is not an embarrassment to say they had jihad, or rather that this is the counterpart to imperialism. he is exciting because he is enervating the pakistani politician. the way he is doing so is not because for activists to be jumping up and down with glee. he is taking pakistan into a bizarre notion. now he is excoriating the west as he embraces islam. he is doing this as a way of recuperating pakistan's sovereignty. he has the blessings of ghq. he is very soft on the pakistan

taliban. violence on the one hand, and there is merely -- really no way of getting at this, then you have to look at the debate taking place in pakistan. i think there is perhaps the best book about the lines of the state and nation. when i look at this, and what i can see, we have fundamental issues that pakistan cannot

resolve. we would have political parties that would be the mediator of resolving fundamental issues about constitutionalism, who is the state for, what is the relationship between the sensor and the provinces. -- the censor and the provinces. they do not seem to be in alignment.

where i conclude that chapter, where i concluded a piece in 2009, and that is contained. the last 10 years of trying to convince pakistan to behave differently with weapons system should disabuse us these are contained. the last several talks i have given i have put forth what i think is a model that we can debate. it is not perfect, but it is the soviet union. during the period of the soviet union, we were adversaries. we had no illusions of friendship. we wanted different things in the region. we operated against one another more than we operated with each other. right? we did not cut off relations. we did not cut off diplomatic relations. we understood the goal, the problem set. we invested in civil society, there will be people to work with. the final point -- and this is where i get my myself in trouble in talking about this --

as we learned, the soviet union could fail. the nuclear problem would be handled. the world was not going to end. going to ambassador schaffer's drive the system in a national crisis. we have a lot to learn from the cold war about how we might manage our future relations with[applause] >> thank you very much. our next guest is william milam, a senior adviser in washington, once ambassador to bangladesh, and subsequently in pakistan before any of that. we were colleagues in the

foreign service, where bill was the shining light among economic officers. i hope he will let some of that presentation this afternoon. bill? >> the light may go out halfway through this, but let's see. anyway, i plan to devote most of my remarks or at least the last part of my remarks to the economy. but because i was one who covered that in the book, in a superficial and not very helpful way, and i think maybe that does bear looking into because in all of the talk we have had, talk we had about pakistan, one rarely hears mentions of the economy. it is in shambles. that me say first that these papers were written first a the

brookings website, and then revised again about six to eight months ago for the book. they are revisions of revisions. you know something? i think it shows how fast things are moving and almost always that we want to stand up here and tell you what i would have done differently had i been writing it today. i will go very briefly through those. the first is in an early part of my chapter, i write something that i thought was quite illuminating at the time, but there was certainly going to be a political solution in afghanistan. anyone who reads that's now says, where has got in this head? the second thing says, i wrote

an article called "lost generation," i thought was not too bad, and it did catch the exclusion elements that chris talked about, but had i been writing it now, i would have translated those in to the enormous volatility and the power of public opinion in pakistan, which drives everything, including probably i am sure the latest downturn in our relationship. and i would have also written in the part on u.s.-pakistan relations that, were i writing it now, i would have played down to almost zero, if you will, the importance of our economic assistance.

it was a great idea, but i think it is not the solution and never was. we need bigger ideas, i think, or different ideas. maybe not bigger. in regard to the economy, one of the reasons one does not hear about it much these days is because for some reason, hard to know what exactly, things evidently seem pretty good in pakistan. the people are not complaining. they seem to be working hard to but in fact i think most economists who are familiar with pakistan would tell you that pakistan is driving over an economic cliff, and who knows when the edge of that cliff will be reached.

things are not likely to be able to stay as they are very much longer. they have, as you well know, because it has been old news now for several months, decided they have no more truck with the international monetary fund, which means that in fact they begin paying back the fund next month, i think, and of that great amount of what they call reserves, which comes in the foreign exchange reserves, most of it belongs to the fund, and what does not belong to the fund belongs to other lenders, such as china. there will come a time in the near future, unless things

change somehow, where they will be down to a very few months' imports, and they will begin to panic, and the exchange route will deteriorate worse than it has. in that sense, and they are heading for shortages on imports, shortages of things like energy imports, or actually pulling in their horns and going back to the imf. what would that mean? the imf would mean they would have to agree to some very, very difficult conditions, difficult economically and probably more difficult politically. much more in taxation. the tax-gdp ratio is now 8%. that makes ours look good. in fact, they have no intentions, although they claim to, to have plans to raise taxes and to raise the revenue base does not look very feasible.

given the political situation. they have also adopted a monetary policy which, in the teeth of inflation, does not make much sense at all, because they seem to be, as far as i can tell, increasing the money supply, which sooner or later you will get to some sort of spiralling inflation, driving food prices up as well as the prices of -- as well as having an effect on their foreign exchange rates. i do not think i will go into exquisite detail on this, but i think the next big crunch in pakistan, certainly coming soon -- well, i have a whole minute left. how about that?

i do not need a whole minute. the next big crunch in pakistan will be on the economy. how it comes out, i am not sanguine. unless they put their tail between their legs, their hands together, but go to the international agencies, the world bank, imf, and plead and promise, really, that they will make structural changes in [applause] >> thank you, bill. our next speaker is shuja mawaz, who was born in pakistan, and since january 2009, the first director of the south

asia center of the atlantic council. having had at a distinguished career before that with various think tanks, since at the imf, the world health organization, and various publications, and he is best known in this town for his book "crossed swords," a history of the pakistan scene, from the president to the pakistan army. shuja, the floor is yours for the next five minutes. >> thank you, i want to add my praise for -- someone i worked with when i joined the it and the council, we produced their first publication that my south asia center released in 2009.

all i can do is echo the comments that were made earlier about hillary. that is where the feedback was coming from. >> that's right. >> my chapter was called the original feature of -- was called cordially "the future of pakistan." the reason i chose the feature was that it was a bit like yogi berra comment about pakistan coming to the fork in the road and taking it. the reason for that is in pakistan there is a great tendency for politicians and leaders to say something purely there is not an appetite for strategic thinking or planning.

as a result, pakistan's economic future is a matter of great concern, and i will not go into the details that bill has just already talked about, but i want to remind people that in spite of all of this, there was a world bank study that looked at 1980 to 2007, the developing world, and the result that emerge from that was the one country that came out with the highest average -- trade over that period was china, at 9.9%. the country that came in second was surprisingly pakistan, at 5.8%. i cited this purely in support of my contention that growth and development in pakistan occurs in spite of government

and in spite of the state, which means there are sinews in the pakistani side, which, if they are allowed to operate, would be to an even keel. i was asked to focus on the demographics. last year when we discussed a book on corruption, i apologize, if i repeat some of these ideas, but with a population of about 185 million, pakistan have a median age of either 18 or 21, depending on who is counting. and so, yet something like 90 million youth that are going to be fed, employment. structure of pakistan's population is going to remain over the next 15 years. another challenge going to occur is something like 80 million youth will be added to the job stream by 2050. pakistan is no longer on the

trajectory which would allow it growth curve. the country is increasingly urbanized, meaning that what have all the characteristics of large cities, and the largethe question is, what will happen when the current census, which is already underway, is completed? if it is completed correctly and if, under its rules the country, it then changes its

political boundaries, there is likely to be a political shift in the countryside to the city, because most of the population is now gravitating to the city. now, there has been a tendency in pakistan's history for the take it away from the provinces

so that what started off as a federation recently became a centralized state, where all the power was centered, normally in the military rulers, or even in the civilian rulers when it took over between long military roles. the good news is somehow after something like 18 years of debate, there was an agreement between the center and the provinces and the national financial commission was agreed to play, under which the three ordered the sharing of revenues between the center and the provinces and try to make up for what had been shortcomings in the previous formula. this was accompanied by the 18th amendment of the constitution, and the evolution of power to the provinces. there was no planning for the implementation of that evolution. there is a squabble between the center and the provinces with the center is saying to the provinces, you handle all these sectors, and the provinces saying, we do not know how we're provide the resources to manage them. then they understood there was a model which the center had followed, which bill did, too, which was deficit financing. they saw that they had that punjab bank as an atm machine. they were not responsible for

filling it. somebody else was responsible for filling it. now i have requests from the other provinces to set up their other banks said they can incurred these deficits and turn to the center and say, please go ahead and play this bill. and just in sidelight to this shift is even in the military the population that has moved closer to the cities or is in the cities is now in being particularly in the officer class. when i was doing my analysis i did a quick and dirty analysis that showed in the decade ending 2005, more officers were recruited from karachi. so a shift in the recruitment to districts that were more in central and southern punjab, remember this is also where the

most militant groups arethat juxtaposition is likely to create a problem. within the power structure of pakistan, we noticed a shift also from what used to be a troika in the 1990's, to a balancing act, where you have an imbalance now, where you have the military, the civilian president and prime minister, you have the media representing civil society and the rise of civil society. where does the future take pakistan? a lot will depend on whether there is a debate within the country, whether that debate, which is inspired by the so- called silent majority -- that may or may not exist -- which they need to have in order to determine what kind of pakistan they want to be.

clash of the old interests, and you will simply have musical chairs from one party to the next. >> thank you very much. [applause] [unintelligible] >> the final speaker will be moeed yusuf. it is not fair for him to have such a long and distinguished list of publications at his tender age, but he does. and i would also add that he and i had the pleasure of working together on a group that went to moscow last summer to talk with pakistan and afghanistan

specialists from the russian academic establishment. moeed has made something of a name for himself, trying to look beyond the immediate future in pakistan, and that is what i am hoping he will help us this afternoon. >> thanks for inviting me and having the as a part of the project. my chapter in this book is called "youth and the future," and so some of the things i talk me and challenge me on the presumptions, essentially to see what i wanted to get away from, which is, did you see what happened last weekend? my answer is i do not care,

because if i am looking at this young generation, you have to move away from what preoccupies us. some of the figures were mentioned. why the upcoming generation is as important as it is. 67.1% of pakistan is below thein proportion, it is second only to yemen. but their, their total size is miniscule compared to pakistan. that is going to be the destiny of this country. what i did in the chapter was in essentially looked whatever whatever has been written about what the youth are seeing their country do, what they wish the are motivated in seeingcompare

that with what are likely to be realities they have to deal with. i will talk about four or five future-oriented projections. which i have in the chapter, and you'll have to go there and see how i get there. if you look at what the youth of our thinking of and what the perceptions are today, some stand out. three or four. one, it is a highly conservative generation that is coming up, not to be confused with extremism, but it is aware of its ethnicity, which may or may not be a change from the older pakistan. in terms of politics, it is increasingly frustrated and discontented with the addition, political leadership, the current government or whether who has been -- ruling them in the past. they do support democracy, but

there is no philosophical commitment to democracy. if you look at the historic trend, one could argue once that frustration level rises to a point, a backing up of the system is fair game. that seems to remain. the most interesting aspect i find over and over, even by evidence of talking to people up across pakistan, they are frustrated, willing to criticize, but none of them are willing to touch politics, because it is dirty business. the question is, you want change, you what positive change, you're not willing to change anything yourself? who doesn't? -- who does it? then you go back to the same leadership. the mindset.

this is an end result paradox for pakistan. third, with the current mindset, the mindset is anti- extremist, terrorists are not popular, butu.s. as well. these will continue to coexist as i mentioned briefly later. these three things stand out for what i want to say here. in terms of the realities they structurally set for pakistan in the next five years to seven education -- all indicators are looking up. qualitatively, not so much. in fact, the stratified system is essentially producing three societies within a society. the public education system, mainstream conservative bias, the private elite system, which is one end of the spectrum, and in the seminaries, few in number, compared to the others. if you look at the narrative in social media now, it is

polarized and divided, pointing to the other for the problems pakistan faces. the right-wing sentiment i am seeing, this is a lead to being part of the problem. western oriented, sold-out-type mentality. they are looking at the right and do not understand what needs to be done. it is inherently seeds for polarization are found in the way they are being about the economy anymore. the next five years to seven years, the projections are grim. you can add these youth and the numbers coming out in the market and not finding the requisite kind of outlets required. what that would lead you to something i call in the chapter the expectation-reality disconnect. you are throwing out people with a certain education and degrees

and essentially underemploying them and leaving some out of the force. has been made that while you are socially and economically deprived, you fall to extremists. i do not buy that. except in the case of pakistan, the problem is not the supply side. the demand for militancy has trumped the supply. the access to militancy is quite open at this point, and it depends on if that continues or not. but it is not too difficult with the type of narrative that has been thrown out in pakistan. let me throw out quickly five projections. if you will. one, there is going to be a tussle that will continue, but the traditionalists seem to have the upper hand at this point, given the way the use mindsets are set up and what the realities may be.

second, there is a likelihood of an increasingly fractured and polarized society, and the narratives are already pointing in that direction. i will go into some detail as to why make that case. -- what i make that case. -- why i do. you can be disillusioned and not do anything. in pakistan's case the extreme sectarian, ethnic, and provincial affiliations, can come together in various ways. what one can say in terms of projection is that none of them look pretty. it depends on how bad it gets 15 years ahead. politically, you can look at

about 60 years and project for, and there's not much change there. democracy is a proper option, but if the leadership continues to fail and the military has a role in continuing that failure, and if they continue to fail, i do not rule out a systemic change in terms of either going back to the military or coming up with some kind of creative model which does not reflect a democratic dispensation. the problem is that the and the structural problems are so deep that no government, any projection i do, i do not come up with any scenario wherein the governments can perform well enough for the people. expectation-reality disconnect that pushes the militancy sentiment among the youth. there is one change that is happening, and we do not know how that will play out, and that is the organization in pakistan. -- the organization -- urbanization of pakistan. the whole of the feudal belief

-- elite is shaky. whether the next generation or the urban bourgeoisie to become more prominent have a different take on politics is questionable. technically, you would argue yes, but in pakistan's case, my experience is not the landlord and feudal holdings that is a problem, it is the feudal mindset which permeates the urban elite and in some ways the urban elite surpasses the earlier ones. whether that will bring positive change or not we will have to wait and see. finally, i think pakistan, given pakistan's internal divisions allow a consensus to be forged on any platform in terms of politics, either a pro- taliban platform or an anti-

taliban platform. i really do not see that as the real danger. what will happen is that the narrative of the street right will continue getting conflicted with anti-americanism and imperialism that is being imposed upon the region. that trajectory is anti- extremist, anti-u.s. at the same time, and you go to crisis to crisis. you are terrible spouses who do not want to get divorced. you go from a fight to the next thank you. [applause]

>> that you very much, moeed. still have a little bit of time for questions. let me urge those who wish to ask questions put up your hand. i will try to recognize people as i see them. identify yourself and your affiliation, and above all, i hesitate to say this, try to be brief so your friends and the yes. >> the substitution of the state as the state starts failing. look at urbanization, and

education, security. in all these areas, the state is failing, but you are surprised by the private effort across all pakistan in each of these areas. education is diverse. it is making a substantial substitution for the state. [unintelligible] water supply. the water supply is given by contractors to provide supplies.

finally, security. most of them in the cities, forces. the question that i am asking is, as the state fail, these substitutions are veryprobably should pay some attention to that. >> important observation about the apparent substitution of private state efforts. behind him. >> hi. my name is tony, and i had the opportunity to be with ambassador hillary in baghdad several years ago.

he referred to me as cousin, although i do not know that there was a direct lineage. i wanted to ask you two questions. easy ones. with regard to recruiting in the army, and we knew of the army as strong influence, i am not sure outstretched those of other areas. i would like to know what the facts might be from that institutionally, and then especially as it relates to little bit more about the level and character of education of the upcoming generation, and particularly, what is the philosophy that is prevailing there -- secularism, tolerance, intolerance? i have heard conservatism. could you expand on that as it relates to the education to the education of the youth. >> the fact that there is more

recruitment from karachi than from the other districts, which are areas of main recruitments of soldiers, was surprising. there has been a tremendous internal migration within the country. no way of pinning down the nature of what has occurred. the fact that people are living in cities, they are acquiring all the traits of urbanization, and the points of view that in the cities as opposed to those who live in the countryside and grow up in the countryside. that will have an effect in time. in terms of the effect on the military's politics are increasingly conservative as the

rest of the country now. a lot of the traditional recruits are not going into the military, so we will have to wait to see where the urban petit bourgeoisie will head. i will leave it to chris to shed a little bit more light on this. >> i had the privilege of working with shuja, and i had of a team of economists, that allowed us to look at those district producing officers. -- the district's producing officers. a couple of things. i have a paper coming out. the first is that increasing the pakistani army is recruiting from the less educated. let all armies, they weed out some. there is going to be this minimum threshold. the areas producing these

officers, that is because even at higher levels of the era of the officer corps, and the perquisites are appealing, but for junior officers it is not that great. thinking of a family making an investment in education allocation, it makes sense to go to the private sector.

the areas producing these officers, that is because even at higher levels of the era of the officer corps, and the perquisites are appealing, but for junior officers it is not that great. thinking of a family making an investment in education allocation, it makes sense to go to the private sector. we see a sweet spot in terms of education for the military, even though they are coming from districts that are less well educated. they're coming from areas that are more socially liberal, and you can quibble with how we define that, but we define socially liberal as those districts where the gap between male and female education

narrowed. you had a generally liberal district, you have women who are more educated than men. the other thing we used to look at this was the age of first marriage. when we look at those metrics, and you can dispute whether they are -- those are interesting. the interesting thing about that finding, you can find steady from last year, the urbanization and the socially liberal populations were interesting. for those of you who know pakistan, it is in the urban areas where political islam thrives. it is not the purview of the villages, as a lot of people here are under the belief. that is it for my comments. >> it briefly -- i see the pakistan education system as comparable to other areas of south asia, which is to say it is terrible. there is a conservative bias that that is what you would see across the region for the most part. where i think we miss the point is talking about education in isolation. the context is more important. the context, the young pakistani generation now coming up is not conducive to tolerance. it is becoming more and more intolerant. it is becoming much more intolerant and polarized. >> i am the former director of operations at the world bank, and i would like to direct a comment to shuja. you touched upon the evolution, and the government has doubted this particular thing as a great success. my contention is that it is mired down in capacity shortage, both at the individual level, not so much individual, but certainly at the institution and mostly at the policy level.

if this institutional capacity and other forms of capacity are lacking at the center, what chance is there for it to evolve that this would be successful at all? do you agree with my contention, and, number two, what can be done about it? >> i think i did mention that the idea was a good one, but there was no planning for the implementation. in my brief comments, i did not go into details of that, but this is exactly it, the capacity was not there at the center, and it is not there in the provinces. what you have done basically is moved a whole sense of responsibilities to the provinces, including a whole chunk of -- that you physically shifted to the provinces without a means of being able to put them to produce.

this will be a difficult transition for the provinces, but still, the very idea that pakistan is not reverting back to its idea of a federation rather than a centralized government, which would be a success of dictatorships, military and civilian both, could take advantage of is a good thing. maybe there is some hope to go back to the comments were the class is too big and the question is how do we fill it. >> hi, i am a visiting journalist from pakistan. i want to make a comment to what was said. blasphemy is not their issue. that is why the guy who killed

-- [unintelligible] in pakistan, we have two types of military organizations. [unintelligible] toward the west of the indus. they followed that sector. that was my point. blasphemy is the issue of the -- it is not the issue of the -- thanks. >> briefly, you are absolutely wrong on every single point you made. i do not need to say anything

else. what people were shocked at one -- came out in support of -- that was their problem for failing to understand who they were. they're not the only issue. they are not the ones supporting these militant groups. false. >> we have time for one more question. >> hi. isn't it a question that the pakistan narrative has failed from the beginning? pakistan was created in the name of islam, was really supposed to be based by the founder of pakistan to be a country for everybody. since that narrative has consistently failed and the

establishment of the people who feel threatened that pakistan is threatened, they are trying to find a new ideology, and that will keep pakistan together. i want your comment whether the spread of fundamentalism and extremism is fanned by the fear that without islamic cement pakistan is going to disintegrate. thank you. >> i will exercise the privilege to respond to that. pakistan was founded as a homeland for the muslims of the subcontinent, and the founder spoke eloquently on what he believed that this meant, and i am sure you are familiar with the quotation from his speech before pakistan's independence. i think it is fair to say no issue has been so hotly or consistently contested in

pakistan, as the issue of what that means, what it means to be the homeland for muslims, what it means to be a muslim country, and so on, and it would take far longer than we have available this afternoon for me to introduce the two different sides to this. what did this all mean for pakistan's future? what you are seeing this playing out on a backdrop that is not just religious, it is social, it reflects the elements happening around the world between muslims and non-muslims and within the muslim world, and all these things are coming together in a rather dangerous brew that the people of pakistan have to sort out, and those who wish i said well from other countries are going to have difficulty dealing with.

with that, let me thank my panelists and steve. the decision has been made that we're not going to have a break. we're simply going to shift panels. this panel will do its best to get out of a way as quickly as possible, and to let the next distinguished group take our places. [applause] >> welcome.

immediately to my left is pamela constable, a staff writer for "the washington post." she has extensive experience in covering pakistani affairs, having served as the south asia bureau chief. she was also bureau chief in kabul from 2002 until 2004. she has continued to follow events in the region closely, as reflected in her new book, "playing with fire," in which she paints a vivid portrait of the country and heard many problems.

bruce on my far right is a senior fellow here at brookings and a leading authority on south asian affairs. he has served in many senior positions in the u.s. government, including senior director of south asia affairs during the clinton administration. he was an advisor to the obama presidential campaign on south asia and shared a review of u.s. policy toward afghanistan and pakistan during the early months of the obama administration. he is the author of his own recent book on pakistan entitled "deadly embrace." on my far left is joshua white, the youngster of our panel. he is a ph.d. candidate at the johns hopkins school of advanced international studies and the jennings randolph peace

scholar. he spent time in pakistan doing research and has presented his findings in numerous forums and gave testimony before the congress. he has been an active participant in several high- level u.s.-pakistani dialogues, and his current doctoral work focuses on decision-making in the islamic parties in pakistan. last but certainly not least, to my right, is marvin weinbaum, a scholar in residence at the middle east institute, and a professor at the diversity of illinois, where he was director at the program in south asian and middle eastern studies. he has also served as analyst for pakistan and afghanistan in the bureau of intelligence at

the state department, where i first got to know him. he has written extensively on pakistani topics for a wide variety of journals and books anthologies. he has long been one of this country's leading authorities on pakistan. as with the previous group, i would like to invite our panelists to gaze out at the next five to seven years of the future of pakistan, predict where it is headed. it has now been a year and a half since the bellagio conference was held, and the biggest change that has happened in the region during that period has been the dramatic downturn in u.s.- pakistani relations, and i would ask the panel to funnel that phenomenon into their five- minute remarks and discuss where things may be headed in

that relationship, which suddenly seems to have an enormous impact over pakistan over the short to medium term. pamela. >> can you all hear me? is this on? we are both at an advantage and a disadvantage in the second panel. a great deal has already been said over the last hour and a half, and i do not want to repeat the points that were being made before. we do not have that much time, if we're on our schedule, less than 45 minutes. i'm going to be very dramatic here, just making bullet points. the previous speaker talked about the solidity of events of which i am certainly a minor

victim. i had to revise my recent book something like six times after it was finished and at the publisher to accommodate such things as floods, covering the country of pakistan, the extension of general -- the killing of -- and then, worst of all, for many reasons, the capture and killing of osama bin laden, of which we were only be able to get something like one sentence into the final, final, final version of the books. the second part i want to make is in reading through these chapters and listening to all these comments, i am struck by the extraordinary commonality of the diagnosis. speaker after speaker, chapter after chapter, everybody seems to generally agree on a set list of problems that pakistan has face for a very long time and it continues to face.

it is also striking how our pretty bleak prognosis seems to be. i have not heard much in the way up optimistic forward- looking places for hope. if you look at the places where people would like to look hopeful, there's always in the downside, media. media has an enormous potential for positive change, but also has a downside. it is pandering to the lowest common denominator in many cases, which is extreme emotionalism, anti-foreigner, anti-americanism, a lot of bad things happening with this great new medium, to the judiciary and, there been enormous changes -- that has had its disappointing side. not that much has changed as a

result of the restoration of -- it has been quite a disappointment, the nadir which was the positive -- yes, there are some positive points, but things are not going very well. i want to talk about a couple of things where i think there are some opportunities possibly for help, for ways that things could be improved. i want to talk about, since we're being asked to, the u.s.- pakistan relationship. we all know it is getting worse. i want to focus particularly on this issue, because i worked a lot about on that on the two years i spent researching might

recent book. that is public opinion. it is very true that, yes, most pakistanis do not support terrorism, the taliban, or cutting off people's hands. at the same time, the body of evidence shows that anti- westernism has never been higher in pakistan than it is now. it is across the board, and we're not talking as other students have said about alienating people. we're talking about all kinds of people. we're talking about broad public sentiment. i would posit there are two reasons this is happening. three, i guess. one is, and i said this in recent talks, what i see happening is this growing confluence of not what i call the al qaeda school of thought,

but two other phenomenon, one of which is the growing emotional and very emotionalistic sensibleness about islam. many people feel this to be the case. there needs to be a much better narrative. that needs to be countered. pakistanis feel frustration. people feel alienated from the state. people feel they have nowhere to turn. they're getting very mixed messages from their leaders, from television, politicians, religious leaders. they do not really have anything to grab on to except

their religion. there are many ways they can go. if you look at what is happening on the campus of punjab university and the appeasement going on, it is very alarming. we do not have enough time here to talk about solutions, but i think there are many areas where it if you want to put it simply, shoring up moderation, trying to isolate the extremists fringes. it is the only thing that is going to make a big difference in the long run. we have to win them over. we cannot destroy them with drones. thanks. [applause]

>> i would like to return to bruce, one of the architects of the obama administration policy toward the region. >> thank you very much. it is a pleasure to be with such a distinguished group. i want to underscore the importance of this project i have been benefiting from it from conception, being able to read the drafts and i can say that "deadly embrace" would not be the book that it is without having benefited from all the drafts. we are, once again, in a debt to his leadership. because of the time and because of a very sore throats, i will try to make two points very

briefly regarding pakistan's immediate future. i fear that we are seeing the creeping establishment of pakistan's fifth military dictatorship under way right now. what do i mean by that? it is not going to be a repeat of the era, it is going to be something more subtle. in many ways, it is another military dictatorship. there is a group in power that makes decisions irrelevant to what the popular vote, what the popular majority is and what the elected government is. that is a phenomenon we are increasingly seeing in today's pakistan. it has been in essence for the

last three years. we are seeing a qualitative change in the power of those four legs. some will say that this was always inevitable. because of the nature of the president was, the nature of how it came to power, was doomed to fail. that is clearer in retrospect than it was in 2008 and 2009. the witnesses are profound and they go to the very core of the politician that he is. it is the benefit of 20/20 hindsight. the facades of civilian government is likely to go on. there will still be president and prime minister. behind that, they will have very little of the real power.

the media will continue to be very active and alive, except when it criticizes the army to seriously. the judiciary will be able to do what it wants to do as long as it does not challenge the military. behind the scenes, the army will decide the key issues of national security and allocation of resources. one can say, this is not new in pakistan. that was in some dispute over the last three years. there was an attempt by civilians to change that. the civilian government itself and many of its leaders, this includes the president, are increasingly intimidated. and scared to death, frankly, of what the military can do. memo-gate is the ultimate illustration of all of this.

it is ironic, since the whole purpose of the memo, was to prevent a military dictatorship, it is facilitating the development of a military dictatorship. i hope that to ever wrote the memo, and to ever wrote about the memo, can live with their conscience about what they have done in the interest of self- promotion. the model that pakistan is becoming, unfortunately, is the south asian version of algeria. a country where the military roles behind the scenes. it is very hard to know who in the military is rolling behind the scenes. an assembly of generals who make decisions behind curtains, behind a false fronts all the time, not a single powerful person, but a collection of

them. in the case of pakistan, it is the corps commanders. the good news is, i do not think the process is a revocable yet. i think it can still be turned around. i think pakistanis can prevent this from happening. new elections to produce strong mandates for a new government could turn this around. it is no guarantee by any means, but it is a possibility. left on the steady drip that it is, i see pakistan going into its fifth military dictatorship. the second point i would beg is also one that is relatively simple. the united states and nato today are fighting a proxy war in afghanistan. this has been true since 2005 as well. many of the veils behind this proxy war are falling apart.

the entire world, the united nations, nato, the international community, is backing the karzei government. the pakistan government is not there. it has been backing the taliban fort some time. the assassination of the president on september 20 it was a defining milestone in the process. it's clearly put pakistan on the side of the force that does not want to negotiate, not interested in a political process. up until september 20, we could hope there would be a political process in afghanistan. when that bomb went off, that hope came to an end. they find themselves on an increasingly dangerous and as lead toward collision course in afghanistan. there are some breaks built into the system. whether they will prove to be strong enough to prevent disaster from happening, i think it is becoming in

question. [applause] >> thank you, bruce. >> thank you, it is great to be back at brookings institute. i see so many familiar faces in the audience. i want to make one point about the u.s.-pakistan relationship. the first, u.s.-pakistan relationship, bruce has written a lot about containment towards pakistan. i think there is a lot to commend that line of reasoning. it is not the most helpful contract. i want to explain why i think that is the case. a lot of people use containment

as a shorthand for limited cooperation on matters of mutual interest in the environment of some discord. i think that can be an element of policy contained. you can also call that in the number of other things. you can call that a modest transactional relationship. you can be realistic about the areas in which we disagree. another characteristic of containment is that containment means planning for the worst case. on this point, i would contend that we already do that. we do a lot of planning for the worst case. we planned for realistic worst- case scenarios, non- proliferation scenarios. we spend a lot of time planning for, what happens if there is another mumbai attack? what is the fallout of that?

we also spent a lot of time planning for highly unrealistic worst case scenarios. what if the taliban will into islamabad and decide to do something there? i think we already occupy ourselves with this kind of planning. again, we do not need to call that containment. the third, one of the senator characteristics of containment is putting pressure on proxy. we saw this during the cold war. the metaphor does not entirely fits because our primary area of peripheral engagement with pakistan is in afghanistan. it is the proxy engagement that is currently carried on in afghanistan. that is likely to decrease over time. the one area where we're likely to continue to engage pakistan

is in relation to those groups that come from pakistan to engage in transnational activity. there is something changing in the u.s.-pakistan relationship. the scope is narrowing. there is more suspicion. we can call that something other than containment. in my chapter, i touched on a number of different things. i speculated about looking ahead in pakistan. i want to touch briefly on three of them. the first is what is going to happen with islam in afghanistan. i would like to highlight what chris mentioned. one of the disturbing, surprising things has been the

vitriol and the violence directed against what has traditionally been seen as a more moderate expression, a more moderate branch of islam in pakistan. we have seen bombings against shrines. we've also seen elements of those supposedly moderate groups that have become violent as well. this was mentioned by the questionnaire. the attack was brought to the surface, a whole stream of radicalism that many people had not seen before. it is not that everybody is crazy in pakistan. we have to see the dividing line, not so much as between the liberals and the extremists. what is the balance today between the liberals and the extremist? but to look inside of all these

groups and to ask some more focused questions, like what did they believe about who can enforce the sharia? a lot of these questions will come down to who can take sharia into their own hands? who can take force into their own hands? as we look to the future, the dividing lines between those groups ever going to be more stabilizing will fall along questions like this. i mentioned in the chapter, i speculated about the prospect of a civil -- a center-right government and marching in pakistan. we could have a very interesting discussion on what that might look like and how it

would impact u.s.-pakistan relations. it would not do anything dramatic to the relationship. it would allow some of the military centers of power and others to deflect even more of their problems with the united states on to the parliament, rendering them moot. i have been studying islamist politics, i've spoken to the party is about to they would like to align with in the next election. i would expect that some of the parties would like to be part of a center-right government. there is now a whole host of opportunities at the provincial level for policy-making that did not used to exist. there are a host of opportunities for islamist parties and coalitions to play around with education policy, and with health policy, and

other things. one final point, i know this has been a discouraging afternoon, the one area where i take issue with is when i looked at the nationalist problems of pakistan, of ethnic fragmentation, these terrible visions of what the state will become. i am more sanguine on this point. the most troubling kind of question is one in which the taliban get really smart and decide to appropriated for their own purposes. today, they have not done that. we've seen the government to a lot of positive the things. the 18th amendment involves a number of powers. there have been little

outbursts of demands for provinces. all of these are possible over time as part of a grand political bargain. the state has been quite adept at dealing with this. at a meeting some demand in a minimal sense in order to preclude a broader tendencies in society. i would not to be borrowed a lesson from what india did in the 1950's and 1960's with the state reorganization, but there are parallels in how they have quieted these tendencies. the state is more coherent than what people give it credit for. thank you. [applause]

>> thank you, joshua. >> i guess you'll come away from this session thinking pakistan is in crisis. i can understand why. the trouble is, this is hardly a new observation. in fact, the immediate crisis is lost. certainly, what we recognize our many of the ingredients that we would have thought would be a game changer is along the way never came to fruition. whether it was because of the vehicles for change were not there, whatever it was, we tended to focus of the deal on a certain resiliency in spite

of everything. maybe an inertia. in any case, the spark was not there. it is not surprising that when i wrote my chapter, and i laid out six possible scenarios, which include all of what we have heard this afternoon, i assigned probability to them. i give the greatest probability to muddling through. i do not entirely back away from that. it just seems given what we know about the country, what we know about the propensity for change when all the same players seem to be on the scene perpetually, and everything changes, but nothing really changes. even with this continuities scenario, there will be changed.

we also have word that if it is ok, there is a silent majority. we have heard that before. somehow they stand apart. if only they had an opportunity to express themselves. it is a state which is taking it away from them and they are more reasonable, more likely to be tolerant and so on. if you do not like the silent majority, civil society is there. if you give it time, it will be able to step up and put one of my best scenarios afford. that is where i was when i wrote the chapter. i am not backing away, but i must say, with the events of

this year, it has led me to question whether it is going to be business as usual. we are seeing a series of developments. for example, which we once thought of as the jihad, some of the conspiracy theories, you cannot leave pakistan or the media and not say, these have become a consensus. we come back to a word that was used earlier. are we seeing something qualitatively different emerge? i leave open that possibility.

is the army simply manipulating things? it seems as though the politically aware public has gone beyond even were the military wants to be. what we have seen is the ability of the policy elites to act with a certain amount of independence of the public, which they have done right along. one story for the public, there are degrees -- their degrees of freedom have shrunk. then i see something like what happened with the media and the cable owners apparently matched a day or two ago and they came out in favor of suppressing stories written abroad that the

critical of pakistan. these are the champions of expression. the cable media has opened up all kinds of opportunities. what i am really concerned about, and i think others have reflected on in one way or another, there is a strong element of continuity, but is it being torn by the kind of rhetoric that we are hearing consistently? the narrative has not just anti-americanism, but islam is a challenge. they do not have to win elections. if they have won the soul of the country.

that is the insidious development here. as we try to dialogue with pakistan, we like to think that we can work within the rational boundaries. it leads us to wonder whether -- we recognize we have to. pakistan is there, we need one another. we have to find at least those common denominators on which we can find agreement. it is in both of our interest. my concern is obviously how much more difficult that has

become. no one has suggested the way out of this. thank you. [applause] >> thank you, marvin. i would like to add my own cautionary note. things are bad now, a very bad. basically because our goals in afghanistan are incompatible. the pakistanis want a friendly state and they do not think the karzei government is back. if we pushed too hard, the danger is, things could get a whole lot worse. if we were to come to blows with the pakistan army, the only force in society strong enough to prevent a jihadist

takeover of the state. i believe you with a paraphrase of colin powell. break it, and you own it. >> thank you. you talk of a fifth coup. is this going to be a function of the structural changes and the makeup of the pakistan army? the fact that they are not going to be interlinked with the

last, in the view of what has happened in the 20 years? to what extent will this be due to the personality of the army chief? they tend to have different personalities and tend to play different roles. >> i very carefully avoided using the phrase "coup." the process is much more slow- moving than that. much more insidious. it is a process of power all moving into the hands of the army leadership. if you look back to 2008, it was not in that case. are changes in the officer corps leading it?

they may affect the tone of what the new dictatorship looks like, and it will be more anti- american than ever before. the intensity of anti- americanism amid young officers is astounding. the personalities is less important than it was in previous dictatorships. i can envision a situation in which an army officer leaves after a historic, but the leadership continues. the collective leadership, which is making the decisions now. in that sense, it is a transformational figure. he does not seek all power in his hands. -- and his hands. >> i would like to add two quick points.

it is important to remember that most important thing for the army leadership is public opinion. they do not want to be out in front of public opinion. that is why they waited so long to move against the taliban. public opinion is getting more conservative and more emotionally islamic. that is very important to remember. the same people are very, you know, civilian and military. it is the same society. if you looked at what happened after the assassination of osama bin laden, they were completely caught off guard, they were completely upset by this at the top. thank you. >> i would also add there is

really not that much of the change. the army is basically -- has always basically called the shots on national-security issues. they have been inclined to let the civilians run domestic affairs and economic affairs. i do not think there is anything at all unusual about what is going on. it is more of a reaction to this current dramatic downturn in u.s.-pakistani relations. >> i have listened to all of the panelists in both discussions. steve writes beautifully. every time, he says, this is my

last book. i think i tend to disagree with her. but the reason they are picking up support is every political party in pakistan is in power or some shape of the other. people are frustrated with every party. they do not see anybody else. my question is to bruce.

after making their recommendations, how do you think the political establishment with democracy is working in pakistan? do you see a silver lining on the war on terrorism? the extremist islamic militancy is marginalized, and how can we make this relationship between the u.s. and pakistan more sustainable, which is critical for most countries, for the region, and for the global peace? thank you. >> silver linings are hard to find here today. you asked me how i think the

support for civilian government has turned out over the last three years, and i made it clear, it is not doing well. that is not the fault of the american effort to back it up, but we made mistakes. it has more to do with dynamics of internal pakistani politics. in 2009 president obama embarked on a policy toward pakistan which i called engagement with drones. that strategy made sense at the time, but i think in light of these developments i laid out, the growing weakness of civilian government and the growing intense evocation of the proxy wars, it is time to shift to a policy of engagement and containment. that is to say to continue to engage pakistan to support the development of civilian government, help the economy,

help pakistanis, but help contain the worst excesses of the pakistani army. we are not doing enough on the containment part, slipping and sliding on it, but without a framework. i would like to underscore that drones is not a sufficient policy. the tendency in this administration is to use drones as a solution. drones are an effective tactical instrument, but not a strategic policy, and we need to reset our policy toward one of engagement. >> we have time for one more question.

>> you mentioned a possible game changer in new elections, and then you mentioned disaster, if the u.s. and pakistan continue on a collision course. i want to say as a pakistani i believe new elections will not be the game changer we hoped they might be because the verdict of the people will be more divided. i think it will be more easy for those who have to carry on manipulating the policy. my question is, given the probability that we will continue on this course, what do you think disaster will be? could you please spell out what you mean by "disaster"?

>> there are any number of disasters out there. another mumbai attack, a mass terrorist casualty incident in the united states that is postmarked "pakistan." becoming a hot war. it could be limited hot war. i would say before ending on the disasters that are coming, because i know it is easy to fall into the trap of extreme pessimism about pakistan. you are almost always right when you go down that road. i prefer to go down the road of optimism. i remain an optimist about pakistan because of the pakistani people, and what i had seen written in the pakistan media. the media is still made up of

scary stories, but is also filled with a lot of thoughtful pieces by people who recognize what is going on in their country. that is a source of optimism. i do not rule out we might have a silver lining some day for the people of pakistan. >> my fear is the united states does not have the ability to make things better, but has the ability to make things worse, and i hope they act responsibly with our dealings with pakistan in the future. >> that may think this panel and the first panel, which are a brilliant series of

discussions on pakistan. when i wrote my book on the idea of to pakistan, i said this could be a major foreign policy problem by the end of the decade, and unfortunately i think i am right. i worked for george shultz once, and he said hope is not a policy. somewhere between hope and despair, and my chapter, which had the benefit of leading these other chapters, i looked at the question of whether it pakistan is irretrievable. one more point. my first book of pakistan was banned and pakistan. given what martin said, i hope this program is not banned in pakistan. [applause] [captions copyright national cable satellite corp. 2011] [captioning performed by national captioning institute]

[indistinct chatter] >> in a few moments, newt gingrich posed a news conference. in about 15 minutes, a look at the federal employee health benefit program. the news coverage of monday's meeting. on "washington journal" we will talk about the date doc the debate over extending the payroll tax cut. -- the debate over extending the payroll tax cut. then we will discuss the postal service's decision to reduce service to that cost with bernie becker. live on c-span every day at 7:00 a.m. eastern.

>> pay you a dollar an hour for your labor. it is the most expensive an element. have no environment controls, no police controls, the retirement -- no retirement, you do not care about anything but money. >> ross perot's book about trade issues. the businessman made two attempts for the presidency. the first time, getting over 90 million votes. -- 19 million votes. he has had a lasting influence on politics. he is our final candidates in " the contenders." to preview of the video on ross perot and to see all the programs from our series, but disease and a gorge -- go to cspan.org/thecontenders. >> a couple of live events on c-

span 3. at 10:00 a.m. eastern, the senate judiciary subcommittee will look at allowing television cameras and the supreme court. witnesses will include arlen specter. at 2:30 p.m. eastern, the proposed merger between a pharmacy benefit managers, express groups, and medco. the ceos of both companies testified before the senate judiciary subcommittee. republican presidential candidates newt gingrich spoke with reporters for a few minutes in new york city yesterday calling a meeting with donald trump. this is about 50 minutes. -- 15 minutes.

>> what is say, -- let me say, some of you look familiar and some of you look different. as i said earlier, we were coming to new york to make the case that if i do become the nominee we would run a 50 states strategy. i believe the choice will be so wide.

ght at 8:00 p.m. eastern on c-span2. >> "washington journal" continues. host: every monday at 9:15 is our special feature, your money. we look at the cost of operating the health care program for those who work for the federal government. our guest is walton francis, author of the "checkbook guide

to health plans for federal employees." cross is for being here -- i think you for being here -- thank you for being here. guest: thank you. we're talking about a total of 8 million people, the largest employer health insurance program in america. host: how does that compare to what we think of as typical private plans? guest: it is quite similar in one respect and quite different in another. the plans to get -- you get are the same as if he worked at ibm, gener l the difference is that federal employees have, issued -- in most cities, 24 to 25 plants to

choose from. other employers offer just one p.o. or hmo -- ptl or hmo -- ppo or hmo. host: you can call 202-628-0184 for federal employees. 737-0002an- 202- you mentioned a lot of tauruses and selection. how is that federal employee choosing which planned ban -- which planorks for them? guest: i help them choose wh the "checkbook guide." people choose different ways.

some people like the managed care, the protection, the arranging of coordinated care. other people cannot stand that. it is driven by what people's preferences are. the main thing is money. plans differ in how well the cover you and in premiums -- they cover you and in premiums. the end ofwe're near the federal open season. it is a one-month period where you pick a plan for next year. a lot of tourists, a lot of options, a lot of flexibility -- a lot of choices, a lot of options, a lot of flexibility.

host: walton francis, author of "checkbook guide to health plans for federal employees." the fehbp was designed as a multi plant competitive system through political accident are resulting from pressures -- wa designed as a multiplan competitive system through political accident, resulting from pressures -- guest: 1 with a good improved benefits -- one way to improve benefits was through the health plan. in the 50's the had to go through private plans. some hmos were created for federal employees. there were a lot of union plans. in 1959, they realized they

should provide benefits of the way that large companies do. the politics of the moment were such that there was a grandfather rule. all the existing plans wanted to stay in the program. by accident of how this develops, they did not set up one single plan. that is how it happened. host: let's hear from mary, calling from alexandria, va., a federal employee. caller: i have a question in reference to what goes into capping the actual allegations that federal employees have to pay. -- i locations that federal employees have to pay -- obligations -- allocations that

federal employees have to pay. those in the washington, d.c. area pay more than other federal employees -- washington, d.c., area pay more than other fedal employees. who determines how much the federal employee has to pay? before i entered the federal government, i worked in the private sector. it seemed as if i paid far less to receive the same benefits. est: the answer is on no one decides, except the employees themselves. the federal contribution is based on the average of plans. there is a complicated formula. on average, it is about 73% of the premium cost, the same percentage as the average for the private sector as a whole.

the neat thing is that while the paroled -- federal pay increase is -- there is a federal pay freeze, there is moneyline on the table. people can switch from the plan they are in to save money. that gives you a p increase if you are interested in changing plans. there are lots of bargains. host: would that mean a decrease in services? guest: not necessarily. eat plan passed a bill the costs of the people who enroll in yet. -- it. hmos are little better at controlling costs. their premiums tend to be about the sa. their benefits are more generous. high deductible plans are now featured in the federal employee program. they have been around for five or six years.

there are very good benefits. host:, let's go to george -- rose in georgia -- host: let's go to rose in georgia. caller: we were given two joyce's. -- traces -- traces -- choices. it does not include deductibles in the $700 payment per month. host: are you a federal employee? caller: retired. my pension is only $900 per month. i am paying $700 for a monthly premium cost that does not begin to cover things. guest: she is not in the rhetoric regular retire me -- she is not in the regular

federal retiree plan. she did not say if she was of a family, but even for family coverage, it is not $700 per moh for blue cross. it does cover medicine. you need to go check with management and talk about your situation. maybe something has been fouled up somehow. that i not a typical experience, or what is legally available. host: we are talking to walton francis, author of "checkbook guide to health plans for federal employees." let's look at you of the numbers. -- let's look at a few of the numbers. guest: over 200 plans all over

the country. most are local hmo's. any one federal employee typically has two dozen choices. they include hmo's, high- deductible, consumer-driven, and fee-for-service/ppo plans. most of those give you the preferred provider benefits. host: is it more expensive to the taxpayer to have so many options? does it matter at the end of the day to the bottom line? guest: it is actually cheaper. the beauty of the program, because it is not one fit -- it

may lower costs and offer better service to increase enrollment. one of the methodist to compete is to keep costs down -- home of the methods to compete -- of one of the methods to compete is to keep costs down. there is a sharp contrast. medicare, government-controlled, government run health plan -- it used to be that everyone had to be in the one plan. medicare advantage. host: susan is a federal employee here in washington, d.c. welcome. caller: i want to ask for advice on an issue i keep trying sort out. it looks like blue cross blue shield is changing its

prescription policy. i have bn losing their preferred -- using their preferred-provider system. i have been getting mailings that they have chosen at cbs care markets -- cvs caremark as their preferred provider. can you help me sort this out? guest: what they have done is gotten bids on pharmacy management companies to tried to get a better deal for the enrollees. that is the way the system works. typically, plans will cover lots of local pharmacies, most chains. walmart, cvs, so on. it might be a reason for you to ange. they are maintaining the same prescription drubenefits. that is quite gerous, particularly for generics. you pay almost nothing. host: if you're federal

employee, the number is 202-628- 0104. let's go to a republican caller in florida. caller: good morning. i do not want to talk about health care. host: what do you want to talk about? caller: i want to talk about congress, who are supseto take care of the law-abiding citizens in the country. give us a question for our guest, relating to his subject matter. caller: if you would listen -- i want every federal employee to do what they have asked everybody else to do, take a 10% cut for the next o years. you take a big dent out of the federal budget. host: a sense we're talking about health care and health benefits program -- since we are talking about health care and

the health benefits program, could there be real cuts in the benefits they get as a way of saving money? guest: there is a cut. there is a freeze for federal employees. cost of living up is going up. there is like a 3% salary cut that will happen automatically next year. it would not surprise me if it does not happen another year or two in a row. host: there are ways the government could tighten or restrict the plan to save money. guest: they use to pay 60% of the average premium, doing some kind of complicated populations -- calculations. it ended up being closer to 70%. it was lowered. that was a trade-off between cutting health benefits or salary. there have been proposals to

cut federal employee health benefits. the simpson-polls commissioned argued for that -- simpson- bowles commission argued for that. , >> i think we would not natape everything -- caller: everything was working before the private-sector unemployment when so bad. now that revenue is gone. -- went so bad. now that revenue is gone. we have to pay into our own benefits, which we never hado do. i think it is 7000 regulations got erased that the administration put in. the private workers would go back to work. the revenue would be there. we woudln't -- wouldn't have

this problem at all. guest: i don't think there aren't a lot of opeople -- people who disagree. in fairness, the administration has proposed reforms to save money, but it will play out as the congress, president, and voters all struggle with choices. host: kin, you are on with walton francis. caller: i am a retired federal employee with an hmo. the monthly premium jumps in 2012. without doctor copays, drug

copays, this premium accounts my gross income. toouldn't there be a limit prevent people from exorbitant costs -- to protect people from exorbitant cost? guest: the eight to well into a hard time -- the hmo is in a hard time and has to increase cost. find a lower-cost plan. there are plenty of choices. you've got less than two weeks period.federal open

you could get a decrease. host: let's look at the nu mbers. guest: good numbers. host: how so -- how so? guest: they are correct. yeara $50 billion per progm. huge. opm does a great job in day-to- day and year-to-year management. the medicare plan -- drugs take

a higher prescription. this program controls drug costs, too. caller: i am a postal retiree on assistance. my premiums have jumped. i am with aetna. $580 to moring from e than $800. the plans in my area -- we have, like, four hmo's. way out of reach. i look at the ppo's.

when you go to pay for certain items, like having a test done, they take a big chunk. 10% of the total cost, which could be thousands. anything to offset. i have to find another plan. i have not been able to find anything. they do not give the postal retirees a good choice. guest: she has the same dresses. she has read the two dozen plans to choose from -- she has the

same choices. she has two dozen plans to choose from. in her case, look at blue cross basic. is this -- it is a ppo plan that keeps you in the network. has the copayment the structure the most hmo's have. whatevery 10 bucks or for prescription drugs, $30 for the doctor. it has very good -- host: why does usps want to pull out of the program? guest: it was set up to run on a

business pasis. congress cannot close a rural without an act of congress. they are suffering badly in the economic climate. they have an aging work force. they have their eye on $30 billion that they would have to pay in under current law to cover the cost of their future retirees, $40 billion that has already paid in for their current retirees. the only way they could pick up to get the really big taxpayer subsidy they are looking for was to pull out of the -- they claim that it can run the program more effectively than the personnel. that is simply not true. they're more expensive.

they are benefiting from being in the same pool as other federal workers. host: if the u.s. b.s. pulls out of the -- usps pulls out of the fehbp, what are the implications for others? guest: if you are an hmo in some small town or small city, the postal workers are probably a big fraction of the work force. you will think twice of -- out staying in the program. it could be hugely disruptive. a lot of plans in this program are postal worker union plans, but anybody can join them. the irony is postal worker priums to maintain current benefits will have to go up at least 10% because of the more

expensive structure of the workforce. host: james is running is from illinois. caller: thiss a simple question. i have been disabled and on a pension for about 12 years now from the postal service. i have blucross blue shield. question is, why did they offer only two plans? my wife and i do not have any children anymore. why did not offer a couples-only plan -- why do they not offer a couples-only plan? guest: the law does not allow for the option. it is common in the private sector. this law says there are only self-only or family-only. because you are older, you are more expensive. people in their 50's typically cost twice as much on average as

adults in their 20's. kids are che to cover. there was a couple premium just for people who had no kids. you're lucky you don't have it. host: walton francis, author of "checkbook guide to health plans for federal employees." linda from cromwell, connecticut. caller: i am a single, retired teacher, geing my health insurance through the school system, cigna. it costs me $630, which seems exorbitant. i'm thinking of mong out of the state, but i have to keep this insurance. i wondered if there was any recourse to recover that cost. guest: i thing she is a good example of why this is such a

good program. she is stuck with whatever deal the school board cut in terms of retiree benefits. if you are paying $6 a month, you are paying a lot. they are not subsidizing your premium very much. you are stock. -- stuck. if you are -- for a federal employee, you could pick plans to keep costs down. when you turn 65 and join medicare, you will find there are some very expensive choices called medicare advantage plans. it are just like federal employee plans. there are hmos, ppo's, and fee- for service, with premiums no higher than medicare part b. host: good news. channel 11 news --

talking about the postal service in particular. it says -- what the thing, -- what do you think, walton francis? guest: it's not the size of the purchasing pool. be a lot of plans only have a few thousand enrollees -- a lot of those plans only have a few

thousand enrollees. some plans offer better bargains. host: there is competition. guest: it works. it keeps cos down. xpayerthe plans are ta paid/subsidized. the government should offer them to everyone. guest: choices have to be made in terms of wages and benefits, including health insurance. there are really reductions being made, just not in this program at this time to the question of the model, for everybody, it has been proposed many times. there have been bills introduced in congress to let all the unemployed, and insured in america -- uninsured in america join the system.

it was based on fehbp. the state-insurance exchanges are modeled, in large part, .fter the fehbp it is a proven success. host: a customer, patient could have more to choose. by making it a broader marketplace, you create incentive for companies to lower -- lure clients over. guest: absolutely. massachusetts has a couple different companies whe people have 15 to 20 plans to choose from. they can go to the plan to offer

a better deal. host: good morning, texas. caller: several months ago, newt gingrich was a new program. he gets his health care still from the federal government -- was on your program. he gets his health care still from the federal government. why is that? if he quits in the privat sector, he would not get it. i am under the impression that, after five years, these guys -- why is it that they can collect? guest: the members of congress and their staff are in the same health insurance program as the rest of the federal employees, on pretty much the same terms and conditions. i have no personal knowledge of newt gingrich's health coverage.

it is quite possible he was able to retire and keepis health insurance in the retirement. there is an interesting twist on health reform. one of the provisions is that, starting in 2014, members of congress will have to join the health insurance exchanges of this like the uninsured. for now, they suffer the same -- asefit from the same choices everybody else. host: sheila is a federal employee. caller: i make $30,000 perear. people always talk about the government employees and what they may. if the government -- if all the employees would stop, the united states would shut down. as far as the insurance, i think medicare for all. they take medicare adam are checked anyway. i think that would also get a lot of money to medicare. thank you.

guest: that is an option. what the postal service is proposing is to require all postal retirees to go on medicare. most federal retirees a left medicare. medicare becomes their primary payer -- retirees select medicare. medicare becomes their primary payer. there are improvements to be made in the way the program is designed as it relates to medicare. medicare for all is a whole different issue. i do not think very many people, certainly not congress or the president, have proposed that kind of radical reform. >> -- host: good morning. caller: i have a couple of quick questions. what is the average age of the fehbp client? second, wired the blue cross blue shield standard rates t same across the country -- why

are the blue cross blue shield standard rates the same across the country? my understanding is that opium will be required to provide multistate qualified health plans. if the private sector decides not to participate, it is in that kind of a back door way to have a public option. guest: you are very well informed. most of the pls and the system, what i call the national plans -- in the system, what i call the national plans, have been around a long time. a g-- hmo's come and go. some have been around forever. others can and leave. there is free entry for any hmo, but not for national plans.

it is something of a myth that costs vary widely. there are better subsidies in high-cost areas. when healthth reform -- health a compromise was struck, including a couple of features such as co-op plans starting in 2014. opium is supposed to run and manage two multistate -- opm is

supposed to run and manage two multistate programs. it was between -- given that opm has an incredible track record of managing the program well, indeed, they are running or facilitated the management of the feature that is currently operating, operated by one of the fehbp plans. we'll see how it plays out. we have a well-functioning, existing system, competitive. it keeps costs down. it keeps benefit choices where people want them. if it ain't broke, don't fix it. host: question coming in by e- mail for our guest, walton francis.

guest: a greatuestion, again. there is a pool. l current federal employees d retirees -- everyone in the untry -- they are in the same pool, including 20-somethings who think they are immortal and have no health care costs. it includes a 80-year-old boss. it includeshose 65 and up who elect -- typically, they will get part a for free. most elect to take part b. there is no special for any group. thoseho elect to take part b are paying more. i mentioned the wraparound.

you could go out of network. host: let's hear from camisa, a democratic caller in dallas. caller: i am a federal employee. why would youecrease our pay and an increased our health care -- and then increase our health care? all of us do not make the same money across the board to that is obvious. why would you do that the federal employees? it is not our fault the economy is bad. guest: a another -- another great question in sharp contrast to the previous caller. health plan costs go up every

year. as you mentioned, the federal share will be going up 3.8%. that is not big. you can shop around and save $1,000 or more. it's like giving yourself a pay increase. host: stephanie from utah. caller: we live in rural area in utah. we have three plans available in our town. because of the zero area, the docts are -- because it is a rural area, the doctors aren't attracted to the area. i have to disagree that we have hundreds of cices. we only have three.

they are national plans. can you comment? guest: i can only say there are rougly 20 plan choices for every federal employee. go online to www.opm.gov/insure to get a very excellent exposure to the choices you have. or the checkbook website. shortage of is a networks of providers. they work great in cities, not well in rural areas.

what i have advised people is to ask the providers, say, what plans are you? it's very likely he's in at least the blue cross programs. host: walton francis, author of "checkbook guide to health

many of these are of inferior quality that are not illegal in the countries in question. we have found that roughly half the drugs are directly contributing to resistance. they are also increasing proliferation of brands in many of the countries of the world. nigeria and kenya have over 200 different brands of therapy on sale. we are working -- i am in favor

of free trade and open markets but this is not a quality control market. there is considerable free-for- all in those markets because the medical regulation authorities have limited capacity. a significant positive note that the united states is supporting the excellent program at u.s. pharmacopoeia which is helping developing countries to identify unregistered illegal medicines where they cause problems. most will. from different research, colleagues of mine have undertaken, it is simply getting the medical parties to control

the market is important. the united states program is deserving of continued support. the second major problem related to increasing resistance has already been mentioned, this telamon of therapies. -- the sale of mono therapies. some companies in china, vietnam, and india still producing them. this is again a major contribution to resistance. in order to combat those sales and credit taste -- and replace them with a combination, there is a subset -- there's a suggestion of subsidization. the affordable medicine facility for malaria is currently being

funded by the global fund in those countries. it may have significant impact where it works well. but from my assessment of this, this is a project that has run ahead of itself. it is not achieving its aim even though we are in the first phase, we are already seeing significant problems. it is exacerbating existing problems with diagnosis. this is not insignificant but is increasing the number of people being treated with malaria drugs who do not have malaria. secondly, there are ordering practices going on. act treatments, 70% of the orders are for adult treatments. malaria is primarily a childhood disease.

so there are significant problems that we are noticing there. the subsidy is a postal -- as opposed to massively reduced the price of the drugs during my research team found that the drugs were two to find times higher -- to five times higher. the impact is still very worrying. of the four pilot countries, they account for 80% of the annual global production capacity if all of those orders are for film. that is a major problem. the united states so far has boycotted the amfm for good reason. you might wonder why i am mentioning them if the u.s. government is not funding it. procurement programs will be seriously detailed and there are serious problems in procuring

medicines over the next six months. it is distributing -- disrupting distribution systems, creating huge problems. a global fund already does not have enough funding and is probably short of funding for this program. it should probably be stopped now before it completes the initial phase. i like experiments and find out when things are working. this is an innovative idea. if it continues for the first phase, we might learn information. but in my opinion, the u.s. government should press harder to end the program or elites limit its scope before even greater damage is done to the distribution system. i could go on another of in challenges but i will end there. >> thank you very much. please proceed.

>> members of the subcommittee, thank you for the opportunity to testify on the great strides we are making toward eliminating malaria as a public offer. members of this committee on both sides of the aisle have been great champions in the fight against malaria and your support as helped save countless lives. i like to echo ambassador green 's, that this is an under publicized success story. the ceo of the advocacy organization, thank you for that generous introduction. you are very big shoes to fill. we were to build support for the fight against malaria among policy-makers, the public, and businesses and we have provided 2.7 million life-saving mosquito nets. thanks to the partnership, there

have been remarkable offenses and the fight against malaria. global malaria deaths have fallen by over 20% and in less than five years, malaria cases have been halved in over 40 countries, and childhood deaths felt almost two and a thousand. but malaria still kills a child every 40 seconds. to address this major health threat, the president's malaria initiative was launched by george w. bush with strong bipartisan support from congress and has been continued and expanded under president obama. since its founding, the emi has distributed mosquito nets, life- saving malaria treatments, and protected more than 27 million people as a result of residual spraying. the successes of pmi are many and are found in my testimony but here i will mention just two.

a 40% reduction in childhood deaths and in tanzania, childhood deaths fell by 28% in the same period of. the success is linked to the global fund. the leader of pmi so that coordinating payments is critical to the success of a global fund and emi. under the leadership of president george w. bush and with bipartisan foreign congress, the u.s. pledged a its founding and continues to be the largest single donor. the u.s. does not contribute more than 33% total funding by a lot. the global fund provides nearly two-thirds of all of malaria funding and has approximately 200 million bed nets and

treated many cases of malaria. the u.s. is helping win the battle against malaria today. u.s. support is just as indispensable to the efforts to develop new ways of fighting malaria in the days to come. a remarkable innovation in this fight as you have haired -- heard with additional protection against malaria is possible. since the day of walter reed itself, this proud tradition has been carried on by the walter reed army research institute to develop this impressive new vaccine. sustained support for malaria r&d is crucial to develop new ways to treat malaria as well as combating drug resistance. the remarkable progress was critically dependent on robust funding for we're making major

progress toward the day where malaria is is a disease of the past. the stream cannot be realized unless funding remains strong. there and investment of less than 1% of our budget, the u.s. and improve millions of lives, helped build robust and future trading partners, and contribute to our national security. just this week, africom published a statement saying that malaria remains a direct health for u.s. personnel and that command. widespread disease can contribute to the stabilization of the society, leading the field face. -- the speed up reversion will be, i am afraid, in our face. there has been bipartisan leadership across the globe, multi partisan leadership across a group. it has been an incredible public health success, and let me

highlight the one partnership produced this document on the deck at a partnership and results in malaria control. i refer the committee to this should there be additional questions about the extent and the numbers related to this success. we do this as people and a number of us have actually come down from the american society of tropical medicine and hygiene annual media being held in philadelphia. that is a remarkable meeting. many of the people there are malaria experts, certainly not all of them, a number of them working in the neglected tropical diseases. but they provide a huge leadership and have for a generation now, and will continue to do so for subsequent generations. that leadership and the science side has finally turned to incredible success in the program side.

that is what makes me proud as a scientist, as someone who cares about malaria, and as american citizens about our country's investment in this. i do not think there is any better. thank you very much. >> thank you, dr. perry let me begin with a question. i want to thank all of you. your full testimony will be made part of the record. they are very much filled with recommendations in the data. all interested parties should be very well acquainted with them. let me go to ambassador green effective for you spoke about the importance of leadership and others who might want to step into this and speak as well, please do. how much u.s. funding is needed on the immediate term, this fiscal year, and going out into the near term to ensure that there is no, as you said, no

speed up rivers and -- no speed of reversion? that this terrible parasite fights back in recent gains could be lost, i thought that was very telling and true. if we could start with that. and secondly, ambassador green, you talked about malaria early detection systems and how it has been created and how well it has worked. i am wondering if the best practices being replicated and if anybody else would like to touch on an, anywhere else. it ought to be rolled out as quickly as possible. and you spoke about the importance of faith-based collaboration's, and without full cooperation with the faith-

based community, we're up to 7 percent of all health care delivered via a health care institution or clinic, to bypass that would mean that fewer people get and director of by all in the case of hiv aids as well as testing and all the other important things. but you highlighted how the catholic bishops and the muslims are working so well together to train 300,000 to carry the message to villages throughout nigeria. it seems that that is not only an important health care initiative, but also mitigates some of the unnecessary and deleterious animosity between muslims and christians in nigeria, where there has been a flare-up in recent months and years. >> if thank you, mr. chairman. i will attempt to partially

addressed the first two questions that u.s. with respect to funding, and dr. bowen can talk about the state of funding and requests. what separates the malaria challenge in our approach to it, to some of the other challenges and choices that respectfully you face here in congress, is that we precisely know what to do. this is a question of our willingness to invest in necessary resources. the technologies are fairly proven. it is a financial challenge and a challenge to our commitment and leadership. a name that has come up a couple of times in the testimony that i would commend it to you is rather admiral tim zimmer.

i believe he is an outstanding leader and not just global health but in logistics. what he can tell you is to take a look at the map of africa and tell you in those countries in which pmi is operating, precisely what we've been the world community will get for the investment of resources. in other words, you can boil down to the bed nets that can be purchased, the rounds of indoor residual spraying that can be purchased, precisely what we will be able to get with resources invested. you can also tell you geographically and one of the things that i think it's remarkable about his leadership is when he takes a look at that map, he is able to tell you precisely what we need to be able to go in to certain countries and had them to the list of those nations that will see a reduction in malaria up 50% or more. the same is true with respect to

your second question. this was a project developed in cooperation with the president's malaria initiative, working in tanzania, with the public health leaders in tanzania and in zanzibar in particular. it was launched just a couple of years ago but it is shown remarkable progress. one thing that you can count zimmer is that we will take his best practices and spread them wherever we can. one of the reasons it was pioneered in sands of our because we had seen such progress down to the point of below 1% infection rate for the question as, what does success look like? when do we cross the goal line? this is an effort to do just that. it can take a remarkable gains, lock them in, and take those

final steps to stamp out whatever minor outbreaks that we see, god willing. with respect to the faith-based story, nigeria in particular, it is really remarkable as you pointed to. it is remarkable for two reasons. its advantages are twofold. in terms of being able to deliver product, i was always amazed as an ambassador when organizations in the west would come to me and talked about reaching out to parts of the country, having no concept whatsoever about the logistical challenges that presents. these are remote areas that are oftentimes completely cut off in terms of modern media access, in terms of the traditional infrastructure that we become accustomed to. faith leaders are well established in every corner of the land, of course, so when you are able to enlist the armies of compassion there, you have a

built-in distribution networks and move product very quickly. the other part that i want to focus on his faith leaders are able to pierce through the lack of education and knowledge that in some ways is the most daunting challenge that you face in some countries. when i taught school in kenya, my students were convinced that you got malaria from rain. you could see how they would jump to that conclusion. that would be relatively harmless except that it if it came from rain, why would you sleep under a bed net? in listing respective faith leaders whose voice an opinion is held in high regard and are trusted in our listen to, they are able to get through that. -- and are listened to, they are able to get through that.

with malaria no more, we did a focus group and we ask young mothers why they did not sleep under a bed net. a lady said to me that she could not sleep under a bed net because at night, with her spirit after body and went out into the village, if she slept under a bed net, it might not be able to come back. an american recovering politician can say over and over again that is not what happens and that is to no avail. but the local feith leader comes and says, this is why we need to do this, that is the voice that makes a difference. the nigeria's story is the most remarkable in terms of numbers and it really is a model to hold up as a success. i think we all owe a debt of gratitude to the center for interfaith action against global poverty, for their funding

institution which has spearheaded this from our perspective. but the best news is that it does not just confined to nigeria. the story is in many other parts of the content as well. >> if i might just picked up on two points from ambassador green. on the feith based organizations, quite recently i worked for the gates foundation , and had the privilege of meeting with a leader or fln it was 120 degrees, where the entire leadership of northwestern nigeria was there. when the leaders said to cooperate with the vaccination program, it was an extraordinary reach. just on the funding, we strongly support the president's request

pmi. the math here is a grim but inescapable. for every $50 million cut, that means 1 million fewer bed nets distributed and 2.5 million fewer combination therapies. >> i echo my colleague's request that that funding be medicine as possible. we also need to think about funding efforts that will improve malaria treatment. so i refer to the remarks i made before about the pharmacopoeia project. the extremely important role, they have the confidence to help their regulating authorities in these countries.

i think the global fund is spectacular but their recent review panel recommended that the global fund mandate the outsourcing as the norm except call local institutions according to local standards. at its 24 board meeting, it merely decided to give consideration to the recommendation. in africa where we have looked at these and the private sector market, in one study we did publish, 28% of these drugs were stolen and diverted from the public sector. that is because of poor management. i think that the u.s. should be pressuring the global fund as hard as it can to not only look into the recommendations of a

high-level panel but actually enact them or potentially restrict the funding from the u.s. government. >> mr. schmatz, you identify the growing threat as a chief challenge to controlling malaria. dr. bate, you talked about mono therapies, and you point out that producers in china, india, and vietnam a particular ignored these policies and continue to manufacture these drugs. dr. bowen, you also talk about drug quality in your testimony and you know some progress being made. what about those countries that continue with market seems to me that china is increasingly garnering the market of the

manufacture of drugs of all types. this could be a serious detrimental effect of trying to use these combination therapies has to talk about your testimony. why are the who's policies being ignored and resisted by these manufacturing companies? >> the extremely good manufacturing in china and india and pakistan, i know them as well, they are brilliant at getting their product into the market. that is one of the reasons why there's so many different brands and so many good anti- malarial is out there. we should probably have stressed that before. the problem is that you've identified correctly that they are not -- some of the manufacturers are not adhering to that. in every sense, limit donor support for any manufacturer that is selling a mano therapy even if it is selling a

combination. it would still be in breach of a guideline. that is the only short-term thing i can think of. >> one aspect of that that does work, for global funds and other donor organizations, in many cases countries cannot buy drugs that are not qualified by who. that is really an important standard to stick with. not just to enforce it everywhere but the funding that is used from the storm organizations, if it cannot be used for those other products, it will not be. folks sit toward the ones that are quality drugs. -- focus it toward the ones that are quality drugs. we need to make sure that those quality standards are met, and again, those drugs qualified by the world health organization

should be the ones that are bought with those funds. it's much more difficult in countries to deal with drugs to come from other sources. >> i would add one more comment, witches, the ultimate responsibility to resistance is two-pronged. one prong is to implement the safeguards that were identified as counterfeit and substandard medications. but this is ultimately an arms race with the disease itself. you can slow the pace with adequate controls and we certainly should. but the other prong of the response is reversed research and development so that there is a constant stream of new approaches and new treatments. >> mr. chairman, if i had added cushion all thoughts. -- if i could add additional thoughts. that focuses on the producers. some might be tempted to ask, why can we bandies in country? the difficulty is is that if you are a poor family in tanzania,

and you have access to a mono therapy which were told will in fact address malaria for you, although in the future, it may lead to resistance, but it is much less expensive, it is very difficult to expect that family not to take the less expensive drug, because in so many cases, they are facing the challenges of poverty. i would also hearken back to alma, the african leaders malaria alliance. there's been a remarkable development, and i think it offers great hope in this area. dr. bowen put up a scorecard and i have been very impressed with how strongly they have tried to share best practices. quite frankly, they hold themselves and their colleagues accountable to the standards. i think the emerging african leadership does offer real hope

in this area. >> dr. steketee, you always great questions and we will submit written questions, but you in your message talk about prevention in pregnancy and point out that coverage of women with intermittent preventive treatment for women has been slower and not as well supported. efforts knees to be helping the susceptible women. we know that malaria contributes to a decrease of low birth weight. i am wondering what your recommendations would be there. is that something that from a policy point of view has not been emphasized? >> thank you for that question. i spent much of my son's career looking at malaria and pregnancy and its prevention.

-- much of my career looking at malaria and pregnancy and its prevention. this is really low hanging fruit. where people pay attention to it, the programs have done quite well. that is, we've got the insecticide treated nets and the inner man treatment for those pregnant women. it is typically administered through clinics that are some of the best attended health facilities by the target population. so the women come, and one of the challenges is that it is just been off the radar. it is not been as important as the insisted side treated nets. . >> set-aside treated nets. -- the insecticide treated nets.

we're looking for new drugs as well, but in the scheme of things, having said that, this was actually raised at the malaria forum and was highlighted and there is a process under way as we speak looking at some of those policy issues and some of the performance issues. solving them and experiences says that they are relatively easily solved. it is just a bit more attention than these to be paid. >> tomorrow morning at 7:00 in philadelphia, a meeting of the partners will occur. i think this one fell off the radar due to lack of attention. the drug is cheap, this is really doable, it should be delivered. and the resources exist. we just need to make sure that we pay attention and work with the leaders and hold ourselves

accountable. tomorrow morning, we are on our way. >> i want to comment on the resistance question. one of the big problems we have with the current resistance program now is that the drugs that are combinations, those six-dose combination drugs, almost all of them were used as mono therapies. putting the medicines together, you can extend the time of resistance. there was resistance to both of them in the parasite population. but when you put them together, they're still that potential for that. the goal is that the new drugs that we develop need to be made in 6-those combinations immediately and never be

available a single entities. that would definitely extend the life of many of those new drugs we develop a going forward. >> you mentioned that we were closer to have of malaria vaccine that worked. you said that it is possible that the malaria vaccine could be available by 2015. is that possible or probable? how far are we in terms of -- you talked about this really -- the whole resistance problem, at what point does our current treatment become obsolete? we are in a race for time. how much of our race are we in? and finally, to dr. rabinovich if i could. he said that there was investment in methods to control mosquitoes. the bbc in august and i'm sure you're all saw it did an article

about holding the promise to stop malaria. it talked about developing 10,000 mosquito embryos with dna designed to turn up the gene to facilitate development. should we give much weight to this is a way of controlling the very population of mosquito's? >> thank you for those questions. the first question is about a vaccine. the results that were published in october are the preliminary results, the one-year results, of the first vaccine, which has been tested at 11 sites in five countries in africa. that is still ongoing. we need the full result from the

toddlers and the baby's just recruited. we will have those results available to look at in 2014. now when these to the evidence- base. if they can protect children from number of years, we want to make sure that there is no rebound. it is something that the advisory committee at the who and the member countries will consider. the evidence so far is that it is about 55% at vacation at preventing malaria and clinical illness from malaria. -- 55% edification -- effectation @ preventing malaria and clinical illness from a letter. the story is still to be told but it is the first time that we have really shown a large enough population that you can have an impact with the vaccine. the second question was about resistance. the place where resistance has been shown is not in africa, but

it will move over to africa, historical resistance is not clear to us but it began in vietnam, thailand, cambodia, and then india and then it hops into africa. it was recognized by studies for looking for resistance. they evaluate how well the drugs are working. recognizing that along the thai- cambodia border, they have gone together to decrease the amount of malaria their and nearly eliminate it, fearing that it would move onward. and that really is a global crisis if we were to lose the combination therapies. we're excited about the portfolio, oz, but they're not available yet. we really have to pay attention

today.stance to act's the third thing that you mentioned was about mosquitoes. it is important to consider innovation also in ways to control mosquitoes. we know that bed nets right now are at the core of they impact in africa today. there are several approaches and the one you referred to is to modify the mesquita said that it cannot reproduce. that is one idea being protest and -- tested. another way is to have an infection within the mosquito that requires other approaches. and there may be other innovative approaches, not just insecticides, the with helpless in the fight of decrease in the rest -- in the risk of being

bitten by an infected mosquito. we need to make sure that the methods work and that they are safe and evaluate them as to which one is introduced. they will be concerned about modified organisms. so there needs to be of full valuation for their inclusion in the global program. >> one point, which on the research agenda, although this is a hearing primarily about the treatment, i think it is somewhat worrying that only 4% of the global malaria budget is spent on areas of insecticide research irregardless of bed nets or spraying, we will need better insecticides. with the exception of the gates foundation, there is very little effort in that area. it is probably more contentious. people do not like insecticides. but that is an area in the short

run that needs to be ramp up, because until we have -- and this is not to downplay the vaccine, but until we have a much more effective vaccine, then we will need to -- insecticides and new ones at that. >> one last question before yielding to my friend with regard to vector control. our malaria-bearing mosquitoes spreading, despite our efforts with bed nets protect individuals during see most fearful times, at night, during sleep, when children and adults could get bitten? are the mosquito's that bear and carry malaria spreading in their borders? i share the -- i chair the line

disease caucus here in congress. we know that the line disease -- lyme disease take spreads an ethics people with disease. should americans be concerned? has malaria come to our shores? other countries like africa and other intimate areas? >> thank you for that question. i just i like this because i think one of the potential progress particularly with african leaders banding together and allowing them to cross borders with the right ideas, so i put that on the side as a critical issue. so the movement of mosquitos,

they like to move as little as possible. it is a fragile woman mosquito, because those are the ones that we care about. she would like to go and find a very close body of water to lay her eggs and and then return to the house where she came from. so she has very little incentive to go across borders. for the most part, the mosquito itself will not be for the transmitter of across borders. it is people the move the parasite and make as concerned about that. having said that, we think of populations of misdeed is. if you have a very good intervention, which we do with insecticide treated nets and indoor residue all spraying, that will kill all of that population that has the particular behavior of eating in doors and among people sleeping in night, essentially killing all of those.

there may be in the midst of that population some that did not read the textbook and a bite someone outside and they get their blood meal and they are able to continue and they stay outside of that immediately targeted area of in six. -- of insects. we in with an evolving population with how good our intervention is.

they start to lookthey start toe created the wrong thing, that is, we have now allowed them to survive but we have killed all the others. mind you, those of the ones that are less likely to fight in doors. and they are less likely to transmit on going. they actually become a weaker transmission for the malaria. we may need to go after those. and it evolves because we're using just one and we are discussing and if it goes on as we speak. who has produced a draft document for controlling insecticide resistance, which includes the idea of combination therapy for dress, but of rotating insecticides. we're not allowing a population of resistant muskie is to evolve. there is a lot of work being done on that. as long as we do not lose sight of it and i will highlight the idea that research is actually critical. >> their high-tech methods for mosquitoes, all very important, but there is a lot of low tech work it can be done. we're working with an organization and senate called -- in senate called -- senegal,

making sure that they're not tires lying around that can collect water. >> dr. bate. >> thank you very much. a very in-depth discussion. according to who, insecticide treated nets distributed between 2007 and 2008 need to be replaced. what steps does your organization take to ensure that the nets will be replaced as needed? and in your opinion, what steps should the donor community take to ensure that the nets are

replaced? and also, proceeding that question, there was always concerned about the treated nets and there was initial opposition in some countries. could you tell me how that has been overcome? i suppose that it has been, but you still find some resistance to that, and how you keep account of the replacement needs for the nets after several years of use? >> let me take that question on. we've actually worked with a number of countries now in that process, and this is where the country logistical system has really dramatically changed in the last few years.

in 2005, 2007, we had a hard time understanding exactly where the nets were needed, where they were, where they were not, and how to understand when to replace them. we have now gone to the point where almost village by village in many countries, they have a roster of nets and households, which ones are short nets, which ones are losing and that, maybe it burned last night on the stove for the kitchen, maybe it is just now torn too much. registering its loss. so the systems are categorically better. for example, we have been working in zambia a lot. they have district by district regularly updated numbers as to how many nets that have on stock, how many are in

households, how many they anticipate needing to replace in the coming year. and what the resources are. and unfortunately is the ups and downs of findings that determined that tron insecticide treated nets that come to the country. so that the country does not have the money to procure and a hold of. because this is so seasonably tied in many places, if you miss one season, you allow your entire population to inadequately protected for that season. one of the challenges for the country is to take them formation and try to match it with some consistent funding so they have supplies when they need them. >> thank you very much. so the question really has a lot

to do with the manner in which the individual countries have worked on their health systems, delivery systems, and how have your organization's work with the basic things that you mentioned, keeping the inventory, making sure the people know if that a program is going to start -- it is there any program that goes into communities to build that kind of very basic infrastructure up? >> one of t