participation in contact sports. this is one hour and a half. >> good afternoon. >> good afternoon we're going to do to be creative because we are going to have a series of votes at 2:30. what i'll do is recess the committee and we'll go over and vote until the very last vote and we'll cast the vote at the very beginning of the last vote then race back over here so that we can continue the hearing. there's also some breaking news just an hour ago.

the nfl agreed to eliminate $675 million cap on concussion related claims available to thousands of players as part of a major lawsuit. so without objection i will enter the nfl's statement in the record. part of what we're going to discuss today is traumatic brain injuries, a bump, a blow, a jolt to the head or penetrating head injury that disrupts the normal function of the brain. more mild t.b.i.s, more commonly referred to as concussions have been the center of increasing discussion within the sports community in recent years as a growing number of current and former athletes say

that they are suffering from memory loss and other impairments caused by repeated blows to the head. of course, we are seeing the t.b.i.s that are coming home from overseas with our men and women in uniform and the performance of their duties as well. the centers for disease control and prevention have looked at 1.6 to 3. 8 million recreational sports related t .b.i.s. they say they occur in the u.s. each year. such head injuries are not limited, obviously, just to one sport. they occur in a wide range of

sports. and most recently, we were reminded that the story in the "new york times" with the graphic pictures of the games going on in brazil right now in which one of the soccer players was completely knocked out. over the last few years, much has been done to increase awareness of the risks posted by sports-related concussions and thanks to a number of partnerships and initiatives, research is under way to help us better understand the cause and the long term impact of concussions and what we can do to prevent them. these initiatives involve a number of organizations. while we're making progress, it's important to note that much more research is needed.

and to see all of the links to other things such as alzheimer's. today, we're going to hear from two former professional athletes who had their careers cut short due to concussions. now they're going to wonder about their function in the future. we're going to take testimony from two prominent medical researchers who will discuss the latest research and i'm going to give that privilege of introduction to senator warren after i turn to our great ranking member, senator collins >> thank you very much mr. chairman. i very much appreciate you calling this important hearing so that we can better explore

the relationship between traumatic brain injury and diseases associated with aging such as alzheimer's, parkinsons and lou gourig's disease. as the senate cochair of the alzheimer's task force, i am particularly interested in the research conducted over the past three decades that is linked moderate and severe traumatic brain injury to a greater risk of developing alzheimer's disease and other forms of dementia. one troubling study cited by the alzheimer's association found that older individuals with a history of moderate traumatic brain injury are more than twice

as likely to develop the alzheimer's than a our seniors with no history of brain injury. those with a history of severe traumatic brain injury were found in this study to have a 4 5 time greater risk. finding a way to treat alzheimer's is among my heightest priority as a senator and has been a focus of this committee's work. if we are to prevent alzheimer's from becoming the defining disease of the next generation, we must strengthen our commitment to research leading to a better understanding of this devastating disease. while researchers still have a great deal to learn about how

head injuries affect an individual's risk of developing neurological diseases like alzheimer's later in life, there is increasing evidence of a relationship. women even more than men maybe more likely to experience long term symptoms such as cognitive and visual impairments after sustaining a severe head injury. we know that currently almost two thirds of americans living with alzheimer's are women. there are many important research projects being conducted on t.b.i. and link to neurological disease. for example, the national institute of health and national football league have embarked upon a $60 million four year public-private partnership to advance research that may lead to the improvement of t.b.i.

diagnosis through better imaging technology and improve treatment for those who sustained serious head injuries. indeed, while those who had participated in contact sport or served in the military may face a particular risk for t.i.b.i. related health conditions. the leading cause of t.b.i. among seniors is falls. according to the cdc individuals over 65 have highest rate of t.b.i.s. more research is required to establish definitively the link between head injuries and neurological diseases. it is clear that this important research could lead to a better understanding of such devastating diseases as

alzheimer's and parkinsons. this research could bent our veterans and troops on the ground far too many of whom who have experienced t.b.i. and its painful lasting effect. mr. chairman, thank you for holding this hearing. we have a great panel of witnesses. i look forward to getting their insights and learning more about the current research on this topic. >> thank you senator collins. i want especially recognize kevin turner. kevin was a star fullback at the university of alabama. he played eight seasons with the new england patriots and the philadelphia eagles in the 1990s's since being diagnosed in 2010 with a.l.s., kevin has worked tirelessly to raise awareness about the disease and

its possible connection to traumatic brain injuries. kevin, we thank you very much for being with us here today. senator warren if you will introduce two of our panel. >> thank you very much mr. chairman and ranking member collins. i am pleased to have the opportunity to introduce dr. robert stern and chris nowinski. dr. stern is director of boston university of school of medicine. he is director of the clinical corps of the boston university alzheimer's disease center.

he received undergraduate from welllynn university. he served on the faculty of brown medical school and the university of north carolina school of medicine. dr. stern's research has led to more than 250 peer review publications and helped us to better understand the effects of trauma and aging on the human brain. he's here today with m r. nowinski who is the cofounder and director of sports institute. it is focused on addressing the issue of brain trauma through education, through policy and through research. he received his undergraduate degree from harvard university where he played defensive tackle for the football team.

after college, he became a professional wrestler. in his own experience in that sport with head trauma, led him to cofound the sport's legacy institute. he currently serves as an advisor on the nfl players association traumatic brain injury committee and ivy league concussion committee. chris received accolades including distinguish service award for his work advocating for improving safety standards in sports. i am very pleased that dr. stern and mr. nowinski are here today. thank you both. >> it's my pleasure to introduce ben utrecht. who is a former nfl tight end for the cincinnati bengals and the indianapolisñr colts.

if i recall, you were on one of those teams that went into the playoffs and perhaps you can tell us the rest of that story. dr. jacob vanlandingham, he is professor at florida state university college of medicine. what we'll do, we'll start with you mr. nowinski and go down the list what your written statement is entered into the record. if you would just share with us for a few minutes and then we'll get into questions. >> thank you for that wonderful introduction senator warren. chairman nelson and members of

the committee, thank you for inviting me to speak today. i'm founding executive director of the sports legacy institute. it's a nonprofit organization dedicated to solving the sports concussion research. i also have a personal relationship with concussion. tremendous concerns, i increased my risk of developing a brain disease in the future. it's my hope this hearing raises awareness of the urgent need for funding for research on traumatic brain injuries as well as the tremendous opportunities we have for the prevention of their long term consequences. i never had a second thought about concussions or brain injuries until i was 24 years old. i became a prowrestler, known as a super star with w.w.e. i got to travel the world playing a bad guy or heal. remind you this is a character i played. it was a performance to entertain our fans and it was a

lot of fun. in a match, i was kicked in the head by my opponent and my world immediately changed. my head became throbbing, everything got foggy. most importantly, i forgot the script. i couldn't remember how i supposed to finish the match. i was stopped by an athletic trainer who asked if i was all right. i lied when i said i'm fine. even though the headache was killing me. it extended beyond the headaches to depression and sleep walking. i lied about my symptoms for five weeks. i met dr. robert can who helped me understand all the dings i've been getting were concussions. to think that at 24 i was learning how fragile my brain was. that i am now higher risk. my ignorance cost me my career.

cost me at least five years of my health. .... brains of former nfl players studied have been found positive for this disease and athletes as young as 17.

also, my friend kevin turner is here in the room, who is courageously taking on this issue. i will defer to dr. stern, but the reality is, we need answers quickly. it may be massive. least 3.8 million concussions per year. we have to recognize contact sports are constantly evolving. we do not know what the effects are of exposing children to repetitive brain trauma. the sports that our 11-year-olds played in 1950's are not the ones they play today. until title ix, few women were playing contact sports. we do not know the answers. this is a public health crisis. what we work and we applaud the state laws that have changed the way we play sports, it is not enough. -- one of the things i do if i train wrestlers

on concussion. which is fun. before they get into the ring, they have to listen to me. we think we can train adults. we do not know if we can train children. we have kids playing contact sports that will not recognize a concussion. it will become a problem for athletes and most certainly for our military veterans. a new initiative we announced today, oh that we hope will we hopethis -- that will prevent this, we teamed up to educate parents and coaches on the risk of heading in soccer before high school. we were joined by former includingeam players brandi chastain and our own dr., to say that we do not need headers. it should not happen.

underestimate the long-term impact of rain injuries. with one in four boys and one in 16 girls playing contact sports, we old them better. we need to find a way to minimize the consequences of this inevitable brain trauma. thank you. >> thank you. sofirst of all, thank you much for this opportunity. it is truly a privilege to be here to speak about something that has impacted my life in ways that are very scary, and unknowns as a husband and father have put me in a situation where i do not know what my future is going to look like. as a small kid from minnesota, i do not know how it happened, but i found my way into the nfl.

to play withgot the indianapolis colts and then two years with the cincinnati bengals. i am a husband and a father of three beautiful girls. thankfully i do not have any football players in the family right now, but the perspective of a father has really become part of my life. 27 neurologists make up the academy. they are the leaders in the world of neurology, along with their foundation, the american brain foundation, whose goal is to cure brain disease through exactly what chris talked about, the importance of raising money for research. i hope i never forget the night of february 4, 20 07. it was an amazing night in miami, florida as we stepped out into the stadium, the biggest stage in the world. i do not even know how to put into words.

over 100 million people tuned in to watch the face-off against the chicago bears. i will never forget two weeks prior, our all-pro kicker telling the team, don't you dare blink at kickoff. already won three super bowls. he had quite the experience. there i was standing on the field between the manning and peyton manning and tony dunn g. and i remembered his words -- don't you dare blink. his hand drops. he releases the players. he puts his foot on the ball. i have never in my life seen so many flashing lights. it would rival the experience of neil armstrong. it truly felt like i was dancing with the stars. it was the greatest experience of my life. we won the game 29 to 17, and

forever i will be able to wear this ring on my finger in remembrance of that game. it was a dream come true. two years later, that dream was shattered. down on ae up face training camp field in georgetown, kentucky, strapped to a board, puts onto an ambulance because of my fifth documented concussion. life,e first time in my my brain became a priority. and the reason why it became a priority was a 29 years old, i started to have memory problems. mind -- it took losing my mind to care about my mind. my memories began to fade away. one story i have shared is going home to minneapolis and spending

time with friends, my wife and i, sitting around the table, and his weddingought up and i said, why was i not able to be there? and i got the strangest look from him. and his wife brought over the photo album from their wedding. page after page. i sang a song at his wedding. and i have no memory of that experience. it is completely gone. then there are behavioral changes. is hearing my five-year-old daughter tell our doctor that ate times she is afraid of me. father, it puts the idea of the effects of traumatic brain injury on a completely different level. i can't help now but throw

myself onto a new target -- numerology. opponent, brain disease, and in particular, traumatic brain injuries and concussions. seen lives ripped apart by brain disease, alzheimer's, epilepsy,s, encephalopathy. can become our new coaches. you can help decide the game strategy, put in the work and research and create policies that can change this nation, connecting people to their most valuable asset -- their mind. education and awareness. it is changing the nature of a person. it is getting them to truly care so they can take the education and awareness and m clement said

because they are passionate about who they are -- implement it because they are passionate about who they are. numerology -- our numerologist's numerologist our create the cradle for our brain. it is time for all of us to realize how special our brains really are. ihave a number of policies would love to share with you and question-and-answer time. thank you. >> thank you, mr. utecht. van landing him. >> thank you, mr. nelson. thank you to the committee for giving me the opportunity to speak on traumatic brain injury. i am a researcher. with my own experience brain injury. i was not playing football. i was assaulted.

i was down in gainesville and a vagrant assaulted me. i had three hemorrhages on my brain. weeks in intensive care and 18 months with amnesia. i was one of the lucky ones. i got my memory back. whatpeople who experience a lot of us have experienced are not that lucky. home to get my phd in neuroscience and focused on research. most of my clinical and recent research over the last 17 years has been focused on traumatic brain injury. i have put the last five years more and to focus on concussions and mild traumatic brain injury. to give you a little bit more background, what causes a concussion is the brains leans forward, is accelerated, and is against the skull, and it will be kicked back the other way. it goes through this acceleration, deceleration. a lot of people think that the

brain is only damaged by hitting the enter part of the skull. actually the brain is sort of like jell-o, and it stretches. the accelerating part of the brain goes faster and it stretches the brain in between. it is that stretching that creates the breakdown in metabolism in the brain. electricity in the brain does not run quite as well as it used to. when we have a concussion, often he will be able to get to the right answer. we are delayed. our thought processes are delayed and getting -- in getting to that answer. i think it is important to note not only are we having concussions in athletics. we mentioned it the -- we mentioned the elderly. we mentioned the military. we also have a problem with falls in children. we do not want to forget the pediatric population. by midnight tonight, nearly 38 children in this country will

die from a traumatic brain injury. folks, a lotthese of these kids will continue to have problems for the rest of their life. it is really important we put focus across the age span, across the lifespan, if you will. if you think about pediatric willatic brain injury, we notice they often take a lot longer to get better after concussion. what may take an adult like myself seven to 10 days to get better, it may take them seven to 10 months. they get behind in school. they do not graduate with their fellow schoolmates. a lot of issues are different and need to be respected when coming up with treatments. the same goes for the elderly. when we think about sports, we always go to the nfl and

professional sports. i think we have an even worse problem in high school athletics. because it is an immature brain. if you do not have a fully developed brain that is injured, it has a harder time recovering. we have a high school player playing football who is to 40 pounds, still big, hit with a tremendous amount of 0 pounds, who is 24 still big, hit with a tremendous amount of force. so, when you have a concussion, most people think you go rest and you just get better. about 20% of people do not get better. they end up with postconcussion syndrome, which chris alluded to earlier. it takes up to 20 years to get over postconcussion syndrome. we see a lot of sleep difficulties with postconcussion syndrome. if i had a time for every person

i knew who had a head injury and sleepeep problems -- and problems, we never recognize that. thoseer put effort into sleep patterns. and that is such a huge part of helping that bring get better. unfortunately, concussions can be difficult to diagnose and treat. every injury can have a different constellation of findings, and these findings can be subtle. the common factor is when folks are injured and they are athletes are in the military, they do not want to tell the truth. they want to intentionally mask it. the same thing goes with an elderly patient. not wanty patient does to lose their independence. they are not engaged and wanting to give up driving or whatever it may be. the world health organization has stated as the lifespan increases, we are going to see

surpass many other diseases as the major cause of death and disability by the year 2020. in conclusion, i would like to transcends generations of populations, from the infant to the elderly. concussion, you are more likely to have two, and so on and so forth. it in my areessional opinion, we dealing with two major research and development issues. first, because concussions are compounding, we need to develop new acute pharmaceutical treatments. we treat everything else with drugs. why don't we put a focus on developing a drug for this condition? an acute give treatment after concussion, we can reset the brain, curate at that point, and then it is not a compounding issue. you are not more likely to get a second concussion, and so on and

so forth. chronicr issue is encephalopathy. these pathologies are being seen down in the spinal cord, leading to lou gehrig's disease or anterior lateral sclerosis. we need to put precedents on developing drugs that can stop this pathology. so, we need to stop concussions in the beginning, prevent it from being compounding, and then we need to put a focus on new drugs that can stop or halt progressions. is developing an .cute treatment for concussion we will design it as a field deliverable. it will be a nasal inhalant to get more of the drug to the a medic, and ambulance technician, and athletic technician can give it thediately and we can stop

consequences and their track. we also looked at be developing steroid drugs this summer which will be focused on alzheimer's disease and lou gehrig's disease area -- neuro trucks. thank you for giving me the time to speak. >> thank you, dr. vanlandingham. issues up deal with here like the cuts to nih and having to restore those. we are very sensitive to what you say. >> [indiscernible] good afternoon. esther chairman, ranking member collins, distinguish members of the committee -- mr. chairman, ranking member collins, distinguish members of the committee. it is a pleasure to be here today. .y name is dr. robert stern

i am a phd at the boston school of medicine. i am the director of the boston university alzheimer's disease center. for the past 25 years, i have been conducting clinical neuroscience research into issues pertaining to the aging brain. in particular, alzheimer's disease. since 20 oh eight, my research is focused on the long-term consequences of repetitive brain trauma and athletes -- in athletes. t.have been studying ce brain a progressive disease that can lead to dramatic changes in mood, behavior, and cognition, dementia. leading to it is similar to alzheimer's disease, but it is a unique english easily this

through postmortem neuropathological examination. orginally called punch drunk dementia appeared to list the listica inentia pugi the early 1900s when it was only got to happen to boxers, it is widespread. it has been found in athletes ranging from football, soccer, and rugby players. for somesuggests, individuals, repetitive impacts to the head trigger a cascade of events that lead to the destruction of brain tissue. these changes in the brain can begin years or even decades after the last trauma -- or after the end of that blood involvement -- and can lead to memory loss -- or after the end -- andetic involvement can lead to memory loss, depression, rage, suicidality,

boop my problems, and, yes, dementia. problems, and, yes, dementia. i have been privileged to interview the family members of former athletes who were after deathth cet with my colleague and her team. from these interviews, i had begun to learn about the clinical course and presentation of this disease, but more importantly, i have learned about the tremendous pain and suffering the family members experienced while their loved by cet.fe was destroyed privilege ofad the meeting nfl players who have participated in my study. i hear their stories. i speak with their family members. i listen to their fears that they have cet, or that their fellow former football players

have or will get the disease. they have all witnessed firsthand the tragic downward , that sadly seems to become an expected consequence of playing the game they love. study isof the detect to develop objective biological test or biomarkers to diagnose cet during life. note, rightparate now, today, in the next half-hour, the first nfl -- former nfl player in our study is going to undergo a very exciting new that scan that is designed to detect the abnormal protein found in this disease in a human being while they are alive. this afternoon. this will hopefully improve our .bility to diagnose cet

and that ability to diagnose cet during life is the next critical step. it will lead to answering important questions about this disease, such as how common is it? what are its risk factors? how can it the prevented? how can we treat it? veryis point we know little about this disease. one thing we do know is that concussions are just the tip of the iceberg. hearing a lot today about concussions. we have been hearing a lot about concussions in sport and the military. the thing i am most concerned about are the things that we referred to as sub concussive blows, or hits to the head that rattle the brain and likely do the same type of thing that dr. tolandingham has mentioned those neurons, but without causing the same symptoms of concussion. and those can happen many, many

more times than anyone ever expects. 1000 to 1500 times in a typical football lineman, perhaps 100 times during heading in a season in soccer. that is what scares me. in order to tackle the complex onue of cet, we must expand issues to detect nero generative disease. we must break down the silos of individual research labs, institutions, and disciplines, and begin to conduct multidisciplinary, collaborative research across research centers, bringing together the scientists, novel methodologies, and state-of-the-art technology. i fear we have a major public health crisis looming, and we must act now. as you have been

hearing, this requires tremendous financial support. and as you know all too well, current nih funding is all too low. i would like to congratulate this committee for leading the effort on increasing nih funding for alzheimer's disease research. however, we must now have additional funding or research ofusing on cet, and because their similarities, new discoveries about cet will expand and inform our knowledge of other degenerative diseases like parkinson's, alzheimer's, and lou gehrig's. favorite pastimes in this country such as football, hockey, and soccer involve blows brain head, leading to disease. we much learn as much as possible as quickly as possible to determine who may be at risk for cet and develop a method for

treating the symptoms of cet. i would like to close by thanking this committee for your commitment to improving the health and well-being of older americans. thank you. >> thank you, dr. stern. senator collins? you, this or chairman. i would like to thank all for witnesses for truly exceptional testimony. wasutecht, your statement so moving and riveting. you mentioned during your comments that when you were strapped to that structure, that was your fifth documented concussion. what happened after the previous four? ? didyou treated each time you try to conceal that you had such as mr. non,

wednesday mentioned? tell us what happened. >> shore. a number of answers -- have a ever concealed i have had a concussion? yes, i have. there is tremendous pressure in sports to continue to play. not only do you not want to let down your teammates, who at the time your family -- who have become your family. you do not want to let down your coaches who have worked countless hours to put together a successful plan, and an injury can remove you from that plan. so, yes, i was put in a position where, i wanted to play. and that pressure kept me from being honest. i regret that. worse --ussion got each concussion got worse. as the doctors of talked about today. my third concussion was simply a player jumping over me in pursuit of the tackle, as his

foot lightly grazed my helmet, and i was knocked unconscious for 20 seconds. i watched the film. i see myself get up and runoff have noideline and i memory. it was the first time i ever experienced amnesia. that was midway in the first quarter against the denver .roncos in december 2007 i don't member anything from that game and so we went to halftime. -- once iy became began experiencing short and long-term memory issues, which led to my final concussion, and eight-month rehabilitation process. each team at that time was set up differently. for the indianapolis colts, they who was a neurosurgeon one of our team doctors, who treated the players who had concussions. in cincinnati, it was a

neuropsychologist who treated players with concussions. is one of the things we have really wanted to change, making sure players are actually seeing a neurologist. those are the experts who can diagnose and manage concussions properly. >> the comments we just heard reminds me of when i first learned about the link between traumatic brain injury and neurodegenerative diseases, and doctor fromith a maine who had a patient come to him, and he was being treated stressttraumatic syndrome, and the doctor asked if he had ever had a concussion? and it turned out that he had

several and cautions and dramatic rain injuries while he traumatic brain injuries when he was in iraq. he was diagnosed with having posttraumatic stress, when in fact he had a tbi. it turned out that the tbi caused him to have a form of epilepsy, which the neurologist then treated him for. is, is itstion to you your experience that patients diseasesodegenerative often have a hard time getting a proper diagnosis? , senator.ou that is a great question. the answer is, there is no former applets have a very hard time getting the right diagnosis. -- former athletes have a very hard time getting the right diagnosis. new, they are not

trained for it in medical school. when we go through our brain bank records, every person wasnosed with cet originally diagnosed with alzheimer's or some similar disease, but until the last couple of years, none were a diagnosis,s meeting many were probably being mistreated. howr. stern eluded to, horrible this diseases for individuals, and especially their families. do a important we at least better job of trying to treat them while they are alive so they can live a better life. for is something i hope myself. i am 35 now. onset of the symptoms for most people is about 40. it is a ticking clock for me and

a lot of people. >> you mentioned that a produals with cet have team, and i know from my work on alzheimer's, that that protein in people with alzheimer's also. i would talking about the same protein? is there a link here? is a wonderful question. it is one of the exciting things about working in this disease. there is a definite link, and yet they are completely distinct. the difference is in alzheimer's disease, there are two proteins that start accumulating in abnormal fashion, and an abnormal form of those proteins. one is called tau and one is called amyloid. , we do not see vietnam

alloyed. and when we do see proteins, it is indifferent kinds of plaques than in alzheimer's. the places where it starts to accumulate is quite distinct from alzheimer's disease. to answer your question, we have cannotrstand that we right now diagnose these neurodegenerative diseases accurately while people are living, including alzheimer's disease. we have been studying alzheimer's disease since 1905 when it was first discovered. and yet we still cannot truly diagnose it during life. fortunately, we are getting very, very close. in parts due to the help this committee has given to support research. but we still can't do it. with cet, we have only been studying it in depth for five or six years. what we are able to do, and what we're doing with my research

right now is exploiting what we have learned with alzheimer's disease to learn about cet. tau now with a developed forlly alzheimer's and other neurodegenerative diseases, we can quickly come to answers about cet. >> thank you. >> is there something we need to be aware of with regard to helping you involving experimentation on living patients? money, money. that is what it comes down to. it is not just the responsibility of the federal government. this needs to be a partnership ,f the federal government foundations, and the private sector. these types of research studies -- and to answer the questions the right way -- costs tremendous amounts of money. to get to answers quickly, we must have adequate resources to

do so. so, yes, indeed, we need intinued assistance increasing the budgets. not just reducing the cuts, but increasing the budgets at the national institutes of health, for neurodegenerative disease research in general, but i would hope for and ask you to start a special line of research for supporting chronic traumatic encephalopathy, so we can understand the distinctions between this disease that may affect countless people in the future and diseases that have already been receiving funding such as alzheimer's disease. suppose senator blumenthal -- >> senator blumenthal? chairman, formr. holding this important panel. each of you has been extraordinarily insightful, and that is based in part on

research that you bring to this to be and just to add chairman from question -- money, money, money is often very importance. it is also how the money is spent. and also, what can be done to prevent cet? one of the areas as education. the corey stringer institute at the university of connecticut, as you know, has released nine recommendations for lessening incidents and reducing long-term effects of dramatic rain injury --traumatic brain injury, and the experience of the states in adopting those recommendations is very, very mixed. connecticut has implemented only for. most states have implemented even fewer of them. there is a lot of work to be done in educating parents, trainers, but also public officials, as to what can be done.

you know, one of the areas of meury that was unknown to concerns respect riding -- horseback riding, which is in fact the leading cause of sports ,elated traumatic brain injury of all recreational sports. think about it. iding is the leading cause. why? a lot of young writers are wearing helmets need a velvet -- s are of young rider wearing helmets made of velvet with no real protection. think of a football player wearing a velvet helmet, nothing more. i am planning to introduce a measure, which i am naming for a o'donnell,, kristin from connecticut, who was thrown from a horse while riding,

suffered a traumatic brain injury, and died the next day. ore one of these traditional velvet caps. her parents had no idea that they were buying a decorative helmet, rather than a real, protective gear. so, the bill i will introduce, the kristin o'donnell equestrian safety helmet act, would require helmets sold in the united states to meet minimum safety standards. i do not want to go too much into detail, because i have limited time, but i want to , ink you for the support terms of the factual background you have provided for this kind of measure, which i think can be replicated in other sports areas as well, and i'm sure we will be

talking about them in the near future. ask mr. nowinski -- you are now 35. your injury occurred when you were 24. how are you feeling now? >> thank you for asking, senator blumenthal. it is up and down. these days, i still get way more headaches than i would like to. right now, i feel pretty good. but, you know, as part of dr. stern's study, i did my annual phone call testing my cognition. there was stuff i was proud of. there is stuff i do not feel so good about. i am happy where i am, but i am always wary of where i am going. head thatk in the caused your injury was, in a sense, a routine part of the sports? >> it was an accident.

we were not supposed to actually do that. just so you know. >> but accidents in that sport frequently occur? of thee sort of part routine? you say in your own words -- but when you are in a contact sport wheret kind, particularly the routine, so to speak, is to actually do damage -- at least fake damage -- to another person, it is easy to make a mistake. just like if you are throwing a fake punch. if you do it the wrong way, it you will hit the person. >> with a real punch. [laughter] have happenedst to you repeatedly before that when, as you say in your testimony. you suffered repeated blows to the head. of course, the sport and so forth. in your experience, our people and that sport -- i will call it

wweort for the moment -- wrestling or similar kinds of this repeatedof impact of the blows that are struck? actually, yes. wwe has become a close partner. we honor them last year because they have become a real leader on this issue. >> and you participate in some of the educational sessions? i go back and train the whole roster. when they get new rosters, i train them before they get into the ring. they made a unrestricted gift to support our research at boston university. it has been rewarding to see that culture change so quickly. many of my friends are still wrestling there. they are in a much safer place. they have protections in place

that will hopefully minimize the risk of long-term damage. >> in terms of the contact sport area -- and any other folks on the panel should feel free to comment as well -- how is the insurance coverage for that sport and others, so far as you know, relating to this kind of injury, which, as you have just , is noty compellingly just a one month or one year recovery period, but it can be used literally a lifetime? difficult to speak to all insurance programs, because i know there have been a lot of changes, especially recently in many sports. i think you make a good point that this is extraordinarily expensive to deal with these consequences long-term. i can pass that down the panel, but it is a significant issue. quick.ll comment real

and we have hmo's in the state of florida that will not even reimburse for a concussion diagnosis. even in the tallahassee area. with othercome up things, like claimed that there is memory impairment, and we get reimbursed based on that code, but there is still not a specific code for multiple hmo's that will reimburse a concussion in the civilian world. >> is that true in medicare as well? >> in medicare, people are fornitely supported dementia-related conditions and weessments, but often what are seeing with this disease of chronic traumatic encephalopathy is it does not develop exactly the same way as alzheimer's .isease and other dementias there could be mood changes

without the memory problem, initially. in those cases, they may be treated as having a psychiatric disease or illness. the funding is quite different in those cases and much more limited. before i return to you, i want to get an understanding of how could concussions have an effect upon lou gehrig's disease? als. that our special guest is with?ed with -- afflicted i want to stress it is not necessarily concussions. it is repetitive brain trauma, including subcontracts of hits, that does not include being knocked out or having changes in symptoms. it is the little hits over and over again that could start the cascade of changes in the brain cells that lead to the death position of this abnormal tau

that leads to the destruction of the brain as people live longer. what we have seen is in some cases, the abnormal tau, and another protein called tdp 43, is not just in the brain of an individual with repetitive brain trauma, but also in the spinal cord. it leads to the same types of alterations in motor functioning, in strength, in weakness, as one would see in run of the mill als. it is not that it leads to the same type of als that might be caused by another underlying factor. it results in the same type of motor neuron disease caused by repetitive brain trauma, is what we currently think. >> senator, please continue. >> thank you. mr. chairman, you are very, very gracious. i am over my time, out of my

time, and i'm going to yield to some of my colleagues in light of the vote we have coming up. >> senator warren. >> thank you very much, mr. chairman, ranking member. there are places like boston university that focus on traumatic brain injury, and have revealed that athletes and veterans with chronic traumatic encephalopathy or cet exhibit structural changes to their brain that are similar to the brains of people with alzheimer's disease. and the patients exhibit similar symptoms. i know we have been talking some about this. but i want to ask the question a little bit differently. we do not know the root causes of these conditions, because not everyone with a history of head trauma develops cet, and not everyone who develops alzheimer's disease as they age. currently lack

effective diagnostic tools or treatments for either disease. so, the question i would like to ask for dr. stern and dr. vanlandingham, how can you use what you learn about traumatic brain injury to inform study about other age-related neurodegenerative diseases. dr. stern? senator warren, thank you for that question. that was the question that got me involved in the study of chronic traumatic encephalopathy. as an alzheimer researcher -- alzheimer's researcher, i was never very interested, except i once was at a lecture and mr. roommate was in the audience, and it led me to find out about this burgeoning topic of chronic traumatic encephalopathy. and the reason i got involved was for just that reason. it was a close enough cousin to alzheimer's and other diseases

that have been studied that we could exploit what we find out about one to learn about the other. and so with chronic traumatic encephalopathy, we know the necessary variable for developing this disease. the necessary variable is repetitive brain trauma. articulately said, that is not the only variable. who hasnow everyone this disease has a history of repetitive brain trauma. by that nature, we are able to then look at a group of people at high risk, very high risk for developing this disease, and study them longitudinally, and use new tests and follow them until death and have my colleague and other narrow pathologists examine them. that is a very unique thing. in alzheimer's disease, we do

not have that ability. we do not know who is at high risk for getting it, until we might be able to do a special kind of pet scan that can test the amount of amyloid in their brain. now we can use both sides of the picture to inform the other and make us get to answers in a much faster fashion. , did younlandingham want to add anything to that? >> i will reiterate, one of the most common questions i get from parents are, when should i make my son or daughter stop playing the sport? how many concussions? and i am like, well, everybody is different. you would like to say after three, they are predisposed to cet. everybody is different. but i agree with dr. stern, it is a population that can be studied in years to come and you'll get closer to the right answer. i would like to add one comment

to the lou gehrig's issue. i do a lot of clinical research with animals. we can give one single concussion to an animal and we protein in theau spinal fluid. that not only bathes the brain, but also the spinal cord. bathing thetely spinal cord after a brain injury. your comments, both of you, dr. stern and dr. vanlandingham, reminds me the wonderful thing about science is discoveries do not occur in isolation, that what we learn about studying one disease can pay dividends in shedding light on other diseases. the director of the national institute for mental health told the health committee last year that we are on the cusp of a

revolution and brain research because of the incredible tools that are now available, that have not been there before. yet at this critical moment, we are cutting back on in age funding. year after year, adjusted for biomedical inflation, and i age from budget has shrunk to the point that we are investing less in research with nih than we were in 2001. let me ask the question this way. if we could double the budgets of your centers, what could you do, and how much faster could you do it? go first?want to >> i will go first. >> you have to show was the aspiration here, dr. stern. >> with a double budget, we would not just double the speed at which we could answer important questions. it would be an exponential increase.

one of the things that has been happening across the nation has been the loss of young investigators and senior investigators. young investigators because there are no jobs for them, because of nih cuts. there are no jobs for young postdoctoral fellows or new researchers trying to get in the an assistant professorship. senior researchers are having to close their labs because for the first time ever, they have no funding. havese of that, we cannot continuity and research. we can have the numbers of people to focus on a particular question at any given time. the startingf points. why we would be able to have much faster answers. have aad money, we would real meaningful staff to answer the questions. to do would also be able much more with technology. and that is what is so wonderful

about doing this type of research in 2014. when senator warren was out, i was mentioning just now, this moment, we are putting one of our former nfl players in a pet scanner to look at how the tau protein is in their brain. it is the first time we're doing it. it is very exciting. to have support for that, to double our budget, to continue that research, not to close it down, we would be able to life very,t during very accurately within the next five years. >> dr. vanlandingham? by saying i work for two different nonprofit companies, a for-profit company, and i am a professor at an academic institute. there are various thoughts that go through my mind to answer this question. i think if we had funds from the federal government, let's say, that was sponsored private be easier that would

for private companies to get investors. it would improve the value to the investor by having federal government support. that is a little out there. the eighth pharmaceutical companies do not do r&d anymore. small pharmaceutical companies are the ones that have to go out there and either raise the money or fight for the grants just to get this to a point where it can go into clinical trials. professors and academic institutes of wonderful ideas, but they hardly ever try to commercialize them, because they do not have the means in which to do that. ,our question on how much money doubling the budget -- for $20 million in a year, i could be in a phase two clinical trial for concussion, a first drug, if i had $20 million today. >> i appreciate it. ,e talk a lot on this committee for example, about alzheimer's.

the alzheimer's association says is our nation continues to age, alzheimer's disease is projected to cost our nation $1.2 trillion by 2050. over and over, we understand the importance of research. not just for people's lives, but the importance in terms of how much money we have to spend to care for people. it clear.t to make we cannot stand by and do nothing. we must increase our federal investment in medical research, not slash it. is our only chance to bring costs under control and give people a better quality of life. thank you for your work. thank you for being here to raise awareness around this issue. and thank you, mr. chairman, for letting us go over. >> amen to your comments about

research. senator -- to squeeze ustry in before we have to go to vote. the vote will be called momentarily, but we do not have to go right at that time, and i will wait until the last possible minute. offer see if i can quickly a number of questions that are left. dr. stern, how does a tbi differ in a military combat injury versus a sports injury echo -- sports injury? >> the brain does not know what is hitting it. however, there is something new that has been occurring in the last 12 years in the military in iraq and afghanistan, and that is these roadside blast injuries that occur to our servicemen and women. the blast injuries are not a

direct hit to the brain or the the blastthrough waves. and often what happens with that type of injury, the person not only has the effect of the blast on their brain and those brain cells, but the person is also thrown and hits their head within their vehicle, on the ground, etc. that is a different type of injury. on ans a double dose individual, who is already been exposed perhaps to similar injuries. but just like the stories you of our football players and other athletes who want to hide their injuries to be able to help their team be strong, our military personnel to the same, all too often. what we need to do is make sure we reduce the repetitive nature of those types of

injuries. the type of injury that one gets, let's say, in a foot all , isium -- football stadium not necessarily going to be that same type of last followed by followed bylast hitting, but it is going to be some kind of impact to those brain cells. the was described early, stretching and sharing of those neurons that lead to this within thosesis nerve cells. it does not matter how the hit happens. the same changes going to occur, leading to the same acute symptoms. >> i want to ask, mr. nowinski , do you have any observations about player suicide? >> clearly, it is a concern. whether it is in wrestling or in the nfl.

last thing you would ever want to see occur. i think at this point, there's just not enough information to be able to say that they are connected. i think that is one more thing wouldunding into research help us to provide, more context between a relationship with depression and traumatic brain injury, but at this point, it is not there yet. when we look at some of these players who have come to this point, it is really hard, i think, to make that connection yet today between traumatic brain injury and suicide. >> thank you for the question, chairman nelson. is extraordinarily complicated. there are some them -- there are some things we do know. one is a cute traumatic brain risky does increase your of suicide or suicide ideation within the next year from

certain studies. we do have in our brain bank some teenagers who have taken hours ofes with in 24 suffering a concussion. there is something going on there. in long-term cases, people suffering from cet, it is hard to know if there suicide was linked to anxiety or depression issues the disease brought on. certainly what is consistent in it hasases is alienated them from their families. they are unable to work. that guilt had some role in their conscious decision to take their lives. but it shows how much this disease does affect families. toif i could add something that, just talking about the science of it -- suicide is a very complex, very tragic occurrence. but what we do know is

they can indeed be to changes of the motion and the changes of impulse control. fose are two of the big thing -- affected by this disease. the amygdala, the home of a emotional regulation. and the bottom parts of the frontal lobe where we control our impulses, where we stop our inappropriate behavior. if you have an individual who sadness ande and emotional this control -- discontrol and then they have the inability to stop an impulse, that may lead to that very tragic recipe that eventually turns the suicide. -- to suicide. more subject to

this type of injury than men? >> the data would say yes. in sports like soccer and basketball where the rules are very similar, women suffer more concussions. the prevailing theory is that it is likely biomechanical. takes less ofit an impact for their heads to move rapidly in the brain to move quickly. and playingitle ix organized sports for not so long, we do not know the long-term consequences. we only have a handful of female brains. we are not sure what we are seeing there but it is this concerning -- a disconcerting. coach or are the team dr., what is your best way to make an assessment as to whether or not your player should be able to continue? >> i would say first, you do a

memory and attention test on the sidelines. nowadays, we know a lot of arees after a concussion related to balance impairment because of inner ear damage during the concussion. a quality test for balance as well as quick thinking memory attention is probably the most common thing today. thates that get into impact -- the immediate postconcussion assessment and cognitive testing? >> the impact test is the most common assessment for - - not really sideline testing, but athletic testing. is used most commonly as a baseline test before a season. after someone is injured, it is used again to compare the performance what it would not be used on the sideline. it takes too long, the environment is not appropriate,

and what is very important to know is that many of the symptoms of concussion are not immediate. they may not occur for hours or perhaps the next day. if you are a coach trying to make a decision, have adequate medical staff on hand whether that be athletic trainers, or team doctors who are well-trained in concussion assessment. and those medical professionals should take it very seriously and be independent of the coaching decisions. so they are not pushed in any way, shape, or form to send someone back to play before they are ready. one other thing to note on the impact test is -- we are finding that athletes are now failing the impact test on purpose so that their baseline is now lower to start out with. if in fact a concussion occurs, a do not have to get back to

what truly is the normal baseline, but one that has been fabricated because of choices they have made during the test taking. this is about changing the nature of this injury and really getting people to care about their brains so that they don't make choices like that. case, you mean that enables them to get back out on the field. >> it takes their baseline and lowers it so that their results do not have to come back to what really would be there normal baseline. -- their normal baseline. >> they would not take the impact until the day after. you are doing a quick and dirty on the sidelines to decide if they are going back and immediately or not and then you're holding them out and doing that check towards baseline the day after and every seven days until they return to normal. >> there have been a number of athletic organizations that are

getting involved in the business of donating millions of dollars to research. some through nih. the public be sure that these donations do not bias the outcome of the research? >> i can speak to the nih donation by the national football league. the nfl gave $30 million to the anndation for nih which is organization associated with the national institutes of health to accept money from the private sector to then be used for peer-reviewed research. there is this firewall between accepting the money and then the review that is done through nih, not through fnih. the goal of the nfl giving that

money was so that it didn't have any conflict of interest, so there was not any length favorites -- playing favorites. supporthere to truly research of vatican be peer-reviewed and funded just like any other nih research. in that case, i strongly support it. >> final question. a recent medical journal said emergency room visits for these 's haverelated tmi increased by 92% over a 10 year. period. parent, you have a child, they want to play sports. if it is a contact sport, do you let them play? let's go right down. mr. nowinski? >> after doing this for a long time -- >> we have to go vote. >> i am saying definitely no

context boards with repetitive brain, and -- trauma before high school and then after that, we will see. i think do not let them get hit in the head hundreds of times a year before high school. >> i have to agree with mhim. there was a high school in texas who has gone through flag football up until high school. you see players in the nfl who did not play football in college -- they were about ballplayers but they became pro bowl players in the nfl. ct remove context boards until high school and still teach fundamentals? correctly how to tackle but removing the contact? i think you can. >> i agree. i still have my concerns about how large and fast high school players have gotten today, it would still be a major issue. but, at least we have removed

anybody under the age of 15 or 16 from being engaged. >> i think we have had a tremendous knee-jerk response in our society to limited research that have led to a lot of, perhaps, scary stories that are passed along. that is before we have adequate science. we also have to think rationally and make rational decisions. i think people are now understanding that hitting your head over and over again is not necessarily a good thing for you. i would agree with everyone else that at the very least, contact sports with repetitive hits to the head should be limited to as late as possible. >> we especially want to thank our special guests. andant to thank all of you most illuminating. senator? >> i am wondering whether the record could be left open. this has been such a good panel.

i have additional questions i would like to submit. >> the record will be kept open for five days. >> thank you. >> the meeting is adjourned. [captions copyright national cable satellite corp. 2014 >> several live events to tell you about. victims of child trafficking maybe unidentified or unreported because of gaps of training and education. that is on c-span [no audio]

-- c-span3. and hearing on european energy security. chaired by chris murphy of connecticut. it was part of a delegation to eastern europe that included a stop in bulgaria where numbers urged government officials to [inaudible] that would allow russia to transport natural gas to europe. and the returns affairs .ommittee you can see that on c-span2 at 7:30 p.m. eastern. >> 19 keep in touch with current events from the nation's capital phone, anytime with c-span radio on audio now. call to hear coverages and journal"washington

program. you can hear audio with the five networks sunday public affairs programs. distance or phone charges may apply. >> now a look at the israeli-palestinian conflict hosted by the woodrow wilson international center for scholars. this is little more than an hour. >> got it -- good afternoon and welcome.

this is the day after a major federal holiday. it speaks well of you that you explore what is an incredibly timely and troubling topic. to me, someone who watched the middle east very carefully during 17 years in congress since -- and made 25 trips to the region, there is clearly reason to worry that it could be on the cusp of a third intifada. that is something we will explore. hopefully, heads will prevail. the tit-for-tat where watching -- we are watching hourly between the israelis and palestinians is extremely worrisome. i have heard conversation on some of the talk shows today

about the need for special -- a special envoy. that is what our moderator was asked about on cnn earlier. most think the egyptians are in the best position to play that role but as yet at least to my knowledge they are not playing that role. comes at aversation crucial moment. for starters, who are the palestinians? governs themnt if any. does the palestinian authority reflect the integration of thomas or not -- hamas or not? investedn center has considerable time. close to half our briefing which

are conversations about hotspots, close to half of our knee and -- nearly ground [inaudible] have been devoted to the region. our guests will be introduced by aaron miller. we have hussein ibish, a senior fellow at the wilson center, a close friend of the wilson center, shibley telhami is professor at university of maryland, and rob danin is the former secretary of state on near east affairs. our moderator is aaron miller. the show begins right now.

>> thank you very much, and for your leadership in the wilson center. i want to acknowledge three people who are not here. they may be watching. a wonderful person, who is having cataract surgery today. i know you are watching, and thanks for everything. when i drafted the invitation for this event, it read something like syria-iraq may be dominating the headlines, but the israeli-palestinian issue remains. for this event, it read something like syria-iraq may be dominating the headlines, but the israeli-palestinian issue remains. none of us who have watched this issue and followed this seriously include my colleagues would reject the idea that violence and terror has been a handmaiden of this process for over a century. what we are witnessing may or may not be new, but it is a

reminder of the costs and implications of no resolution of the conflict. since 1967, i would argue you had a different iteration, a sort of perverse dance with its own perverse intimacy between israel as the occupier and palestinians as the occupied. it took the conflict to a different level. israeli power is strong. palestinian power is weak, which is also terrifyingly formidable in its own right. together this interaction guaranteed and continues to guarantee real dysfunction, tragedy, and of violence in this content. the answer to this, we know what it is, a two-state solution, the least bad option, but that is not happening right now, may not happen in the future. we have chosen to focus on the

palestinians and their politics, because i believe the two peoples may be focused in the months to come. i would like and i can influence the research -- to a certain degree my colleagues' presentations -- by arguing they should stay away the peace process. i cannot control your questions. it is not a problem of one hand clapping. reality is influenced by israel, but we want to drill down now on the palestinian guy mentioned. i want to close by saying one other thing. it is important to focus on the palestinians. the years i was working we did not. we focused far more on trying to understand the israeli reality, which is necessary, but by no means sufficient if in fact we

really want to produce an equitable and durable solution to this conflict. the rules are simple. five minutes each them and we will start with you. i may ask a question or two. then we will go to your questions. again, one last comment. questions, not station identification. we really want to get in as many questions as we can. there's only one way to do that -- no comments, just questions. thank you so much, and thank you for coming. >> thank you. the first thing i think that ought to be noted about what is happening at the moment, in the context of this flareup of tensions to the palestinian

polity and what it says about where politics are, is that it is inescapably connected to its broader regional context. what has happened to palestinians and within the palestinian polity and what is going to result is reflective of and dependent on broader changes in the arab world. there's no way to separate the palestinians out from the broader regional context in which they participate. while we look at this, remember that a whole series of questions are being asked of the arab world, which are not resolved yet, and it is reflected in iraq and syria, lebanon, kuwait, and libya, among other places. i can mention those because they are all experiencing their own crises. i think there are related and analogous questions being asked in all of those crises as well. in this context, one of the most difficult aspects, not only for palestinians, but also for israelis and others, is nobody is in clear control of the situation partly because of where it is flaring up and partly because most of the entities, including palestinians, are in their own form of crisis.

for one thing, a lot of this has been focused on east jerusalem and other parts of jerusalem as well. in jerusalem, really, the palestinian security forces cannot maintain order because they do not operate there. they just do not have that -- to do it there or the manpower. president abbas' ability to influence what is happening in jerusalem is limited, even that is being greatly undermined, so that is one thing. even further, this is being manifested in arab parts of israel as well, and there i think the ability of traditional palestinian leadership to exercise any kind of control is perhaps even less. and so in a certain sense it is very hard to lay the consequences of things that happen outside of their area of purview at the doorstep of say

the plo or the pla because they do not control the situation. and their ability to control what happens in areas that they do have authority in is being very much undermined. in addition to which, obviously they do not have control over the people in gaza. it is fair to say that hamas is experiencing a very serious identity crisis and leadership crisis as well. and the ability of its political wing, particularly the politburo, but even others within the political leadership to control all its factions is certain the questionable. the extent to which anyone is could in control of the situation as it is unfolding in terms of creating a real break on it or imposing a political solution is quite limited and it is very important. this is particularly the case given the level of anger that

has been brooding over the years, that has driven the situation to the point that people can target children, knowingly, deliberately, callously, and call for revenge as a substitute for politics and policy. and that i think is the fruit of some very seriousness by all parties, and there it is, for all to see. it is driving things. in addition, those calls for revenge only increase the cycle of incitement, and obviously, just behind the scenes, settlers are taking advantage of the situation to create more robust attacks on the ground than before, that are much more robust than that, and it is very worrying. the other thing going on is that

realities on the ground have been allowed to slide by a concatenation of certain things of which everybody has the share of the blame. particularly since the state and institution building program that was bringing deliverables to the ordinary palestinian people, particularly in the west bank, was defunded and allowed to fizzle. we have not had a political safety net to catch that fought at all. and no obviously peace process to back it up. so in that context, you have to ask where political momentum for sustaining and unsustainable status quo might come from. it has not, and everything that defines the status quo who is in crisis, influx, and may not survive the president's duration. i am inclined not to prognosticate, although i may be asked to, but to be analytical and rather than prescriptive, i

would say you can see all of the different feelings leading up to this current situation in almost with the dark inevitability of greek tragedy, and where it is going to go from here could be very grim or it could be attenuated, depending on how responsibly it will behave in the situation. and it is hard to evaluate how that is going to work out because as i say it is not always clear what the ultimate address is, and with that i will stop because i've used up my five minutes. >> thank you very much. >> i would like to make a couple of points. the first point is that the current situation reminds me of 1987, the advent of the first intifada. i happened to be visiting in jerusalem just as the three young israelis were abducted, and then went to ramallah after the first israeli operation that led to the death of a palestinian and then was shot

down while i was there. and my reflection is based on a couple of things. just before the abduction of these israelis, i had met with a prominent israeli journalist who was frustrated that there was an absence of hope in part because of the absence of urgency, that the israelis live in what appears to be normal lives and there's no sense of urgency, no cost. she was hoping for a follow-up to the european action against settlements as something. obviously, these tragic events created a sense of urgency. when i look at it, i reminded of 1987 for two reasons, and that you can capture in the mood. one reason is when you look at the advent of the first intifada, it was really a marginalization of the palestinian cause internationally. the 1980's were characterized by the iran-iraq war, in that mood

is similar now, where it clearly the egyptians, and the saudis and the qataris, everybody is occupied with their problem and not enough attention is being paid to what is happening in the west bank and gaza, and that is what is the problem for the palestinians. if you look back at 1987, it was in the marginalization of the palestinian leadership from the people. what we had seen really beginning with the israeli invasion of lebanon in 1982, was the plo became exiled in tunis and pretty much remote and effective in catering to the palestinians. the palestinians were left alone. we do not have palestinian leadership in exile, and they are in ramallah and gaza, that you have a sense when you talk

to almost everybody, including the moderates who want to work, with the palestinian authority, that they are disconnected from the public. the public does not take it seriously. in fact, one of the reasons why we had that national government is they both risk being totally irrelevant, and each individually, and they came together to become more relevant. that is the context in which it takes place. add to this the fact that there is a creeping realization that may be the days of the two states are numbered if they are not gone already, and there is the sense of kind of reconciling themselves to a reality that is not happening. it is only a matter of time before you will see something take place. we risk a major intifada because of the circumstance. the second point, when you witness the ugliness of the death we have witnessed, where there have been horrific murders of young people, cold-blooded on

both sides, and you would hope and we all have asked that question, and people start asking themselves, is this what i want to become is this what the conflict is making of me, is this going to lead to applying that breaks on violence? i have the unfortunate feeling that it that it will not. this is not just because of research i've been doing over the past 10 years. i ask israelis and palestinians and other arabs about empathizing with the civilian casualties of the others when they witness them. and the liberals and others will feel empathy and pain, but the majority, unfortunately, will not, and they will feel more resentment and say they brought it upon themselves. the first reaction we get from israelis and arabs is when they witness civilian casualties is they say they brought it upon themselves. that appears to be very much a

function of one thing -- their assessment of whether there's going to be peace or war. they have to harden their heart to prepare for conflict. when there is peace, they empathize. where there is a prospect for peace and hope, they empathize. we are at a moment where people are assuming we're headed to conflict and they do not want their hearts to empathize. they want their hearts to harden to fight a bloody war, and that is the reality we face. >> under the time limit. rob? >> thank you. as we speak, this afternoon israeli troops are massing on the gaza border and hundreds of rockets have rained down on southern israel. we may be heading for a major confrontation that i would argue neither side really wants, but neither side may be able to

avoid. i will focus on the israeli side. what we have today is really the utter despair of palestinian politics. the two major forces are both reacting to events, not leading them. neither of them have a strategy for attaining their national goals right now. what it means is they are locked in the politics for survival. there've been no palestinian elections since 2008. no presidential -- or legislative elections since 2006. the divisions in the west bank and gaza controlled by hamas are widening. it is against that backdrop that you have to look at the national agreement reached in april between the two sides. they did not agree on any

vision, on politics, on how to reconcile their competing services. they set up a mechanism to try to address the absence of legitimacy, and that was elections. it was a response to something that is popular amongst their populace, the clamor for unity on the ground. now, the problem has been for hamas, controlling gaza did not really produce anything. they were being squeezed by egypt, and likewise fatah was not producing anything. you saw that spray-painted graffiti. this is against the backdrop of the recent violence. against that backdrop, we had

the national unity government since april, and it has hurt the palestinians, where 50,000 palestinians in gaza have been not receiving their salary payments since the agreement was reached. hamas is under pressure now by israel at the same time to rein in radicals, but it needs to show it is not passive to israel. you see neither side within palestinian politics really wanting this government to survive, but not wanting to be blamed for bringing it down. both are having a sense it will just atrophy by itself. are we on the verge of a new intifada? i agree that there are real analogies to the situation in 1987 and 2000. what you saw in both cases was

popular discontent with the official plo leadership, when they seem to be so removed from hardships on the ground. in that situation you had palestinian leadership play catch up with developments on the ground, not lead them, and that situation is rife today for the similar type of situation, even the absence of leadership within palestinian politics. what we do not know is what is brewing underneath the surface. there've been committees that have come out that are added hating a third into the topic, but we do not know yet. what we do know is the leadership is reacting and not leaving. this is not a strategy forward. short of an intifada, there are things that can unravel. things that can unravel i quickly. tomorrow there should be a beingence by leslie

newspaper. the palestinians were pressured not to go. with this showed, the first any --was that anything, raise rose going to breakdowns the one major attainment that we have seen in the last decade between israelis and palestinians, unprecedented, and i will and on this note. the price for returning to negotiations will go up come on down. and it is already pre-stop with that, i will and. >> i never thought that the could be a more annoying. societies end up having to take a long and -- long look in the mirror. whether we took a long look in the mirror with the candy exact jewish and assassination, i

don't know. -- whiskey kennedy assassination, don't know. in effect, the travel ovation, establishment, could it have any amelioration of effect. what would it -- require from an external entity. >> when people assume that peoplet is a mission, find it the cult to question the moral stance. there are two things that work for both israelis and palestinians to have more inflection. -- reflection. one thing that is happening in

the region, people are terrified. they know how ugly can get. with the death of several people over the past couple of weeks, horrific. what when you compare it to what is happening in syria, or a rock, people don't want that. you can see the backlash. we can see it even in the rallyingbout people behind the state with this anarchy. i see a mood that does not want to see an explosion. aching get a lot buddy and allot worse from of them. as one. second, perhaps on the israeli side, there is a real internalization that it is a -- if a two state solution is going to happen now, it's never going to happen. whether he was a delusion or not, there was a sense that

there was more time. i don't think anyone believes there is more time. they may have to figure out a more -- another way, or perhaps they will have to swallow hard and do what they have to do. those are elements. they are providing sums restraint -- some restraint. when you get benjamin not to --e -- n'djamena tejano benjamin netanyahu looking like therestraint person in reaction, it gives you a flavor of where things are. i think that is a point. whether that will be enough, it does require leadership. in the end, obviously, events on the ground, some they can read -- preempt leaders. hmas norr

the leadership can see what is different. what came before might actually be an ally. including what came in the first and second intifada. if i'm looking for hopeful friends, are there any? >> you asked about third parties. that is an area for hope. ways inthere are two which you can look along the immediate -- beyond the immediate crisis. -- dave lend

themselves to the question of what can be done, by third parties or national, including the united states, for what change can happen. are very dependent upon the supporters for budget -- otherd others things. they gives regional and national players more of a say in the way that house means see things evolve more than normal in what usually occurs. there has been a great constriction in the event of palestinian in the last few years. the inputs are restricted. there has to be an opening up of palestinian political space. this is actually -- absolutely crucial. third artist can play a big role. the other thing is the frustration that we see on the palestinian side does not only have you with little will -- political frustration that can

be explained in the political context, but the shutting down of space in civil society and economic growth. it was there in the institutional and state building. to veryin, it goes straightforward things like -- that israelis can influence and third parties, in terms of economic growth. there are things that all kinds of funders can do in terms of a large amounts of small projects, small projects that cannot be hijacked. big orrojects it can be little cleans for lots of little projects throughout the territories that can be transformed. i think it is very possible. it has not been tried. i don't see why it should not succeed if people want to did. >> on the question of violence, i think that what we have seen the last few days has been a real convergence of violence in

three distinct areas. one is, israel itself with the air communities. the second is the west bank. the third is gaza. i'm more concerned about israel and the violence there. it is in gaza that i see in next -- and next violence and that -- -- incalate torry minds the absence of violence, would it was hoping to hint at or suggest is that in terms of israeli or politics, i don't think either side will be right in terms of the political movement that will be needed to make clinical progress. -- political progress. >> one lightning round question. that is, a concerns john kerry, and not the broader issue of his comprehensive agreement. what should the u.s. respond to

now? in the battle days when there were only two sides to this conflict, and right now there are three. and it used to be air if that and the israeli prime minister -- arafat and the israeli prime minister and thomas, and we would usually pack our bags now. in september of 96, we ended up spending three months in pursuit of the agreement that we actually got over hipper on -- , but that was actually worth this. should john kerry, and the tiredness of the situation that exists right now, should john ?erry pack his bags >> pack his bags, no. the u.s. has a resulting -- a

role to play. it or not, int think this administration believes it has one more shot at trying to get them back at the negotiating table. if i am in their place, i would say that what we have seen is horrible, but this is an opportunity. there was a sense of urgency before, but now there is an urgency. i can try to turn his urgency into a way to get them back to the negotiating table. that is the way he's going to think. therefore, the real escalation is going to take us way -- away from what will make us lose control. we have to figure out a way to prevent the escalation and how to stop it. and we have a role to play in that. where will the influence come from? where is the leverage? who has the leverage? at the majorack confrontation between israel and hamas and when morsi

was an ally. for, us -- a way the to get a way for government. undoubtedly, it will be a way for the egyptians to figure something out, but in the end, it will be an israeli decision. frankly, i don't think that, us is in the decision. i am just wondering whether there is anything, really, the u.s. can do to stop the israelis from carrying