nih. then comes the $50-some billion to take that basic knowledge and convert it into real medicine that can save a real human life. where does that money come from? essentially from two sources. sales of product, existing roducts, and then investment and people who buy stocks on the open market. those investors don't make those because they want to cure disease. they do it for return on investment. this is among the most risky enterprises there is to most projects fail over and over of money expenditures is enormous and most of the dr. hamburg's company proves never returns

the investment. so to attract those we have to make sure that those investors have confidence that if this is a good product it will be approved in a timely fashion and that it will be reimbursed in a reasonable fashion and if you look at -- i hate to do this but if you look at the case which cures hepatitis c, no more liver transplants, it will save american society enormous numbers of dollars. it's going to cost to pay for that drug but in the long run it is because of successes like that that investors will say yes let's put more money into this enterprise. >> i think this idea has multiple layers of benefit to health care and the development of new medance. we had a truly net worked

electoralcal medical records in the u.s., it would also be a network for health care providers to find patients similar to their own in terms of demographics to stage of disease to collaborate in terms of treatment and health care and finding out what has worked, what hasn't worked and u how can that be done in a more systematic way. it would allow us to follow patients treated with different drugs according to label and not according to label to see at kinds of adverse events with the way physicians are treating their patients. but in addition, it could also benefit the cost towards clinical trials. right now you have your medical record, electronic or not, and you have a data collector that pharmaceutical companies use to collect data for the trial. and data is entered separately and then has to be verified by

individuals who go to the site to verify this transfer. if the medical record became the primary source of initial data entry there would be no need for that. data would be easily uploaded and be the primary data. there would be no need to clean data, which is another process. so this would have tremendous impact not only on health care but also on the costs of clinical trials. >> dr. carden. >> just before we move completely off the question of funding i h -- nih thought i would raise one point in support. virtually every major farma has reduced its rd resource over the past five years and those same companies are trying to find better ways to work with

academic investigators so that really both sides play to strengths in a collaborative way and farma brings what farma does very well, chemistry, interacting with regulators and works together with those investigators. to bring that basic science. amongst those creative ways to work together are emerging some threeway partnerships with the venture capital community. so we're creating companies and jobs together with those scientists that are n.i.h. funded. to the extent that funding goes away we go from job creation to reduction because those young creators no longer have an outlet. so everyone loses. >> did you have a question? >> we've gone over this at

length but i just wanted to hime in. on the discussion regarding funding for young investigators because i've lived through this. the federal government spent considerable amount of money to train me to become a physician scientists and then it was very difficult to secure funding early in my career. so i went in an entirely different direction. and certainly there were a number of colleagues of mine who i thought were extraordinarily talented who also chose to pursue different career paths because of difficulty with secure funding early on. i just wanted to bring that oint home again. >> while we're talking about funding, one thread that i keep hearing is cost.

he cost of regulation. we can talk about electronic health records. the availability of data through that for both comparative as well as predictive analytics but the hipa law is going to restrict the access to that. it started out as the health insurance portability and protection act. for the purpose of being able to move from one insurance company to the other and protect that. and so that the information was available. the regulation that has come rom hipa is strangling research as well as the ability to compare the health analystics there. so it's like the patient protection affordable care act. a little over 2,000 pages.

it has spun more than 700 regulations and the regulations exceed 21,000 pages at this point. and i would assume that continues to grow. so when we think about funding also think about the ability to reduce cost so that we are able to use the dollars better than what they have been in the past. >> thank you. i wanted to ask a question. we had a hearing in the health ubcommittee i think the end of july on whether there are currently any barriers to communicating on how drugs and devices are working in the real world. and we know we continue to learn about them after f.d.a. approval or clearance. the question is, how can we ensure that truthful nonmisleading information about real world safety and effect --

and this reaches doctors and patients, as soon as possible? what role do you see for companies that have dealt with these products playing in the process? >> well, first let me comment on how important the ability to monitor products in the post market setting is and whether it's drug or a device, the ability to really have that life span approach has been enormously valuable to the f.d.a. and congress has worked with us to give us the tools and the authorities for a more robust post market individualles approach and we appreciate that. many comments made about the interoperability of electronic health records speaks to the availability to do post market surveillance in, as effective a way, as possible. but we do have systems in place

stronger now on the drug side than the device side, to be able to monitor many patient lives and experiences with products in the post market setting and on the device side we're in the midst of really expanding those activities and i think it will make a difference. and it makes it -- frankly as you're looking at the premarket approval, if you know you'll be able to follow in the post market setting where you learn much more about a product than you possibly can in the premarket period with a limited set of clinical trials even if they're large clinical studies they don't give you what the real world experience does. so that's very, very important and we really value the ability to do that monitoring and sometimes ask companies to do studies in the real world. in terms of how do you communicate to patients and health care providers, that's a bigger question in many ways

because it really does involve the partnership of our having the information and making it available but also many others including our partners in the health care delivery system itself helping to give the information out. and i would say one thing that is important to it is that f.d.a. has i think increasingly realized our critical role and rather than operating sort of in isolation really trying to work more closely with our stakeholders and partners to get information out, whether it's patient groups or health care providers or professional societies, or the media, but that has to be the communication issues become i think really ones where there has to be this two-way communication. we need to be able to provide the best possible information as quickly and clearly as possible and using all the

different tools of the media that are now available to us. but we also need to get that feedback back to us, where the problems are, where the gaps and understanding about appropriate use. because you can have the best drugs possible and if they're not effectively used they don't provide benefit and they can even provide harm. >> jim. >> i took your question to go to the issue of off-label promotion. am i right about that? so when a drug -- already well, i didn't. i figured it was a broader question. >> it may not have been but i'm going to run with it anyway. when a drug is approved it has a label and it's clear the company is then permitted to promote the product to physicians and patients for that matter consistent with the label and not to push -- because product has not been approved for other use. doctors on the other hand have the latitude to use a drug off

the label and beyond a label. and so what happens is sometimes companies -- and their overly enthusiastic sales forces -- commit violations and for that they are freetly fined and fined in huge numbers, billions and billions of dollars of fines have resulted from these cases. nd we have a system where -- a former employee for instance or current employee can blow a whistle they can get a lawyer and then under situations the lawyers and the whistleblowers can take huge percentages, 10%, of what could be a $1 billion fine. so there's huge incentives. and then if the company lilt gates and loses they get delisted and they can no longer have their drugs reimbursed by the government programs. so that's death to a company. so they settle and they settle for huge amounts.

something we need to protect against bad bare here but i think we need more clarity from the congress and from the f.d.a. as to where the lines reasonably should be drawn to avoid both the ills that are derride from inappropriate promotion and the ills that are derived from overpenalizing behavior by some portion of a company. >> and just to elaborate not speaking from a legal point of view but from a medical point of view, off label use is very much a reality and we all know that. and in many areas of medical practice it is especially important and prevalent. and i think if we could really move toward provision of more integrated medical records, more openness of communication, we could learn a lot about off

label use that would be very valuable toward advancing medical practice. and the way the system currently works it's usually not in a company's interest to do the kind of data collection and studies to bring a product that's already approved for one use before the f.d.a. for a second or third off label use but in fact it is very important from the perspective of medical care and patient benefit to know as much as we can about those drugs and their use in other medical treatment settings than just what it originally came for the f.d.a. for approval for. > mr. chairman, off label is a no-no word in my world. if that was not your intent, then let me go back from a safety perspective from the patients. i think the f.d.a. is doing the best job in the world when it comes to patient safety. and their warnings systems with

or without post surveillance, post surveillance where appropriate is a new and -- a new tool to be used in this manner but i do not think that we have a patient safety issue in this country. i think the f.d.a. is doing an excellent job in keeping risky products off the market or taking them away once they find out there's risk. >> venture capital going to the e.u., what's their record on patient safety? >> it depends on how you measure it. we know one thing is there are not more recalls in the european union than there are here in the united states. they have a different recall system. but all in all i would claim to say -- but i don't have any scientific data to support that -- that we are not riskier in the european union than we are here. i can assure you for the company. for the company i don't have -- -- i don't have data to support that. i would think the we would work

closer together that products apprufte in europe would have a fast track approval here. we're working on lippeds. we're three generations behind and we're bringing the lip yids into this country ufment we're working backwards to get the next generation in. there would be a way to fast track and use that data and the experience of 20 years in europe to get these products faster approved that would make a dream come true for me. >> i think it's really important to clarify that the device world is different than e drug world in terms of approval speed and where first in the world approvals are happening and on the drug side it really is the united states and we are the model that others strive for. devices is different because there are different regulatory frame works. and i would say in europe as you well know after some very

prominent safety issues there's been some discussion about their regulatory framework but i think the goal is not to sort of look at whose system is better but to look at what is the best system we can move towards overall. and i think we work closely with our european colleagues. i just came back from a meeting where i had an opportunity to be with many of them. and i think that what's crucial is that we really look at the science that needs to drive decision making and when do you need clinical data and when don't you. you mentioned about the device consortium which is a public private partnership. looking at things like developing computer models for doing some of the testing so you don't have to have more expensive and potentially risky clinical trials. you can do some of that testing using various other kinds of

markers and surrogate end point, et cetera. there's a lot i think that's going on. but i do think that you also have to look at the reimbursement framework in europe. this is a discussion maybe we should have more off line. but many of the products that are approved first in europe with less safety and efficacy data in fact are not reimbursed by the national authorities. they're available to patients who can afford them and data is collected. and we also do use data from europe for approval here. but it's a different context. >> reimbursement is quite different with the private insurance systems. i'm glad to hear what you're saying. i don't think we have a dissent there. working together and finding these commob ways and using knowledge to get the products faster but safer to the patients we have a certainly a common mission. >> absolutely. and i think progress is being made. >> i agree.

>> i've been asked to say that for those folks watching on c-span we want to hear from you. please email your ideas to cures at mail.house.gov. your input is critical. this has been a tremendous forum. some wonderful enlightening and interesting discussion. now, members are going to be having forums like this all over the country in the next month and when we get to washington we will meet together, share the insights that we received at these roundtables, the recommendations and ideas, and i would like to thank all the members, we have lost a couple, all the panelists, the public for attending today. i would like to thank each of you for taking time to be here. we look forward to working with you in a collaborative effort tomorrow on this. so thank you. and this roundtable is adjourned. what an energetic rec.

-- presentation.

to becomenecessary the mayor of san antonio to become secretary of hud, but it does not hurt. i am proud of san antonio. it is the seventh largest city in the country. there has never been a city larger than san antonio to have had an african-american woman in sanwhich we now do antonio. it is an inclusive place. even though the african-american population is relatively small, she succeeded coolly on -- juli an castro and speaks to the kind of breadth of the city. i am proud of what we have accomplished. lisa, you are a pioneer in your own right. lisa has been a fellow -- presentation -- president of the

aarp foundation for 10 months. she was a president of a college in upstate new york before that thank you to you and the aarp foundation for this report. withhe rest of the team, whom i have worked over the years. best placesf the for analytical work on housing in the country. i thought chris did a great job of taking the mass of information and making sense of it. thank you very much. to you and your team for that could work. these are two organizations deserving of the respect accorded to them. the joint center for its high-quality analysis. foundation for decades of advocacy,

establishing lifelong sustaining programs. iconic programs. insurance. so many other things that touch the lives of seniors across the country. importantly, for sending the warning bell of the work we need to be doing as a country to support older americans. this is a most important report. it is hard to break through the clutter of important subjects at a time when the news is full of worrisome crises. isis advances. the palestinians trade blows. russia threatens the ukraine. we face unaccompanied minors at the border. v.a. care. congressional stalemate. it is hard to raise a subject like this to the level of attention it deserves. on housing and supporting aging americans addressed and -- addresses a set of demographic and financial

demographics which have the power to profoundly impact our nation. and its people. may not be in the headlines daily. they may be slower burning. they have the power to profoundly impact our way of life. they may not affect all of us personally today. the effect some of us today, including people who are suffering deeply because of the way the issues come together right now as we speak across the country. of everythe life american, including every person in this room, will be touched. the challenges of housing and supporting an aging population are not unique to the u.s. japan is the oldest country in the world, and aging most rapidly. because it is not

a country that has welcomed is actually losing population. some of the northern european countries like france, scandinavia, and russia, are on a path to declining population. spain and portugal are on the same path. china, by 2040, will have more people over 65 years of age than the u.s. will have residents. will400 million people have reached 65. the dynamic is impacted by their one child policy. the interplay is huge on the world stage. error aging problem as a nation ngy be different -- our agi problem as a nation may be different. we have a growing population. we were real 6 million in the census of 2010.

inwill be over 400 million 2050. you have resources being generated, taxes being paid. the economy growing. that is hugely important. largely a function of the fact that we have younger populations and immigration. lest you think these things are unrelated, they come together in the national debate. still, despite the fact that we will be growing and will be able to manage some of these issues -- at least will have the resources to do it -- the absolute numbers of aging air americans are starting -- of aging americans are stunnin g. about whateflect some of these things mean.

this report is about housing and support systems. the scale ofby demographic change, and also about money. the personal assets that people have or don't have to provide for their own housing. we have a big problem. the scale of the change is big. population of 20 million americans over 65 will grow to almost 40 million by 2030. the over 65 population will double over the course of the next 20 years or so. that is a mass of people. and get off this, an airplane and see how many we'll chose there are lined up. ourcharter site he --

society is changing because of the size of the consolation that is aging. we are talking about eating -- doubling the over 65. that is because the blaber boomers, twoy point 8 million turning 65 in 2011. today's population of people over 85 6 million. that will grow to 20 million people in the same timeframe. the over 85 ovulation will triple. by 85 years of age, two out of three adults face cognitive, hearing, mobility, or vision challenges. the scale of the real-life impact -- what this means for real people in massive numbers -- is huge. the second dimension that makes

this an important issue is money. how do we pay for the needed housing and care? if wen make the case, knew at the systems to pay for it were, it would solve itself. the market would respond and the government would have enough money available. if you don't have the money, that doubles the impact of the problem. many aging americans do not have personal savings. governmental budgets are strapped. in 2012, 1 third -- one third of households were burdened. 20 million people were paying more than the suggested 30% of their income for housing. half of those were severely cost

burdened. meaning they paid more than 50 percent of their budgets for housing. that's the number that chris was referring to earlier. they pay 40% less for food than the average household and 70% less for health care because they.do not have it . pay 50% of their budget for shoulder and have anything left over for the other things. these are people over 50. 6.5 million65, households have incomes over $50,000. -- $15,000. imagine trying to live on that. that is an increase in just a day code -- over a decade ago. 77% of those are cost heard and with more than 30% of their budget go to -- going to shelter.

in our country, those who have invested in home ownership have some net worth. assets. it is hard to believe that among the elderly, those who are owners -- people over 50 years of age -- among that age group, those who are owners having it worth 44 times that of renters. 44 times. that translates into realities . among homeowners over 65, most have enough wealth to pay for about nine years of in-home care. 6.5 years of assisted care by cashing in on the equity of their home. for renters, what they have available to spend on care is about two months. of those whoons

are owners and those who are renters in terms of what they can translate that into in terms of their care is huge. as chris said, two out of three older adults with disabilities rely on care from family members. spouses or usually adult daughters. the ratio family caregivers is declining from seven to one 2321 by 2050. to one to three to one by 2050. aging reality, those numbers will increasingly drive the budget deficit. i served on a bipartisan committee. thes abundantly clear that aging dynamic, in particular health care costs, will drive the budget deficit.

as we confront these two realities, the scale of demographics and the financial dimensions, it is clear we will need more housing that is age-appropriate for the various stages of aging. housing that is accessible, affordable, well located, linked to services, with trained staffs. healthy and safe. we must provide it because, first, it is a compassionate and responsible thing to do. it is consistent with our ideals. we don't leave people to suffer in their most vulnerable years. we never have believed that as a country. it is consistent with our ideals that we do not. [applause] it is kind of a printable. -- principle.

secondly, it is necessary to make our communities and society function or we will be overburdened with the cost of caring for those were left behind. and because we can link housing and health. type of step of the housing that is necessary, we can do better. place, for people who say they would like to stay in their own home for as long as possible. new approaches to independent level -- living, the first level of congress and -- care. new ways to pay for assisted living, the next level of care. very costly. more memory care units for the onset of alums related to dementia in its various forms including alzheimer's. where we know brain science is not keeping up with other forms of medical science. people are physically ok but at some point, begin to lose cognitive capabilities.

nursingnew skilled facilities for the number of people who at the end of life will need that kind of clear -- care. let me say a word about these pieces of the spectrum as we need them over the span of life. aging in place. the vast majority of people, when polled, say they want to stay at home. something like 94% of elderly americans live at home now. connection to health and peace of mind for many of them that they are at home. a doctor at stanford has put together a framework called compression of morbidity. to changefind ways the arc of decline over time,

imagine an arc that begins around 50 and declines over time. if we are able to change that trajectory to one that is on a plateau for a longer time, and then inevitably there is a drop but a sharper drop at the very suffering and also, a men's-- cost to society. the end-of-life costs are the most expensive. how do we keep that trajectory it includes many elements such as fitness, illuminating things like smoking, dealing with diseases that were debilitating earlier in life. providing people with physical conditions at which they can stay strong. socialize. get exercise. that is the significance of this whole issue related to the

number of people aging in place. it involves, as chris said, renovations as well as new prototypes of housing. renovations, fixing homes to put in ramps at the appropriate time . the lower kitchen cabinets. change that room fixtures. put different kind of lighting for security. accessorize with security devices by which caregivers can be called at the appropriate time. tole range of things related renovations. new -- interesting work being done on new prototypes of homes. there is a company in florida that creates what they called the liberty home. it begins with zero step interest is and wider hallways. bathroom fixtures at the appropriate height. turned handles instead of knobs that make it hard for the elderly wrist to turn.

they are finding if they do it at the time they construct the home, it ends up being cheaper than having to come back in and it do it later. there is no problem in having these things in place for younger generations. we can create the life span home that lasts over a lifetime. there are things that local government and the national government can do to encourage both the renovations as well as the new prototypes. universal design features by ordinance. builders as is being done in ohio to encourage the inclusion of universal features. grants and loans from states as is being done from massachusetts. hud and the federal government can play a role in community development block grant programs , which has a great deal of discussion -- discretion at the local level. timee always felt it was

to think about something like the weatherization program, which has done a good job in retrofitting homes for energy. we need to think about retrofitting them for life span capabilities. we can adapt that program or the same thing and create lifespan settings. even programs like medicaid can be adapted so renovations are possible under it and medicare as well. i am vice-chairman of habitat international. is to my commitments incorporate a prototype home for our volunteers. if they are going to be building, we ought to be building with some of these use in mind. habitat will be building 100,000 homes a year over the next several years to read -- years. we are about to finish the millionth home around the world. it is not an insignificant

commitment from volunteer organizations. and then there is the reality of changing existing communities. naturally occurring retirement communities. any new communities we build. -- and of the new communities we build. likeognize that places that exists. everyone was older. a place like where my mom has lived until recently, in the neighborhood i live in now in west san antonio. the problems were different. they are not the same problems you encounter any younger neighborhood. they are issues of security. you think about it any different way. the need for in-home care and nutrition assistance. we have whole communities across america.

inn you saw that map, 5% 1990 of those counties. they had populations over the over 50 years of age for 40% of the population. in 2010, that is 33% of counties. at least 40% of the population is over 50 years of age. this is a national problem of importance.transportation is a huge issue. done town hall meetings with elderly populations in these naturally occurring places, the site isolation as their greatest fear. a sense of loneliness as children have moved out. there is no way for them to drive.

their fear of going out by themselves. aging specialists who are able to help them get to doctors' offices and groceries, very important. agingnk the offices on and their emphasis on care in homes. like those offered by mercy housing missions. in san francisco, for example. we are seeing communities doing things like changing zoning. interestingly, one of the most aggressively creative cities is new york city, which is changing, first of all it ranks highly as a place for elderly to live because it is walkable. public transit is available. you wouldn't have thought of new york city as a good place for analysist they did an

of the best places for aging and new york ranked highly. along with other places working to change zoning. zoning units that make it possible to place a unit on a lot adjacent to an in assisting home -- to an existing home. and of course the virtual village network, which tends to be a little bit on the upscale side. they are working very hard to try to find ways to make it more accessible. elementso to the other of housing. things that can be done beyond those living on their own. independent living. new approaches that involve cohousing. approaches to providing services through interagency collaboration. thateality is, for most,

many people who need independent living or other forms of assisted housing cannot get it because two out of three elderly residents a legible for federal assistance do not get it. it is not available. assisted care, the chair i'm sure -- the challenge is trying to pay for it. medicare provides only afterterm care hospitalization. we have some new thinking we have to do about these critical programs and how they pay for assisted care. memory care, we need a lot more of it. my mom lived in the house that she and my dad bought in 1945 where all of my brothers and sisters and i grew up. until one month ago. she made it to 90.

on july 11. two weeks later, had a fall and went into a facility, a hospital. the doctor said, we would not be responsible if we let her go home. and therientation forgetfulness would only result in a situation like this again. we began to look for in memory care facility. we looked for days before we could find a facility that did not have a waiting list that was 3, 4, six month long. found a wonderful place in the end. the truth is, she doesn't want to be there. she wants to go home. it is a sad thing for me to visit her. it ends with her crying as i leave. then i want to go out to the car and cry myself before i drive away. very difficult thing to

find quality memory care. we need more of it to read skilled care nursing is the next step -- we need more of it. skilled care nursing is the next step. facilities are older. we need more of them. we need more ways to pay for this. the long and short is today's report should be heard as a wake-up call. it stresses why we must act. why? because, i will repeat, it is the compassionate and right, the civilized and responsible thing to do. we owe the generations that have gone before. the truth of the matter is the human body wears down. it loses strength. as frailties increase, so do disorientation and even depression. andgivers are saddened frequently at a loss.

i edited this book on the subject of independent living. i have probably made 40 speeches on the subject. easily 35 out of those 40 times, someone, when we get to the questions, stand up and describes a personal circumstance in which they are in complete despair. it is not unusual for somebody to break down and cry in those sessions. there was an article in today's washington post entitled "we are not ourselves." it quotes a doctor. this is what the doctor said about the interface of the problems of cognitive disorientation and aging and housing. he said, this is a disease where you never twin. it doesn't just take down the sufferer, it takes down the

spouse and children and friends. ofare dealing with a reality what the human body can do over time to read it is a practical fact -- over time. it is a practical fact. if we don't have good housing solutions for people, we are not doing what we ought to be doing. when you overlay on top of these physical realities, these chronologic realities, the financial inadequacies, then we are courting family meltdowns. we are also courting the potential for a breakdown of societal systems. we will not have the resources or the ability to deal with people and cannot leave them on their own in this foldable state. ?hy communities cannot sustain economic prosperity. if you go to communities in the

rural heartland, the young people have left. we look at those immunities and and refuseommunities to accept throwaway communities. why do we accept throwaway people? finally, i would say because we know from many other applications of housing policy, the primacy of decent shelter to read -- shelter. homeless, for example. can't deal with homelessness if we don't deal with housing first. we understand the role of a safe, decent, stable place to live. that same logic applies to older americans, too. dosing has everything to with the hope of staying independent and healthy for as long as possible. that means social contact, exercise, piece of mind.

familiar surroundings. trained help. to restand decent place in the most vulnerable years of life. our country must face some basic facts. today's report makes the effects clear. we are aging. we are not ready. we are not preparing well enough. we will reap the sad consequences. we will see many people suffer. it doesn't have to be that way. we can go to work now. we still have time. we are just at the beginning of the baby boom surge. the critical mass is when those theirst turned 65 reach 80's. we must think anew. we must plan comprehensively and act with determination. we must fulfill her

responsibilities as a great and compassionate nation. thank you very much to all involved. >> all right.

who is winning the fight on the right? i want to welcome back mary catherine. guy, james golden, newcomer. great book out there. thanks for being with us today. last night at the opening of ummit 2014, we heard, we heard the remarkable dr. ben carson propose a truce between the "rinos" and the tea party. somebody came to me afterward, two sisters,. the simon sisters the first words out of their mouth for that they are loving the program. right after that, john, don't ever let the establishment takeover the western conservative summit. you have to keep away from those "rinos." so there it is in a nutshell.

one approach is conciliation. the other approach is polarization. let's get started with guy benson. who is winning the fight on the right? establishment versus tea party, drug legalizers versus drug enforcers, foreign affairs and national security hawks versus noninterventionists. who is winning, and are we hurting ourselves more than we are hurting the enemy? >> thanks for having me back. i heard this is a record-breaking year for the summit, so thank you all for being here. john and his team put on a tremendous event. all of us do a lot of conferences over the course of any given year, and the western conservative summit is one i'm always looking forward to. it is a loaded question that john asks, obviously. he covered a lot of ground in his question.

i would say there's a few different ways i was ruminating about how to answer this. you can attack it from various angles. you can look at the 2014 cycle and some of the primary fights that happened. who has had the upper hand on this tea party grassroots versus establishment sort of struggle going on? there are examples in both columns. mitch mcconnell easily won against the tea party challenger in kentucky. he -- on the grassroots side you have nebraska with his primary. eric cantor was defeated, something no one saw coming. and then the sweet spot examples, one right here in olorado. consensus-building candidates for the republican party. maybe we can get into that later on.

another way to phrase the question is to look at it through the prism of the upcoming 2016 cycle and the potential republican field of candidates. while i think that is wildly premature, the first rule of political commentary is that it is never too early to baselessly and recklessly speculate about the next presidential election, so perhaps we will get into that. but if you want my candid and honest opinion to the very simple question, was winning the fight on the right? it is this. the left. the left is winning the fight on the right. because we are spending an enormous amount of time and energy and passion and money beating the tar out of each other. i was reading in "the wall street journal" earlier this week -- >> you what, -- would, rino. >> it is a rino publication. they had an info graphic about

spending from the biggest super pac's on the right and the left. they took the top three super pac's on the right and the top three on the left, harry reid's group, house majority pac, independence usa. they broke down the numbers. the democratic super pac's have spent $24.1 million, where the republican side has spent $13.8 million. so for a party constantly wringing its hands about big money in politics, the democrats are very comfortable spending lots of big money as long as it is big liberal money on politics. but if you look down a little further into the numbers, and this is where the journal's piece was so important, of the $13.8 million spent by topper publican leaning super pac's, 74% of the money was spent fighting primaries. 74%. on the democratic side, of the

$24 million, 90% of it was on general elections to be the right, to beat conservatives. only 10% went to primary fights. i'm not here to say we should not have robust debate on foreign policy and social issues. we should have those things. we are a party and the movement of ideas, and debating things openly is important. i'm not saying we should just crown people nominees without blinking an eye and sort of do with the democrats due, immediately and unquestionably stand up and salute. they are much better at that than we are. i don't think we ought to aspire to be just like them. however, we have to think about too tediously when it -- strategically when it makes sense to fight against each other, went to kiss and make up and go on to the real battle united. if we don't do that, the left will continue to es for lunch every single -- eat us for lunch every single cycle, and they are absolutely thrilled to see this inter-necine fight

play out. that is the challenge, to figure out how to navigate hose seas. on a positive note, what you have done on the senate race in colorado is exactly what needs to be done nationally. thank you. >> thanks. that gets us to a great start. thinking about that acronym we throw at each other on the right, "republican in name only," "rino." do you hear the other party calling people a "dino," democrat in name only? we do agree that the socialist progressive nostrums that failed again and again are as extinct as a dinosaur but they on't call themselves that. that is revealing. guy says the left is winning the more we fight amongst ourselves. what say you?

>> they have won in a couple instances, but you cannot talk about this without looking at where the battle between the nonestablishment and establishment comes from. that comes from people being very frustrated with republican versus democrat, not seeing a difference in the parties in ashington. the reason why we have a conservative movement and the tea party movement the way we have seen it is because after the reason why we have a conservative movement and the tea party movement the way we have seen it is because after president bush left in 2008, president obama came in and people said, there's not a lot of difference between and what big spending republicans are doing and what big spending democrats are doing. that's why it is important that grassroots activists got into the cycle and had a historic movement. the debate is a very important thing. we can talk about serious issues without demonizing each other and come to some agreement. guy is right when he says the left is winning when we cannot come to agreement on big issues

we agree on. the fact is, the establishment and conservatives agree on a lot of big things that can have big political impact. obamacare is one of them. the irs scandal is another one. if we focus on issues we can all agree on to fight the left, that is how we can win. it is really important to stay focused, that this is not a one-size-fits-all policy. guy pointed out the differences between lindsey graham winning in south carolina for example, different from what happened in virginia with eric cantor. the immediate headlines in the media, tea party loses or establishment wins. the media fuels a lot of this war going on between us on the right as well, whether it is true or not. it is important to have healthy disagreement, and the best solutions are found by looking at our differences, airing our differences in a nonpersonal attack way.

behind closed doors, talking about how we can come to agreements on some very big issues. we have a lot of them. you mentioned libertarian versus social conservatives. comment -- a lot of libertarians are pro-life. that is an issue we can win on. that is an issue that can bring other people were not on the right in on according to polling. there are a lot of things we can come to an agreement on. nobody is going to get everything they want. one of the biggest frustrations, when ted cruz did the filibuster, for example the , immediate reaction was he is crazy, why is he doing this, everyone will remember the government shutdown. nobody remembers the government shutdown. that was a false idea put forward by the media. i don't like this idea that the establishment, whenever there is any idea from the grassroots it is put off. when you have been in power for 30 years, you feel threatened and don't want that power taken away from you.

but going back to the point at the beginning, we have to take a serious look at where the fight on the right comes from. in terms of big government it is time for big government republicans to take a hard look at the way they are voting the way they are in bed with crony capitalism. [applause] you know, it is really easy for people who have been in the senate or congress for 30 years to disapprove new ideas coming from the grassroots and say they will not work, when i don't think washington is working very well. we have seen conservative grassroots really infiltrate and cause problems, and there has been frustration about gridlock. but the point of the way the system was set up is for there to be gridlock to slow things down. it was set up in a way so we were not going through all these things. when republicans were in charge

under george w. bush, we didn't do a very good job. when we expanded government significantly. when the left came in in 2009, government was expanding significantly. we are at a tipping point where we have to rein government in or we will never be able to fix it. we can come to an agreement on the right. we should do it in a way that is not attacking each other necessarily. we need to take a look at where the fight comes from. it comes from people in washington getting very comfortable agreeing with each other on both sides of the aisle and not wanting to rein in government spending, which is why we are here today. >> that's great. thank you very much. [applause] james, move that laptop off to one side and get the camera in. get a load of the hat and jacket on james golden. [applause] summit 2013 veterans will

remember that i had serious fashion m.d. when -- fashion envy when moderating the james golden panel a year ago. my staff did focus grouping. i wanted to be as hip as james golden in 2014. clearly, i have made very little progress. i am wearing the new centennial institute limited edition 1776 signature tie. the 2012 edition was blue. the 2014 in addition -- the 2014 red, we hope politically prophetic. it is a great conversation starter. be sure to get one at the exhibit booth. this is where i have gone out and gone pretty wild. with the example of george h.w. bush and egged on by our media team, we are now into the crazy socks.

[laughter] the ankle downm he's no longer a dinosaur. i will be working on the rest of me. come back next year. who is winning the fight on the right? no crossroads of america gets more of this debate than the rush limbaugh show. when somebody dials the number and waits in line for 90 minutes, you are holding them. what do you think? >> number one, i think you are a pretty hip guy, and proof positive is you are making such a difference with your leadership. the western conservative summit has grown to be one of the premier political events in the country. congratulations to you and everyone who put this together. [applause] you speak about rush. i want to say how blessed i am to have worked with rush limbaugh for so many years, and what a great and amazing human being he is. i thank him.

i thank god for bringing that man into our lives and our country, and for all of you who listen and support the show, thank you so much. who was winning? it's obvious, you told me the left is winning hands down. they are winning it on a few -- not just the left as we think about it. the left-wing media is having a field day. we are political fodder. is as if they play us conservatives as if sometimes a stradivarius. they know what we are doing -- they know what will set it off. if you want to know who else is winning, the forces of intolerance are winning. look no further than what just happened in mississippi. for an example of what happens when this gets really ugly. and people are prepared to put everything into this battle against each other, and yet what we keep waiting for is for somebody to take the same energy

and oppose the administration in washington, d.c. and that never happens. [applause] so what we get is this full-fledged war, and it has been a full-fledged war on the tea party since almost day one. i have never seen in my life where you have a majority handed to you in an election that can flip the house. the 2010 midterm elections were historic, and they should have been. because it was a sea change. instead what you have, politically as a backstop to what was going on with the obama administration, you have the republican leadership pretty much ignore the victory that was handed to them and squander what could have been a natural alliance with the tea party. [applause]

who won? are they winning? is the tea party winning from this? absolutely not. the only people who could be winning politically are the left on this. one of the things we have to do as conservatives is win. this is a war for the heart and soul of the republican party. a third party will not cut it. you will just dilute it to the point that we will never win elections again. [applause] we conservatives have to win this fight for the heart and souls of the republican party, and that is our mission. it is that simple. [applause] >> well said. fourth point of view from the panel. mary katharine hamm was with us when the summit was just getting started back in 2011. she was with us via skype last year.

i think it was a historic first. the first official western conservative summit baby got into this world. as part of the next conservative generation. baby is at home now with dad, 11 months old. i'm glad you're with us in person. who is winning the fight on the right? >> thank you for having me. thank you for allowing me to skype in last year. i would have brought in my daughter, but frankly she is a lot more quiet -- was a lot more quiet last year than now. it is an honor to be with you guys, who do so much work and wage this fight in ways that are big and small all the time. it's really cool to be here with you, who i have heard so much about for years. to meet you in person is a blast. to echo a couple things you said, yes, the media is interested in our fight. that's part of the issue, and

playing into that that is something we need to be wary of, especially when things get so ugly, as in mississippi. a brief example, a friend of mine who does conservative politics got a call from a reporter the other day putting together a panel of conservatives who disagree on gay marriage to talk about where the issue is going. when there are so many other things to talk about. she said, i am not really so interested in relitigating all these issues we disagree on. when she was done having this conversation with the media, she comes to me and says, i have never seen a panel where they put democrats with fracking advocates and have them fight about what they disagree about. [applause] i think we need to be aware of that. some of these things are not easily changeable. if you go to war with the media. the media you have, not the media you want.

but being aware of that is important. i want to maybe take this in a slightly different direction by saying that i think one of the issues with the fight we have with each other is that it can wall us off from the new people we want to speak to. because they hear a bunch of "more conservative than you" bickering, and they just cannot relate to that. because perhaps they never identified as conservative. perhaps they are hearing only fighting, not ideas that speak to them. so that is something we need to be wary about. and i want to offer a couple issues where i think we can speak to new people, and for the most part many establishment folks and tea party folks and libertarians can come together on something. i apologize, i will get a little al sharpton on you. because these are going to rhyme, all right?

here are the issues. overregulation, food and libations, education, and innovation. these are all areas where the left is full of nanny-state fundsuckers, trying to ruin everything. [applause] on overregulation, most of us can agree. this is something where the debate is healthy, because it is true that within the establishment the people who you have on the opposite side of these issues from conservatives, the opposite side from where they should be, they are establishment republicans. they have been inside too long, and they are functionally with the left on some issues. i think the tea party has done an amazing job of pulling some of those people back to where they should be, and we continue to fight that fight. on overregulation, we all know

that it crushes dreams. it creates situations where people cannot rise up. that is something we can all agree on and make an argument about. many people in america do not understand that these new regulations, there is a hundred hundreds- by the handed down every day, they diminish the american dream little by little every time they happen. on food and libations, first of all, young people who we would like to reach really hate michelle obama's school lunches. [applause] they also are not particularly fond of soda bans. >> when did the first lady turned into the lunch lady anyhow? >> so that is an area where we can talk to new people. sometimes locally, frankly. when you have some people who

are default liberals who really love food and farm to table and all these things the left talks about, those things require freedom. they require the fda not to come in and say, i'm sorry, your homemade sausage you would like to sell to your neighbors does not have enough nitrate in it for our taste, so you are not allowed to make those transactions among three people. -- those free transactions among free people. when that happens, it crushes dreams, crushes a small business, and makes life less fun for people who would like to eat delicious pork products. we can make that argument to people. education, obviously. freedom to choose is of dire importance, of the most importance in communities we are not reaching. finally, innovation. that's right. you like my al sharpton bit?

uber, i know you guys know about it, the alternative to taking a cab. liberals love it. they are literally limousine liberals on this issue. they love having a limo pick them up because they ordered it on the smartphone, so suddenly they are libertarians and they don't want government and taxicab companies to come down on these things. young people are very transactional about politics. what is it doing for me? sometimes that makes me sad, because a lot of times we go, thank you, government, for doing this for me. but we can make an argument that this is where the government is standing in your way. it is not doing things well. this is the left teaming up with unions to keep you from new innovation. so there are some areas where we can all say, i am on board. republicans, many of them establishment, have been good at identifying areas where we can make an argument.

so i want to offer that with the caveat that yes some of the people we do fight on these issues will be establishment republicans sometimes. >> thank you. that's great. [applause] three years at the summit. speaking of food and libation, i see your al sharpton and raise you dr. seuss. your fans, they always say "less green eggs and more hamm." i have a food theme. green eggs and ham does not work as well as sirloin steak and tofu. work with me. >> green eggs is just a metaphor. >> it is -- going out on c-span, folks. i want to go through the lightning round as time wanes.

james and i are the ones with living memory of the great reagan victories of the 1980's. you have living memory, but you were all fairly young. the gingrich revolution of the 1994 sweeping the house and senate with the contract for america. we wax nostalgic and say, it was great back then when the right was not so divided. we had our eyes on the prize and agreed on 80% and disagree amicably on the other 20%. i will start with you, james. is that just a false nostalgia? was it really better, or have we always have these fights? >> reagan was a better leader than what we have today. if you remember, the left absolutely detested ronald reagan. as quiet as it is kept, so did certain republicans who we would now call establishment republicans.

they did not want ronald reagan as their first choice. what made him a great president, ronald reagan did not waver from his convictions. he knew what he wanted to do. [applause] we are talking broad strokes. you can start going into the nuances of policy, but when you look at would reagan wanted to do, optimism was number one. he believed in the greatness of the american people, and he was not afraid to say it. this is a great country. i love this country. every particle of this man loved america, and that is one of the reasons america loved him back. number two, he wanted a strong defense. he understood what the risks communism, and still are, communism and terrorism. and he was unafraid to build up the military. and he understood economic policy. they made fun of him, and yet this man together with margaret thatcher and the pope changed the course of history, rollback communism, gave us economic

freedom and prosperity that has been unmatched since then, and did this with an unfriendly media and democrats that could not stand him. it is possible to do this again. [applause] >> so maybe it comes down to a leader who can inspire us around that approach. i asked the three of you, i think of these young guns, katie, how about you? you didn't live through that period, but as a pundit, have we always had these battles and divisions that we overcome? >> i had the honor of being at the reagan center yesterday. so i got a refresher on reagan's time in office. we have always had these battles, but what made reagan a great is when people said it was impossible to get this done in washington, he said, i don't

care. we are going to do things this way. i think we can do it again. there have always been disagreements, and that is healthy. disagreements spur great ideas. i think disagreements allow us to come up with new ways to do things and to get rid of bad ideas, and we are always going to have an establishment versus grassroots battle, as long as people are allowed to stay in office for 30 years at a time. when people want to hold onto power, they are not going to give it up easily, and they will want to disagree with people who want to pull back government, because that takes power away from both democrats and republicans. when people feel threatened, they disagree. i think we can do it again. but we are on our way. the 2010 election was an extremely successful, historic indictment against big government, and in 2014 we have some really good candidates who i think will go to washington

and try to do their best to turn back the tide. we can do it again, and we will continue to have disagreements, but that is ok. >> i want to ask mary catherine and guy to give us a name or two that we would all agree -- it is futile to look for the next reagan, but that ability to inspire and unite around a common vision and bridge the divide. who do you see out there, mary catherine, who is good at this? >> let me say first that when it comes to reagan, i got a refresher course as well this week because i watched the address reagan gave after the korean airlines flight was shot down. thank you for thinking of me as somebody who didn't live through those years, but i do have some memories of it. [laughter] i noticed there was not an applause line for under 35 in the crowd, but -- i do remember

some of that. i rewatched the speech and expected, of course i will like reagan better than obama, if that is all the comparison is. i am wired that way. but when i watched it, what really struck me, having been in politics 24 hours a day during this era for a while, was the intellect he assumed in the american people. the confidence he had in them to listen to that 15 minutes of very prosecutorial laying out of the facts. >> he gave us credit. he approached us like grown-ups, like citizens. >> that something i frankly get frustrated thinking about. maybe if you are explaining, you are losing, but i need to explain some things. you see studies of millennials where they are all over the map of what they believe politically. not a lot of confidence in government, yet they want government to do everything.

they want budget cuts, but not to anything they like. there are always these paradoxes that make you scared that you cannot reach people. so having confidence that we can and being a good communicator and giving the american people credit is part of the battle. so i want to commend him for doing that. >> it is great to go back and find on youtube reagan addressing the flight shoot down from 1983. closing out very quickly, a couple names that you think are on the political scene and perhaps rising stars who have that ability to pull it together? if you care to mention a name or two that are examples of how we shouldn't do that, do that, too. >> you talk about how things have changed on the right. i want to point out quickly how the left has changed over the last few decades. in 1993, the religious freedom

restoration act passed congress with three total dissenting votes. both houses. 97-3 in the senate, unanimous in the house. sponsored by ted kennedy, signed by president clinton. this past week, every senate democrat voted to overturn the hobby lobby decision which was based on protections in that bill. we are not dealing with our daddy's democratic party any more. not even close. there's all this attention to how the republican party has gone to the right. they never talk about how radical the democratic party has become. [applause] so i wanted to make that point, which is not responsive to the question, but it is important to point out. >> we are on a hard break. i need a name or two. >> i will answer that question. i have watched with scott walker has done in wisconsin with great admiration.

they have thrown everything they have at the guy, and he has stood up to them, laid out the facts, treated the people like adults, got his agenda through, beat them in their redo election. and he is in for a very tough fight again this year. the media is out to get him. the long knives are out. if he can win for the third time in four years in wisconsin, he should at least get a look from our side heading into 2016. [applause] walker looks great kicking off the summit a year ago. lots of us were here. >> as we wrap up the panel, we thank mary catherine hamm, james goldman and guy benson, and as the rookie, katie, we want to initiate you. they got their glamour portrait

last year. i hope we have the slide. please come back up -- thanks. [applause] [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2014] >> on the next "washington journal," a look at the militarization of police forces. we also discussed the threat of the islamic militant group isis with former under secretary of defense political affairs. welcome byts are phone, facebook, and twitter. "washington journal" is live every day at 7:00 a.m. eastern. >> several live events to tell you about, including the secretary of state on u.s.-muslim relations. introducing a new special representative to muslim communities at 10:00 a.m.

eastern. 11:00 a.m., brookings hosts a discussion on the threat of the militant group known as isis and al qaeda. we are also covering maryland haven't -- we are also covering tavenner, head of the centers for medicare and es.icaid severvic our coverage of the debate to the midterm elections continues this evening. democratic incumbent senator kay hagan and her public and challenger, state legislator thom tillis. polling indicates that the race is a tossup. next, a center for strategic and international studies discussion on global health. panelists include director of the national institute of allergy and infectious diseases. olapredicts that the eb

outbreak will soon be a security issue. this will an hour and a >> thank you for joining us the first day after labor day. summer is over and fall is beginning, we are thrilled today to come together as a of larry's work and his important opus on global health law that has come out this year. when larry raised the idea a few having a bookut event, we do different kinds of book events.

we were honored to be able to do that. he is such a pillar of our community here. he has done so much over the years in leadership at the o'neill school of medicine and his prolific output. he has had so much influence over all of us in such a constructive, forward looking, gracious way that we thought it was a great occasion. forward l, gracious way that we thought it was a great occasion. thank you for turning to us and let us pick it up. we are thrilled to be able to do it. we also thought, let's do this as a conversation around big questions and big ideas and bring in larry's closest friends and allies over the years that could help in the celebration in a deliberate tom at interactive brisk discussion. the. agreed to

since 2004. another huge presence in our matters pertaining global health. we will be joined by tim evans from the world bank of the third party to this. the way we will go about doing our business, we will run up to .:30 no later we will see how things go. we will open up with larry saying a few words about this work. it is the culmination of many years of effort. large,ot just the only comprehensive and cyclic ketek -- encyclopedic work. i wanted to have him offer a few quick reflections from his chair around the genesis, the

experience of writing the book and then we will morph from there into the discussion. the discussion will be centered around to questions that are very future oriented, each of them. trying to get us thinking about the future. ,he first one is going to be what is the single this -- biggest challenge or problem we need to keep our focus upon looking ahead over the next 5-10 years? we have international law expert. tony coming at this from a perspective someone involved deeply in the science, research, development and technology. tim evans, someone whose life is centered in the science of delivery and implementing

programs. so we will begin with the first question and will morph into what we believe the biggest idea will be over the same time that and changennovation the calculus. so welcome, thank you for being with us. you have the biographies. i will not go into great detail. we have close friends and call uponat we constantly integrating any dimension of global health. thank you. a great location. >> it is a great occasion. wanted to start by thanking you and cs i asked -- csis,

because there is no place like this in america. you have built something incredible. a longtime friend. i feel like i am surrounded by friends but more than that i am surrounded i two of my heroes that have worked so hard and global health. there is no book on global health law and governance. as and to think of law esoteric field, but in fact the governance of global health is really critical. think about the tobacco control or ebola. governmentlared up emergency of international health regulations and evoke various powers and the like. what really drew me to the book

local healthof two marriages operating out there. is what you hear from the really great thinkers in global andth indicates foundation who. that is the story of remarkable progress where we were to where we are now with incredible achievements through the millennial development goals of the sustainable development goals. that is a true narrative, no question about it. if you look at age and mental health and malaria, we have done very well. i also have done work civil forety around the framework mental health so i have talked to people on the ground.

their experience is completely different, a different narrative. there is is a narrative of deep impoverishment. and narrative few can see in west africa today quite frankly of food insecurity, human rights violation, ebola. a hole for i-80 of other conditions. people are afraid to go to the hospital. we are really facing a crisis there. it turns out both global health narratives are bright. globale improvements in health, but those improvements are not equitable across the board. is a reallyustice major theme in this book. i asked three basic questions and then i will move on. the first question is what

would've perfect state of global health look like? if we could what we aspire to, what would it be? for that, i try to place a premium on public health public health services. disease prevention and control are really important. not think ofe do as global health but it is. air, sanitation, hygiene, vector control. all of those things make life much more livable. the second question is what would global health with justice look like and the third is how we would get there? if you do manage to pick up my book from the outside, i think the best part of it in the best advice from harvard, they said do not get someone like

bloomberg or bill gates to write the forward, no one cares what they think. so i did. what we have in the beginning our global health narratives, stories from children around the world in their own words. it is really powerful. it is really important for us to capture the idea of what it is like to live in a poor country filled with injury and disease. without further a due, we can get on to the important part. not mention at the outset that over the course of the discussion we will open things up and hear from you. please think about your comments and questions as we move through this dialogue. we will get through this quickly. want to begin by offering

a few minutes of thoughts about the most important problem and challenge? come on up. we are just getting rolling here. welcome. >> great to see you. offhy don't you kick things with a few things around what is the biggest challenge we face in looking ahead? >> i think the biggest challenge is equity and justice. mean this tobacco guru lipservice is very small. they argue with one another. ofo not know how i got part it, but i was. they talk about and games and tobacco. they are very popular with aids. -- talk about end games.

you can get it with all these different areas. i asked them an ethical question. i said suppose you could get to the end game in tobacco, which means you have a prevalence rate youercent or less, but still have mentally ill, poor, working-class with relatively high rate. would that be ethically acceptable to you? every single zealot said yes, it was acceptable because the main goal was held improvement. biggest goal was health improvement with justice. trying to look and make the world a place where it does not matter if you were born income paul a or new york -- in apollo or new york or mail or female or

with child or an adult or sick or healthy, disabled or not. what matters is that you have to live intunity and the conditions which are healthy. one thing that really struck me, i came back while i was doing the last chapter of the book from a very typical sub-saharan african city. i came back and i realized i really was not feeling well. i did not have malaria or anything like that but my throat was bad from the fumes. my tummy is was a little bit bad. i came backzed when from any of the lower income countries i did not feel well. and that told me something.

that's when -- where euclid makes a lot of difference. it was not the doctors i concede that the environment in which i laid in which people live every day of their lives. >> thank you. is the singleout biggest challenge or problem for the next five or 10 years is one that is certainly not new or creative but very real. it really has to do a bit with what i am as an infectious disease hersen in dealing with the problem as i stated is the disparities in health and developing versus developed much, which relates very to the justice that larry was talking about but i am thiscularly involved in

with the arena of ebola. let me just take my 2.5 minutes that i have left to go over that with you. i always talk about disparities in health. malaria,about malnutrition, lack of clean water -- all of the things related to countries that are or are limitedch in resources -- resources related to health. me thing that has impressed like nothing else is what i have experienced over the past couple of months with ebola. some of you may have heard me get the i always question, should we be worried about ebola here? on answer is someone look it a plane from west africa and end up in west africa or london and be well on the plane get here,

get sick, go to an emergency room, get sick, maybe die in infected nurse or doctor and everyone will realize it is ebola. will be isolation and the proper precautions in the outbreak would end their. in west africa we are dealing with a situation where we are seeing an exponential case with 1500 plus deaths and the projections of going to 10,000 cases is not hyperbole because now the curve is exponential. the reason it is happening is because of the disparity in health care capability. is the only reason it is happening because you cannot have infection control, no infrastructure for isolation. no infrastructure for quarantines and properly and no

infrastructure for contact tracing. if there were the first two or three cases that were in the united states, it would be very frightening to everyone, all over the newspapers but it would stop. so i was adding prepared to get of what i think the granite -- greatest challenge is is just that. there would not be be ebola academic if there were not absolutely does an -- stunning disparities upheld in the west african countries compared to our country. >> great. this is going to be a bit of a repetitive theme. there may be selection bias at work.

let me first apologize for being late. it was something called ebola consuming many of us that are directly or directly involved in the response. not think today there is a greater challenge, because i think it is symbolic and indicative of the vast disparities that continue and which not only threaten the country's and the economies and butility and security, certainly has made it clear the west african context is with beast --haky with respect to containment of ebola and the rest of the continent and therefore the rest of the world.

but i wanted to first begin by saying congratulations to mary. i do not know very as many as well of -- as well as many of you but i have always thought from a distance he has been a mess leader -- massive leader and really writes what he talks about so eloquently and that is bringing the discipline of law to global health and i feel this book that i have not read but will give it a glowing endorsement based on your reputation, but congratulations, i am delighted to be here. having wasted two of my three minutes now or spent them on more important things, add my me, thes on this. to biggest challenge is inequality or in equity. withineen countries and

countries, the fact that you have major gaps in life expectancy and health achievement in this country with all of the means that it has to is an assault on a fundamental sense of justice. thatnk it is also one needs to move increasingly to evaluate equally, no matter where they are based. i think that i -- ethical principle needs to be much more fundamentally ingrained in everything. the challenge of that is multi-factorial. i think we will have more time to chat about the points of to really allow the principle to manifest itself in a meaningful way. thatld say, however,

relative to where we were 20 years ago, there has been a massive mobilization and something called global health or around global health that has multiple manifestations, which i think embodies to a significant impatience sense of and intolerance of local inequities in health, and i am personally encouraged we are moving but when you look at the clearcrisis today, it is we could move an awful lot faster, and i think we have to look at how we can do that. ebola first came to our attention earlier in the spring and the initial response was it andnot look that different we moved into april and june and

perceptions began to change, there was a certain confidence in the ability at that time to toll use the tools we had address this. there was a recognition that the inequities and gaps were feeding ,reast along with distrust mobility and speed that was happening. wasquity was -- inequity recognized in west africa. i do not sense people made the leap from that to say the inequities of that kind were more than and normative consideration, that they were more than something to lament as versusty of life

something that is normative and ethical. strikesething that security considerations in a way that would motivate people to see inequities as something that requires much more aggressive action. today, when you look at what is happening with the exponential leap over the past six week's, one of the stunning things to me is that it is not registered as a security issue. it is competing against some geopoliticalble crises, in which there are no major ones.hree the field is very crowded. when you all raised these issues and reference the ebola crisis

and very poignant excruciating example to witness and our lifetimes, the backdrop of dramatic gains made in the past years, how do you make the case, the security case? the inequities are the ones that have to be addressed. i think we are still struggling today as this crisis unfolds. we are still struggling how to for not just our government but many others. >> i think you are very insightful. you raise a lot of important questions. undoubtably it is a geostrategic security issue. the whole region that is destabilized. ebola is first and foremost a traveledisis but has

and cut off food security, employment, the economy, to that he. all of that is down. focused on the whole region of the world. there has been international spread. invoked a public health emergency. and yet government has and basically left to itself with the u.s. government and others but not at the higher u.n. level that we need. i think it is clearly a security issue. i think my worst fear is this could be another haiti where it humanitarianuge response. then when the humanitarian response gets up and leaves, the

same conditions exist. you still have the fragile health systems. you still have enormous deficits and doctors, nurses, midwives. there are places like liberia thatand one 20th ofng like what they would need in terms of health work force. and yet they have lost a lot of nurses and doctors to ebola. what will happen when we do contain it? we will eventually and then move onto the next thing. this is a development issue as well as a security issue and infectious disease issue.

>> scanning back to the point about security humming you said when will this we recognize as a security issue? soon. it will be recognized soon because if you look at the kurds and projections of mathematical have 3000when you people infected and 1500 die, that is a humanitarian issue compounded by the fact that people who do not have ebola do not go to the hospitals because they are afraid. many people are dying from bleeding ulcers and automobile accidents and the need for care at birth and do not have it because they're just not going to the hospital. it has become a security issue when you look at the model that goes from 3000 to tens of thousands and government starts collapsing. remember in the mid-to early , andof the aids epidemic

it was not that early into it when it became -- that it became very clear in the developing world that there were militaries of different countries of strategic interest that had 30-35% of the people were infected. i remember because i went with colin powell to the united nation special session on aids, and he, for the first time articulated he consider this a security problem. then all of a sudden everything "and people began to consider that. so i think it will happen and reasonably soon if you look at the kurds of where it is going exponentially. >> one is how do you make the

on that front,nk is weakest link in the chain one that is a threat to us all globally. -- two five when who thousand five when who passed the world will health regulations all countries were supposed to become a client by 2012. any experience in the low income or more -- or even middle income country after every country signed up for that knew there was not a snowballs chance in a hot base for that to actually happened. because the investments were not being made. is the threat to disappears,en it

the countries did not make basic investment in the core infrastructure. emma when you have something like this and no where near the infrastructure you need , then you do not have the ability, which is not complex to really snuff it out he for it essentially becomes endemic. so the rationale for investment needs to be strong, but it has to go beyond the immediate threat and look at the return on investment from investments in health. evidence.ve tons of larry summers, commissioner on investing came out to show it is one of the best investments that with respect to economic growth in the economy. really need finance

to understand these sorts of investments are not only ones that help people live and survive, but ones that make abundance of sense in terms of prosperity and economic growth. toing said that, in addition mobilizing, as larry said in, hopefully the commencement level of response, and i would like to are aboutear, that we 25-30% of the mobilization ofessary is the who roadmap 400 90 million and have not heard it from the u.n. senior warden nader david navarro in terms of what is required above of the immediate health response to respond to the crisis. the price tagged will go up.

tore is a long way to go respect of the immediate response. the challenge is that it needs to happen tomorrow, not in three weeks. i was listening to the president of the u.n. this morning. and she said we need a search at which isty paramilitary in character. she was saying the biohazard haved that many countries has to be deployed in the to seec if we are going there grate of response necessary to get on top of it. this is coming from the institution that has cared for two thirds of all of the cases to date in west africa. so i think there's sense of the urgency is critical. the feeling we can do that --

assuming we can do that, and that is a big assumption, because i think all of you in haveoom, in addition to us a responsibility to make sure the requisite mobilization takes legs, but the aftermath is critical. here we need to begin thinking about the investments, not only --help answer structure health infrastructure but particularly the health infrastructure that will make sure we do not have a repeat of this in west africa and affected countries but in others and that is why we designated half of the designated response for building the median to longer-term public health infrastructure we think would be necessary to look with equipped countries to be able to respond to these challenges. thank you.