is a traditional organization. as far as we can tell, you have dso, which was funded to the tune of $800 million that accomplished nothing other than spend a lot of taxpayers dollars. it was so bad in coordination. they were required to courtney. we were told in our latest audit -- they were told to coordinate. we were told in our latest audit -- we have a number of audits and investigations dealing with it. it was a good idea, but it was poorly executed. host: mark, fort lee, new jersey, a republican. caller: listen, someone has written a book about hezbollah and at some point they intercepted some money that was being sold as counterfeit american currency. skid loads of it, billions of dollars. billions it or millions,

anyway. when they found out it was election currency, it was not counterfeit at all. we were spending so much money there, throwing it away. all of our foreign aid is being funneled into the pockets of cronies and patrons and nepotism and everything else. this is a do-gooder's view of the world, and they are not doing good to the american people. our roads, our bridges are collapsing. we have jobs paying pennies to work for the day. this is disgusting. it turns my stomach. i am tired of all these people telling us how we need to help others and we are not helping ourselves. $19 trillion is paying for all of this, $19 trillion in debt. host: john sopko? guest: again, i do not do the policy. i just see how it is carried out, and i do agree with the caller. there has been a lot of waste fraud, and abuse.

we wasted a lot of years in reconstruction. i do not think we asked simple questions -- the afghans -- do they want this project? do they need this project? can they use this project? we never really considered corruption. afghanistan is one of the most corrupt countries in the world. we never designed programs to protect ourselves from that. we never took into consideration the security situation. so i agree with the caller on their point, although i would make the distinction that, acturedevelopment is a very efficient way, if done correctly, far more efficient than sending troops on the ground because the troops cost a lot more money and a lot more lives are at risk. just keep that in mind. that $1 trillion we spent in afghanistan, only less than 20% dealt with reconstruction. the rest was war fighting. host: let's get to the new

leadership in afghanistan shroff gandhi. -- ashraf ghani. guest: i am very impressed with him, addressing problems. for the first time it looks like we have a willing partner who wants to particularly address the problems of corruption. we brought the case to his attention dealing with a $1 billion fuel contract that the afghan ministry of defense was letting. the price was fixed in dubai and it would cost the afghan government over $200 million which means it was going to cost the u.s. taxpayer because it was taxpayer money. we brought that case and the allegations to our military. our military went over, and we

did not just brief somebody in the afghan government. we briefed the president. the president took charge. he fired generals, canceled the contracts, and started to investigate it himself, and we have been supporting him and his team on this. so this is something new. we never had a team in the palace that cared. they talked about corruption, but the usually blamed it on the united states. then you got a new regime that looks like they are trying to do something to renew that number of contracts. so we are very impressed. however, i am like president reagan. my job is to adjust and verify. host: we have a half hour left with our guest, john sopko. chapel hill, caller: i just want to thank c-span for allowing everyone to

call in. ok. i have a few questions. how long have you held this position? who held it before you? who came up with the idea of sending $600 million? my question is, why are we not building schools? host: first, to the position itself. how long has this position been around? guest: sigar was created by congress in 2008, unfortunately about eight years too late. the first person who held the position actually resigned under a lot of pressure for not being aggressive enough. the position was then vacant. they had been acting for about one year or so and then i was appointed by the president three years ago. who made the decision on buying the airplanes that didn't fly? we are trying to find out.

you may wonder can't you find out? isn't there a name on the paperwork? we are in afghanistan and the paperwork is hard to find. more importantly, we have a criminal investigation going looking at this. i will tell you, we will hold people accountable for buying planes they do not fly. if it is criminal, we can turn it over to the department of justice. if it is civil, we can prosecute that in a civil case. holding people accountable like firing them are reprimanding them we have no authority on that. we have to turn it over to the various agencies, including the department of state agents. that is one area where we have had problems. we have identified a lot of waste and abuse. as far as we know, no one has lost the job or even a promotion

, or gotten a loss in their salary because of all of the problems. we have identified departments and that is a problem with the government, and personal accountability. host: from twitter a viewer would like to know more about your office. give us the basics. what is the budget? are you in good shape? guest: we've approximately 200 employees. they are split between auditors and investigators. then, a support team of analysts and management specialist. we have about 40-42 and afghanistan. the rest of back here working the u.s. portions of the

cases and audits. we have gotten strong support from the administration. but mainly from congress. we have gotten all of our budget requests, which is about $56 million. we have a problem right now, and i think a be the caller -- i think maybe the caller had seen some press on this and that is that out of the blue, we were told that we would have to reduce our staffing by about 40%. we were told that by the state department. now, i have a problem with that. not that i think we should have a lot of people over and afghanistan, especially if they're not working, but my people are working. we have a new cooperative government that we are working with, but i am an independent inspector general. you read my statue, it talks about independence right through it. since 1978 ig's determine their

staffing. when we submit our budget, we do not submit it through the agencies, we submitted directly to congress. so, for the state department, who we investigate, to tell me how many people i need to have in afghanistan is in direct cottage into my independence. it is similar to the wall street banks telling the bank examiners how many bank examiners you should have. or the teamsters union and the american trucking association telling highway patrol in new jersey you will only have 20 guys, we will tell you how many guys he will have watching the highways. this is absurd. so, we will fight the cut. we may cut our staff. if our staff has nothing to do there is no reason for them to be there. remember, i'm trying to save money for the government, i'm not trying to waste government

money, but it is our decision. host: back to the phones. bill has been waiting in north connecticut. caller: thanks for c-span. i am tired of all this military spending. and u.s. military aggression. we spend more money than on any other 10 countries in the world on defense. we are always looking for a new enemy. if iran gets a bomb, and it will hurt us, we forget about the monroe doctrine. we tell people to stay out of makkah, get we are meddling in other countries. all these politicians, all they want to do is have continuous wars on and on so that they can bring more money into their districts for the military. it is really disgusting.

it is what will take our country down, just like rome. you can only go so far with it because before military spending used to prop up the economy because it was put on the tab, now there is no tab to put it on because the united states is broke. we should have only making decision on wars, veterans who have served in the service. guest: well, i understand the caller's frustration. i think a lot of people are frustrated with the government. all i can say is that -- you know, i will paraphrase what churchill said, democracy is the worst form of government. the united states has a lot of

problems but i don't know anyone else doing it better than we are. he has an opportunity to voice his opinion, he has an opportunity to vote, to petition congress. i keep reminding people at state and aid, we are the only government who created something like my office. we have 30 or 40 independent inspector generals who are appointed by the united states and the very next day, they start investigating his policies. i don't know any other country in the world. i tell aid and stay, if you want to sell democracy, tell them about the ig concept. i get calls from germany, it england, sweden, latin america, and they asked me, how can we create sigar? how to create an independent

agency totally separate from the executive branch. i think that is a wonderful sign. host: your term, does it have a specific link? -- length? guest: i serve at the discretion of the president. my agency is a temporary agency. i believe in temporary agencies. it goes out of existence when the amount of reconstruction funds go below 250 -- $250 million not yet spent. we could be around for a while. host: from twitter, one viewer wants to know, where does the money come from? is a part of the foreign affairs budget? guest: there is an account which is the overseas contingency

account. it comes from state and other accounts, foreign affairs as well as military. what is interesting about reconstruction is that 60% of it is coming from dod. a lot of the reconstruction money has been in building the afghan army and police and providing the with salaries, bullets, you name it. host: one march week -- one more tweet, how does the war on afghanistan compared to other wars? can you compare? guest: i can't really compare. i will throw this out, we have used government contractors going back to the end of our independence. ironically, someone told me, if you look at the famous picture of george washington going across the delaware, the guys

rowing are contractors. we have always used contractors. we have always use contractors. they are better to use and have more flexible than actual government employees. host: clarence is calling from decatur, georgia. caller: good morning. first of all, the last question, where does the money come from? it comes from us, from our pockets, from the taxpayers. that is not my comment. my comment is that i'm retired from the military, i spent two years in vietnam. i have seen how much money has blown it goes down these rat holes, and here we are talking about $10 billion. yesterday, "the washington post those quote made a big deal about the money spent in baltimore over the last 10 years

which is a small fraction to the money spent in afghanistan, which we do not know what the outcome will be. yet, we cannot spend and we are condemning the people in baltimore and the leaders there because of what happened to 130 million dollars. shame on this country. shame on us that we can go around the world and spend $110 billion and feel good about it, when people are upset that we spent $130 million spent in baltimore. shame on us. guest: i agree with the caller that we should not waste this money. that is basically what my job is, appointed by the president to make certain that somebody is there who will find people who are stealing the money or miss

you think the money, and try to hold them accountable. i agree with him. we have to keep in mind, the amount of money spent on foreign assistance is miniscule in comparison to what is spent in the budget. i do not know the exact number, i think it is 1% or 2%. we are not talking about the biggest expense of the u.s. government. keep that in mind. we cannot tell it's our budget by cutting all foreign aid. i think that would be cutting our nose off this by ourselves. this is a way to do democracy building around the world. it has to be done. it is very risky. it has to be done well. that is what my argument is. let's think before we spend. we probably spent too much money in afghanistan. too much money, too fast, too small of the country, with two little oversight. that is the big problem in

afghanistan. i think even the afghans, bashar gotti -- ashraf ghani has said that. host: give us some more insight as to how it is like on the ground there? everything, from freedom of movement, cooperation with people, you mention paperwork the you cannot find. in the bigger picture, if you could. guest: look, it is getting more difficult to get around because of the security situation. i remember when i started coming just three years ago, i could travel around most of the country. i could go to to heart rot kandahar -- herat, kandahar.

we traveled around without military escorts. we don't have any people in those cities. another city that is very dangerous. it is very difficult to get around. it is very difficult to get sources. we cannot go out and talk to the afghans in many places outside of the wire. they have to come in to see us. we get a lot of information from them. we use afghans as sources. they do monitoring of sites for us. we tried to come up with other means to do it. this is not your normal ig operation. my auditors whereby javits -- where black jackets, my agents are carrying machine guns when they go out there. this is not your ordinary situation. host: as you mention security there is this headline in "usa today."

afghan deaths, injuries up 70%. a number of afghans killed in the police and army are worded, the number is up 70% in the first 15 weeks of 2015. lisa, you're next. caller: i do not understand for myself how we can spend so much money overseas helping everybody else with the budget that evidently we do not know what the roof is because we keepp raising the roof. we are so in debt, even our great-great-grandchildren will be in debt, yet we cannot help our own veterans. why we have ain fundraisers on television when we cannot even help our veterans?

but we can spend billions of dollars overseas supporting people who do not even really want our help? i do not understand. host: thank you lisa. we have heard this theme a little bit in the second. anything else you want to respond to? guest: i think the afghans -- again, i have to go back to -- they did not invite is there, we came. we are trying to fix and help fix a country that has been in war for 30-40 years. it was the home of terrorists who attack the united states. we madee the decision to get in there, catch those terrorists , kill as many as we could, kick them out, and try to form a government that would keep them out. now, you have isis appearing there, there is some evidence of that, at least it is reported in the press. i think it is an important issue. we cannot ignore the rest of the

world. if we do, we do so at our peril. i will only say that. again, i do not do the policy, but obviously, i believe in an important foreign-policy tool which is redevelopment. host: and terms of how the money moves, for that last caller, a twitter viewer says, could you take any leftover reconstruction money from afghanistan and use it here? guest: that is up to congress and the administration. i do not recommend that, but we do recommend programs being killed that are not working. host: other headlines, this is from "the hill" -- another damming afghanistan reconstruction report. what is the reaction? guest: very adjusted, they support them. i was told by a ranking member

last week that we are their eyes and ears, we speak truth to power. we do not varnish what we say. many of the reports that they get back from various agencies who are trying to protect their budgets and programs are just happy talk. that is the role of the ig. we speak truth to power. we have gone strong support, and i think you can see it from the appropriators and others. host: let's hear from robert in jonesville, louisiana. democratic caller. caller: yes, sir. i appreciate c-span, i watch it every day. i watch these republican congressman in the house. every time we turn around, they say, we are broke, we don't have any money. also, i'm a self-employed contractor. anyway, i just can't imagine, it

blows my mind that we spend $110 billion to rebuild something that we tore up when afghanistan ought to rebuild its own places. what blows my mind is the budget that was passed i paul ryan, he wants to make medicare of voucher plan for old people. yet also, they took away the meals on wheels deal for old people. and they want to cut social security for old people. a lot of republicans don't even understand what is going on. anyway, i watch c-span every day as far as the house and the senate. what blows my mind is i can't believe the congress would give $110 billion to rebuild something that we tore up to help the people. why are we in their rebuilding everything when afghanistan ought to rebuild its own of a structured?

what we need to worry about is our own infrastructure here in the united states and promote jobs and rebuild our bridges our roads that are filled with potholes in every state. it just blows my mind the way that congress -- i mean they do not care about nobody but themselves. host: all right, we get the point. guest: once again, i do not do the policy, i just see how it is carried out. i know the caller may not like the answer, but i think that is a question that should go to congress and the appropriators and off the writers. i will say this, i harp on this a lot, but the fact that you have c-span, you have voters -- and i hope whoever called votes, can see what is going on on a regular basis on the hill, and you see government officials

like me come in, and i am subject to questioning -- i think it is fantastic. i'm not doing this so that i get another invite and more coffee from c-span, but you do have great donuts. what is really important is that most of the world does not have it. just like they do not have ids, they do not have a free press. going back to what the caller said why don't the afghans do this? they only raise $2 billion in taxes. it costs $5 billion to $6 billion. you see the gap. we are doing that. as far as rebuilding, we did after world war ii. we helped rebuild germany. we helped rebuild italy, who was part of the axis, and we helped the rest of europe.

this is not unusual to do something like this. host: time for a couple more calls. wes, harrisburg, virginia, republican for john sopko. caller: good morning. this is wes. i am a world war ii vet and ex-employee -- x government employee. as background. i'm really interested in the government and of it, namely the employees in need, real intelligent, dedicated employees who are not merely bureaucrats but have training and are kind of backdoor policy writers writing be contracts. they have to be exposed to what they are writing the contacts about, and other words, have the knowledge of that comes with

experience and learning. i really appreciate your being an independent investigator and finding out about the subjects. i wrote a specification for dump trucks for the army, and everyone was criticizing it for being a white elephant and wasting government money. the result was that a dump truck carries dump gravel and dirt. it is not the means of transportation, so we had one hell of a fight to get quality dump trucks from the tradeshows and going out to the field, and getting the information.

have fun with the rest of the day. host: thanks for calling wes. guest: i think wes, that is a great point that you make. that is one of the issues if you read our report. we have contracting officers who never are in the country, or do six-month tors, or you get some poor sergeant who knows nothing about electrical requirements. and they're building a hospital he doesn't know, but he has to sign off on this. unscrupulous contractors will wait when the new guy comes in who is on a short tour, who knows nothing, and say, + all of this. that is why we get so many buildings that fall down, so many problems with construction. i think wes is totally on point. we need career contracting officers, career contracting officer reps and they need to

be there longer than six months, for one year or more. if we did that, and we inspect the buildings before we cut the checks, we would have saved billions in afghanistan. this is not just a complaint with the military, it is a complaint with the aid and state and other agencies. that is what we are fighting you can see it in our reports. host: andrew, independent. caller: hello, i want to thank c-span for putting on a good radio show. i had a couple of questions. one was whether there were publicly issued reports regarding the money that is spent, and the other question i have is whether the compliance related to any of this money what were some of the controls over the money being spent?

thank you. guest: all of our reports are public. that is our policy. if we finish our report, it is up on the website. if it is worth writing, it is worth publicizing, unless it is classified a violates the rights of individuals. for the active control requirements, there are some. there are many control requirements on the money being spent, most of them were waived or ignored by contracting officers who did not know what they were doing. we find that time and again. we are not holding the contractors accountable. we are not holding the co's ncoand cors accountable. people get in the country for a

short amount of time. the common, and then they are gone. all they want to do is sign off so it looks good on their performance reviews. that is a serious problem. we are starting to do a number of "lessons learned" reports. i hired a sharp team who are subject matter experts who lived and worked in afghanistan who will be performing these reports. i hope the caller will come back in a few months when we issue the first one, and we will issue a series of them, so that we do not make the same mistake again. whether it is syria, lebanon, someplace in africa, it doesn't matter. we can't keep repeating this. host: jason from san diego, california. caller: good morning, i will be brief. you mentioned, a hospital being built. did we provide a health care system for the afghan people? guest: yes we do. we spend millions of dollars per

year, as well as some of our allies. we pay for salaries of the doctors, clinics. we have allegations that many of those clinics do not exist or are not open. we build hospitals and clinics that even the afghans did not know we were building until we gave them the keys to it. yes, we do support their health care system. host: we are just about out of time, what is next for your office? guest: we have a lot of reports coming down. actually, one that i spoke of dealing with this headquarters we call it the 64 k, 64,000 square-foot headquarters that cost the u.s. government $30 million we've promised to find out who was behind this which the commander in afghanistan did

not want. we also have a report looking at the dod organization about some problems with their extract of work -- extractive work. we have a report coming out on the rule of law programs which have not been done well. we have a number of audits coming out dealing with how we handle refugees, which is a big issue. again, we have a problem with lack of capacity. plus, a number of criminal investigations will be breaking. those are some of the issues that we are looking at. we came out with a list of serious problems, and about seven of them i talked about here. we're folk in focusing on those issues. host:

each person on the panel about these issues as they come up. throughout history, the practice of medicine has been largely reactive. even today we have to wait until the onset of most diseases before we're able to treat them or begin the process of curing them. science doesn't fully understand the genetic and environmental factors that cause major diseases such as cancer, diabetes, alzheimer's disease. because of that, treatments are often imprecise and often unpredictable and often unfortunately not effective. this budget that you all have proposed really proposes a revolutionary concept of precision medicine and initiative that would really address each individual in a

precise and often different way instead of one size fits all approach, the precision medicine industry will allow physicians to individualize the treatments on patients based on their unique genetic makeup. by having access to each individual's genetic makeup now the physician has the potential we hope to decide the use or not to use specific and targeted drugs. as the chairman of the subcommittee, i certainly will support this project. i hope we can prioritize and intend to prioritize funding for n.i.h. as one of the things the committee does, even in a year where our funding challenges are greater than they sometimes are. we always have funding challenges at home, at work in the government. have those funding challenges but part of that challenge is to

decide how to prioritize how we spend our money and certainly i'm anticipating that this committee will be as supportive as we possibly can of not only the precision medicine initiative but also of the ongoing to work of n.i.h. and the promise it holds for the future. i look forward to working you dr. collins, with the ranking member and members of this committee as we pursue the ideas that you're going to bring to the table today and the potential of what can be done in nih largely and specifically at each of the institutes that are well represented here today. we're lucky to have the chairman of the full committee with us. the ranking member of the full committee will be here as well and it is a great honor and opportunity for me to get to work with senator murray. senator murray if, you have an opening statement, we'll have that before we go to dr. collins. senator murray: thank you chairman blunt.

thank you to you and your team for being here. i look forward to this really important discussion today. all of us can agree there is a lot more we need to do to keep families and communities healthy. and continue investing in priorities that strengthen our economy in the middle out. of course, the work of the national institutes of health is vitally important to this effort. the nih supports basic research that makes medical advances possible. it gives hope to those that are living with chronic and life-threatening disease and helps drive economic growth and competitiveness. we have all been touched in one way or the other by the research nih has supported or efforts to reduce the incidents of diabetes

and preterm births. biomedical research is an important investment to ensure our government works for all of our families. the investments we make in nih as well as in education and programs in this bill will help ensure that america's workforce in the years ahead will be able to create and taken to jobs of the 21st century. that's why like chairman blunt referenced, i am deeply troubled by the erosion of nih's purchasing power over the last decade and equally concerned about the similar erosion that has occurred in other categories of the budget that is essential to provide a strong and growing middle class. making sure that we are investing responsibly in our national priorities like research and infrastructure and education remains one of my highest priorities. of course last month, the senate debated and passed a budget resolution and unfortunately that budget proposal and the one that was passed by the house falls short of the funding level

that we do need to ensure stable and increasing support for nih and other priorities. i'm very proud. as you remember, back in 2013, democrats and republicans were able to reach a budget agreement. to roll back sequestration for fiscal years 2014 and 2015. rather than going back to the days of uncertainty and counterproductive cuts, we have to build on this bipartisan agreement and replace those automatic spending cuts for 2016 and beyond. the president's budget would do just that by fully replacing sequestration of defense and nondefense discretionary spending. that approach makes it possible to provide a billion dollar increase in funding to support nih efforts and increasing our understanding of the human brain and understanding the growing threat of bacteria and advancing work on developing a universal flu vaccine and finding treatments for curious and diseases that cause suffering and cut lives short.

their budget also supports a bold new initiative to support molecular biology. and data management. so support the shift from one size fits all medicine. to one tailored to specific individuals. precision medicine holds great promise for further advancing the treatment of cancer and full spectrum of disease. i'm very proud that my home state of washington is home to several institutions that have been pioneers in the field. that includes the cancer research center. that includes the university of washington which is using precision medicine technology to tackle breast cancer, eye disease and alzheimer's disease. dr. collins, and the clinic researchers i met with back home believe these new approaches are going to transform the field of medicine and i know that is something you agree with. while there is much opportunity, however, funding constraints have made it harder than ever for new researchers to land their first grand. the private sector funds very

little basic biomedical research leaving researchers dependent on a stretched pool of funding for nih funding. i'm pleased to see your budget is sensitive to the problem and focuses on nih's resources. to identify and support innovative and exceptional junior scientist. this is just one of the challenges the nih faces in what many feels is a remarkable time for medical research. i'm hopeful the democrats and republicans come together this time and build on the bipartisan foundation that was set in last congress so that we can make the investments we need to seize on these opportunities that are so important for our families and our economy. thank you very much, mr. chair. chairman blunt: thanks senator murray. dr. collins, we're eager to hear from you. dr. collins: it is an honor to appear before this panel given its long history of supporting nih's mission.

so seek fundamental knowledge and apply it in ways that enhance human health, lengthen life. as a federal reform agency we're acutely aware that to achieve our mission, we must serve as effective and efficient stewards of the resources provided by the american people. one way we're doing this is by focusing on prioritization of nih resources. this involves developing methods of portfolio analysis, of identifying scientific opportunities, fostering creative trends. enhancing the use of the common fund. we're also forging novel interagency partnerships like the nih f.d.a. project to build human biochips to test for human drug toxicity like the one i'm holding. seeking to identify new drug targets for alzheimer's disease, type 2 diabetes and autoimmune disorders.

to help set priorities, we are developing an overarching nih strategic plan to be linked with institute and center plans and this will set the stage for the future of biomedical research. we're also working to optimize the peer review process. to enhance the diversity, the fairness, the rigor of nih supported science. finally, we remain firmly committed to strengthening and sustaining the biomedical workforce by incentivizing early stage young investigators and revitalizing physician and scientist training. with these goals in mind, we are confident we will able to support the best science. while advancing our core mission and inspiring public trust. we take this stewardship responsibility with great seriousness. let me assure you the future of biomedical research has never been brighter, thanks in large parts to nih's strong support of basic science. the foundation for discoveries that have long made america the world leader in biomedicine. one exciting example is the

brain initiative. this bold multiagency effort is enabling development of innovative technologies such as what you see here on the screen to produce a dynamic picture of how individual brain cells and circumstances interact in time an space. this initiative will give us the tools for major advances in brain disease. from alzheimer's and autism to schizophrenia, epilepsy and traumatic brain injury. scientific advances are accelerating progress towards a new era of precision medicine. historically, doctors have been forced to base most of their treatment recommendations on the expected response of the average patients. recent advances, including the plummeting costs of dna sequencing make it possible for us to provide a more precise approach that so with this in mind, we at nih are thrilled to take a lead role in the multiagency precision medicine initiative.

in the near term, this initiative will focus on cancer. such research will include efforts to understand why cancers develop drug resistance. tracking ways of therapeutic response. as a longer term goal, nih will launch an unprecedented national research cohort of 1 million or more volunteers. they will play an active role on their genetic and environmental information is used. there is no better time to embark on this enterprise and move this precise personal approach into virtually all areas of health and disease. in closing my opening remarks, let me share a story that highlights the promise of precision medicine and puts a human face on it. seven years ago, at the age of 12, alana simon received a devastating diagnosis. this disease was poorly

understood and there were no effective drug treatments. alana was fortunate to be diagnosed early enough that with surgery to remove most of her liver, she successfully beat the cancer. but the story doesn't end there. four years after her surgery alana began interning in her father's lab at rockefeller university. reaching out through social media, this woman found 15 other individuals with this same cancer. their tumors, including hers could be subject to dna sequencing. the results were nothing short of remarkable. alana identified a genetic mutation that appeared to be driving the cancer in all of the cases, providing a target for a designer drug that is now under active development. since then, alana has published her findings in the journal of

science. participated in the white house science fair. entered harvard and introduced the president at the white house launch at the precision medicine initiative. this is the kind of scientific success we want to see replicated over an over. with your help, the time is now to celebrate such breakthroughs. thank you, mr. chairman. my leagues i want to introduce. over here to my left, dr. tony fauci. dr. gary gibbons, dr. thomas insel, dr. doug lowi and dr. jon lorsch. thank you. chairman blunt: thank you, dr. collins. we'll start with five-minute

rounds and probably have as many rounds as we can while we have this great opportunity to talk to you and what you're doing on precision medicine. obviously, a long path into the future where precision medicine might very well define most medicine at some future point. what would you maybe see as some five and 10-year short-term markers to see getting where we all would like to get as we move towards this precision initiative? dr. collins: i very much appreciate the question. it is something we're all quite excited about. actually we just concluded yesterday, a two-day workshop trying to map out exactly that kind of issue. what kind of uses could a cohort of a million individuals be put to if that were present five years from now? as an example, we really don't at the present time have the

ability to take full advantage of what we have learned about individual differences in drug response and see how those work in the real world. the fda has on the label now more than 100 drugs, information that say knowing the genetic information about the patients would be useful in this situation in order to choose the right dose and make sure it is the right drug for that person. but in practice, that is not happening. logistics are not there. imagine, though, you have a million people whose complete genomes have been and are available with the click of a mouse. so that when a decision is made about writing a prescription, it is possible for the health care provider to immediately know whether the dose needs to be adjusted or whether that is just the wrong drug for that person. we could rigorously test what is gained. a large scale study of this

sort, which is currently not possible, would be an example. i want to turn to my colleague dr. lowy. the other part of this method is an early focus on cancer. dr. lowy: thank you, dr. collins and thank you chairman blunt for your comments and strong support of nih we really are at a reflection point when it comes to cancer treatment. as a result of the genomic revolution, we now understand in much more detail than ever before that cancer instead of being one disease, even breast cancer, for example, is many different diseases and the opportunity for targeted treatment that we hope will be better, smarter and have fewer side effects really is at hand. we already have several clear

examples of targeted fda-approved drugs that are able to do just that. with the new precision medicine initiative, we are able to at a much larger scale to be able to conduct clinical trials that involve both adults and children, that instead of being focused principally on the organ site where the cancer develops instead is focused on the abnormalities in the cancer and the targets drugs that treat those specific abnormalities. i have gone in this in my written comments but i just wanted to highlight for you some of the key elements. >> dr. collins, the million person cohort, how would you intend to do that?

dr. collins: that is a topic of intense conversation right now. the next meeting which is going to be in senator alexander's state in nashville, at vanderbilt, will look at this kind of question. what is the ideal kind of cohort you want to achieve as far as demographics? we believe we can accomplish some of this by taking advantage of cohorts that have been put together by various delivery systems, perhaps the veterans administration. undoubtedly there will be gaps in terms of the representation. we want to be sure this has power to be able to tell us things about health disparities. we need to figure out how the fill those gaps. by august, this working group will make strong recommendations and we will be ready starting in fy 16 which is not far away. to initiate process of putting this cohort together. chairman blunt: thank you. senator murray?

senator murray: let me just follow on that. this million person cohorts is very intriguing. it has to be done right but how do you ensure it successfully represents all elements of the u.s. population? women, minorities. dr. collins: we very much want to have that kind of ability to follow on that. this million person cohorts is very intriguing. sample across the population. obviously women and men. obviously multiple different racial and ethnic groups across socioeconomic status, across age. with a million, of course, you have the opportunity to have a lot of people involved. that is the point of this. having that kind of power. exactly how we do this is what we have charged this group with wrestling with. i think we might want to oversample certain minority groups in order to be sure we have enough representation to be able to have powerful observations made possible about health disparities and certainly we will want to be sure that involve women in 60% of the population that gets studied.

one more thing i think i should say, we think to have participants in this particular study not just as subjects, they are our partners. they are going to be at the table as we design this study and are already at the table. i think that is going to be critical for defining the nature of what we're about here. we're asking people to be volunteers. we're asking them to share information. they will get back lots of information but we want them to feel like this is an important national program, being part of it is something to be proud of. senator murray: how long will this take? dr. collins: it will not be an overnight effort. we expected to take a couple of years. we hope to begin even before we reach that large number. senator murray: want to ask a

specific question. your budget, to bump budgets suggesting the rates of dementia are falling. that is intriguing and unexpected. if accurate, it is very encouraging. what is nih doing to confirm if those trends are real? dr. collins: we observed those papers as well with great interest. it was surprising. there is reason to be a little skeptical about whether one can be confident in conclusion. much of this data is based on death certificates. as we know, death certificates often do not accurately record the cause of death. it may say pneumonia or cartel year when the primary problem was alzheimer's disease. there are two bump different -- two studies underway to see whether there is in fact

evidence to point to that decrease or whether some of this is a diagnosis issue. it is possible because there is a vascular contribution and perhaps we are doing better now at managing things and that category that that might have resulted in a diminution or a delay in onset. we need to know the answer and i appreciate you raising that. senator murray: it is intriguing, if it is true and we learn something, that would be outstanding. i will be following that, too. since 2009, nih has been monitoring the disparity between application success rates and earlier stage investigators, i mention this in my opening remarks. i mentioned this in my opening remark.

as you know the latter experiences the significantly lower success rate -- to our experienced investigators. while securing an initial grant has always been challenging, we know that. i'm very concerned that it's much more so for those scientists and physicians who have just completed their training and may end up driving promising talent from the field. can you tell us what you are doing to level the playing field in terms of experienced and less experienced investigators? >> i appreciate the question very much because this is something that i think troubles all of us. i'm going to is ask dr. lorsch to answer the question. >> so we are very concerned about this, senator, as well. we are looking at a number of different ways to address it. in addition to targeting the first application i think a critical stage is often their renewal. if you get them into the system and they aren't able to renew their application that's a significant vulnerability for them. so we're going to look at that stage as well. we're also looking at a funding americaism pilot. -- mechanism pilot.

we think it's going to be more efficient in terms of getting the taxpayers more for their money and also more flexible and stable for investigators. we will be actually in the near future rolling out a new version of this pilot program. >> i think this is so important. we want to inspire people to come in if they think there's no chance or we're losing a lot of our knowledge as we have an aging cohort. i think that's trouble. >> as i may say, i think there's no magic that will really solve this as long as the budget continues to decrease because that's affecting everything. we're doing everything we can to protect those early stage investigators but there's only so many things you can do. >> thank you. >> chairman cochran. >> mr. chairman thank you. dr. collins i see you and think back about our trip to mississippi where you reviewed the results with local researchers of an idea program.

that indicated to you i think at that time that there were opportunities for accomplishing breakthroughs in medical research among economically challenged citizens and i wonder whether the n.i.h. grant success program and process has resulted in funding that has led to breakthroughs in research for cardiovascular diseases which seem to target african americans in greater numbers of percentage of the population than others. what is your latest information you can provide the committee about the need for continued funding for that program? >> well, thank you, senator. the idea program is one we are very proud of and which gives an opportunity for funds to be made available through several different kinds of programs to

states that do not have as strong tradition in terms of research intensive universities but who still have remarkable talent within their state borders. and i am going to ask dr. lorsch who oversees the program now to say a bit of a word about how that program is going. we're actually quite excited about it. dr. lorsch: thank you very much. it's one of my favorite things to talk about. as you know, the idea program aims to ensure that cutting-edge biomedical research is being conducted in all 50 states. the easiest way to think about it is what it would look like if it were not being conducted across the nation, if it were only 25 states. if you think about every dim ention of research, whether the kind of questions being asked, the approaches being used, or very importantly our ability to

attract young talent into the system. something senator murray addressed as well. those things would all be diminished dramatically if cutting-edge research were not going on throughout the nation. and that's why we're very committed to this program and think it's an essential part of our portfolio. >> thank you. now, to follow up the actual request. is it your intention to make a formal request for additional funding or what is the status of the administration's position? dr. collins: so, the idea program in the president's budget proposal for f.y. 16 is the same as for 15. and the reason for that is that there was an exceptional increase for the idea program going from 13 to 14 and we're now just trying to normalize those kinds of trajectories for all parts of it. but you should not take that in any way as a diminution for the program.

you also asked about cardiovascular disease and what that effect has been on minorities. i can't help but say that i often go is the jackson heart study. if it's all right i might ask dr. gibance to say a word about the status of that particular study. >> thank you. dr. gibance: thank you, dr. collins and senator. as you're aware, we've made tremendous progress in bending the curb in reducing coronary disease by 70% over the last 50 years but there's still pockets of communities and segments of our population who have not enjoyed the fruits of those advances including african americans, particularly in the southeast. the jackson-hart study has emerged as a national treasure in providing us with an opportunity to further understand where the drivers of these disproportionate burdens of disease in african americans.

indeed one example is that we recognize there is a great prevalence of end-stage kidney failure amongst african americans, five-fold more than the rest of the population often drive bin high blood pressure which is very prevalent. but thanks to the study and advances we're making in genomics we're now discovering and funding research that's discovering the genetic basis of this predisposition, identifying genes and indeed sickle cell trait, something that was previously thought to be relatively benign as important contributors to these health disparities. moreover, these pathways gives us insights into how we actually might prevent this disease and actually bend the curve, a key driver of end stage renal disease and expenditures for health care in this country. so again we should be quite proud of this national resource in jackson, mississippi.

>> thank you very much, mr. chairman. >> thank you. senator mikulski: mr. chairman. dr. collins and all of you we're so glad to see you once again. and we have talked among ourselves under the leadership of senator blunt. we would like for the subcommittee to be able to visit n.i.h. so they can talk in more depth and more first-hand to see the great work that's being done by the people who work there. and of course you know if you're the senator from maryland, n.i.h. and university of maryland and hopkins. long to see you, long stappeding friends, to new friends. we're going to get right to my appropriations question. the president has put in his request a $1 billion increase. i want to know what that means. and is that enough? i understand that n.i.h. has

lost 20% of its purchasing power since the doubling ended in 2003 due to inflation. i am concerned that, yes, you have more than the management capability to set priorities you're going to have to end up picking winners and losers. winners and losers in the united states of america. you can't doll up an n.i.h. just because there's a headline or world crisis. we turn to dr. fauci and your leadership during the ebola crisis and we've turned from aids and so on. you can't dial up a national institute. we want a cure for alzheimer's' and we want it yesterday. we all share that all around this table. but with the resources that you have i'm concerned. i'm concerned that while we go for precision medicine, which i support, i worry about zip code medicine.

the disparity in baltimore this morning between the neighborhood in which i live called roland park and a neighborhood called harlem park where they filmed the wire about two miles from where our disturbances are occurring is a 2-year life expectancy even -- 22 year life expectancy even controlling to violence. i could go on about it. as you know we've got a lot of issues here. dr. thornton, our superintendent of education talked to me about the 85,000 kids who went home fine on monday. 300 created disturbances unacceptable. but we talked about how damaged our children are. i said what do we need in our school system? mental health, mental health mental health. either our kids are addicted or their care givers are addicted. i don't want to pick winners and

losers between the 26 institutes. what is it that you truly need to do the job you need to do care for america while we're trying to do our job? >> i think all of our hearts are deeply troubled and wish for the best for that fine city. we have seen over the course of the last 12 years a significant diminution in n.i.h.'s ability to do research across the board and our most important resource the people doing the work are clearly pretty stressed at the moment. if you try to plot out what the reasons for that are, and i show you a graph up there, the yellow line is basically what our purchasing power is for biomedical research going back to 1993. and you can see there was that doubling between 98 and 2003 but since that time we have steadily lost ground.

the sequester added an additional severe blow to our ability to get our work done taking as it did $1. 5 billion away in the middle of a fiscal year in which we have not fully recovered. the $1 billion in the president's budget would go a long way towards putting us back on a stable upward trajectory and we have waited a long time to be able to achieve that. it would allow us to give 1200 additional grants in fiscal year 2016 compared to the previous year and that would be welcomed indeed. it would allow us to do things like the precision medicine initiative which we would want to have focused on looking at health disparities with the ability to not only get answers as to causes but come up with implementation plans for intervention. >> so the billion would help. but what would lifting the cap do? >> certainly if you look at that diagram you can see that we are down more than $10 billion over

where we would have expected to be if we stayed on that dotted green line which was the trajectory for n.i.h., going back to about about 1970. so it will take quite a bit to make up that ground. the consequence of that for people trying to get their research funded by n. i.h. that's the success rate. that's what an investigator who sent their grant in to us is facing. you can see it's been in the range of 25 to 30%. but more recently with the flat budgets we're down in the zone of 16 to 17%, which is very unhealthy and i think has caused a great deal of demoralization. >> what is the number? >> the number of grants is one out of six would be funded at this time. >> and how many do you turn away? >> that would be five out of six. >> but is it 20 to 0, 2,000? what does that mean?

>> i see where you're going. ok. so the number of grants that we fund in each year at the present time is about 9,000. so that means we are turning away about 55,000. and you know what? i don't think i can tell the difference between a grant that just made the cut and got funded and one that missed it. because in that zone they're all terrific. and so we are leaving a lot of great science, maybe half of it on the table, which we would not have done in the past years. >> that's a stunning number. >> yes. >> my time is up. i think we have made our point. you need at least a 5% increase to stay in place and to begin to catch up. >> thank you. senator moran. senator moran: i would pass to the next republican or democrat. >> thank you, senator moran. mr. chairman >> the problem is i can't find my glasses.

[laughter] >> before he finds his glasses dr. collins. >> i think we have just seen a parable about the importance of medicine. >> i was trying to think how to do that. when we get to one minute i wanted to switch to a red tape topic. but to begin with let me start with where the other discussions are. i went to the precision medicine announcement that the president made to demonstrate support. you were there. senator murray and i are incorporating the president's proposal into one of the top priorities of the health committee which is our innovation with which we are working with you about. how important would a properly functioning electronic medical system be to your effort to develop a cohort of 1 million individuals so that you can sequence their jen omes? >> senator, it would be

enormously important. we're counting on being able to utilize the advent of electronic records. there's a lot of work to be done to have those be truly interoperable. >> but the faster we get that going, the easier it will be to do what you're doing and i would assume you mentioned clicking the mouse if you're a doctor and you're prescribing a medicine you want to find whatever the genetic information is if the electronic medical system isn't operating well makes that more difficult. is that right? >> exactly. and the many doctors are a bit frustrated about this. >> they're really frustrated. >> yes. your institution vanderbilt has been i think in the lead here and looking at ways to try to make this system more optimized which is one of the reasons we're bringing that to >> they do a terrific job. but it's -- but we're going to work on that. and the administration and senator murray and i are setting

up a working group to identify the five or six steps that we can take to improve the electronic medical records system. so we will be working with you on that. the day you and i visited last week on the same day dr. vittner came by whom i had never met which i thought was interesting because if i have it right the two of you led parallel efforts to sequence the genome, one public one private. he said that his institute in california also plans to identify 1 million individuals and sequence their genomes. now, based upon the experience that you had earlier when you were working parallel side by side, is there any -- is there anything comparable about what he is doing and planning and you're planning? is there anything to learn about the early experience about collaboration? that's a lot of sequencing. are they just completely

separate or do we know yet? >> i think there are wonderful ways to make this a collaboration. i ran into him in the hallway after he had just been visiting with you and i've been in touch repeatedly over the years and made a plan to come visit his institute there in california. exactly what his plan is in terms of who the million people are that he will be sequencing hasn't fully emerged so everything is a bit of a work in progress here. but i promise you there's so much to be gained here by working a way that this can be collaborative. one thing though that we will be very clear about with the public project once again is we want this to be a project where scientists researchers with great ideas are going to be able to get access to the data as quickly as possible because this will be incredibly valuable as a resource and that will be an important part. >> well, but it's interesting development and huge. i mean, 1 million individual cohorts.

has that been done before? dr. collins: no. not in this country and not anywhere. the british have a cohort of half a million but of course we have to be bigger because after all -- we also have a very different population. the british cohort which we will also link up with and learn everything we can from because there's a great opportunity for international cooperation but it's a different population. >> we're lucky to have this collaboration. now let me switch to red tape. what i want to invite you to do is to submit to the committee that senator murray and i chair and cochair and i imagine senator blunt and senator murray would be interested, too, your list of regulatory obstacles or administrative obstacles that make it harder for you to succeed. you mentioned that you would like to have the money that we

appropriate for one year carried over to the next year like other agencies do. you mentioned the amount of paperwork you have to do for scientists to go to conferences. you actually mentioned five or six or eight or ten other things, some of them have to do with what the office of management and budget requires i assume. but some of it has to do with thing that is we do. so i would like to invite you to give those specific recommendations and see if we can fix them. this innovation project we have going means we are going to have a law passed and beck include some of these things. i would also like to include in that whatever we can do about the finding that 42% a scientists spends is administrative work. you get $24 billion yo you give to universities. if we could reduce by 5 to 10% the amount that's spent on administrative work, there's $1 billion.

senator mikulski was asking about $1 billion, there's $1 billion. so i simply invite you to work with us on that. and while we're trying to appropriate more money we might be able to save some money and that would double the amount of money that would be available to you. dr. collins: senator, i would be glad to submit that list. and i appreciate what you and senator murray are doing with this innovation project because this could help us a lot getting some of these obstacles out of the way. >> it could double the savings might double the amount of the new appropriation. >> thanks. you got your 30 seconds back and a little bit more and everybody is doing a good job trying to hold to their time and we will have time for a second round. anybody can stay for that. and we would like that information when you put it together, senator collins for this committee as well. senator durbin.

senator durbin: thank you so much. let me say at the outset address my colleagues here. gathered in this room at this moment are the key players in the united states senate when it comes to this whole issue of medical research. senator alexander is chairman of the help committee or whatever nomen clay tur is these days. with his ranking member senator murray. senator blunt is chairman of this appropriations committee. again, with senator murray. my overall chairman of the committee thad cock ran and chairman of the defense appropriations subcommittee which i'm honored to serve on as ranking. and we have an opportunity here. we know that the american people are skeptical if not cynical about who we are and what we do. but my guess is if you had to pick one hearing room on capitol hill this morning that virtually every visitor and every family would be interested in hearing what's going on it it would be this room at this moment. there isn't one of us who haven't vulnerable to some medical diagnosis for ourselves or someone we love that could be life changing.

and we pray when we look in the eye of that doctor and say is there anything you can do he will say we're in luck. we have a new drug, a new surgery, a new approach. can i suggest to my colleagues here on both sides of the aisle. wouldn't it be significant in our lives and the history of america if we decided to be the driving force to make sure we make a statement once and for all about biomedical research and the future of this country rather than let it be tossed about by the whims of budgets year in and year out? i look at senator cochran and our defense appropriations subcommittee and i chaired it before you and i said i'm going to focus on medical research and the department of defense. the first year we increased it by 28% and the second 11%. and i have contacted dr. collins and said are we able to coordinate this? so that the flagship n.i. h. can work with the department of defense, c.d.c. , department of veterans affairs, even the

department of energy to make certain we're moving in that direction. so before i ask a question i just hope that before we think about an infusion of oako funds strictly limited to the defense department that we kind of stand our ground here and say it won't be strictly limited. there are some things that need help and this is one of them and we want to put in our bid and make our stand to make sure that medical research, biomedical research starts moving forward again. dr. collins suggested to me a couple years ago 5% real growth tor 10 years. i wish we could do more. some are calling for more. but i urge everybody here because gathered in this room at the moment are the people who can make the decision in the united states senate and i've talked to each one of you and i know you're all committed to it so i hope we can reach that point. and congratulations having been chosen to be a member of the irish american hall of fame in chicago, illinois, on saturday night. congratulations.

are we coordinating this research that's going on across the federal government in medical research? dr. collins: thank you, senator. yes, i think i can say with considerable detail and confidence that we are. you mentioned the interactions of the department of defense and you and i spoke about that and we actually went back and looked very carefully at our portfolio and theirs to identify whether there were areas that were duplicative and we did not find duplication. we found synergy. we found great examples of places where a particular problem with getting funded by both agencies but in a way that covered different parts of the problem. we also are working more closely i would say than probably at any time in history between agencies like f.d.a., c.d.c., the c.m.s. where we just recently left we had a meeting of senior leadership and with darpa where we're working in a whole variety of interesting ways to develop a combination of life science approaches carrying with me

today three different organs on a ship. this is a blood brain barrier and this is a kidney and lung they are all basically taking advantage of stem cell >> water? >> just happen to have it here. that's a collaboration of trying to put basically a lot of human biology on a chip to enable us to be able to test new drugs for instance, to see whether they're toxic or not. >> i don't have time for you to give an adequate answer but yesterday i was visited by barbara striesand who was pushing for this area of research to make sure that women are included in heart research trials and she believes that adequate attention has not been paid in this area and some share that belief. so i hope that we are thinking about the appropriate diversity in the testing to be able to come up with the results that help all of us across the country.

dr. collins: senator i totally agree with you. i've also met with ms. striesand and i think she is a very effective advocate for the importance of taking takes to the needs of women's health. one thing we have done is insist that people looking at animal models have to study both males and females. traditionally many of them have studied only one sex. that's leaving out a lot of important insight. >> thank you, senator. senator moran. senator moran: thank you. dr. collins i could see you earlier but couldn't see what's in front of me. nice to be able to see both. thank you so much for being here. dr. collins you were in my office late last week and we had a conversation. i want to ask you to follow up on the conversation that we set, kind of if someone can humbly give you an admonition, i tried to give you one, and you talk about in your testimony the stewardship initiative at n.i.h. in my view, they're related. and i want you to tell us again in more detail about what you're indicating in your testimony

about shuredship at n.i.h. but i want to reiterate what i indicated in my office. many groups, people, individuals, folks afflicted by every disease ask members of congress for help at n.i.h. to find a cure and a solution to their health and their lives. we have taken the opportunity to defer to n.i.h. to make the decisions about prioritization of medical research. the theory i think has been before i arrived in the senate and became involved in this issue the theory has been that scientists should make the decisions about where the most promising opportunities are in finding the cure or the treatment. but what i want to know from you is that you are fulfilling that responsibility. that n.i.h. in the absence of congress's direction about where to focus the dollars that n.i.h. is making the best decisions

possible to find the cures that are the most readily available and most demanding by our citizens and the population of the world. in other words, if you don't do that prioritization, then i think it is going to become incumbent upon congress to make decisions that are better made by you. dr. collins: senator, i appreciate your raising this issue. it's a very important one. and even as we hope and pray for a lifting of sequester caps that would allow n.i.h. to get back on a stable trajectory as well as many other important activities of the government as well, we take very seriously the importance of enhancing our current focus on stewardship to be sure that we are paying absolutely close attention to how every dollar is spent. and so over the course of the past many months sort of looking at areas of that sort we have in fact quite a vigorous plan here in terms of how to put forward those stewardship initiatives.

one is to develop an overarching n.i.h. strategic plan covering our entire 27 institutes and centers each of which has had its own strategic plan but we have not had those --. and we will have that and will submit it by next december. we also can use new methods that are actually much more sophisticated than what we've had in the past to do a portfolio analysis and see exactly where are our dollars currently going? are there gaps, are there areas where we have piled up things in a greater proliferation in some spots and enough enough in others. we are going to look closely at our portfolio of hiv aids research now that it's 2015 we desperately need to find an answer to this disease and to end this epidemic. we need to focus particularly heavy on vaccines, on new forms of therapeutics, on potentially the cure.

we have an active grant by grant review going on right now of our hiv aids portfolio to see how that matches with the priorities that should be most appropriate at the present time. we are going to make sure that we have best practices for how funding decisions are made within the institutes because peer review is part of that but not all of that. we have to make decisions based upon scientific priorities that our counsels and directors are responsible for and we want to make sure we are making the most of those opportunities. we will continue to look for partnership soss that as much as possible we can find other dollars besides the n.i.h. dollars to pursue other important projects with other agencies or the private sector. we will focus intensely on early stage investigators which have already been raised as a major issue and some we're very concerned about how could we enhance the opportunity to give those early stage investigators the confidence that there's a career path for them and they could take risks and do innovative research without fear of losing support.

and was mentioned by senator alexander we're going to look closely at administrative burdens many of which we don't control but for the ones that we do have some say over we are going to try to do everything we can to reduce those and give skinaltses more time to do science instead of paperwork. that's a partial list of what is a vigorous array of act tivets but i want to assure you very much from my own personal commitment here that we are taking this with great seriousness. we don't expect people to say you're just n.i.h. so you deserve dollars. we have to show that we're using those wisely and every dollar is being put to good use. there will be much more to say in the coming months. >> as you heard from senator durbin and every member that's spoken we're interested in finding additional resources for you. we understand this cannot be resolved only by your efish sis but as we find those additional dollars the assurance that i am looking for is you then the have the capability to ensure where

those dollars will best be spent for the health and well being of our country and i thank you for your answer. >> thank you. >> senator schatz. senator schatz: thank you, mr. chairman. thank you dr. collins. identify become increasingly interested in telehealth and i think there are a number of federal agencies doing great work in this space, the d.o.d. and v. a. come to mind. i think cms has some work to do some of that has to do with their statutory challenges and some i think they could push their authorities a little more. and i know that n.i.h. is doing a number of research projects. i wonder if you wouldn't mind taking a minute or two and letting us know what you're up to and what you've found. dr. collins: i appreciate the question. many of the institutes have investments in this space. and i've got to tell you that

more recently what's really emerged as an even more hot area and a very promising one is the idea of m-health using cell phone technologies to make this more transportable where people are walking around with their own potential telehealth in their pockets. i can think of a telemedicine application the eye institute is using to try to assess with babies in the newborn icu which of those is developing a retinopathy by taking photographs and sending that to an expert across the country to say this baby needs treatment, that wunt doesn't. dr. gibens has an application for asthma. dr. gibance: certainly one of the areas of concern with asthma, the leading chronic condition affecting children relates to being able to transsquend those geographic barriers where there's a particular problem. a lot of times it's getting a sense of the child's symptoms and course of disease. and that's where there's an opportunity to use leverage technologies that enables that information to get to the experts necessary to manage that

care. other technologies that actually exist on the smart phone now are able to assess the breathing capacity of the child. and we have a program that we're funding that leverages resources that are local such as schools where this information can be ascertained the child's symptoms and disease course, developed, and a treatment transmitd in that local environment. leveraging those local resources. so we're looking at using these new mobile technologies in different ways to enhance care for both children and adults. >> thank you. and let me just make a small point about telemedicine telehealth. this has been something that people have been working on for decades and as a result people think of vtc or telemedicine sensor-based delivery of care. and i think that it's entirely possible that for at least some treatments that the mobile phone just sort of outpaced all of it.

so i want to make sure that when we do national health policy and we do our appropriations and we encourage you to do telehealth that we are not conceiving of a sort of 18995 center for -- a 1995 center for telemeden but we're enabling people to get the health care that they need through their phone, hipa compliant and all the rest of it. but it's important to say because i do think we have a statutory infrastructure and some inertia that is based on what was possible ten or 15 years ago. dr. collins: senator, i'm glad you point this out. i think our portfolio has shifted dramatically in the direction of m health mobile health using cell phone technology which is bursting with potential for whatever thing, either for maintaining health or for perhaps using this to monitor chronic illness many of us now walking around with wearable sensors. i have my fit bit. i don't know how many people have something that's currently monitoring their physiology.

but that's such a great opportunity for medicine and we are all over that. >> one other question with respect to telehealth i think we're going to come up against the question of scoring. i think with respect to medicare reimbursing for telehealth services there's sort of an ongoing discussion about whether or not it will increase total cost to the system. my strong belief is that it will decrease total cost to the system. that doesn't mean that cbo scores it accordingly. i'm just wondering whether you are doing any research that gives us any insights to what would happen to the total cost within a health care system utilizing m health. dr. collins: we're certainly interested in rigorous studies to assess whether m health applications are improving outcomes. there's so many potential applications that are out there that people are excited about but many of them have not really been put to a test and in order to decide whether you're achieving any cost savings first you have to figure out did this application actually improve the long term outcome. did you reduce illness?

did you manage it more effectively? that is in our sweet spot in terms of what we are trying to support. >> thank you. >> senator. >> thank you. and i want to thank the panel. this is very interesting to everybody. i am going to make a quick comment about the i.d.e.a. program that dr. lorsch i believe you're in charge of. two of our institutions in west virginia are the recipients of grants there so i would like to invite you to join me in west virginia to show me what's going on and what the possibilities are there. >> i would be absolutely delighted to come. >> good deal. my real passion here in the area is also mer's both of my parents -- is alzheimer's. both of my parents just recently passed away. both of them with had increasing dementia. i'm going to go back and look at

the death certificates and see what was actually listed as a cause of death because having lived through it, when you said that it may be decreasing my eyes almost popped out of my head because what i saw just on the ground i can't imagine that that's the case. and it could be just poor data. i hope that -- i know that you are getting ready to revise the research milestones for the national plan. could you talk a little bit about that what n.i.h. is doing in that area? dr. collins: so alzheimer's' disease is an area of intense focus and has of course enormous consequences. we need to find answers here. 5 million americans currently affected. the cost personally to those individuals to their families is enormous. the economic costs we know is approaching $200 billion a year just in the united states. so we need to find ways to prevent or delay this disease. and there is effort across many different parts of n.i.h. to do so but led by the national institute on aging.

this extends from very basic science studies trying to understand what is actually happening in the brain that leads to the deposits of these proteins amlloyd and tall. and an interesting recent development has been what's been called alzheimer's' in a dish. namely, the ability to take stem cells, add an appropriate cocktail to convince them to become nure ons, put them into a -- neurons, put them into a petry dish but not as flat cells but in a three-dimensional space where they act more like they would. and you can then tell the difference between those cells if they came from somebody with a dominant form of alzheimer's' as opposed to a normal person. that is an enormously powerful development because it gives us a chance to look in human cells in a way that doesn't put people at risk and allows, for instance, screening drugs which to see which of those might be more promising. so that's a basic part of it.

on the clinical side, i think just a month ago the report by biogen of what appeared to be a possible positive result first time after dozens of failed trials from a ant body has gotten a lot of people interested in whether we might be on to something. now, very small trial. only about 300 patients. you always have to be careful here because it's so easy for those things not to be replicated but the initial excitement is certainly something with cautiousness people are feeling a bit more optimistic. one thing we are doing is to partner with industry in an unprecedented way. >> is that the accelerating medicine partnership? dr. collins: it is. i personally cochair the executive committee of that group and we've only been at it a year and we're ahead of the schedule that we thought would be possible. that also is showing some considerable promise all the way from the basic to the clinical.

so i think we are on a role here in terms of tackling what has been for most of the years that we've studied it a really frustrating disease. we're starting to get a much better handle on what is going on in the alzheimer's' brain. it's clear that one thing we need to do as we're try clinical trials is to start early before too much damage has been already done to the brain. so i assure you this is an intense area of focus. >> i would encourage that and will be a great supporter of that. i just read an article i believe in the sunday paper about a clinical trial or -- a small area, i believe in south america, that identified they had a pocket of early onset alzheimer's' in the 40's, age bracket, very interesting to me because it mentioned some of the same things you mentioned. >> that's an n.i.h. sponsored trial in columbia for a family that has this form. and they are involved in a very significant way in these

clinical trials. >> the interesting thing for me too having lived through it with two parents, it's not the same for every person which makes it more difficult in terms of researching and figuring out how to attack it. so there's a lot of families across probably every family sitting up here today and in the audience who has been touched by this. thank you. >> thank you. senator baldwin. senator baldwin: thank you. and welcome. i want to start asking some questions about chronic pain opyoid treatment, and alternatives. so let me just give a little bit of contact. obviously we know that chronic pain is a condition that affects over 100 million americans. and for some individuals prescription oipyoids are an important part of a treatment plan but it's also clear if you are following any of the trends in the nation that we're in the midst of a national crisis as a

result of significant overprescription of open yoids -- of opiods and misuse. dr. collins, you recently stated in i think it was a blog post that when it comes to chronic pain o open oids are not always the answer. and speaking to the lack of evidence -- well, let me see what did you say. there's an absence of unbiased scientific review to examine evidence of the safety of long-term prescription opeoid -- opiod use and the impact of such use on patients. so i would like to talk first off two questions related to that. first is please tell us about the collaboration you're doing with the v.a. on inquiry into alternatives, pain management strategies, not just for

physical pain but also ptsd. and then in what time you have remaining if we do what potential does the research on the effectiveness -- what does the latest science tell us about the broad use of op oids to treat chronic pain and what is the n.i.h. doing to expand our understanding of pain management? dr. collins: thank you, senator. this is indeed an enormous concern. an enormous public health problem. 17,000 people lost their lives last year to op oid overdose most of those unintentional. the number of prescriptions written for opidds is dizzying. it adds up to basically one prkspr american per year.

-- prescription per american per year. that doesn't sound like what we need to do in order to deal with the problems of chronic pain. it is in fact the case that studies that have been done on the use of op oids and chronic pain generally haven't been carried out for more than four to six weeks and oftentimes chronic pain goes on longer than that. the data we do have certainly would cause anybody to conclude that op oids are probably not a -- opiods are probably not a good choice for chronic pain unless it is associated with severe tissue injury as in the case of, say, cancer. so we have a lot that we need to come up with in terms of alternatives. and that's what these 13 projects that we're doing jointly with the v.a. and we in this case the national center and the institute for drug abuse, working together on this, i think they're trying to assess for various types of pain, particularly if it might call central pain coming from conditions associated, for instance, with ptsd where the use of a drug like an op oid

-- an opiod which is better suited for peripheral pain just doesn't seem to work and in fact carries a lot of risk. so alternatives such as ant depressants, cognitive behavioral therapy interventions that involve something that might seem new age but actually seems to have some value to a lot of people. yoga. all of those being looked at as alternatives to putting people down a very difficult path of op oids which may lead to addiction and all the problems associated with that. meanwhile, the national institute of drug abuse is deeply enzpwaged in looking for -- engaged in looking for other alternatives for pain management that are not addicting coming up with op oids that can't be abused because they can't be injected. all of those are high priorities. i traveled to atlanta this year as i did last year to the summit that hall rogers, chair of appropriations in the house, runs every year that there were a thousand people there from all over the country working

together to try to tackle what everybody now sees as a major and growing health problem in the u.s. we will do everything we can to help with that. >> i have just a couple of seconds remaining so i hopefully have you follow up in writing. but one of the high lights that you focused on in your testimony was shared priorities to improve opportunities for the next generation of innovators and researchers across our nation. and i know that you've initiated and we have talked much about the initiation of a number of policies to promote new researchers. we've i've had a significant -- identified a significant gap on the date ave of the existing workforce and we have a lack of comprehensive way to track the success of the careers of researchers.

i have been working closely with you on my next generation researcher act that would ensure that n.i.h. accelerates current and new policies to address this and foster new researchers. so let me just say that i would like to hear more about why we don't have a good system in place already to track this information on our biomedical workforce. and what additional steps n.i.h. is taking to address this gap. dr. collins: i think we will take that for the record or when we get to a second round if senator baldwin wants that to be her question that would be great. senator cassidy. >> gentlemen, i'm a doctor.

i know so much of what you all have done. dr. fauci, in 1985 when i was a resident at l.a. county hospital the diagnosis of aids was a 100% death sentence. now if you take your medicine you are more likely to die of alzheimer's' than aids, it seems. so thank you all from a guy who has seen first-hand what you have done. i want to build upon that which senator moran was saying. when you said dr. collins, that the report would be available next december do you mean 2015 or 2016 in terms of rebalancing how your spending priorities? >> that will be december of this year 2015. >> there's an article from 2011 suggesting that the funding with disabilities life years adjusted accounted for 33 or 39% of the variance and there was no other correlation. what other factors will you be using to determine whether or

not you should rebalance funding or how you should rebalance? >> so generally we look at the public health burden and it is a very well established way to do that. we also look at scientific opportunity because it's not going to be successful to throw money at a problem if nobody has an idea about what to do about it. we look at what our peer review process is telling us about the excellence of the science. >> now, i don't mean to interrupt. i've got four minutes. to a certain extent though there's a certain sort of the past is prolog on that approach. when i look -- i'll tell you my concerns. i look at, i've done some back of the envelope figure and we've been looking at this for a while. the work being done for vaccine for hiv aids.

the best i can figure is we're spending $400 million for that and less than 600 million in total for alzheimer's'. so just the vaccine aspect of hiv aids we're spending two thirds as much as we are on alzheimer's' on a per death may tell me it's wrong, we're spending almost $190,000 per hiv death and we're spending $6700 per alzheimer's' death. 10% of our budget on hiv aids, 1.9% on alzheimer's'. i can go down the list. i'm a hep tolls so there's similar numbers where we're spending as an economy for alzheimer's' we're spending -- you mentioned $200 billion a year for liver disease, 51 billion, and hiv aids 16 billion a year. so there seems to be just a total out of whack in terms of the burden on society death dalis, cost of medicare, medicaid, eat set ra and where we're spending right now. can you correct that at all in a relatively short period of time?

dr. collins: our goal is to end the aids eep demic and we are not there as you know. i i accept that. but if you look at the incidents of disease there's far more incidents of alzheimer's' than hiv. and the means of preventing hiv is well known. obviously vaccine would be the holy grail. so are we going to wait -- i guess my question is, we have this balloon note on alzheimer's'. 1200 billion climbing. are we going to wait until we figure out a vaccine for hiv aids before we begin shifting to the new battle? you see what i'm saying?

>> i think i do. and again, i want to assure you that we are looking with more scrutiny than ever at that hiv aids portfolio. i should ask dr. fauci to weigh in here since he is the expert for us. dr. fauci: i certainly understand the point you're making but i think one of the other variables that was not mentioned is the ability or not to completely end something. and i think when you're dealing with an infectious disease that has epidemic and pandemic aspects to it that's really a different story in some respects from other diseases which are equally as serious as devastating and have impact on society that don't have the potential to actly be complete lid ended the way we did polio in this country and the way we did many other infectious diseases. so although i fully understand and appreciate the point you're making i'm looking forward to a time when i'm sitting in front of this committee and we have ended the aids epidemic and there won't be any argument

about what you want to do with the money because you don't need the money. >> i accept that and that's a good point. but does that mean that we increasingly consume -- because i think in 2011 the budget for hiv aids was about $2.5 billion and now it's almost $3 billion. and so it just -- we have to set priorities and we are spending $300 billion a year on alzheimer's' dim dementia. it would be great if we can -- spending $19,000 per death for hiv aids and 6700 for alzheimer's' seems like a prioritization which doesn't reflect that we're spending 200 to 300 billion a year. dr. fauci: i get your point. but also just to get this point on the table is if you do the kinds of calculations of how much money you would save per hiv infecks prevented and you do the math on that, you're talking about even a vaccine that isn't the best vaccine in the world that's 50% effective we would save about $6 billion a year just on that. so those are the things that we're aiming at. the other point i want to make is that when dr.

-- dr. collins was talking about relooking at the portfolio, one of the first important steps is to look at the portfolio itself and then say within that portfolio are we actually spending money on the most high priority within that, and make that as the first shift. and then take a look after that and determine about the redistribution. so we are looking at that and taking it very seriously. >> i'm way over. thank you for your indulgence. >> thank you. senator lanchingefrd. can i do one wrapup question. i pleesh the conversation that's -- i apprecate the conversation that's ongoing on this and this is one of multiple diseases that has a tremendous expense, consuming a great deal of both financial cost and pain across the entire country. last year congress passed the alzheimer's' accountability act which required a report and to be able to get that budget east

mat together what it would take. when do you expect that to be complete? >> i appreciate the question. yes, this was an act which got folded into the omnibus bill which basically asks n.i.h. to put forward a bypass budget as we do now for cancer. the instructions are such that we are to have the first version of that by sometime this summer in order for that to apply to fiscal year 2017. and we are on track to do that. i should say we will in the next 24 hours issue a new set of recommendations about alzheimer's' research based upon the summit that we held in february and the sintsdz sis of those recommendations. so that will be coming out together. >> thank you. i look forward to going through that report. i am like many people, i watched my grandmother do the long

good-bye. we have all walked through this. my mother currently has parkinson's. >> because we had this conversation about alzheimer's' and aids i would say that we have actually increased spending since 2011 by 40%, more than any other disease, specifically because of the scientific opportunities and the enormous public health need. >> thank you. mr. shats had mentioned when senator schatz was talking about telemedicine. obviously we have work to do with cms on the building process of that as well. but let me do one caveat and this is not to belittle them at all so i'm not going to pick on somebody that's not here.

the census bureau in 2010 spent $3 billion developing a hand held device to do the census on and had to punt it. so we literally lost $3 billion on a hand held device to take the census that they went back to pen and paper on it. as much as we can use current technology and allow the private sector to take the lead please continue to do that. i know n.i.h. has done that a tremendous amount. but don't reinvent the wheel. >> i'm totally with you. with this precision medicine initiative there's enormous interest from private sector. we have no need i think to develop any of our own because they're chomping at the bit to have theirs tried out. >> thank you. please press on with that. let me ask a general question. we see an increase in cost in drug and device development over the past several years. it seems to continue to accelerate. can you help me understand what is driving the increase costs between basic research and clinical research all the way from the time of concept to the time of actually getting in the marketplace what are the key factors that you see that's increasing the cost more than anything else?

and i know it's not only one thing but if you can give me a couple things here what we should watch for. >> a lot of it is the high failure rate and that is in fact very troubling when you consider how rarely an idea about a new drug makes it all the way through to f.d.a. approval it's less than 1% of the time. so all that cost of the failures has to be added into the overall enterprise. one of the things we're doin is the formation for the national center for translation sciencings which aims to identify some of the places where failure happens, where bottlenecks occur and develop new technologies in concert with the private sect tor see what with k be done about that. i mentioned this idea of human cells on a chip as a way of testing drug toxicety instead of using animals and is looking like maybe it will work. you actually identify the subset of individuals for whom that drug is particularly well suited. you run a much smaller trial and have a much better cost of success. so cost goes down and chance of success goes up. those are things in the work.>> is

there any one spot where you see cost increasing more than any other area? dr. collins: the clinical trial is the most expensive part. if you have to do a clinical trial of thousands of people and follow them over a period of time that is going to be very expensive. we have to come up with ways to do smaller trials. to have biomarkers to let you know if the drug is working without waiting four or five years to see what happens. those are really high priority. >> thank you. >> dr. collins, i wanted to ask you about your opinion about some work i've been doing to drive this senate appropriations committee to have one unified federal electronic health record between d.o.d. and v.a. my hope is to make sure that using the 25 million patients that the v.a. has and the 2 million patients that d.o.d. has we have