Transcripts For CSPAN3 Politics And Public Policy Today 20240622

As one of those District Centers is taken over within hours the Afghan Security forces are taking it back. They have the ability now, the capability to react much quicker, to move forces all around the country to go back and take over those District Centers. I think thats a sign of progress as they move forward. Again, they have technology, they have the people they have the training. I think the difference this fighting season is getting the right leadership in place, holding the leaders accountable for the welfare of soldiers and police. And then building the moral of the folk as they continue to take the offensive. Theyre very defensive in nature. 80 of the Afghan Security forces are on check points and youre vulnerable to attacks. Thats where theyre taking a lot of their losses on the small check points. Afghan local police were designed to be the guardian tofs village. Theyre supposed to guard that village. But theyve employed them five kilometer, 10 kilometers outside of the village. The taliban sees the soft targets and take over the check point. They roll up the next one, roll up the next one. So theyre learning that as they go on the offense when they do these planned operations, actually the number of casualties are much much less because theyve planned them out, theyve planned the medevac medevac. And when theyre movable theyre not a target for the taliban. President ghani is working that very hard. The Senior Leadership is working that hard. Its in their dna to be on the check points. The Senior Leadership is working hard to get them off that. Well see continued progress. Just to remind folks, i last year it was estimated that 5,000 afghans gave their lives army and police in defense of their nation. This year the pace is a little higher for this time of the a year. Another concern is that a lot of people go awol, they dont complete their service. Before i move on to the last question for you about the future of the Afghan Security forces, how would you describe the Current Situation where theyre losing people through awol or attrition . Attrition has a big issue. Weve done a deep dive on it open worked with ministry of defense to focus on what we can do to help them. Lose probably in the neighborhood of 4,000 per month. A lot of that you would think is battlefield casualties. The biggest case is people who go awol absent without leave. It goes down to leadership. Why are they leaving . You have young soldiers or police that have been fighting for two or three years and they havent had a break. Theyre maybe not getting the right food they deserve. They havent had an opportunity to train. And so when it gets down to leadership and taking care of soldiers and Police Something we take for granted in all of our Services Back here, all of the noncommissioned officers with than they dont have the same thing in afghanistan. Theyre growing it but theyre not there yet. When youre fighting all of the time and need to take a break and you have no other way, you go back home and dont come back. Thats the biggest issue. Were working on leadership, working on ways to retain people. When they enlist in the afghan army this is an all volunteer force. A lot of times we forget about that. And you have somebody that enlists for three years. They want to what we call reenlist, they call it recontracting. You take a young soldier thats been at it loor three years, he doesnt want to reenlist or recontract for five years. He may want to do it for another year or two years but they havent allowed them to do that. Now theyre doing that. And now they have money for bonuses for people who do reapply. I think thats going to grow and maintain the army at a little higher levels than theyve had. It really goes down to leadership and really fighting at some common things about taking care of soldiers, taking care of police. Once they do that i think the soldiers will stay. You know senior afghans told me they dont need adviser to talk to them about patriotism or fighting. They got that down pat. And we know theyve been fighting for many years. They need the right leadership to show them what right looks like to stay in the army and to stay in the police and think theyre making the adjustments now. A final footnote on that. Some people said that the loss rates between kushlties and awol are unsustainable in the Afghan Forces. Would you describe them as unsustainable . Again. Any casualty is a shame. And we have to take shock in that. We can never forget about the sacrifice of the martyrs of the police or the army, the Wounded Warriors that they have. Were starting to incorporate Wounded Warriors plans like we have. I think again, that if they get rid of the attrition piece of it, work very hard on recruiting for the whole year what they do now is they dont recruit during the fighting season. April through october they dont worry about recruiting. And the u. S. Army we look at recruiting all year long. Were trying to have them do that and also make them be accountable. They need a goal to recruit x number of people. Theyre starting to put the measures in place. Once they do that, any that they lose by battlefield losses or any they lose by going awol is not good but i think theyll overcome those. Last question to you before i bring in the audience. When you look ahead to the next 18 months and we look ahead as a United States to our future role in afghanistan, obviously were hoping that the congress will continue to appropriate funds for Economy Development into many years for the future because the after glance dont have a sustainable economic base to pay for them on their own. Were thinking i believe, about two different priorities for us. One is our Counter Terrorism needs, to what extent we want the ability to have american drones, american commandos, american intelligence into the longer term future. The other question is what kind of support does the afghan army and police still need even potentially beyond the time fraim thats projected. What criteria are you examine to evaluate that progress. You talked about air power in other sessions, youve talked about intelligence, medevac. I know there with a few things on your mind. Thank you. Many of the gaps it seems the challenges they had we identified years ago. Onallen before him all identify its going to take a long time to build. Logistics in the u. S. Army is a very very tough things. Logistics and the terrain you have in afghanistan quadruples how hard that is. Being able to take all of the sources, trying to figure out what that really means. That took us many years to do. And so those areas that we identified will continue to work on those. And thats where were really putting the priority on our advisers. Our advisers today are really our weapons system. This fight changed owe the years. Where we had plooiftsrivates and sergeants that were in the fight. I have senior ses civilians senior civilians that are experts in planning programming budgets, that are experts in transparenty accountability oversight, rule of law, sustainability strategic communications, we work on those areas every hard pap and we have metrics that we measure. Every single week i get an update on the functions. Over time well come to a point where were going to say, thats the best we can do or theyre not going to get any farther than that. Or i have six months left and i need to prioritize. Im continually assessing the Afghan Security forces both the police and the army as we go forward. I do think for the long haul intelligence, aviation for sure, it just takes a long time. It takes two to three years to grow a pilot two or three years to grow maintainers. We started late growing their air force. Were going to be there for a while to work hard on the air force. Sustainability is another area. We built a lot of mechanics to work on their Weapons Systems and vehicles but what we didnt do well is we didnt build the middle management. Its going to take time to build or senior commissioner officer to get in there and keep the maintenance going. Those areas well continue to look at. I assess those every week. We make adjustments based on up put i get from the afghans and whats important to them. And i think as we go forward were really looking at what it means post2016 from a u. S. Per secretive on ct as you talked about and then more importantly building an afghan capability for the region. President ghani said he wants to be a regional player in ct as well. The last thing i would mention is nato has come on strong as well to say what role can we play after res lawsuit support. And so the defense minister weve brought together the equivalence and all of the countries come out loud and strong saying they want to continue to contribute to the future afghanistan. And the way theyve gone about that is we did a Needs Assessment saying what do they need two years from now in what areas leadership is an area they talked about. Maintenance, aviation, intelligence. I think youll see nato come on board as we continue to work through that to continue to apply different countrys resource to continue to build on the capability of Afghan Security forces. Nato officers are willing to stay a little longer . I think nato quite frankly is waiting to see where the u. S. Is going to go. Every day were assessing that. I owe back my Senior Leadership at the end of the fighting season an asaysment. And based on that well make decisions on where we are in 2016 and beyond. Thank you very much, general. A question about the Afghan Government and then i want to ask one about the region and wrap up there and go to vonda. We hear various reports about how the president and chief executive officer are doing in wringing along their broader political movements, forming a cabinet. We hear a lot of reports about how long its take fg theing for the cabinet to be formed. Can you explain what you think are the most important highlights if for audience to understand . How well are they doing . Are they starting to make headway or is it an exercise in capping the tensions that are so severe they could explode into conflict or civil war at any time . I think the National Unity government, the construct is the best political conduct to deal with the deep challenges. And whats important to recognize is that this is a very unique arrangement thats been made that hasnt happened in the past in afghanistan. And you need to put it in context, the wider context of where we were a year ago and how did we end up in this arrangement that we have right now. A year ago we still had president karzai as president who had been president and leader since 2002. And every five years theres an election thats held in afghanistan and they had one in frill of 2014. President karzai was allowed to stand as president. So you had a whole new crop of candidates who were standing up. In fact you had 26 candidates declare running as president. When we think there might be a lot of candidates running for president here afghanistan had more of them. But at the end of the day you had eight candidates run frg the election in april of 2014. And in order to win the candidacy, you had to reach over 50 . But no candidate was able to reach that threshold. So the two top candidates, first one was abdullah with 45 of the vote and ghani with a lower percentage forced a Runoff Election. And that Runoff Election happened about two months yards in june which was then contested because of how some of the it switched from abdullah being on top to ghani being on top. And so there was a wide recount that happened for a number of months. So you didnt have an arrangement in place until september. And that arrangement was helped brokered by secretary kerry and the United States. In order to wring the leaders together in order to try to help govern the country together. This was a very unique thing. As i said before yb you just had president scar zie at the helm and now you had the unique argument where ghani was president and abdullah who was the chief who had handled daytoday operations. And so this is this is very very different. But whats fascinating to see is how both leaders have a very different approach to common problems but how their strengths actually have a real tendency to compliment one other if theyre able to Work Together on the issues. And whats most fortunate is that both abdullah and ghani are generally on the same page when it combs to broad based policies. When it comes to security they agree. When it comes to regional relations, they agree. When it comes to womens rights they agree. When it comes to reconciliation they have a broad understanding that they need to move forward. Those are key things. That shouldnt taken lightly with regards too the earlier challenges that we had previous you lis. Where are the challenges that they face . They face difficulty in regard to personnel agreements. This has led to a prolonged time to name a cabinet. Its important to put anytime a wider historical context. Even when president karzai was president , it took him many month to put together his cabinet. But under the current government its a bit more unique now. Where are the benefits that come from this. While it does take greater time in order to kind of come to an agreement on an individual and have them go through parliament once that agreement is made, that agreement is much stronger because both of them are able to reach it and also deal with their own constituencies who fundamentally disagree. But if theyre able to reach it it strengthens the bonds of the decisions they have. Weve been able to have an entire cabinet formed except for the minister of defense. And it was a real surprise that he was not able to pass parliament a few weeks ago. Its good that hes still serving in an acting capacity. But whats also important is to look at some of the other senior government positions with regards to governors. Where more than twothirds of the governors have been placed and theyre looking now at other sub national leadership. And whats important, i think to kind of keep in the back of your mind is that the more time that evolves with this National Union government in place the stronger the bond is. They have a greater vested interest in working through some of the daytoday problems they have then kind of throwing that away. While there are challe they face others outside the government saying things need to be changed, they do recognize that, they definitely hear that, but its not at the point they want to bring this down. Theres too much of a vested interest. They know that the whole country recognizes the value of the International Community in afghanistans kmu future and they want to work through those things. If i add very quickly, the last three our formonths weve heard that in a few weeks the National Government will fail it will fall and they continue moving forward. And as matt said, over time they continue to understand the strengths and weaknesses of each other. When theyre together i actually think they compliment each other than they work very well. And again on all of the National Level strategic issues, theres no daylight between them. Its about picking people as they have to satisfy different groups that have helped get where they are is where they come into issue. Theyre working very hard at that. Everybody understands president ghani had to get some medical treatment done on his foot and he went to germany. And i talked abdullah before they left. Over the last several days, theyve been talking every single day. Yesterday they did a teleconference from germany back to afghanistan and talked about the issues at hand. Between them they understand how important this is. They know this is a tough fighting season. They know that the National Government is the way to go. 80 of the people in afghanistan said that the National Government is our only way forward. Ive talked to civilian leaders and what they will tell you is there are people out there trying to do things 0 to keep the National Government from moving forward but at the same time they understand how important it is. I think theyre not going to let that happen. Again i feel good about the future of the government. And its their appreciation, both gone any and abdullah and their teams around them of the International Community. That rang so clear when both of them came here to washington in march. When ghani addressed congress with both of them making the rounds on the hill, meeting senior u. S. Leadership and expressing their appreciation for all of the sacrifices that america has given and to be able to Work Together as a partnership is something that really cant be spoke about enough. Before i ask you about the broader region and maybe to mention anything about the peace talks as well, and recognizing that the ambassador is not hear joining us is there anything that one could say that ghani and abdullah have begun to deliver for the Afghan People . Obviously making a government work and continuing the fight and preserving the securities in the big cities, thats already a lot. I dont want to be unrealistic. Its only been nine months, ten months now 11 but still. Is there anything else you would point to by continued modest growth in the economy, any Development Program thats got their signature on it. Anything thats a good hopeful sign of where this government is going in afghanistan . I would the Economic Issues have something they view as top priority. And i would say its right on par with security and they both go hand in hand. Whats very interesting to see is how they both engage the region in a very robust way on Economic Issues. To the north dr. Abdullah given the relationships he has there has really been pushing forward on those things. With regards to the east ghani and his relationship, to be able to bring Economic Growth particularly in the west. Opening up trade routes with pakistan that hasnt been established in the past. The iran accord opportunities opportunities with afghanistan to have greater trade with the staings sanctions possibly be lifted. It can serve as a great benefit to all in the region. Afghanistan sees its role as being critical in terms of being a source of stability as opposed to instability. And at the root of that is Economic Growth. A theyre still in the 5 to 8 growth per year. Theyve done pretty well, started from a very low base 2001, 2002. But theyve done reasonably well and some of that was propped up by the influx of our dollars and so forth. I remember when i was in afghanistan in the 2011, 12 and 13 time frame people were scared of what would happen this year. Have they been able to keep i chugs along even though weve reduced or presence . This gets back to another area where they know they have to address it together. This is something they cant fight on, given the scale and the importance it has. I mean our withdrawal from the country in the terms of the force numbers has really kind of left a bit of an economic gap. But its something that theyre like, okay, we know we need to do this and we need to kind of be able to reach out to the region. Whats fascinating to see is how ghani is not only reaching out to the immediate region but also the wider region of being able to promote afghan first and be able to see, listen even when it comes to saudi arabia china and some of the Energy Matters it really is a keypoint that he emphasizes time and time and time again. We saw it a few weeks ago when ghani was at the bricks summit in moscow. He knows if theres ever going to be long term stanlt its going to rest at the economic base. Last question for me. Youve been mentioning the economic dimension of key relationships already. General, you mentioned earlier some of the interplay with the conflict in pakistan and pakistans own security efforts. Starting with you matt anything else of note in the region of late with regard to chinas role in the peace tacks pakistans role in the peace talks, anything else we should understand that you think is particularly salient now . Ive been in afghanistan for over five years and everyone says this last year was most critical for a, b and c. But i must say that this past year has been fundamentally different than others. I know it sounds like a broken record but it is. There have been a number of strategic shifts that have happened in afghanistan in the wider region that i think a lot of folk couldnt have predicted. They present both great promise and peril to the region. Thats why theres this readjustment going on. Let me explain a few of them. I think there is issues with regards to fak stan. Weve all been reading about this in the press. Ghani pushed toward with trying to be able to have the undeclared state of hostilities, his words, not mine, of having a thaw and be able to have a fundamental shift with them so there can be greater economic report, can be andress with regards to Security Issues, there can be other sorts of mutual military cooperation. A year ago we didnt know whether the u. S. Would still be in the region either. The bsa had not been signed. So the bsa was signed. A year ago less than a year ago you had this horrific attack in pakistan that some of you may recall shower in december 16th of 2014 where about 142 people were killed in a school 135 of them children. It was very graphic. And in many ways, the way it was described to me i can see the reason why, it was pakistans 9 11 which really kind of woke them up with regards to their own Security Issues and their own borders that have to be addressed. Youve seen pakistan take on many of the security challenges within their own country, with regards to the operations going on that general campbell alluded to. There are secondary effects with regards to afghanistan which pushed the insurgents over into afghanistan which is another reason why the security situation has picked up at times. What youre also seeing is with regard to greater reachout to the northern stance, not only on Security Cooperation but also economic cooperation. Were seeing advancement to the piece Initiative Things that we didnt necessarily anticipate would take the momentum that they did. There are all these things that are happening that are truly strategic in nature. The region right now is really in flux. And i really do think that we have a great strategic opportunity in front of us in order to help to be able to make sure that afghanistan doesnt return to the threats of the past. Because theres such change but also theres a lot of promise thats there. Anything you want to say at this point, general . Again i think weve been in transition the entire time ive been there from a government perspective perspective, a regional perspective. The changes that weve had based on both president ghani and dr. Abdullah abdullah, being a commander in chief looking at a wider regional perspective engaging the pakistan, i think we did not see that with president karzai at least the last several years. And its an attempt to make sure that people understand you cant talk about afghanistan unless you talk about pakistan. President ghani understand that. He did not see a lot of return from that and took a what he did in reaching out and trying to drive the taliban to the Peace Process is going to be a good thing. We shouldnt kid ourselves. Its not going to happen overnight. I think its going to change the dynamic. There is going to be fracturing inside the taliban. Its going drive some to the table quicker. It could drive other to isil or daesh quicker. But as matt said i think this is a strategic opportunity to have a country in that part of the world that wants to be part of the International Community that had Senior Leadership and wants to move forward. They cant do it without the community. We have communities that continue to provide people or money and i think for me the International Donor piece and making sure that people understand what they do to contribute to afghanistan is making a difference every single day. Its going to be very important. I look forward to working hard with the afghan to pursue that. Im going to ask vonda to participate. Her book is one of the very best books on the subject. Id like to turn things over to you. Thank you very much gentlemenforcoming for your analysis and most of all for your commitment. You spoke both of you of the importance of the National Unity unity either insdoors or resolve this institutional arrangement. And prior to that the elections which were supposed to take place this year, theyll likely not, now are delayed, could you give us your reflection of what kind of preparation is being made for the parliamentary elections. What are the politics of that and also the impact on the Security Forces. If we see for example that a contested one, and if that happens in 2016 yet another year of transition potentially, u. S. Withdrawal or change, question of nato support, the timing of that and preparations that the afghans are putting in place, security preparation political thinking of the sux juxtaposition of them coming together at the same time. Parliament is on recess as you know and i think there be a lot of discussions as soon as they return in order to address that more directly with regards to particularly the parliamentary elections. What will be interesting from my viewpoint is how they will be carried out from a security perspective perspective. That too will be fundamentally different from in the past. In the past the coalition has been there to provide a lot of air lifts assistance. And while the afghans have their own air lift it certainly isnt in comparison to the past. Being able to time that in regards to the weather and the fight theyre taking on themselves is going to be a real test for them. And i think as we all kind of do our own analysis on this stuff, i think that will be a real milestone on them being able to stand up and do that from a political perspective and a security perspective. With regard to sueecuring if theyre given a specific event of the lockdown, last year that was a very safe event. I was greatly impressed with that. They flooded the skoen as made sure there was nothing that would threaten that from a security perspective. I dont think that would be a problem from them being anyone to perform. How it works out politically, i wouldnt want to guess on that. I mean what i have seen over the past year has constantly, you know, surprised me in terms of the twists and turns that are associated with these sorts of events. And i think right now its definitely on everybodys mind. The date hasnt been set. Of course that will be a political calculation on all sides. But what ill be looking at, just because of the vantage that im at working with the military on this, is how the Security Forces perform prepare themselves for it and be able to ek cute those things. I dont think they can even talk about it until they figure out the election reform. They Just Announced here the last couple of weeks the Election Forum committee. They had their first meeting about two weeks ago and i think theyre going to work forward what that reform means. When Parliament Comes in theyll talk to parliament and then theyll decide the dates. And i think theyll make those decisions in the next month or so. I think from a security perspective, you know, if its before the fighting season or after the fighting season in 16, we have several months before that. Once the Afghan Security forces if its a specific event, they have no issue really doing the Detailed Planning to get ready to do Something Like that. I think theyll do well. Wu theyve got to get through election reform before they get anywhere on that before they have the election. Let me start taking two at a time and then well turn to you gentlemen again. Right here the second and first rows. I work for the bbc and id like you to tell us a little more about mullah omar. And also you talked about how afghan is near and dear to you. Im wondering what youre most proud of it is there anything specific about your experience there that youll remember as your legacy. Thank you were tara. And then david please. Thank you very much for you courage and service to our country. I really admire both of you. My questions are aimed to be a little tough and maybe hard is it true or false . Dpef natalie not over three years ago the chief of staff told congress that it was a Strategic Asset to the organization. Since then pakistan to me its quite clear has been complicit in keeping the death of mullah omar secret leading to more deaths of afghans and americans during this twoyear period. The question i ask all the time is how can we trust pakistan. So my question to you is the same one i get asked by audiences when i speak to them. How can we trust pakistan. Is pakistan with us or against us in afghanistan. I have a second question related to that. In his recent book, the former director of the cia said that the intelligence missed the boat on calling on the rise of daesh, the islamic state. Intelligence agencies missed the death of mullah omar. General, the former head of bia says the Intelligence System needs to be reworked. Are you satisfied that youre getting the right amount of intelligence . Does our Intelligence System need to be reworked . Ill let you guys divvy them up as you wish. If i can remember all four of them. Let me start with an easy one on what its meant to me. I went there in 2002, gree as a colonel, i went back as a general, my son is a sergeant in the army. Hes been there twice. Ive lost many friends in afghanistan and iraq as well. Whats impressed me the most is working with the Afghan Security forces, the men and women that continue to understand how important their role is to bring about change in afghanistan and they have no qualms about putting their life on the line to the that. I say this is an al volunteer force. And to see these young men and women for very little pay under very very harsh conditions continue to move forward every single day for the good of afghanistan, to see them get an award, a little certificate, stand up in front of a crowd and yell out for afterghanafghanistan it makes you get goosebumps. Theyre very giving people. They take care of me and my men and women. When weve had green on blue attacks, theyve gone after that very hard. They understand the sacrifice that our men and women have endured. They understand the sacrifice that our families have gone through. So when you work with a partner that is like that, you dont want to fail. You want to make sure that everything that you do that you can put your best effort forward. Thats the way it is with the Senior Leadership and the way it is with the Afghan Police and army ive dealt with on three different tours and many trips there. Im honored to have the opportunity to continue to serve in afghanistan and i think that people ask me all of the time is it worth it. Is the sacrifice weve had worth it. And i have to look the parents in the eyes and tell them their son or daughter has paid the ultimate sacrifice. I do believe in my heart that it has been worth it that we have made a difference and that well continue to make a difference. When you talk about the definition of hope and what that means to the Afghan People its about what our men or women here in the United States and many owe countries have done for the last 14 years. They understand that. And i think if you ask any afghan on the street whether or not they wanted to have a continued presence by the Coalition Forces overwhelmingly you would find out that that is very very positive unlike what you may hear in other countries. In afghanistan, they understand the sacrifice and want us there. On mullah omar, what would tell you is i think for many years there was speculation about whether he was dead or alive. But sort of that myth out there, his presence they were able to keep alive through folks out there. As matt talked about in the other engagement that we had, the taliban are really in smaller groups the way they operate, all they had to have is the notion that they had a spiritual leader, a commander that was out there that kept them moving. Knowing that hes been dead for several years, since about april 2013 thats going to cause people to think the taliban fighters, what have i been doing this for. And i think theres opportunity this there for both afghanistan to push this and to bring in brother and sister afghans, part of the Peace Process. And theres an opportunity for pakistan to help and move forward to facilitate bringing the taliban to the table. Brought up how can we trust pakistan. I have a very Good Relationship with general hill. I try to talk to him over week. I go over there once a month. I was there ten days ago talking to him. Most of my conversation is about how can we bring the Afghan Security forces and pakistan Security Forces together to fight a kol mon enemycommon enemy. In general heel and now president ghani and dr. Abdullah, you have two Leadership Teams that understand its not business as usual. To get after the common enemy theyre going to have to Work Together. Theres years and years of mistrust. And if you talk to any Afghan Security force the first thing theyll say is hey, pakistan has been harboring these guys killing my brothers and sisters. But they also understand that they have to have peace with pakistan before they move on and i think thats where president ghani and dr. Abdullah are trying to push forward. The connie piece has been the number one threat to Coalition Forces and i would say Afghan Forces as well. And theres no doubt in my mind that pakistan, over the years, has probably not done enough to be able to help us get after the threat. And i had a good oneonone discussion with general heel when i was over there ten days ago. Thats going to take time. I think as they look at it, they have a lot of other issues theyve got to deal with inside of pakistan and they dont want him to turn on them. But i think youre going to see a concerted effort by pakistan to continue to drive the taliban to the peace table to really drive down the violence level over the next couple of months. President ghani has been very strong with general heel on giving himdics out there to say, you need to do this to show us that you really mean what you say this time. Its not like it was last year or the year before. Again, thats going to take time. Vi seen any measurable changes in pakistan against a connie . Up front i tell you know because im so worried about the threat that they bring to kabul. They are the folks that work suicide vests and will continue to put the pressure on pakistan. I think well get after it. You want to comment . You know, mike flynn is a good friend of mine, we dwrugrew up together. Im not going to comment on his comments. Over the years weve learned a great deal from a conventional perspective in all f our Services Joint and intraagency perspective. What we do and how we operate today is light years from where we were 13 14 years ago. And our Intelligence Services is the best in the entire world. Do they have challenges . Yes. But i would stack that up against any in the world. And the cooperation we have between the military and the intraagency to include all of our intel community, we dont agree on everything and quite frankly i think they have a view that is glass half empty all of the time and maybe glass empty with a lot of holes in it. Ill argue about that. And if you go back and look at years and years worth of intel reports, afghanistan should have been done a couple of years ago. But thats okay. They look at it very hard. We Work Together on assessments as we move forward. Were never going to agree 100 . But i would not want to be in afghanistan without the Intelligence Team that we have that provides indications Early Warning in that relationship that help us mitigate the force protection issues that i ever single day. Anything you want to add matt . Just in regards to what ive taken away in these eight and a half years. Whats most valuable to me is the camaraderie with afghans and iraqis. Its something that will always be deep to me and a sense of purpose that it gives and things of that such. With regard to mullah omar you know whats important is that all sides continue to try to push towards peace. Thats the real drive that will continue. And you know these are the sorts of things these challenges, these curve balls that come in are the sorts of things that come up and the issue is whether youre able to remain focused pen athink all of the primary players are focused on that, being able to reduce violence and bring about peace. Thats the key thing in order to keep in mind with this. Because it gets back to the point i alluded to with regards to how at least president ghani is trying to deal with the problems of pakistan. These are problems that are gone on for 30plus years, ending that undeclared state of hostility. Knowing this is not going to be something youre going to achieve in a few weeks, few months, maybe even a few years. This is going to make many many years and its going to take not only just dealing with the taliban, which is of course what gets the headlines but all of the other hosts of issues that they have to address. Thats a much more important comprehensive matter. I know that president ghani is dedicated to it. I know that chief executive abdullah is dedicated to. Youre given those sense of indications to a degree from spak stan as well. While the trust may not be there to what we all may wish, the issue is whether youre able to identified certain interests to build momentum. Theyre working at identifying those to build the mo men full and to be able to achieve the end goal. If you dont pick that guy back there hes going to hurt himself. We have time for rounds of two more questions. What im going to ask is that each person only ask one question. Im going to start here with the third row the two gentlemen in the third row, one question each and then well have a final round. Thank you michael. Im representing the International Stability Operations Association 50some companies who provide services to d. O. D. , state and usa in afghanistan. As you draw down uniformed troops in afghanistan will you be turning more to contractor to fill some of the gaps in training, maintenance et cetera . Thank you. Here. Thank you very much. General, good to see you. Im in washington. My question is that as for this deal socalled peace deal where the taliban is concerned they have in the past been terrorists and killed hundreds of thousands of people and had a deep root in pakistan and afghanistan of course. What is the future of the deal and finally what role do you think this triangle, India Pakistan and china will play. India invested dollars in the future. Thank you, sir. On the contractor question i think over time you know, what weve tried to do is in areas that we couldnt have military we needed contractors, both in iraq and afghanistan, we built it up to a point were very dependent upon the contractor to do the skill sets that we couldnt afford to have soldiers or airmen or sailors or marines do. That number has continued to rise. What weve tried to do in afghanistan, as weve retro graded out equipment and people weve tried to strike a balance of both military and contractors. As we move forward well continue to have that balance as we move forward. Theres many critical areas that contractors provide that we could not do our mission without them. Well continue to have contractors on the battlefield. What we have to do is balance that and make sure that as we move forward that we try to look inside of afghanistan and have more afghanistan folks pick up the jobs out there to build the capacity. Please, general, either way. With regards to the Peace Process one the role that china, india and others play in it, again they all have a vested interest in there being peace in afghanistan, be it economic interests, be it political interests, be it regional stability interest. And thats what i think why theyre playing a role in this. As we all know, china played an observer role in the talks in early july. And i think being able to do that provides greater greater impetus behind the collective effort. India has invested a lot of money out west in afghanistan. And i suspect that they dont want to have the investments come under security threats. And so again its finding those common interests among all signs in order to kind of achieve desired ends is what needs to be focused on. There will be all of these things that happen on the side that take your eye off the ball and stuff like that. The question is whether theres still the political resolve, particularly in afghanistan and with the taliban in order to achieve that. And the fact that youre able to have those talks happen in early july, the first time you had afghanistan and the taliban sit down to address this longterm problem thats plagued them both is not something to be cast away. Its something significant and its going to be a long process but i think its something thats worth the effort that all sides are contributing. Anything you want to add on that pakistan india china russia, all the countries are taking an interest and understand from a regional perspective that its going to take everybody working together in a stable, stronger afghanistan is a good thing in the region there. So if it takes India Working pakistan working, china working, im all for that. I think the important piece that weve always said is this has to be afghan led and president ghani has taken that on and well continue to move that forward. Do you see any indications that the taliban are going to look to this year and next year as their opportunity, any indications theyre becoming somewhat discouraged . Because even though theyre killing a lot of Afghan Soldiers and police, theyre actually not taking a lot of territory. Maybe im oversimplifying, but im wondering if theyre finding the going a little tougher than they expected. We talked numbers. Afghan numbers and the reporting of insurgents that have been killed is three or four times higher than it was last year. So the Afghan Security forces have taken casualties, but theyve inflicted a lot of casualties as well. I think we see signs of fracturing in the battlefield from lack of supplies, lack of money. Theyre competing against isil now in parts of afghanistan. So i think they have some significant issues. Now they found out if youre a taliban fighter, you found out the guy youve been following for the last two years or you thought you were that was the spiritual head of your movement has been dead for 2 1 2 years. Somebodys been playing you here. Why do you continue to fight . So i think theres an opportunity for both sides here to come together. I think afghanistan will take that opportunity. I think the taliban will the have to work for theyre tired of fighting. They want to get on with their lives. I think the only way theyre going to do that, because the Afghan Government is not going to fall to the taliban and they realize that now, they got to come to the Peace Process. So theyre not taking territory. Theyre not meeting any of their strategic level goals they set out. Theyre going to take a District Center but theyre going to lose it. So theyre not going to gain terrain that, you know you talked about the cities, theyre not going to gain any territory that means a great deal or has value to afghanistan. The president from the very first day he took over office in his inauguration speech he reached out to the taliban and said, you are brothers and sisters of afghanistan. You need to come to the Peace Process. We have to have a political solution. I am opening this up to you. Hopefully this will speed that up. Again, i think youre going to have folks out there that are going to be irreconcilable that want to continue to fight and theyll have to deal with them a different way. Before the last round t sounds like youre saying, if im hearing you right, that if the taliban made any net gains at all this year, its 1 or 2 of the population at most. I dont want to convey a false percentage. I think its very small. I couldnt put a percentage on it. Theyre not holding terrain. Theyre not gaining more terrain. They are taking a District Center here or there. Theyre losing it within 24 hour, within 48 hours. Theyve lost the support of the people. You know, every poll or survey we take shows the taliban Approval Rating is less than 5 i think. So they dont have the approval of the Afghan People. Theyre tired. I mean, the Afghan People are tired of this. They want to move on. They want the same things we want. They want jobs a roof over their heads for their kids, their kids to go to school. Thats something under the taliban they couldnt have. So they dont want the taliban to come back. I couldnt see the taliban coming back. Two more questions. I think well go to the gentleman here. Then three rows back woman in the red shirt. Im sorry, up front. Then woman in the red shirt. Mark Schneider International crisis group. General, good to see you again. Let me push a little bit harder on that question. This year since january, youve had the highest rate of attacks on the taliban since 2001. While its clear that they havent been able to take cities, they have been able to essentially threaten a lot more cities outside their normal area of operation. So theyve managed, if you will to sustain themselves over time. Obviously the nsf as well. But the nsf, as you said, is stretched thin. My question really is, are they going to be able to continue to maintain their ability to provide security unless we maintain our level of support both in terms of air support, logistics, et cetera, not just through the end of next year but beyond. And isnt that the only way to get the taliban to come to the peace table, when they see theyre not going to achieve their objectives militarily . The last question, then well wrap up. Thank you, mark. I am a womens rights activist in afghanistan. General, thank you so much for being so active with the National Unity government. I see you almost weekly with either one. You made that remark about the fact that we are getting involved with Wounded Warriors in afghanistan and bringing some help to the wounded soldiers. In my work, i have seen some impact of not the Wounded Warrior but just the returnees to their families. As you know afghans marry very young, so most of the soldiers have wives and daughters and sisters. When they return a lot of the problems happen at home. Is the Wounded Warrior project will it have an emotional counseling part . Not for the Wounded Warrior but for the rest of the soldiers. Thank you. Thanks for the question. On the first one again i think, you know, from a sustainment piece on the afghan side, the Security Forces are doing, as mike said, 98 , 99 of this on their own this fighting season. Im providing train, advise and assist at the core level, at the ministerial level, and tactical t. A. At some of the special operating force levels. So they have this. And they have this at a time when its been very very tough. And i think they continue to progress. I dont think that i think the taliban are starting to realize, and i think they realized before this fighting season, that they needed to do something spectacular this fighting season in order to make a statement to say, hey, we are relevant, but again, theyre not making the gains that they talked about. Are they having highprofile attacks . Yes. And those are very cheap. One or two people with a suicide vest running into a place that houses ngos. Thats very, very hard to stop. But i think, again the Afghan Security forces continue to improve. The people need to continue to stand up to fight this. The people need to continue to stand up and identify somebody in a village that doesnt belong there. As they do that and they partner with the Afghan Security forces, then i dont think theyll be beat. You mentioned cities. Id talk more in terms of villages. Theyre check points. Small District Centers in the middle of nowhere. The only place city wise theyve even come close is up in kondus. The reporting that was going out there, which made it sound like it was going to fall in the next 24 hours, as i talked to the Senior Leadership, as we took a look through the different sensors we have, i didnt see that same picture. So we probably well we, and more importantly, the afghans, the way they get their messaging out probably needs some improvement. Weve talked to them about that and said, you really need to get the right message out because when you dont do that, the taliban have a much better, you know, prop began that machine, just like isil does. They get the message out first. They dont have to tell the truth. And then all of the sudden it balloons and starts picking up steam and all the sudden the whole country is going to fall. Again, i havent seen that. If youre on the ground and your house is under attack or you lost a loved one, then of course, you know, youre going to have a completely different outlook on life and a feeling that the government is not supporting you. From a strategic level that i look at it from, the taliban are not winning. The taliban are not making the gains they need to get. The Afghan Security forces, although very tough continue to make progress and i think theyre resilient. And with continued progress and the right leadership and Holding People accountable, then i dont think that theyll have issues against the taliban down the road. On the Wounded Warriors, maam i would tell you, were in the early stages of trying to build that program. I think its a great idea of what you talked about bringing that emotional piece to the families. Weve sent back senior afghan leaders, sergeants majors back to the United States to view how we do our programs from all the different services. Theyve taken those ideas back to afghanistan. Again, were just starting to figure out how to do that. Everywhere from providing martyr payments to families that lose a loved one, to providing health care for, you know Wounded Warriors and making sure they get the right care. Theyre working very hard on their procedures to take care of people. I talked about this earlier, about not having seven or eight people in the back of a pickup Truck Driving around, get hit by an ied and you lose all of them. Wear your body armor, wear your head gear. All your soldiers and police carrying a tourniquet, just like u. S. Police do. Were working on all those at the same time. As we continue to do that, i think youll see the afghan died of wounds ratio will continue to go down, just like ours did in iraq and afghanistan over the years. Theyve got a lot of work to do, but i think just that theyre talking about taking care of martyred families talking about taking care of Wounded Warrior families, i think thats a good thing. I think the International Community, the u. K. Is stepping up there, the u. S. Is stepping up there, and i hope to see other countries step up as well. Matt, any final words from you . Im fine. Please join me in thanking these two. [ applause ] [ applause ] one last thing. Hopefully i never lose the opportunity to talk about the great men and women that continue to serve in all of our services, the great civilians as well. Many of them have returned three, four, five times. Many of them have sacrificed a great deal, and we can never ever forget our families. We could not do what we do without having our great families support us, being in the military. One half of 1 of your country does this. One half of 1 so that the rest of you and the people here in the United States and the rest of the world can enjoy what you enjoy every single day. So we shouldnt take that for granted. I dont take it for granted. And i try to make sure every time that i go to sleep at night that ive done everything i can resourcewise, decisionwise to set our men and women up in the best possible position in terms of force protection, on and on. Again, we couldnt do it without the support of the american people, without the support of 42 countries that are tied in to our support. If we start taking that for granted and we dont take care of the families, dont take care of our Wounded Warriors, we dont remember the ultimate sacrifice paid by our great men and women, then shame on us. So thanks for your continued support. Again, i do see afghanistan continue to make progress. A glass half full. Im starting to fill that grass up every single day. So thank you very much. We thank them too. Thank you. [ applause ] with congress on its summer recess this month, were featuring our cspan cities tour, which visits literary and Historic Sites across the nation to hear from local historians author, and civic leaders. Today we travelled to ft. Lauderdale to learn about the citys history. Watch that at 6 00 p. M. Eastern on our companion network cspan. And tonight at 8 00, the leaders of canadas four major parties participate in a televised debate. Its the first and so far only televised debate scheduled with all four party leaders. The participants are Prime Minister Steven Harper of the conservative party, new Democratic Party leader thomas mulcare, justin tredo and elizabeth may. Earlier this week, Prime Minister harper called for the election to be held on october 19th kicking off one of the longest campaigns in modern canadian history. The debate will be live on cspan and cspan radio at 8 00 p. M. This weekend on the cspan networks, politics, books, and American History. Saturday night at 8 00 eastern on cspan congressional profiles with four freshman members. Pennsylvania democrat brendan boyle, Louisiana Republican ralph abraham, michigan democrat brenda lawrence, and tom mcarthur. With elections coming in october, well show you a debate among the four National Party leaders in canada. On cspan2 saturday night at 10 00 eastern on book tvs afterwards, Charles Murray argues that through the use of technology, we can rein in the power of the federal government. And sunday evening at 7 00, susan souter talks about the city and people of nagasaki japan from the morning it was bombed to today. This weekend on American History tv on cspan3 we commemorate the 70th anniversary of the bombings of hiroshima and nagasaki, japan, and the end of the war in the pacific. Our programming starts saturday morning at 10 00 with a conversation with president Harry Trumans grandson. Later, well visit the American University hiroshima nagasaki atomic bomb exhibit. And sunday morning at 10 00 our coverage continues with the 2 00 documentary on the making of the atomic bomb. Later, interviews with two bomb survivors. Get a complete schedule at cspan. Org. The atlantic hosted a recent forum focusing on alzheimers disease with panelists exploring this form of dementia and how it impacts the elderly as well as the cost associated with care. Among the speakers, senator susan collins, the chair of the smeshl committee on ageing and senator dick durbin, who both urge bigger roles for the federal government to play with regard to special research for treatment. Good morning, everyone. I am margaret low smith, im the president of atlantic live, the Live Events Division of the atlantic and im delighted to welcome you here for alzheimers the cost of caring. Were here to talk about a disease that steals language and memory and the presence of the person we once knew. One in three people over the age of 65 dies of dementia so we know the impact is massive, affecting family and friends too. How many people in this room have a parent or have had a parent or loved one with alzheimers . I see very few hands not up. And i think it is not surprising that i have my own story too. My late father was a theoretical physicist and he led a life of the mind and in the end had profound dementia and we watched his mind betray him. I remember he was trying to get into a assisted living facility and he had to take a test and the test was can you name three animals and he could only come up with the name of insects. It was ant, spider, fly. It was a painful moment for all of us. In the end he could barely feed himself and barely talk. So we all know it is costly emotionally and financially. Some estimates say that alzheimers cost americans more than 200 billion a year. That is 200 billion. So this morning were going to hear from people in the front lines of the disease, from researchers working to find new treatments to Family Members figuring out how to care for relatives and from two senators trying to coordinate the National Response to alzheimers. A few notes before we get rolling. Were on twitter atlantic undercore live. Use atlantic underscore alz. And were streaming at atlantic. Com live. Were taking your questions after most of the sessions. And importantly, i want to thank our underwriter who made this mornings conversation possible. The Alzheimers Association. And now were going to hear a little bit about the associations work from the president and ceo harry johns and here to lead the conference is the coanchor of pbs news hour judy woodruff. Judy, the floor is yours. Thank you. Thank you, margaret. Im delighted to be here for this important conversation and really pleased to be able to have this discussion with harry johns. Weve just been chatting about this. I want to say that i too i was listening to margaret. I have a personal connection. A close cousin whose wife has been diagnosed for a couple of years and ive seen perhaps as all of you have, perhaps the physical and the emotional and the personal toll this can take. And i want to launch right in with you harry johns and ask about the role of the Alzheimers Association. How does the association fit into this big alzheimers picture . We practically every day pick up the newspaper or look online and there another article or maybe another Promising Development out there about alzheimers. How does your Organization Fit into all of this . Well, Alzheimers Association is the leading nonprofit entity in the world in Alzheimers Research, care and support. Here in the United States, we provide care and support to individuals 24 hours a day. 365 days a year because as youve indicated, the devastation to the families as well as the individual is so great. They need that kind of support each and every day. And then were dedicated to ultimately ending the disease so well no longer have to provide that kind of support to people. So Thomas Reuters has recognized us as the highest impact resource organization. And on profit world around the globe. And third only behind the federal government and the chinese government. So we work hard to Fund Research but we also work hard with people here in this city, inside of the beltway to do the Public Policy that will ultimately allow the change in the course of the disease. There are 5 Million People in america with this disease and 15 million caregivers, 47 Million People worldwide. The scale of the impact of the disease is just staggering. You just heard 226 billion a year in cost for care alone and that is going to go up to 1. 1 trillion by the middle of the century, just over a generation, if we cant change the course. How does the you said you talked about the research that the association sponsors. How does that work . Do you employ the scientist . What is your relationship with the scientists, the money you raise, how does it get to them for their work . We fund globally. So we have a group of researchers around the world, 6,000 of them, that help us identify the very best projects. They the scientists are not on our staff but we have access to the very best scientists around the world. I think you know, right now the reason were here is were running the Largest Research meeting in the world. We move it around to locations around the world. So we have researchers here from everywhere who are working everyday on this problem. So we not only directly fund as well as try to move Public Policy to increase funding that is so badly needed but we also convene to gain collaboration around the world on the latest that is happening so we dont lose what is the advance of that communication. This meeting used to occur every two years and weve moved it annual because that exchange among the scientists is so valuable and so productive. Is research the only thing that the association is focused on . No. In terms of care and support, in every Community Around the United States, we have chapters who make a difference in peoples lives every day because of the very kind of thing that youve experienced yourself. My own mother had this disease. So ive seen it up close. And my wifes mother just died with the disease, within the last several weeks, actually. So i too have seen it up close. Im sorry. I appreciate that. So again 15 million caregivers right now who need the help. And all of that is set to triple by the middle of the century again if we dont change the course. So those people need the help every day. How do you know at any given time and i want to ask you about the fundraising and the support that you have to get from this government and other governments. But how do you know which research to focus on . There have to be so many promising, smart, young scientists out there that say i have an idea and how do you decide . The first thing that is absolutely true i dont. I dont know. Im not a scientist. But again we have access to the very best scientists around the world. At this meeting we have, about 4500 people, most of them scientists, and again many of those people work with us on an ongoing basis. When we get applications for projects or applications for funding, we have thousands of people around the world who help us choose those projects, along with what is a medical and Scientific Advisory council made up of people at the top of their field. So we can look at a project on any kind of vertical basis and have experts from around the world to take a look at that to see what they think is the most promising. We have for years and years at the association funded what is the cuttingedge of research when others wont. When others havent been able to. What is an example of that . Well, we funded Technology Early on, about a decade ago, that identified the plaque youve heard about the plaques and tangles of alzheimers, the hallmarks of the disease and we funded research when no one else would back at that time period that has now changed the field of Alzheimers Research. That identification of the plaque has led us to know now that those plaques accumulate as much as 20 years in advance of the symptoms occurring. So the thinking in the field today, very different than it was just a few years ago, is that we must intervene in advance of the symptoms. And if we can do that, we can potentially slow or even stop the progression. If we could slow the progression by five years, we could cut the impact in half. Both the human devastation and the cost that are so devastating already. But my understanding is you are still i dont mean you personally, but the field is still a distance away from being able to do that . We are a distance away potentially from ultimately realizing the ambition of the Alzheimers Association. Our vision is a World Without alzheimers. Were a distance from that. But again, im not a scientist. But the way i read the situation is we are within a reasonable period a few years of seeing what would be the initial treatments. We have treatments today that dont actually change the underlying course of the disease. But i believe were a few years from seeing the initial treatments but it will take years to develop what will be the sufficient treatments. Not unlike hypertension or aids, it will more likely be a cocktail. The disease is heterogenerous, so it is not one drug or Silver Bullet to fix this. So you are talking in the nearer term slowing the onset and slowing the progression. If, in fact, we can see a drug that has clinical effect, then the potential there are a number of prevention trials now underway. Im proud to say the association was an early funder of those to get those started and they wouldnt be possible without the technology i mentioned. So those prevention trials have the potential to do exactly what were discussing, which is to slow or stop progression. So when you make the argument, as you do, to members of congress, to those who have the ability to determine how much support youre going to get from the government, which has to be the biggest source of support. Absolutely. What is the argument you make . There are so many other important causes out there that effect peoples wellbeing and yes, alzheimers affects many people, but how do you make that argument . I worked in cancer for many years and im proud to say we worked hard. And twothirds of Cancer Patients are cured. And at the cancer institute. So cancer funding is high for many years and weve seen the results. We funded hiv a. I. D. S. For years and weve seen the results, chronic disease today. Heart disease and mortality down. All of the diseases have mortality rate down as a result of in vestments made in the past. In alzheimers disease, we have what is a triple threat. There is really nothing else like it in terms of the impact that has so little done about it at the federal level. It is huge prevalence and growing. It has huge costs and growing. And it is the only one of all of the leading causes of death in america that has no way to stop it, prevent it or even slow it down. So the investments today until just recently, it was about 400 million being invested in Alzheimers Research even though it is costing 226 billion annually, going up to 1. 1 trillion with a t. So members of congress and i have to give credit to the leaders in congress, chairman cole and his committee in the house and chairman blunt and Ranking Member murray and that committee in the senate and those leaders in the congress that have stepped up for 350 Million Investment in the appropriations, yet to be approved. Still not approved. We need to see that signed in law. Those are big advancements if we can see them. But we believe that the Alzheimers Association convened a Science Group and that group believed we need to reach 2 billion. 2 billion annually. Yes. And right now were only up to 600 million. So the underfunding of Alzheimers Research has a direct impact on what is the failure of the change in the course of the disease unlike what weve seen in cancer, hiv aids, Heart Disease. There is a clear correlation between making the Research Investments and seeing the mortality rates go down. Is there an alternative if you dont get the federal government funding that you need . Is there anything in the private sector to rival what the government the federal government potentially has the ability to do . Well the Alzheimers Association again funds directly. Were about to initiate a Research Effort on our own to raise our level of funding of this to a higher plain. From private givers. From private givers. But its impossible in any disease to not have the strong investment of the federal government. Because there is a an enterprise, if you will, a nonprofit organizations, like ours, the federal government, and the private sector. It takes all three sectors to make it work. If you look at the gains that have been made in cancer, Heart Disease, a. I. D. S again, all of those situations require all three sectors to make it happen. S again, all of those situations require all three sectors to make it happen. S again, all of those situations require all three sectors to make it happen. S again, all of those situations require all three sectors to make it happen. Again, all of those situations require all three sectors to make it happen. But im thinking im thinking of you sitting down in the office of a member of congress or the office of a senator, what are you saying to them . Because they must know. Theyve seen the statistics and they know the number. And they are being asked by cancer, heart, you name it hiv to support us. And not to mention the enormous array of other good causes out there. Well, youve rightly anticipated what has occurred. Ive been in that situation. You are correct. You know, it has taken some time for people to understand thoroughly what is the impact here. But what we see today you know, one of the things thats happened thats important to this, either the Alzheimers Association also has made a huge effort at getting the American Public to realize the impact of the disease. If you take a look at what is a. I. D. S. Or any other cause, the first has to be a discussion in the American Public about the issue. When i came to the organization, there was not discussion about alzheimers. It was pretty much taboo. So weve raised that discussion. Im proud to say the Alzheimers Association really pushed the discussion thanks to help from you and your colleagues, talking about things in the media. Weve worked for media very hard. We fund advertising about this issue, to get the word out. Years ago cancer wasnt discussed. Once the discussion came to the public attention, once it was important to the public, things changed. Funding for research changed at the private level, at the public level, when Research Funding changed, cancer changed. And weve a lot to do in cancer. Twothirds of the people being cured is way beyond where we are in alzheimers. Every person who gets an alzheimers diagnosis will die with it or of it today. And many people dont realize that it is a leading cause of death. Many people dont realize alzheimers is itself a cause of death. But sixth leading cause of death based upon cdc statistics and beyond that, again, years ago in cancer, way underreported, and still true in alzheimers today. We just did a survey that showed that 45 of the people who have a diagnosis know they have it. The docs dont tell them. Its unimaginable is that right, that many dont know. That many dont know. Half arent diagnosed to start with and half that are diagnosed arent told. That echoes what happened in cancer. So again, the public discussion is a huge part of driving the answer to your question about having members of Congress Step up on this. And ive seen members of congress now in the past couple of years, last few years, really step up on this and see what needs to be done. On both sides of the aisle, a bipartisan effort. And i will say, too, that another part of that is leadership from the top. You know, there are about 20, give or take, president ial candidates right now 21, as of today. There you go. So each one of those candidates has an opportunity to be the first president to truly embrace this issue. It has not yet truly been done. So any one of those people, all of them as far as im concerned, i would hope they would all embrace the issue, because there is leadership opportunity here both for the congress and for the president. Instead of the sixth leading cause of death, it is more likely higher. The most recent Study Released indicates that instead its probably about 500,000 people a year who die at least as a result of this disease. How important, then . I know there are still people who believe who are ashamed, embarrassed to talk about a Family Member with alzheimers. Its still very delicate. How do you change that . Because it sounds like thats an important part of the story. It is. We continue to try to raise the discussion to reduce stigma, and i believe weve come a long way. Just sunday here at our conference, we hosted a session of people who have a really rare form of the disease. The genetic form of the disease which is absolute. If they have the gene mutation, they will get the disease and thats only 1 of all incidents, all prevalence, but to see those people together, to come to that meeting together and to talk about that and to be public about it is the kind of thing that can truly change the discussion and the stigma. I really give them great credit, anyone who has a diagnosis, people diagnosed and their caregivers who step up to talk about this have the single greatest effect on answering the issue youve raised. Im being given time cues, and i cant read it to save my life. Its over there in the dark. Is it finished . All right. Any last thought you want to leave everybody with . I appreciate anyone who is helping us advance this. It takes a huge team effort to do so, and i particularly thank the leaders in congress who are stepping up on this. Even if those appropriations go through, weve still got to get it much higher. And if we make those investments, the science is promising enough that we can change the course of this disease just as weve changed the course of others. It can happen. It can be done, we just have to invest to see it done. Thank you very much. Thank you. I appreciate it. Thank you. [ applause ] thank you, judy, and thank you, harry, for that excellent beginning. As we just heard from harry johns, of the top ten diseases that take the most american lives, alzheimers is the only one without a viable treatment of any kind. So finding one will take enormous scientific and Financial Resources from multiple spheres. So with the budget stretching to keep up with the cost of care and the cost of research, where should the money be going . Here to address this vital dressing is dr. Richard mose, a distinguished fellow at eli lily, and dr. Lori ryan at the National Institutes of health. Theyre joined by atlantic contributing editor mary louise kelly. Mary louise, take it away. Thank you. Good morning, everybody. So were going to be throwing a lot of facts and figures at you all this morning, and im going to focus our next session on one that we just heard in the last conversation, and its this, that alzheimers is the sixth leading cause of death for americans. Of the top ten, it is the only one with no way to prevent it, no way to slow it down, no way to stop it from developing in the first place. So were joined by a great panel to talk about this, lori ryan and richard mose, and i would like to throw this question to both of you. The big, wideopen question, lori, maybe start with you. Why has alzheimers proven so tough to crack . Alzheimers is a very complex disease, and thats one of the things that weve discovered over the last decade is that theres multiple different risks that get you to alzheimers at the end of the day and your risk might be different than mine. Mine might be cardiovascular and yours might be genetic, so trying to untangle all of that has proven very difficult and its likely that were going to need treatments that are probably going to be different for different individuals and a little more of the Precision Medicine is what youve heard from cancer and things like that and ultimately trying to identify what the risk factors are and in trying to actually attack those for different people. But that would also be true, obviously, of cancer, although you dont fully understand, but there are many drugs on the market. Cancer started before if you think about the war on cancer, it started in the 1970s. So alzheimers, the program that the nia funds started in the mid80s, so were a bit behind in terms of where we had the Research Effort. The Scientific Community. So the real focus has come a little bit later than it started with cancer, i think. This is something that eli lilly have been focused on since the 70s. Yes. Its important to understand that until relatively recently, many people dit think of alzheimers as a disease. Alzheimers original patient was a lady that had a very young onset and of course, when it happens in the 50s or 40s people clearly identified it as a disease, but for a lot of people, including in the medical community and probably until the late 70s or 80s, thought this was an inevitable process of normal ageing and there was no way to intervene there, but beginning in the 70s and the 80s we begin to understand that it has a specific pathology and there is a biochemical abnormality that goes on and there are certain highrisk groups that have genetic abnormalities and that opened up an opportunity for a company like lilly to develop a pharmacology that would intervene and slow that process which in some people is clearly abnormal. So weve been late to the game, but now we have the tools and the scientific basis that accompanies Companies Like lilly to think that we could have a medical impact on this disease that would be real and meaningful for patients. We were talking in the period in the 70s and 80s when finally research and attention started flowing in. Drug after drug after drug looked promising in the early stages and failed in Clinical Trials and in some cases was shown to accelerate alzheimers. Is the basic issue i mean, we know we have some insight into what causes alzheimers. Its plaques that form in the brain and choke off neurons and sr. The problem that the drugs that attack that also attack harmful functions . Thats what were constantly grappling with here . I think in the case that i was responsible which we thought was promising and was found to actually make patients worse name the drug for us. The results of those studies have been published. A cup of things about that. One is what we now believe was the drug was having effects which we didnt understand when we introduced it in the patient and those were causing adverse events and its important to understand when we go into a new area that as lori mentioned is highly complex. We have to learn as we go along, and each new effort to develop an intervention that goes into patients that has a specific effect. If it doesnt work, that closes that avenue off and directs our efforts toward Something Else and over time we get better and i think what were seeing now is were beginning to see a few compounds that have fairly specific effects that seem to be positive, and im sure that will ultimately lead to better efforts to go in that pathway and find complementary things, so i dont think we should view failures, really, as failures of the scientific process. The process is working. Its moving us in the right direction, but well have dead ends along the way that well have to work through. I totally agree. Absolutely. We learn from the trials and theyre not failed trials if we can understand why things didnt work and yet pathology is and things that we didnt know before. Absolutely. We have to test the drugs, and this is the way it has to be and it has to be a systematic process and thats the way science works and everybody would like things to happen very, very fast and unfortunately, we have to do Due Diligence in the drugs. Bring us up to speed on what the landscape looks like now because we are hearing what may be the glimmers of promise that we are maybe turning a corner. Give us a sense on what are the most promising things in development right now . At the nih, we fund both basic science and we allow the basic work that goes into the discovery process and we do fund some trials and things and we partner a lot with Companies Like lilly that we are cofunding some of the trials and trying to leverage our resources and there is a large landscape at the nih that we look at so the lilly drugs are certainly one piece and theyre very exciting, i think, now because we realize that we do have to go earlier as you heard harry say in the other segment that you have to go earlier and other changes occur in a decade or more. Part of whats going on with these drugs now is that theyre going into presymptomatic and people that have high levels in the brain or genetic risk who do not have dementia currently and if you intervene can we slow the process . That again is something thats being tested right now, and its very exciting to be able to go earlier until we had, you know, the p. E. T. Scans that could show am loud on the brain and things we were not able to see these change os curing early. Now we have ways to identify it earlier. So its been very helpful. I think these trials that are looking at presymptomatic, these are extremely important and will be telling us if we can have an effect. Flesh this out for us a little, richard. Yeah, i think the ameloid or abeta related compounds are the most advanced, and they come from a lot of work that was supported by the nih and private funders, including the Alzheimers Association that lead to the amyloid plaques and so the pharmacology around that largely comes from the pharmaceutical industry and its building upon those advances and those are kind of the leading edge. Along with that, we developed these tools that helped us identify people, as harry mentioned way before they developed symptoms. 10, 15 years. Its like if you get ath ro sclerotic plaques and a long time before you get dementia. That looks like we need to move those Clinical Trials earlier. So were learning on the diagnostic side and the therapeutic side and beyond that, we have other aspects of the pathology of alzheimers disease which are less well understood and havent led to pharmacology yesterday, but that includes these tangles that grow within neurons. There is apoe which is one of the wellknown risk factors. Theres no pharmacology around that. I assume over time well develop over pharmacology approaches to this disease that will improve it. Let me stop you for a minute on this idea of testing people. Any of the three of us could be 10 or 15 years away from being symptomatic of alzheimers. Specifically, what kind of tests are we talking that youre working on . I was reading a headline this morning. Saliva tests may look promising in terms of starting to identify genetic markers. What else . I think as we were mentioning, the p. E. T. Scan has been a turning point which we can image amyloid in the brain. Yes, were looking for things that are less invasive and thats much more difficult and we can see amyloid build up in the brain early on and we can scan people and because we have highlevel amyloid, youre at risk and youre not necessarily going to get alzheimers. Those are the individuals that are going into the a4 trial. Older adults and high levels of amyloid that are cognitively normal and they dont have dementia. Can you get in there for someone who has the drug like lilly does and see if we can slow that into dementia. The idea that these tests could somewhere down the road become a part of an annual physical . How are you identifying do you test everybody . Is that the goal . Well, i think theres a lot of discussion. The best test, the one that convinces people the most is as lori mentioned, the brain scan that detects amyloid. This essentially allows you to do in a living person what we used to only be able to do after a person died see the pathology of the disease. The trouble with that is its sort of invasive, pretty expensive. Im not sure anybody would want to do that. So theres ongoing efforts to find less invasive, less expensive ways of identifying people who might be candidates to get that sort of scan so that you dont overuse those sorts of scans. And theres a lot of work of that sort going on that would be, say, blood tests or cognitive screens that would be helpful. History presumably is a factor in there. Yes. Do as you look at the spectrum drugs and possibility of research out there, is it correct to say were not likely to come up with some miracle drug Silver Bullet for this . That alzheimers, as you mentioned, is a complicated disease and probably preventing, curing it, slowing it is going to involve all kinds of different therapies that may be very different from patient to patient. I think thats true. Obviously amyloid as richard mentioned s one of the main players were looking at, but there are other adjunct iive pieces. Im going to touch on lifestyle interventions that dont cure and prevent alzheimers, but they can certainly help you and delay when you might get a disease. Having a healthy diet and healthy life. Thats what we can sort of do for people now and look at these other potential disease targets and theres not pharmacology now in terms of drugs, but people are looking at these novel targets and looking at ways we can intervene and theyll be unique characteristics with different risk profiles for different individuals and that means youll get maybe a different set of drugs or recommendations, interventions for you that i might not get. As you look at the landscape and youre trying to figure out at the nih and who to partner with and where to prioritize funding dollars, how do you distinguish in terms of prioritizing a drug that will prevents alzheimers or slow it . The way the nih funds is we have a strict process and applications come in for funding and they get reviewed by peers and the Research Community and based on how they score, nih can make funding decisions and we have the benefit of having the input from the Research Community to help make those decisions and see where things look the most promising and we utilize that information and obviously, a lot of what nih does is basic research and we do the translational moving from the basic sky tones identifying new targets to get us into early stage, maybe Clinical Development and clinical intervention and we do run the whole gamut, but a lot of where the bulk of the money goes and other people use like the pharmaceutical companies to take it further. To look at where the future might go, this is a complex disease and i dont think well have one treatment that will satisfy all, but as we move toward treatments that would slow the underlying pathology of the disease, once those would be introduced in combination with lifestyle things that may also have a key role to play just like in diabetes you have the drugs and you also have to keep your lifestyle in check, et cetera. What we would see from a Public Health point of view is down the road, i dont think well see the disease disappear, at least not in my lifetime, but what we would hope to see is the risk for people at a given age for actually developing dementia and the accompanying disability will start to go down. The way we see rates of heart attack and stroke have gone down with the better control of cholesterol and Blood Pressure and so forth. And if im hearing you correctly, it sounds as though one of the things thats really changed in the last few years is recognition of the importance of Early Detection, early treatment. Is that i mean, when we talk about because we are seeing headlines every day of glimmers of promise and that maybe there is some that when we hold this conference two years from now, well be able to say, actually, there is a drug that helps prevent it. Is it the Early Detection thats been the pivotal change . This has been incredibly important. We always talked about the mantra of Early Detection, but the work of say the diane study which are these people who have the genetically determined form of the disease where with those people, we know now with absolute certainty that the pathology begins 15 or more years before they actually develop symptoms and weve been able to map out that trajectory in the courageous families where the disease is determined by a single gene mutation and it turns out that thats probably the case in the more garden variety disease and that just provides absolute certainty based on data that that is where we need to go. Is it a challenge finding enough people to sign up for these Clinical Trials, people who are relatively young and not showing any symptoms . Its harder because we have to screen a lot of people to identify people who are at risk. You would be surprised people are very worried about alzheimers disease. People are very fearful of it. You can understand why. Its not just that you understand something that will cause death but causes great disability and burden for the person and also the Family Members. So people are worried and people are very anxious to actually participate. Weve been very encouraged by that. Its just that its the screening process is very intense for these prevention trials, making sure we have people who do have that level of risk. I think its challenging but heartening people are really interested in volunteering. We acquaintcant do it without the volunteers. Absolutely not without the volunteers and their families. Theyre critical. When you talk to people as weve seen with many people in this room, if youve watched a relative or somebody you know go through the disease, its a great motivator to not want that to happen to your children or whatever. So that is what really gets peoples interest. You see in family where is theyve had two or three cases in the same family. A lot of times theres fear in the family as to whats going to happen down the road. But its also a great motivator to get people interested in Clinical Trials and to support the kind of work that the nia is doing. One thing i want to touch on briefly is that alzheimers occurs at a greater rate in women than in men, a greater rate in the africanamerican population than in white. Is that helpful as you are not helpful, obviously, in terms of people getting it, but helpful as you try to identify what is going to stop this to be able to study those different populations that it manifests itself differently in different groups. Its actually critical to understand the different groups and the populations. We know one of the reasons for women is that women live longer, but it looks like theres some research that suggests thats not necessarily the only factor thats going on with women. With people, africanamericans, hispanics, some of the issues are related to Health Disparities and when you get seen by a doctor and whether or not your cardiovascular disease has been taken care of. Its critically important to understand whats happening with diverse populations as well. It is critical to understanding disease. Weve been talking about priorities. Talk to me about the priorities are we getting the funding right in terms of were talking about cuttingedge research to find a cure. Theres the whole flip side of the coin of providing for longterm care and assisting people who are afflicted by this disease and people who are trying to take care of them. From the federal governments point of view how do you strike that balance . At the nih, our total focus is on research. For us our mission is Public Health and finding ways to intervene and with basic science or even doing Clinical Trials that are going to advance Public Health. I think we come at it from a different perspective. Different aspects of the government have different challenges. For us, its a mission. Care is also equally important. My father has alzheimers disease. 92 now. Hes doing pretty well. Im also his primary caregiver. I can certainly see the challenges of caring. Both aspects are critically important. It is a challenge, you know, to where to strike the balance. Luckily, i have we have a lot of good people in policy that are trying to figure that out. Well, look since i work in a forprofit company we try to identify areas where theres a high unmet medical need but the science has advanced to the point where at least we can imagine theres eventually going to be a medicine that we can produce there. So our focus is on the medicines and the diagnostic tools that go with them. But were well aware from our Clinical Trials and interactions with physicians that if there isnt the appropriate incentives for them to make the diagnosis, if there isnt the appropriate caregiving systems in place for families to take care of these patients, the medicines will never be used. All that has to go together. Id love to open it up to questions now. If you put your hand up i think we have mics going around back in the back. Anybody with a question on where the research is going some of the headlines were reading this week in terms of different tests in early phases. Yes, maam, right here in the front. If you just wait one second, well bring this microphone over to you. Thank you for coming here today. My question has to do with misdiagnosis of alzheimers in patients. Do you have can you comment on that . That sometimes mini brain strokes wipe out tissues and doctors characterize this as alzheimers. Im just trying to understand how we can better make that diagnosis for proper treatment. Well i can just give you a first comment. We need to understand theres a difference between dementia which is the syndrome of having cognitive loss, which is progressive over time, and alzheimers disease, which is dementia in the context of a particular kind of biological abnormality. Now, good clinicians, and we probably dont have as many of them as we need, if they do a careful exam they can usually get it right. But there are a lot of times when the clinical picture is not very clear and you can make two kinds of errors. One is we dont want to make an error where we diagnose somebody as being demented when theyre really not. Its just normal forgetfulness and wont be progressive. Or you dont want to misdiagnose somebody as alzheimers when they have multiple strokes. I think the new diagnostic tools being developed such as the p. E. T. Scans are helping us to make advances there, but its still an area of some concern. Another one. Yes, sir. We heard from harry johns i think, very articulately some of the working with done both here in town and around the world on this disease. Since this is an ideas forum, id like your thoughts on whats the biggest shortage right now, ideas or funding. Well, ill try to take that. I think weve moved into an era where we have a lot of good ideas. I mean, look, i keep saying i work for a company that we have to make a profit. We have shareholders. We dont go into an area where we dont think theres a possibility of progress, of actually producing a medicine. In my company, we have plenty of people working on diabetes and cancer and Heart Disease. They all think they got great ideas, and theyd like to take all the money and have it spent there. But we tend to win some of those arguments. Weve kept the company in the business for 27 years. Im not a fan of just throwing money at things where it cant be well spent, but i think if you looked into the nias portfolio or the portfolio grants that the Alzheimers Association has, theres a lot of very potentially productive science there thats currently not funded. I want to follow up on that. You mentioned a couple times you work at a forprofit company. How much is the first drug that works, thats shown to prevent business. I dont know which. You dont want to do share prices. I think we have to assume something, otherwise, we spent a lot of time and i might have to look for another job. If you look at other therapeutic areas that have blossomed once the path is worn. If you look, for example, say at depression, once that path was found that you could treat depression, lots of Companies Develop them and eventually theyre almost now developed and if you looked at Heart Disease and once they found out that cholesterol was a big risk factor and lots of drugs raise hdl, et cetera and most of those are generic and theyre looking for the next thing to up the game and thats the way i think its going to go. I think there has to be to Keep Companies involved there has to be some reward and in other words, we have to be willing to pay for new thing, but thats how we get generics in the end is you get new things and they live to their end and you have to develop something new. Another question. Youve got one in the back . If well come to you next. My question relates to the research being done and we talked about Clinical Trials and most of them are focused on testing drugs and im wondering when you talk about lifestyle day and other things, why dont we see more studies that are focused in changes and lifestyle particularly with children of people with alzheimers and others who are trying to look at how not to get it and it seems like theyre testing different types of drugs. I can take that and obviously for lifestyle interventions theyre not profitable for a company and you cant patent that, but the nih does support and we have a number of trials and theyre listed in clinicaltrials. Gov and the nias has an alzheimers information web page. You can find it and we are supporting a number of trials and we look at both diet ear interventions and cognitive training as well as exercise. So we are absolutely very interested in that and we dont think thats necessarily going to be the thing thats going to stop or slow progression and its something that well need to add to whatever were doing with drugs or individuals. As richard said, lifestyle is extremely important for cardiovascular risk, diet and exercise. Is there any research that shows how much of a different specific toal intriemers . No. Theres a lot of work thats been done with animals that suggest that. There are a lot of observational studies that people who live a healthy lifestyle, and it seems that their age onset is much later and theres the observational studies which is why we have to do the Clinical Trials and they actually are under way. And looking for volunteers, i might add. Step on up. I think we had a question right there. This lady in the gray suit, if we can get a microphone here. Thank you. You mentioned cardiovascular disease a couple of times. Is there a relationship between the disease and alzheimers . Yeah, well, its not quite clear and there are vascular changes in the brain that can cause small strokes that can contribute to dementia and the brain like any organ can have multiple kinds of pathology so we often see people who have some cerebral vascular damage and alzheimers disease, as well, but i think lori may know this better than i. The connection between the two is not very well established, but you also see things like amyloid deposit and around vessels and we really dont understand that aspect of the disease nearly as well as we should. Theres data that says there is a risk factor with dementia and as well as there are people trying to understand that there is an amyloid pathology and dieb eaties is a risk and they may allow you to live longer without having a dementia and those are lifestyle factors that we can do something about. You cant do anything about your genetics, but you can make sure youre eating a healthy diet and thats easier said than done and im not exercising nearly as much as i should, that i know. There are risk factors for sure and were not saying that if you exercise you wont get dementia, but you will extend your healthy period as you age. Another question. Yes, maam, right here. Bob moreno, Alzheimers Association and Alzheimers Impact Movement and thank you for the dialogue and forgive me, i might be putting you on the spot. The discussion seems to have turned it a path over the past couple of years, emphasizing so much on the early end of things, intervening early and getting therapeutics to folks before theyre symptomattic and is there still a pathway . Are there still therapeutics being looked at for those who are already afflicted and something to offer families who are already dealing with this which clearly is an elusive target and been a difficult target. And ill start because obviously, i think youre right and i dont want people to think were not interested in individuals who will have the disease and will be getting it because that will continue and so we and we have funding and companies that are intervening at later stages when someone has either mild Cognitive Impairment which is the stage before you get fullblown dementia or dementia and there are treatments and theyre looking at the behavioral symptoms and the disease like agitation and psychosis and the neuropsychiatric symptoms and even some, were looking at basically regeneration and is there a way to actually have, you know, cells regrow. So there are a lot of things going on that are still looking at late stages and its important and if we can get something to prevent that will be terrific and its going to help a lot of people and well still help people who get disease and the research is ongoing across the whole disease continuum. So there are a lot of things going on that are still looking at late stages and its important and if we can get something to prevent that will be terrific and its going to help a lot of people and well still help people who get disease and the research is ongoing across the whole disease continuum. Absolutely. Thank you for asking that. Thats very important. As scientists continue to refine drugs that will hopefully prevent it. And our greatgrandchildren will never know anybody with alzheimers. Someone who is five years, six years, after the diagnosis of alzheimers. Are you looking at a different category of pharmaceuticals. You can talk about the way these drugs were first tested. I think loris point is quite right. Even if we can slow the progression of the disease and actually prevent its occurrence and just given the demographics, theyll need treatment and there is work ongoing to try to augment or refine or make better the inhibitors that are not part of the treatment and other transmitter approaches and i think its further down the line, and i do think there is a possibility that if we could slow the degenerative process, the brain still has a capacity for regeneration, and people do regenerate and we grow new synapses. Thats how we know the synapses grow and if they could be restored we can imagine down the road and we could get some recovery in patients where the disease has taken hold and if you stop the bad part and augment the good part you could get some recovery and we know this is an important avenue to pursue as well as the prevention. Yes, maam. I had the opportunity to attend the alzheimers set nih in february. I wonder coming out of that, what steps you see important to take in terms of diversifying the participants in trials given the effect on particular population sectors of the disease. Thats an excellent question and Companies Struggle with that, as well and how do we reach out and make sure we have a diverse population that people are included in trial and there are efforts under way to enhance recruitment efforts and to enhance outreach efforts and ill mention the us against alzheimers that Georges Group has, they have africanamerican network against alzheimers and theyre trying to reach out to make sure that we are including everyone in the trials and not leaving anyone out. So its very important. Just to give you an industry perspective, when we develop a new medicine we usually develop it for use around the world. We would generally not develop a medicine for anyone in the u. S. And many other countries have a requirement that in the latephase Clinical Trials we include people from those countries in our trials, japan, china, european union, a couple of south american count ryes and we out of necessity have to go to those countries, but in the u. S. To get a Patient Population in your trials that is representative of the patients as a whole is an ongoing struggle as lori mentioned and its not unique to cancer trials and cardiovascular trials and its a constant struggle and were always looking for help from groups like us against alzheimers and nia and the Alzheimers Association to help broaden the Recruitment Network into Clinical Trials. Right before we came onstage we were talking about the meetings and gatherings in washington this week focused on alzheimers and richard, you mentioned you were surprised at the number of people attending from japan and big numbers of people from the Scientific Community and others. Yes. Well, you know, the aging of the population that we see in the u. S. Is actually even amplified and particularly some of the asian countries. Japan, korea, et cetera. So we know this from our own Clinical Trials, there is a great desire to have new