Transcripts For CSPAN3 Bipartisan Policy Center Hosts Discussion On Cancer Prevention 20161001

Im lisa loy, Vice President for programs here and privileged to direct the Prevention Network which is part of our comprehensive health program. We are delighted to host this event with American Cancer Network and thrilled to be joined by three secretaries from hhs Whose Service has spanned multiple administrations from parties both democratic and republican. For those new to bpc, our mission is to drive principled, actionable policy solutions that combine the best ideas from both political parties. Today were here to talk about health and in particular to talk about ways to promote health and prevent disease, specifically cancer for ourselves, our families and our communities. From individual behavior changes to changes in our environments to policy changes at the state and federal level, theres a lot we can do to prevent cancer. For many of us, cancer is personal, some of us personally or affected someone we care about. Theres a tremendous amount of good work happening to better understand and treat cancer. What we hear relatively little about are ways we can tap into what we know to prevent cancer from occurring. Were fortunate this morning to be joined by dr. Richard wender from the American Cancer Society who will share what the research and evidence shows about Cancer Prevention. Before i introduce him, a couple of housekeeping notes. This event is streamed live online, and a recording will be available later today with a link on our website. If you are so inclined, please tweet or post about todays event using bpclive. After the panel discussion, well be taking discussions. If youre watching online and have a question use bpc to discuss it and well try to get to it. Pleased to introduce dr. Richard wender, the first ever chief Cancer Control officer at the American Cancer Society. Hes a primary care physician by training who has devoted much of his career to preventative care, particularly with a focus on cancer and reducing health despaisparit disparities. Can you hear more about his impressive career and accomplishments in the speaker bio packet. But for now, dr. Wender. [ applause ] thank you so much. Im so excited and appreciative of bpc convening this opportunity to discuss prevention specifically focusing on cancer, and i want to add my welcome on behalf of the American Cancer Society Cancer Action Network and, again, thank you for the opportunity to join with you in putting together this event. Through history, prevention has been responsible for many of the great advances in health. Going back centuries, improving conditions in which people live. Sanitation, getting rid of pests and insects and vaccination are responsible for extraordinary triumphs. As we moved into the last century, the causes of death shifted increasingly, particularly in high resource nations, but its now happening in low resource nations as well. Infectious to noncommunicable, led by Heart Disease, cancer, lung disease and others. The question really has come forth, can these cancers also be prevented, or are our best solutions to treat them once the advanced disease or progressed disease have occurred . We now know the answer. I will tell you it will take both, but we cannot achieve full potential in our cancer fight unless we embrace and implement everything weve learned about prevention. And, in fact, in 1996, the American Cancer Society challenged the nation to achieve a 50 reduction in ageadjusted cancer mortality by 2015. In preparation for this event, i checked the calendar. 2015 has come and gone. Just a few months ago, we published our final report, and the glass is half full. We actually achieved 26 , or we believe we will once full data are in. That we will have achieved a 26 reduction in age adjusted mortality compared to the peak in 1990. And we know, critically, its one thing to achieve it and quite another to know how did it happen . What worked . These two slides show it. A 46 reduction in lung cancer deaths in men. Almost entirely related to a reduction in tobacco use. A marked reduction, about 40 reduction in colon cancer deaths in men in the postendoscopy era, where we remove early cancers. We hit the goal in prostrate cancer. 53 reduction in ageadjusted mortality, largest reduction of any country in the world. Although screening has pluses and minuses, why we recommend decisions, were at a mortality rate last seen in the 1930s. I should say that i put a little window in here into areas weve not been so effective. Pancreas cancer, liver, rising but they point the way to solutions because part of this rise is related to the Public Health challenge of our time, the epidemic of overeating and underexercising which has contributed to a 31 to 32 obesity rate in this country. And the increase in hepatitis c infection. Which has led to the skyrocketing of liver cancer, potentially a preventable cancer. How about in women, sorry. Ill get there. Here we go. In women. Women started smoking later, they gave it up later, so we only have achieved 13 reduction, but its good to see that lung cancer curve has turned the corner. And Breast Cancer, no reduction at all until seven years after acs first recommended screening mammography, and at that point the decline in mortality has been steady due to better treatment combined with earlier detection in colon cancer which has been coming down for years. So we now know, proven, that one of the most effective ways to reduce mortality from cancer is prevention. In fact, the 20 decline that was achieved in this span from 1990 and 2015, about 83 of the total decline was through prevention. 17 or so due to improvements in treatment. So we cannot realize our full potential unless we embrace and implement what is known about prevention. If you do all the modeling together, interesting in 1956 we made this goal of 50 reduction. The best models we have indicate somewhere between 40 and 70 , around 50 of all cancer deaths can be prevented by fully by fully implementing what is proven to work. Fully implementing. Thats a big challenge. One of the reasons were here. The formula is clear. We need to implement the proven strategies around Tobacco Control. Clean indoor air, smokefree campuses, raising the prices of tobacco, denormalizing tobacco and continuing to educate and implement proven Public Health strategies to promote cessation and reduced uptake. Screening. What does it take to increase screening . Insurance matters. Weve published articles showing that people with insurance were more likely to be screened than those without. But thats not sufficient. People also need a regular, trusted source of primary care and our distribution of primary Care Workforce is not ideal across the country. When people see a Preventive Health care, far more likely to receive screening. We now have another health care driven proven way to prevent cancers and thats through hpv vaccination. Human papillomavirus causes all cervix cancer around the world and about half of head and neck cancers. Vaccination rates in this country today, at or about 50 for all three vaccines for girls, and significantly lower than that for boys. Thats something we can truly implement here, and then we have to help implement it frankly around the world where the burden of Cervical Cancer is so much greater. What are the opportunities we have not taken advantage of . I already mentioned obesity where weve gone in the wrong direction. Just behind tobacco in this country today, overeating, underexercising leading to obesity is the second leading cause of preventable cancers, and we believe continued progress against tobacco it will become the leading cause in the United States of potentially preventable cancers. We have not taken full advantage of what we know will make a difference in skin Cancer Prevention. We need to do a much better job of implementing lessons from around the world about the right messaging and sun protection, which does not begin and end with putting on lotions. It against with a very different strategy and making sure that we denormalize and restrict access to indoor tanning. So we know what works. The challenge is to implement it to achieve this 50 . But everyone sitting here also knows this truth, that benefits of prevention are not being equally enjoyed. We are seeing that where you live, where youre born has a dramatic impact on how long you live. Cook county, chicago, alone, highest wealth in the county to lowest quintile of wealth, 40 years difference in Life Expectancy. We believe in the United States and around the world, where you live should not be determined if you live. Figuring out how to make these kind of proven strategies effective presents a challenge for Public Health and all of us who care about this issue. Can we achieve reduction in disparity . Addressing the true what i like to call the true determinants of health . When you look at the data, true determinants of health. Can we address this by continuing to message good health . You know the answer. That alone will not be sufficient. Thats why theres been an Imaginative Movement towards imagining healthier places to live. What i call health and others, the Movement Towards creating Healthy Communities. As was said in the introduction, this was not a problem that can be implemented or addressed simply through the Health Sector. This is an all hands on deck challenge. This demands engagement, yes, of the Health Sector, but it has huge impact on what policies we choose to pursue both at the local, state and National Policies and demands engagement of the private sector, of ceos of small and large businesses. The policy implications are not confined just within health but they are housing, food availability. They are clean air. They are education. Because when you look at disparities, the impact of having a College Education versus never having graduated from high school, its actually one of the most consistent, reliable, unfortunate predictors of true disparities in Health Outcomes. So this Healthy Community movement, i think, is an extraordinary opportunity that will define a great challenge for us. You know, when i think about disparities, and there are so many ways to define them, by color, skin, education level or economics. But in cancer i will just give you one statistic which maybe summarizes all of the challenges we have in front of us. Breast cancer mortality Breast Cancer mortality, 25, 30, 35 years ago was higher in white women than in black women. In the postmammography era as i showed you earlier, virtually immediately, mortality started to decline in white women, and it has declined every year. But for the first 15 years after that period, mortality went up in black women, bypassed mortality rates in white women. Now it is coming down but not as quickly as mortalities declining in white women. While the good news is black white disparities are declining in almost every cancer they are actually widening for black women. Though mortality rates are coming down for black women, they are just as high today as they were 35 years ago. This is not a simple solution. This is not just biology. This has to do with all of these true determinates of health and it defines a great goal for us to focus on. So the answer is clear, and its why im so grateful to bpc, acs can for convening us together to talk about this because this statement is proven that the road to achieving a road with less cancer, ending pain and suffering from cancer here and around the world must include a substantial and sustained focus on prevention. Thank you so much for letting me kick us off today. [ applause ] thank you so much, dr. Wender. Now i get to introduce my boss, former secretary dan glickman. Secretary glickman serves as the bpc senior fellow. Hes cochair of our prevention initiative, cochair of bpcs democracy project. Hes also on the board of the American Cancer Society Cancer Action Network and helped bring us together for this event. Thank you so much, and id invite all of you to come up to the stage now. Thank you. Thank you. First of all, if you believe im leisels boss, you probably ought to be in another room. I want you to know that. Dr. Wender, thanks for the terrific remarks. They really set the stage dramatically. I have the privilege of being part of this organization, which is promoting what i call constructive bipartisanship, not nonpartisanship, but ways republicans and democrats can Work Together on serious issues and health and disease prevention are one of those areas weve seen this year work on this faster cure 21st century ways to deal with disease prevention. Its one of the areas where rs and ds tend to get along better than other areas, which is really an important thing. Maybe we can learn some lessons in other areas as well. And being on the board of the Cancer Action Network, the advocacy arm of the American Cancer Society through my good friend chris hansen, who is the president of that, been able to be in both worlds. Like most people here, ive had family members and close personal friends afflicted by this disease. And it is something that is really critically important. Weve learned that we can Work Together and find Common Solutions to these problems. So youve all seen these peoples bios. We have three of the most distinguished Health Experts in the country right here, right in front of you. So we should be very, very pleased. I think im going to ask the first question, which i think dr. Wender brought about and ask each of you to respond. That is this linkage between prevention and preventable risk factors and how to influence not only cancer risks but cures and ending of the disease itself. The link between risk factors and prevention and ways to actually deal with the disease in a way that disposes of it in a positive way. I wonder if all of you could comment on this linkage. What got to me was his point 50 of all cancers are preventable. 50 . Thats extraordinary when you think about it. I wonder well start with you, dr. Garcia, and well go down the list. Thank you, mr. Secretary. First of all, my voice is raspy. I think dr. Wender made a point about 50 of the cancers that are preventable. We fulfill all the prevention and strategies. I think when we look at hpv, he mentioned. This year is the first, 2015, the first year ever more male die from hpv related cancer than women. We can control that with hpv vaccine. Obesity is an epidemic in this country. Uv protection he mentioned. Minors should not be using bed tanning salons because the chances of melanoma. Tobacco. There has been some decrease but we have vaporizes and ecigarettes. We need all of you to get involved. Those three are major challenges we have. We control those, the rates will come down significantly. Dr. Desalvo. Im so pleased were starting with this concept of prevention, and i want to thank dr. Wender also for his remarks. I was also listening to you thinking that could easily be my speech. Thats the things on the top of my mind. I would just add in a couple of points. As a physician for a lot of years taking care of patients who are uninsured, the bigger barrier for them is they didnt have a way to pay for preventive measures, the colonoscopy, mammography, even followups that might be necessary. So we shouldnt we should take a moment to recognize the advances in prevention include the 20 million more people now in the last few years who have access to getting the screenings, vaccines they need. The work is not done there. We still need to continue to, for example, expand medicaid in many states. Those happen to be states on the map that overlap with many of the major risk factors for cancer. The southeast in particular. We have important work to do to see that thats not a barrier. But i want to pivot to this point about creating the conditions in which everyone can be healthy. Having a Healthy Community allows for us to really move upstream such that healthy behavioral choices are easy choices to make about lifestyle things such as eating and exercise and physical activity but also exposure to Secondhand Smoke or smoke or any other of the potential carcinogens. We have made a lot of progress on the front end of giving people access to some of the known preventive measures and well have more work to do. Our big chapter ahead is seeing were creating this healthy environment, conditions in which everyone can be healthy and it will be a shared responsibility. No single sector alone will be able to achieve it but such great models how that is working and hopefully well get a chance to talk about that. Good. Dr. Ko, you have an amazing background, all these specialties, including oncology. I wonder your comments on this, the linkage between prevention and Risk Management and disease control. First, thanks bpc, secretary glickman for hosting this session. Cancer prevention such a huge Public Health priority and very personal to me because, as the secretary just mentioned, im trained and boarded in medical oncology. My Public Health journey began many years ago when i was caring for patients who i knew could have benefited from Cancer Prevention. Theres so many lives lost where prevention can make a difference. The area of cancer, im so glad my good friend dr. Wender emphasized the point 50 are preventable. Theres a lot of Pertinent Research we can talk about. One key study that came out a couple months ago from my harvard colleague looked at some 170,000 nurses and Health Professionals and looked at their cancer outcomes and found they fell into two groups, a low risk group and highrisk group. The low risk had four features nonsmokers, not obese, no or moderate alcohol intake, and they exercised regularly. That low risk group had half the cancer death rate of the higher risk group. So that is powerful. At a time when were talking about the future of Public Health and the future of Cancer Control, if we talk about those four simple measures and make that apply to the Cancer Prevention landscape, it could really make a difference for the future. So building on that, im going to go back to the same order, dr. Garcia. We now have the Vice President very involved in this moonshot apollo program, so to speak, to end cancer. I know youre at m. D. Anderson which has a major role in this, but almost everybody in the cancer world is involved with it. I wonder if you might talk about that Moonshot Program especially as it relates to Cancer Prevention. I know so much is in the world of research and new techniques, immunotherapy and new drugs. That, of course, is critical if you have the disease. But if 50 of the cancers are preventable, does the moonshot address that as well . So when we started in moonshots at m. D. Anderson, it was 3 1 2 years ago. We have been partnering with Vice President and the white house and every federal agency and currently has been a champion. When we did the moonshots at m. D. Anderson, each of them was divided in flagships. Each one of the flagships, part of this science, each one has a prevention and Cancer Control part, meaning Early Detection or prevention of cancer. I can tell you we are looking at right now, and dr. Wender mentioned this. Genetics and social determinants of health. We believe if we continue finding cures of cancer were actually missing the boat on how to cure cancer. We have to go early and actually target a specific population because they have high risk, like mentioned. We cant treat everyone in the nation the same. You saw the math. Genetics are extremely important. But its not only that, we are sequencing everybody. Thats good. But what about identifying what are the other aspects that will increase and amplify that risk. Not only because of your genetic profile but because of where you live. I should not be having the same i was part of the task force. The same screening as a person who has a higher risk. We should be targeting specific. We do that with every other industry. Lets do that in health, and we will be able to help people. I know im talking too much, but theres a movie called gothica with ethan hawke. That movie changed my life. Hes the imperfect brother. The other one has been genetically engineered. The entire movie he wants to be perfect so he can go to mars. So we can empower using Population Health, using the knowledge we have, transfer that to our policymakers, health care clinicians and allow everyone here to be ethan and be able to go to mars. Meaning that person will know how to diminish their chances of not only having cancer but other diseases as well. So we firmly believe in that, and we are pushing that in the moonshots. As a former chairman of the Motion Picture association of america, i appreciate the plug. [ laughter ] it is an important point that the Entertainment Industry and role models in sports and entertainment can certainly do a lot to deal with this prevention especially with younger people. Dr. Desalvie, i wonder if you have some comments. Thats part of the role of the Vice President serving as role model and throwing a flag saying the time is now to marshal everyone, all our resources to not only address the prevention but find a cure. Its the Energy Around it, across the administration and with the private sector has been terrific. I think what it caused everyone to do across the administration, d. O. D. , dea, Scientific Community, Prevention Health care, also everyone trying to understand what we can bring to bear to make this a reality. Its an important point about the technology component, about Precision Medicine. Which is the president s initiative thats broader than cancer. This Precision Medicine work has also begun to beg a question about precision, Public Health, prevention or targeted prevention angle. Im excited many people in the country are starting to consider how to use big data and analytics to better target prevention not only for people but communities such that we are really pushing the resources where they need to be most to go upstream just at the same time as were thinking about the downstream efforts. To your specific question, secretary, prevention and vaccinations are a part of the Vice President s moonshot initiative. Its going to be important for champions all across government and in the private sector to make sure we keep our eye on that because its an early way we can really make a difference in the lives of so many. Dr. Koh, i want to ask you the same question. You have been one of the leaders in tobacco cessation. This is kind of one of your specialties in addition to all the other things youve done. I wonder talk about prevention but what else we need to be doing on tobacco cessation, which is still i go to this local cvs and i see kids buying they are supposed to be buying cigarettes. Not cvs. Sorry, sorry. Rite aid. Is rite aid okay to mention there . Cvs are the good guys. Its an important point. Cvs is not selling cigarettes in their stores. I apologize. I corrected my mistake and unlike many of the president ial candidates, i admit my mistake. Anyway, watching kids buy cigarettes, which is, you know, probably the most single preventable way to prevent cancers from happening. So many colleagues in the room who worked so hard on this issue. I want to single out my wonderful colleague rosie henson howas with health and Human Services and now is with the American Cancer Society who has been a tremendous leader on that and so many others in the room and around the country. Im so glad dr. Wender showed those critical slides about leading cause of cancer death in men and women between 1930 and today. In 1930, lung cancer was an uncommon disease. For men, lung cancer became the leading cause of cancer death in 1955 and stayed there since then. For women, lung cancer became the leading cause of cancer death in 1987, passing Breast Cancer, and has stayed there until now. The only good news is that those curves are going down. The message from those two slides is that lung cancer should be an uncommon disease, not the leading cause of cancer death in this country. Its thoroughly preventable. We have a lot of momentum now. Theres an excellent article by dr. Mike fiori call Tobacco Control in the obama era where he analyzes the decline in cigarette consumption in this country which has accelerated under this administration compared to other years. Cites a lot of reasons for that to happen. We cant be satisfied with that. We should not rest until lung cancer is an uncommon cause of cancer death once again, and i hope we can see that in our lifetime. The secretary asks how do we address issues like this with respect to efforts in the cancer moonshot. My view, with the revolution in life sciences, emphasis on cancer moonshot, Precision Medicine, we have to talk not only about tailored treatments for individuals but also about improving Public Health and population and health for everybody. The Blue Ribbon Panel for the cancer moonshot came out with recommendations a couple weeks ago. One of the seven work groups was dedicated to prevention. I was delighted to see that. For every major Health Life Science initiative, if we can weave the population into it, i think well be a healthier nation in the future. So im going to ask you to go down an area where i dont know what your areas of expertise are, but assuming obesity is dr. Wender talked about may exceed tobacco as one of the major causes. Obesity is caused by a lot of factors. In may be genetic. A lot of it simply has to do with what you put in your mouth. A famous french philosopher says you are what you eat. I wonder how much of the work in Public Health on cancer really is developed into an understanding of food, how food relates to disease, what foods you should eat, what foods you shouldnt eat. My own experience is that there is a lack of research, good research, and, of course, a lot of Interest Groups in this country and in this world who have a vested interest in maintenance of certain eating habits. But how do you see food and the medical community relating to each other in this issue of obesity . Want to start with you dr. Garcia. As a policy person, i think theres an opportunity, secretary, sir, for six years they are did a great job as a secretary. I think that should be a joint working between hhs and agriculture. We work internationally as well. The issues related to highfructose sugars, balance and energy is something we have to work from the policy perspective. I know theres a lot of trade issues and should not be talking about trade here, but when i was in the w. H. O. , thats was a big issue for us. Talking about sugar, restriction of sugars and restriction of saturated fats. Now, what we are doing, we had Anna Brewster to work with me, and they had worked with dr. Wender in the past. We had this concept he mentioned that were introducing in texas which is about Healthy Communities and vibrant communities. This is not related only to Cancer Prevention, its an entire spectrum of disease and health. Because we know the cause of disease, but we dont know the value of health. Therefore, what were looking right now is having those communities to be healthy. Diet, exercise, uv protection, no smoking and essentially hpv vaccination. And also transferring the knowledge to them. Because if the people are only educated but the knowledge doesnt come to the community, we are missing the boat as well. So i think this is an opportunity to work from the policy perspective. Tobacco, dr. Koh has done a lot of research on this as well. If a kid starts smoking before 21, its going to be 20 times more difficult to quit versus someone who started later on. We have to start with our kids, our families and our communities like karen mentioned before. I think multiagency, multisectoral, multicommunity effort, not just governmental working or Health Sector working. It has to be all forces in this room. Dr. Desalvo, just to follow up, the old adage is, an apple a day keeps the doctor away, unless its loaded with pesticides and then its not so clear. One thing i would ask you is, how much does the medical community really understand about food and what foods are good for you, what foods arent good for you, what foods may be good cancer preventative things . What foods arent . Is there a knowledge gap in medical schools and other places where maybe medical providers arent given the kind of information that they need to have to deal with this problem . Theres a pretty established knowledge gap about diets impact on overall health. A Little Research i did early in my career showed the additional fact that even though clinicians, physicians in particular in this case dont have training and education in diet, they are confident about their ability to educate their patients. Since that work has been done many medical schools like tulane have instituted a curricula not only about dietary education but teaching the medical students to cook, bringing them to a teaching kitchen so they actually have the manual skills to transfer that to their patients or teams. And now many other schools are picking this up as well. Because the deficit isnt just, im going to give you a sheet of paper and tell you. But there has to be some understanding for themselves even. Clinicians sometimes arent always the best eaters. Were seeing Good Movement in education, better programs, tools and skills to doctors and others they need. From a scientific basis, what we released in dietary guidelines for americans in partnership with the usda was a broader picture thats really more about your eating patterns and that it has to do with balance, caloric balance and making sure youre attending to having sufficient fruits and vegetables, proteins low in fat, low salt, low sugar. And we put some limits around salt and sugar to give really broad guidelines and made recommendations around the mediterranean diet. In some areas, the dash diet is more benefit. Important to say as policy matter what usda and nih and others have done is they lay out a road map where we have gaps in science. We want to give the best information thats available to people to make good decisions. So there is a policy and scientific and educational agenda thats well under play. All of that is wonderful except if you live in a community where you dont have access to healthy food or you have to stress eat because of the kinds of Public Safety challenges that you face. If you dont have the conditions in which the healthy choice, easy choice is going to be healthy, that is a significant barrier. So broad Public Policy at the local level. Smoking is a great example. Access to tobacco is not individual sales choice but also you can reduce access to tobacco by making smokefree laws in a community. So Public Health policy like that even at the local level is so critically important and going to address not just smoking but things like access to healthy green spaces and Healthy Foods. Dr. Koh, youre at one of the most famous schools of Public Health in the country. Youre dealing across the board with all of these issues. How well are medical professionals trained . We talk about obesity, but obesity is a combination of factors including what you eat and how you expend your calories and Everything Else. Is this a big part of what your school is trying to do . Its interesting with respect to the two leading killers in our country, cardiovascular disease and cancer, theres a general understanding among public that cardiovascular is preventable but when you ask about Cancer Prevention, is that preventable, most people dont quite grasp that as well despite the growing research, very, very strong research. So i want to point the audience to two very nice publications from the last couple of months. International agency for research on cancer, ir, led by my colleague. This summary on the link between obesity and cancer. Their conclusion is obesity prevention is Cancer Prevention. If you dont have excess body weight, that can reduce the risk for most cancers. Thats pretty profound and again very powerful. We have in the audience here my wonderful colleague, dr. Bill dietz, one of the leading researchers in the world. Raise your hand. He works with us quite a bit here, too. He just published a viewpoint in jama this week on behalf of National Academy of medicine, again, stressing the themes of obesity prevention, making a difference for not just Heart Disease but also cancer, diabetes and other outcomes. Theres some policy ramifications here that we can keep our eye on especially in this city. In 2010, the healthy hungerfree kids act was passed which raised nutritional standards for 22 million low income kids for National School lunch program. We need that to be reauthorized. There is a growing emphasis on physical education as part of a reasonable framework for elementary and middle school education. So these are all themes that should tie together as were talking about health in the future. I want to just add in to what howard has shared, which is if you think about the obesity trends in the country, we know, for example, young kids age 2 to 5, obesity rates are starting to decline. Its an encouraging sign, reflective of a variety of things. It could be personal choice but also reflective of some of the ways weve been addressing systematically the kinds of foods available to kids in head start environment or School Environment. When you see the kinds of policy actions that major cities like new york city take in their School Environment and now thats happening all across the country, we can do so much from a policy standpoint making healthy food available to kids in places like the School Setting or day care setting because thats where theyre going to get a lot of their calories every day. Those changes and reductions in calories and sugar and fat and increases in healthy fresh fruits and conveniently tables will make a difference early in life that seem to be sustained. If you get those Healthy Eating changes early, its sustained across the life cycle. Its reflective of big changes at the policy level and curriculum and institutional level. So im going to ask all of you to follow up on this question. May be a little more difficult for you, dr. Desalvo because you still are federal employee. That is correct. When i walked in i was. But if you were a leading policy official in congress, not in the executive branch, what would your recommendation be to congress in the future in terms of how best to deal with the issues of Cancer Prevention . You mentioned, one, healthy hungerfree kids act, and reauthorization, dr. Koh. If you were sitting around with your list, what should we be doing in society and what should the levels of government be doing to encourage better prevention . Each of you give me your thoughts on that. National academy of medicine came out with recommendations i thought were very pertinent today. Weve heard term health in all policies, weve talked about social determinates. In the future we in the health world have to join forces with those outside of health, in housing, in transportation, in education and talk about health in all policies. So one of the directions was to make that more explicit for the future. I think its collaborations like that and integration of the prevention and healthy wellbeing themes into all future Health Discussions is key. We talk about prevention over here and prevention over here, we talk about individual treatments over here. We talk about Population Health over here, and its got to be put together. Ive had the honor of writing about this recently and i think in the discussion on Health System redesign going on in the area of health reform, prevention and healthy outcomes and good wellbeing should be part of the things were measuring as we try to make our country healthier for the future. Dr. Desalvo, and i promise to protect you. I might be back in new orleans sooner than i thought. Speaking of challenges around healthy food, but delicious food. Were making progress in new orleans. I should flag that. Thats a great example of how a community has been working to create a culture of health. As we look at upstream causes of poor health in our community when i was the Health Commissioner in new orleans. The community said cardiovascular disease is a killer but lets think about why were getting there. Obesity was the major risk factor. So has tobacco. To give you a couple of examples, that city has been systematically working across sectors in a multisectoral fashion to do Health Policies approach to see we have bike lanes and green spaces and the community is now smokefree by law. So they have been taking action that is about environmental and systems and policy level change. We have been calling that Public Health 3. 0 type work, which is really what i think is the next future and the kinds of actions the next administration but not even just the administration or congress but all of us in the private sector as well are going to have to take and that is Work Together in a way to create healthy conditions. Thats going to require a backbone, a champion, chief Health Strategist on the front lines. My view on that is the natural leader in that kind of work is the local Public Health agency, whether thats municipal or state or federal. They have an accountability to everyone in the community and can bring together partners in health care an transportation, housing all the employers faithbased and Civic Society to set a shared vision, for example, we want to go smockfree or have Healthy Foods for kids. The communities that are doing that are showing us that they are indeed making progress on not only Health Outcomes but also the inputs in prevention. And so what i hope we will see more of, and youre seeing some signals from us as an administration, is the willingness and ability to include thinking about the true determinants or social determinants in the ways that were funding care delivery but more importantly, building up strengths and partnerships for those other sectors that have such a key role to play in seeing that we can achieve true health for everyone. Dr. Garcia . So, first a disclaimer. Im from the university of texas, but im going to give you an example that essentially represents and echoes what my distinguished friends have just said. We created an initiative with cgi called a stronger together. And they are here and they were working fro ining from the i. T. Perspective all the way to the policy perspective. It was to reduce infant mortality in the district of columbia when i was the director. A very successful campaign. Example they just mentioned so we created laws so every pregnant woman has access to taxis, to the bus, to go to their appointments. Patients were not showing up. How, if we pass a law, they have free access to care, they have access to care why they are not there . Because the regulations prohibit the drivers of the bus to pick up a mom if she has a stroller with a baby. So we were very smart but not smart enough because we never asked the patients or community what they needed. Thin the other question, why are the taxis not picking them up . After 5 00p. M. , they dont pick anyone up. During the day they dont pick pregnant women, so you could have the best intention and best policy but we had to work health for all. It cannot be in a vacuum, it cannot be in the marble part of washington, d. C. Have to start with wards seven and eight and go to new orleans, to puerto rico, to the south side of boston and ask them what they perceive they need. Match that with the science, and thats when you create real policy that create real change. So we can start thinking as much as we want. I think were pretty cool people here. The four secretaries here. But i think one challenge that we have, we have to reach everybody. So everybody has health for all. With them, not for them. With them, not for them. It should not be imposed from above. It should come from the ground up. Your point about local Health Authorities being a critical part of this is important. So i notice now you watch a lot of Television Like i do so many of the adds are drug ads and pharmaceutical ads and in addition to that theres one in terms of print ads even your center is now advertising as are most of the Cancer Centers in the United States so theres a lot of competition out there for our patience and one center even talks about wholistic care. And i dont know anything about any of these organizations. But in terms of if somebody actually has the disease. What can we do and care actually provides wholistic care including life styles and other things to ensure that they work in a complimentary fashion with the traditional care given to patients and it seems to me this is also an important part of this issue. So to start with im very proud of working for md anderson. An a surgeon and one thing that i learned right away is that we break the silence there. Its like the navy. The cook cannot stop an airplane from taking off and theres something wrong. Its a very wholistic approach. One thing is on their way to help people but we have 27 of the people that show up in our doors and have their own diagnosis. And i believe one of my senior members of my staff has unabled her to have hip replacement because he has no carcoma and our shot is right now we have more centers like you know. We have three or four Economic Centers and four other partners nationally and we have three centers. We want to transfer our knowledge to level up the knowledge of all of our partners. And one of the biggest challenging our nation is the cancer politics. We have to demoncratize the dat. We should not be competing. We should be am lying these. The moon shot is to discover in three years what you can do in 15. And they learn that you had to let the grass grow six inches and it grows faster. And we have to wait and democratizing the data. We have to work with institutions and share that knowledge i think thats a great opportunity in time. And now is the moon shot. When he was in rice university. And with the Vice President and secretary i think is a great opportunity to break these silos and marvel towers called Cancer Centers and make them work with the Bipartisan Center here and many other institutions. Theres a lot of knowledge. This week i spent most of my time with dod. It should be our greatest partner. Were talking about it. This is a great opportunity in time where everybody has to get involved. Dont let the policy makers just think about how smart we are. I mean go ahead. Coming from experience in the Land Grant College field i do know that there is often a fair amount of competition between centers for funding and those kinds of things. And glory. Intellectual property. Glory you said. I came from academics. I know that. As part of the promotion process we built that into the culture. I want to focus on the person with cancer for the moment since you raised that question secretary. If we were sitting here five years ago having this conversation we would be thinking about a world in which people were forced to carry suitcases full of paper from one Cancer Center to the other and wouldnt have a way to integrate their data. Unfortunately hathats still happening in many places but not all places because of the evolution of Electronic Health records. We have gone from 15 of Health Institutions using Electronic Health records and now all. Every hospital in the country has a digital footprint of someones care and this mountain of digital data which is the patience to access and use and carry with them it is their right and they should be demand hag to have a digital footprint of their care is a tremendous resource. Not only to serve them better to make certain theyre getting the right treatment at the right time but also to see if they want they can donate that data to the broader scientific agenda to help find cures and when you talk to patients and do surveys we hear that is what they want. They want the opportunity not only to have Information Available to help heal and cure themselves but they want to be able to donate it for the better public good and this data donation effort has been a policy effort we have been supporting to see that we can create the right private and secure but doorways to the data so that data donation can happen so that Research Centers have the opportunity to get information that can help solve big challenges so that we can use it for Precision Medicine and that would have been here a few years ago and we need to recognize that the reason that the Vice President can call a cancer moon shot is were building it on the foundation of something not only done in the Scientific Community and Health Care Community but consumers can control and be a part of that solution. I want that message to be loud and clear to folks. Thats great an i would just add one other thing, even though food is often viewed as a kind of primitive thing and its foundational. But research into the kinds of foods that are consumed and whether they have any impact on Cancer Prevention or cancer formation should also be part of that as much as possible. Its a great point because i was just now talking about the health care record data. The movement and change thats happening is that people want a full picture of their health and not just their health care. And whether its environmental and that increasely is what we need to be able to see to understand how they got to a place of having cancer. I want to amply identify that this is first of all a critical time to talk about themes for health for the future and some of us need health care some of the time but all of us need health and wellbeing all the time. So i am hoping that in the future we continue to talk about patient centered care thats been a tremendous advance but also talk about person centered care that brings the wellness and prevention themes into discussion and also population cent centered care and diverse by the day and projections by 2043 will be a majority and minority country and im very, very sensitive to those issues and also bisexual orientation and level of disability, geography and income and other dimensions so we need health to care for all populations throughout the life force and talk about health and wellbeing and not just about health care. But im hoping that those are some of the themes that we can start integrating as we move into discussion four. Were fog to go to q and a now and i would ask you if possible please do not give us a summary of the constitutions when you ask a question or if you can state your name and ask your question as quickly as possible. Back to this gentleman. Mike miller, my question is, what do you think the role is for behavioral economics and addressing social terms of health and cancer and its from outside tobacco because you use so much in tobacco, thank you. Let me start with that one. Really have data and research and even change for people with depression. So its Behavioral Health and i think we should do more research about that but i think it goes back to the Behavioral Health of the community and person diagnosed with cancer and effect the entire community and so i welcome that question and there should be more research and i would love to get information on how it occurred. Its such a great question and were still struggling with that in health care actually and much less the broader prevention agenda and we wouldnt want to place too much of the focus on an individuals choices and behaviors though that is a part of the equation. Theres a broader context in which were making those voices and behaviors and we know that in the Public Health world and to me the bigger strategies that we can take that create these healthy environments and i dont mean just having a nice green vegetable at the grocery store, truly having Public Safety and Economic Opportunity and all the true determinants those are the communities based upon data where theres under lying strong structure that overall the gaps in disparities and Life Expectancy are reducing and people are having healthier liv lives. Thoughts there . Its an area of fascinating research. We look forward to more studies. From a Broad Perspective the question is this could help individuals at some level. Whats the broadest impact . Thats an unanswered question now. But i think the Research Endeavors are fascinating which maybe followed closely. Theres a broader way to look at this if you look at the world of social impact bonds and think about the economics of the whole system and not the individual so how do you Bring Health Care and Public Health and the rest of the Civic Society together to encourage them to invest upstream instead of just investing downstream in health care so how do we create that group that theres the opportunity for reib vestment and reward it popular and thats something we have been thinking about is how do we find a way we can use those to invest upstream so the entire community is behaving differently. Theres a gentleman right here. Thank you. I represent the International Private health club industry. We have been working to build on that question. We have been working very hard to promote tax incentives for exercise to lower the cost of physical activity and one thing we found from a policy perspective is we say oh it cost too much to do Something Like that. I wanted to get your sense of what kind of time line are we looking for this research to show the return on investment and really real data . As we increase healthier lifestyles and lower disease costs well Lower Health Care costs and reap a tremendous return. I want to get your sense of where we are in that. Thats a real problem from a policy perspective. You did it yesterday so get going and im teasing. Not really the heres something is they have he evolved im not speaking for them but im reflecting what i heard from the Business Community they saw good process through a variety of mechanism encouraging prevention and screening or even some inkeling that maybe theres some Wellness Programs that may work but they quickly realized there was much more to health than their Health Care Benefits package and what they did in the work place and then the set of family influences and cultural influences so theyre wanting to be a part of the conversation. Nashville health is bringing them together to think about the policies that youre describing might make a difference in their community that may be unusual so theres a sense of urgency because of the day that that were beginning to see plateauing of Life Expectancy in the u. S. And gaps are beginning to widen for populations that didnt have that before. I Read Everything that you said but we face in connecticut with Insurance Companies try to incentivize behavior, good behavior, good healthy lifestyles, the people that were doing the exercise were the people that needed it the least. The people that needed it the most had access to transportation or tile off to be able to do that. So we have to balance everyth g everything. When you look at the federal budget and why its growing so rapidly Health Care Costs become the Fastest Growing part of the expenditure side in large part due to chroniced disease. This is not only an individualized issue this is a massive macro tax issue effecting the public as a whole as well. See this lady right here, we have a mike here for you. Thank you. My name is chandler and im a nurse and i share with parents that were not born in the usa. My mother was a korean war bride and my father was born in japan. So fusion cuisine. I think my mom invented it sounds good to me. And because we know now that obesity is a major contributor of cancer and many, many children spend days in school and school time is constantly being honored as being excessive in cost, we do need to look at the fact that School Lunchtime ought to be considered as lab time. The teachers are not to be involved. They need their break but the School Lunchtime lab time would incorporate a tiny bit of exercise and nutrition completely and totally. Theres peer pressure and just the whole big picture is related to quality of life. Thank you. I could go on but i dont like to. You all agree with her comment . We all agree. Thank you. Lets see. Its this haydy right here. Ill try to get to everybody if we keep our questions short. Thank you. We focus on womens cancer in developing countries and i was wondering if you could talk for a minute about prevention opportunities in africa and latin american. First of all i want to congratulate you guys. I was supposed to be with you but i have no voice as you can actually see. That was supposed to be on wednesday. First of all theyre doing an amazing job related to Cervical Cancers and we have the project echo which is head by dr. Ellen baker, former astronaut that actually works in our office and thats a challenge that we also have to realize is not all about United States. Its about the world. I was just explaining and talking about how were going to be dealing with eastern europe, central europe, africa. Cervical cancer is an issue there, Breast Cancer is an issue there because of the lack of human resources. They dont have pathologies. They dont have the time to check the pap smear. Thats one challenge. The other challenge is we have been so successful now that the women now are not dying from hiv and dying from Cervical Cancer in their 30s and 40s. So i think that everyone should be paying attention to the foundations that are working there. One challenge i have seen and well be helping that from our own institution is were cataloging with nci right now one of the things that is discussing how we can can do this. Find out how many universities are in a town or in a city in africa and what were doing so we can amplify the work. If we do that well be able to see the work that is being done in africa but please everybody in this room look at that data and look at that information and look at what theyre doing and acs is doing and look at them theres a lot of need. When you look at the rates or when we die here, its 20 years younger, 30 years younger for women in africa. And thats a crime. Honestly. We have the resources. We have the knowledge. We have telemedicine put i can be new mexico or md anderson or vanderbilt. It has to be all of us together. I too want to thank you for raising the global context so were very fortunate in the United States that we have cancer death rates dropping 25 in the last 25 years. Its a different story so well make progress in highly developed countries like the us but low and middle Income Countries around the world the cancer issues are getting worse so theres some 8 million cancer deaths around the world and that number is projected to go up to some 13 million by 2030. So this is a global conversation and whatever we learn here in this country we should work with Global Partners and of course each country is different and has a different culture and a different political system. So this is truly a worldwide effort going forward. I thought that gentleman back there raised his hand. Thank you for this panel. My question is about Meat Consumption which is a significant contributor. Dont come in. Im not sure who should answer this question that im coming to. We know that theres a director of Meat Consumption to col on cancer and respeed yated by obesity. And it called for a reduction in consumption and based on this argument in the increased sustainability and meat production is a source of methane and increased climate change. And meat is also a valuable source of protein and iron in the american diet. So whats the policy strategy to reduce Meat Consumption there by are reducing methane production and improving cancer rates and climate change. This is an easy policy question to answer but ill ask if he has any thoughts on this and then i may offer a couple of comments too. As you mentioned, bill, the dietary guidelines just released started to address that anyway and theres increasing emphasis on fruit and vegetable consumption and balanced diets and all address that issue either directly or indirectly, i think in term of getting the message out and and weighed in on that and they want to say theres an easy answer for you right now. Its an issue thats been raised and flagged and addressed in the 2015 dietary guidelines and also addressed more explicitly by international groups. And thats why i didnt think i would direct this question to karen as much. Interested in secretary we have to also realize the reality of people eating the meat. Im a dairy farmer so i have to put it out there. Processed meat is even a bigger issue than real meat but the other issue is when you ask this happened here, two of us working there. When we did a survey here in district of columbia and define why they develop four people and they would never have meat when they were kids when they were poor and they really wanted the do that with their kids and go to a supermarket and see an elderly person buying cat food. Its not for the cats. They dont have cats. So its not only about the macro picture of what we have to do, we have to start with our communities. Its a big issue in term of these parties to access to good food. So before we go with a policy lets find out how we can help these people to change their habits. As a dairy farmer i probably eat red meat once a month. I eat chicken or fish. So it was a big cultural change for me. For breakfast i used to have a porterhouse. Fresh porterhouse with 32 ounces of milk. Thats breakfast on a dairy farm. Plus eggs so i think that we have to change and cheese and salt. I am lactose intolerant now. Just to bills point about in the dietary guidelines we recommended reducing meat intake particularly for some groups that have a dietary pattern thats high so for men and young men its an Important Message just that a lot of men go to meat first and we want to recommend it. We link that to we the federal government link that to some of our programs so that where we can like in meals on wheels for seniors and School Feeding programs or head start programs link those guidelines to the way that were paying for and providing food in those programs so thats one mechanism we kwuz to try to drive down sugar and salt consumption, et cetera. The other piece about the decisions about consumption flies from important policy issues that this whole conversation that we have been having about the shared responsibility at all levels of government and society and actions like new york city take where they have been leaning forward about portion size and calorie displays and using every bell and whistle and flag they can to get the community to change there and in the store. And the information they need to make the choices available that are the healthy ones. Is half the proceeds of american agriculture or livestock. 50 . So when you add fruit, vegetables, grow crops, Everything Else, 50 is in livestock so this is a huge, just think about the monumental sociological impact of livestock as part of this diet. In addition to that, a huge part of crop growth is to feed those animals and theres no question that we have carey crated an environment in large part because of our affluence where people wanted meat and it tastes good. This is a growing trend worldwide. Not so much with cattle but with poultry and hogs. You have seen in china massive growth of consumption and that leads to the political aspects as you can imagine on capitol hill and effects the School Meals Programs and Everything Else without getting into right or wrong. What is missing from this is the relationship between the Health Community and the Agriculture Community on discussing these issues. The only real ones is in the dietary guidelines. So i have been at meetings on food and agricultural where theres virtually no medical people in the room and vice versa. And theres no its not Rocket Science and people get kind of stuck in their own ways of thinking and they dont realize that these are, in fact, the political aspects are complicated and we have to do that much more than we have in the past. Secretary, we do work very cooperatively and this will start under the tenure on developing Research Agenda and usda have a shared work group and inner agency that works at dietary research. And going further upstream on the scientific agenda that needs to be developed and in some cases we published in that Research Agenda and Climate Impact and Food Sustainability to try to build a scientific agenda so we recognized there needed to be a lot more communication and are working much more together including in the world where through taking an approach thats broader we very been working with usda through hhs and this needed to be more conversation and we have created ways to be able to do that. I also think that the medical community themselves thats just not physicians thats everybody else needs to be involved in this discussion. Particularly as they relate to their patients and customers. And its a very small part of the dialogue that people go to see their physician. Were getting a lot of research and we already have some relationship and when you keep looking at that research as it progresses in that research thats going to change how were going to look at nutrition. Okay. Lets see. There was this haydy right here. And a couple more and we have about five minutes and you had a question and you had a question and well answer all three of them so go ahead. Im also a nurse manager who has been managing oncology units and at the bedside for 30 years in the United States and canada. So we talk about smoking se sags and how it relates to lung cancer and i want to know what your thoughts are on ecigarettes and vapors. This gentleman right here with his hand up. And then you and thats it. Im a citizen. To acknowledge the importance of the local Health Authority or the local governmental Public Health department on the agenda that you have been talking about can you describe the ways in which it might be engaged in the initiatives that you talked about. Last questions ladies over with their hand up, see her left. See her right there. Okay. I give you a quick background about myself and about a year ago i became cancer diagnosed stage 4 by pancreas and to the liver. I was very healthy. Eating right. Athletic all of the above that you mention. So it was a very big shock so what i became aware of was eating gmo, nongmo, grass fed. I became familiar with acupuncture and a constitution that not all the people could eat the same thing so i combine the eastern medicine and western medicine and i only had like three to four months but its been more than a year and doing chemo and went to nih and i have done all the research. So i think its more about eating and educating all of the people and doctors physicians to tell the people about what they should eat. I was never aware of gmo, nongmos and grass fed and all of these things so i wanted to get your input about how can we aware people about all of this and bring the cost down because it is very expensive. Not that many people could afford organic. Thank you. So we had those three questions. I dont know if ill take bobbys because i think it was directed at me. Former ceo of the National County Health Officer officials and asked the question about how to get Public Health agencies more engaged and this work that i described earlier, Public Health 3. 0 has been a strategic effort to put a frame around the modernization and evidence hugs of local Public Health its transforming itself just Like Health Care and science has been to really meet the needs about the broader determinants of health while still doing its every day important work and its exciting pioneering work and its been done without a play book and well reduce a report and the success and the federal govern m states. And agencies that tried to support local health and partnerships and others. One really important take away is about doing the work well so that is not to be left behind however that does require some change in the way local Health Officials leaders are doing the way they have to reach out to their additional walls and that takes resources and time and Pay Attention to your local Public Health infrastructure in this country and you ought to because its been increasingly dramatically underfunded and hit very hard by the Great Recession and also buffeted by the good things and Business Model and role in place and working to lift themselves up and to a policy standpoint the risk that theyre in as a country by not being a strong local Public Health infrastructure and theyre going to continue to step up and want to be helpful. Ecigarette issue. Do you want to i dont mean to push it on you. Thats one of the most cutting edge controversies right now in Tobacco Control and Public Health so its a double edged sword. On one hand this could be a very valuable smoking sensation tool and Harm Reduction and if that pans out thats exciting. But on the other side we have now a new source of potential nicotine addition particularly for kids and the use by kids has jumped tenfold in the last five years. The fda just put out regulations for this but that doesnt impact advertising for example. So until we get that information this is going to go on. For those of you following whats happening worldwide the united king tom is much more in terms of thinking of this as a valuable Harm Reduction tool so if youre favoring that point of view its a fascinating point of view. Im just trying to be as balanced as i can. And i think we have to follow this closely and demand the best research and millions of people in the future. We ended with a patient so maybe you would like first of all, you look great. So i hope that it continues for a long time. And i actually think that we discussed this in terms of the lack of data and we need to do more research but i agree with you. I think howard mentioned it before, in term of nutrition were putting calorie intake, high fructose and all of these things. I think we have to know more about not only the ingredients but how they were created and give that information to the public. Give that information to the local Health Departments and the policy makers but i think its going to take some years and obviously i think all of the people here is about the patient like howard mentioned before and having you here being a brave woman just telling the world that youre going through pancreatic cancer is giving me more energy to continue working. Not only Research Related to Public Health and population of health but find out how to be able to save people like you. God bless you. Okay. Well we thank you. This has been a great presentation. Lets give a hand to our three expert who is did a wonderful job. [ applause ] our keynote speaker and i want to close with this one thing. A little bit of a plug for the bipartisan policy center. Our job is to try to bring people together to try to see if there are Public Policy solutions that we can successfully Work Across Party Lines and bipartisan way to get things done and i think the area of Health Research and prevention of disease, something that effects everybody and has nothing to do with what Political Party you are a member of. So were going to continue our efforts in this regard and again i want to thank everybody for joining us today. Appreciate it. This weekend on American History tv on cspan three, saturday night on 8 00 eastern on lectures in history, criminal justice professor George Michael describes the relationship between the extreme right subculture and current politics. Trump said he didnt know enough to categorically reject the support but a couple of days later he formally disavowed any support for duke and related parties. Be that as it may that has not stopped the media from making them racists and bigots. The 1988 Vice President ial debate between republican indiana senator dan quail and Democratic Texas senator lloyd benson. We would be pushing very hard to open up those markets and stand up for the American Farmer and see that we recapture those foreign markets. I think we can do it with the administration. To come in and to tell our farmers not to grow corn, not to grow soybeans thats the kind of farm policy youll get under his administration and one i think the American Farmer rightfully will reject. And at 8 00 p. M. Eastern on the presidency. He wanted to make sure that no agency had particular entree to president elect nixon. They wanted to control all the intelligence flow and didnt want the agency trying to sell itself as the actor in the sbel jebs community. With the release of some 2500 president ial daily briefs of Richard Nixon and gerald ford. They discuss the changes president s have made to the daily briefs. For a complete American History tv schedule two to cspan. Org. Leading up to tuesdays debates we look at past vvpt shl debates this saturday night at 8 welcome eastern on cspan starting with the 1984 debate with george h. W. Bush. You can walk around saying things are great and thats what were going to be hearing we have been hearing that on those commercials for the past couple of months. Well start tonight. They delivered what they called malaise. They delivered Interest Rates right off the charts. They delivered take home pays, checks that were shrinking and we have delivered optimism. The 1988 debate with indiana senator dan quail and texas senator lloyd benson. I have far more experience than many others that sought the office of Vice President of this country. I have as much as jack kennedy did when he ran for president. I served with jack kennedy and i knew jack kennedy. He was a friend of mine. Senator, youre no jack kennedy. And the 2008 Vice President ial debate between tell dell senator joe biden and Alaska Governor sarah palin. Lets commit ourselves just every day american people, joe six pack, hockey moms across the nation. I think we need to ban together and say never again. The middle class needs relief. Tax relief. They need it now. They need help now. The focus will change with barrack obama. Watch saturday night at 8 00 eastern on cspan and any time on cspan. Org and listen to the cspan radio app. Incumbent republican governor and democratic challenger discuss education spending and medical marijuana and health care spending. This is about an hour. From the campus of utah state, the Utah Debate Commission welcomes you to the candidates debate. [ applause ] fweeng. Im news director for utah public radio at utah state wrun ve