Transcripts For CSPAN2 Key Capitol Hill Hearings 20140924 :

>> the world health organization has predicted that the ebola virus will infect 20,000 people in west afterwhat by november -- afterwhat by november -- africa by november. the president of liberia spoke about what's being done to fight the disease in her country where an estimated 1500 people have died. she spoke by internet at a georgetown university conference on ebola. after her remarks, a panel discussed the disease's economic impact in the african countries affected. >> morning, everybody. [inaudible] director of the program here at georgetown and a longtime economic adviser to president sir i have -- sir leaf and others in the government of liberia, and i think we are ready to go. i know we have a connection. there we are. good afternoon, madam president. thank you very much for taking the time to be with us here this morning in georgetown. we have a crowd of a couple of hundred people here that are very appreciative of you taking the time to join us today. so, first, i just want to thank you for taking the time to be with us this morning. >> good afternoon, steve. i'm very glad to be here. >> we just, we know your time is very short -- >> [inaudible] i said, good afternoon and then corrected myself because i know it's morning there. [laughter] >> that's all right. [laughter] we know your time is very short, and we just wanted to ask you a couple of questions on how things, the status of the current situation and where you see things going. first, can you just give us an update on the current status of the epidemic and the outlines of your strategy in the weeks ahead to begin to, or to continue to battle the epidemic? >> steve, the epidemic continues to be a serious situation. her teen of our -- thirteen of our fifteen subdecision requests -- dub divisions are now called response counties. we now have over 1,500 people dead, 85 of whom who were professional or regular health care workers. we have four major ebola treatment units serving you may say the whole country -- [inaudible] to be able to build more right around. we still have lots of people in the communities that based upon culture and condition are still in denial or still using methods of care where they are going to a church or going to the mosque or believing in some, some extraordinary, imagine call way of -- magical way of beating the disease. we still have people, again, based upon our culture of extended family that are not ready to turn their loved ones in each when they see -- even when they see signs of the disease. but we're starting to build mobile everything tus, we're -- etus, we're starting to get a bit more robust in our community work toen able them to take ownership, to expand awareness among them. there are predictions that recently came out from cdc which are very horrendous. they're scary to all of us, but but -- [inaudible] scenario. if nothing is done from at this point in time because we do believe that we have our structures in place now. we have our strategy. that strategy is to make sure that we go to the community -- [inaudible] where they can get early treatment. and we've been successful, steve. over 300 perps, you know, have been treated, you know, and have walked away -- [inaudible] if we get them at an early stage. so all those efforts are underway. we're very glad with the robust u.s. response that's going to make a major difference in our efforts. [audio difficulty] cdc that at measures are put in place in terms of facilities, resources, treatment, awareness -- [inaudible] that the end dem cantic can decline -- endemic can decline as fast as it accelerated, so that's our objective. >> thank you. you mentioned the ramped-up u.s. efforts. last week president obama announced a major new effort that would involve 3,000 u.s. troops, several hundred beds in field hospitals, i believe 17 field hospitals with 100 beds each, supplies, training of 500 health care workers a week. can you tell us a little bit more about, first of all, your response to that ramped-up effort? is it sufficient? when do you believe that you'll really begin to see the impact on the ground? >> we, first of all, have expressed extreme gratitude to president obama and to the united states for this, for this effort. it's major. we already have received brigadier general williams who's heading a team. he's here, he's been around for some of the response counters to do an assessment of where they're going to put the centers. he's participated in our meetings on structure and strategies. we have brigadier general rodriguez coming in from germany on friday who's going to, again, discuss with general williams and others how we can accelerate the effort. but these things do take time. building everything -- building etus is going the take several days. the field hospitals that were promised, we believe they've done the initial a'sment -- assessment, but it's going the take time to get it done. and this epidemic moves so fast that building the facilities to accommodate them, people are dying, you know, dying by the hundreds every day. so it's a question of when can we get the -- [inaudible] of this acceleration. but i believe that given another couple of weeks, we should see that this major effort begins to show results. >> thank you, madam president. you also mentioned some of the difficulties communicating directly to the citizens of liberia around the seriousness of the epidemic, the accuracy of the claims of what ebola is and is not, some of the difficulties around cultural -- around cultural practices, around burial and other things. what's your strategy to given to address that and to get the communication out and the education necessary for people to better understand the epidemic? >> we've got to get right into the commitments at the grass roots -- the communities at the grassroots level, and we've got to use residents; people who can speak the dialect, people who know their culture, people who live with them whom they trust completely. this is an unknown enemy, so anybody coming from outside -- even if you're with the best intentions trying the teach them -- they are suspicious because they don't know. and so getting through at the community level with communities, the young people in communities, the preachers in communities, you know, the teachers in communities. those are the ones that we have to work to through. that's the only way we can break through the denial and the fear. >> beyond the or in addition to the direct impact on people affected by ebola itself, what's the situation with the rest of the health care system and people who are looking for care and treatment on malaria, tuberculosis, other kinds of ongoing health problems? >> well, we have a health care system that's in stress. it was not a perfect one anyway griffin the fact -- given the fact we have lots of rural areas, we have infrastructure problems, getting people to hospitals and clinics is a difficult one given the condition. and now with 85 health workers having died because they did not know how to protect themselves, they are now fearful. many of them have walked off the job, they refuse to go back. as a result, most of our health facilities are not functional. because of the lack of professional -- [inaudible] what this means is that lots of people who don't have ebola are dying, and so the numbers that are being given out include many that are not ebola victims, but who die because they could not access a hospital or a health care center because those are closed or not functional. what this means is that we also stand the risk of some reversals in in the gains we have made in health care. we were doing great in child mortality. we had made the best progress -- [inaudible] we were doing well in malaria decline. the chance -- [inaudible] very high unless we can quickly get those facilities functioning again. and i must say that this has received the attention or partners, that while we are treating ebola -- functioning again for regular health care. and i do believe that as a result of this a positive thing is that liberia may earn a better health care delivery system, and we look forward to that. >> thank you. i want to ask you about the economic impact of the crisis. i know the world bank came out with a report last week, the imf have done some calculations in which they predicted that the economic growth rate this year would be cut in half from around 6% to 3%. that actually struck me as completely optimistic. from what i can tell, the economy has really stopped in any terms of growth and probably contracting. i know the china union iron ore mine has closed its operations along with -- [inaudible] palm oil plantation, the work has stopped. restaurants and hotels are closing down. construction activity is way down. what's your sense of the economic impact, and where is it most severe? how do you see that rebounding in the future? >> all right. the economic impact we expect to be severe. [audio difficulty] as you pointed out at the operational concessions, contracts on our infrastructure, all of those have stopped or slowed. we know that there's going to be price increase after results of shipping costs -- [inaudible] from lie peoria going -- liberia going out, there's going to be loss of jobs because of the close of businesses. hotels ors entertainment centers, general finance is going to decline because general economic activity as a result of so many people with high purchasing power having left the country. we know that what this all will mean is that per capita income will also fall. but let me say that we -- [inaudible] to address this decline. we believe there's the potential to tim late other -- to stimulate other sectors of the economy that have not been very high in production such as our fishing business, other areas that we're looking looking at. so also we are going to get -- [inaudible] from world bank and from african development bank to be able to -- [inaudible] there are many people that are coming into the country. there will be some restoration of purchasing power through the thousands of people that are coming as health care workers or technical assistants or even the u.s. military, and we hope that will cover, you know, in a small way some of the gaps that exist because of this decline. so we're looking at this. a lot of work is going on. i'm glad that -- [inaudible] the executive secretary of the economic -- [inaudible] for africa is sending a team to work with us to determine what measures we can take to stimulate those other sectors that have the potential to make up for the loss of the -- [inaudible] some of the agriculture are still working. maybe not at the same level, but they've started to operate. and if we can show a decline this ebola within the next month or so, we expect that the return will come. but there will be a long-lasting effect that will reduce the growth rate, and that will see some level of decline in per capita income. it will take us maybe a couple of years to restore. >> in the weeks and months ahead, what more can the international community do in terms of the direct impact on ebola itself, on health systems more broadly, on the economic recovery? what further steps would you like to see the international community take? >> as an immediate step, put pressure on the airlines and the shipping companies to stop astra sizing us so that we can reduce the costs and we can have free movement of groups and services as people return to the cup. to the country. again, once that happens, you will have a very positive effect on contractors and workers who part of the reason they're not here is the fear that they would not be able to get out be there were illness or if they had to leave for whatever reason. so that's the immediate thing that can be done. in the longer, in the medium and longer term framework, it's a question of working with us to identify those areas where we can expand production to be able to get the potential that has not been tapped. so it's that partnership that we'll need -- [inaudible] working together, economic reconstruction and recovery. >> very good. well, last question for you, madam president. we have with us a number of students, undergraduates, graduate students, faculty, other people from around georgetown and from our community more broadly. just speaking directly to them, are there things -- what can they do? what would you like to see us do as a small community here in washington, d.c.? >> could be a good case study. [laughter] >> always the academic. always the academic. [laughter] >> you know, see where we are, see where we are today. look at some of the measures we'll be taking. continue to monitor and, you know, evaluate our progress. look at whether our assumptions and our projections are valid, and the result -- [inaudible] stand up to that, give us a report. you monitor it, you see where our projections were right or wrong based upon the results that you would come come up with. so follow the case. i think it'd be a good one because i have confidence. let me tell you, i am optimistic, steve. i know that the growth rate has been projected to decline sharply. i will not accept that. i say we've got to find other potential areas that will make up that gap. and so let me say to them that monitor it. i will be right, that we're going to not only overcome ebola, but the economy will bounce back. challenge me. [laughter] >> madam president, i think all of us want to thank you for your optimism, for your tireless efforts in this, in this time and for your courageous leadership in the past, but particularly in this present time. it's an inspiration to all of us, and we just want to thank you once again for taking the time to meet with us this morning. thank you very much. [applause] >> it was, it was certainly inspireing and, but also sobering to hear directly from president johnson-sirleaf about her challenges and her plans. but i think it's, it was, it was exciting. so thank you to steve in particular for organizing that segment. so let me, let me just try a little orientation of what we're going to do here for the final segment of this morning -- of today's symposium. this panel is entitled "where do we go from here," and accordingly, we've brought together some panelists to help us not only take stock of what we've heard already, but take a bit more of a forward focus on what are the implications of what we've heard this morning and particularly what are the implications as we look ahead to what can be done? and so i'm really excited about group that we have here. and let me just briefly introduce the panelists going across from my left. first is superkemp. -- susan kemp. she is the deputy director of the o'neil institute at georgetown university. susan is trained in law, public health and business and holds jd, mp h&m ba degrees to prove it. she is, in 2001 she served as special consultant to the state department regarding reforms to the global fund to fight aids, tb and malaria. super's also worked extensively on a wide range of health law issues including implementation of the international health regulations, pandemic response and infectious disease control. and so we are looking forward to susan bringing a legal perspective here to the discussion. next to susan we've already heard from dr. rat live, but just to give the broader background, dr. rattle is the distinguished professor in the practice of development in the donald f. mchenry chair in global human development at georgeton school of foreign service. steve has held senior positions in the federal government, chief economist at the united states agency for international development and deputy assistant secretary of treasury. steve, as you could tell from the earlier presentation, has advised the government of liberia among many other governments on chick development issues -- on economic development issues. and then last but surely not least is dr. ron waldman who's the professor of global health at the george washington university: ron has had an exceptional and distinguished career in public health including service with the centers for disease control and prevention, usaid, the world health organization and the united nations. his resumé is very long and very distinguish thed, but it includes really an extraordinary list of initiatives including smallpox eradication campaign, developing a new center for force migration and health, pan pandemic preparedness for the u.s. government and lead roles in both the response to the indonesian tsunami and the haiti earthquake. with respect to the current crisis, he is the team leader for save the children's ebola response. and one thing i would say is i've had the good fortune of actually working with all three of these panelists in different parts of my career; susan with the o'neill institute, steve at state and ron at hhs. and i think we are in for really a terrific panel today. we'll follow the same format as the earlier panel, we'll do some general questions, and then i'll pose to the panelists some specific questions that have been developed by students here. so let me just say that i'm just going to ask everybody to take a, ask a general question to each of you to kick this off. but let me start with susan kim. super, you know, you've -- susan, you know, you've heard this morning much discussion has been about roles and responsibilities of institutions both global and domestic, and the issue of law comes to bear here too because that's -- up, those are the instruments we use to decide who does what, where and when. so i guess i'd love for you to reflect on what you've heard and what you know about the ebola tragedy from the legal perspective, particularly, i suppose, with respect to the implementation of international health regulation. so will you kicks off? >> sure. thank you very much for having me. and as john mentioned, i will sort of be speaking about, within the context of international health regulations or the ihr. dr. cameron, actually, spoke a little bit about them earlier this morning, and really what the ihr is, is a legal global framework to respond to -- todefect, respond and monitor disease outbreak to prevent spread of international disease. they are an international treaty under the purview of the world health organization, and they've been around for a while, since about 1969. but as dr. cameron mentioned this morning, they were revived in 2005 to more effectively respond to diseases that transsend national borders. so sars was a catalyst for this, but also hiv and also, ironically, things like ebola. at its core it is a fairly complicated strum, but at -- instrument, but it establishes a mechanism for capacities at the domestic and international level. so countries themselves are responsible for implementing the different, different elements of the ihr which include sort of monitoring and surveilling local disease outbreaks. one specific criteria are satisfied in terms of severity, sort of the ability -- potential to transcend international borders novelty, then there's a reporting mechanism back to the who about whether they need to sort of sound a more international alert system. and sort of this would be at the global level what you have heard to referred to as something called a public health emergency of international concern. and what, essentially, that is, i guess the simplest way to describe it is a type of global amber alert for public health emergencies. basically, it's a way to effectively signal to the global community that this is sort of an emergency, a public health emergency that will transcend or has the potential to transcend international borders, so people should pay attention and start to mobilize. in terms of resources whether it be financial, medical and also human. and i think sort of additional action can be taken when a fic is implemented, and these include temporary recommendations that restrict travel and trade. the declaration, obviously, has multisectorral implications. these can be very severe because -- and i think you heard from president sirleaf, with the suspension of travel and trade across borders, this has to be sort of a severe economic implication. the who doesn't tend to declare a fic very likely, and tins since 2005 they've only declared them three times. in 2009 it was h1n1, earlier this year it was the with polio, and in august it was with ebola. so specific, i think, to the current outbreak, one of the questions is whether a fic was declared too late. it's hard to assess this, i think, overall, but i think the answer is probably yes in this case. the who declared a fic on august 13th. i think from some of the remarks made earlier today, ebola had already taken a foothold in countries and had begun to traverse borders probably around may or june. and sort of, as i mentioned, as a type of emergency alert system, the declaration sends a clear message that sort of the world needs to mobilize. and because they've done that too late, you've heard sort of the different, the very difficult, i think, consequences of this timeline. measure. >> susan, thank you. and let me turn, if i could, to dr. waldman. i think what susan did was lay out the architecture for the legal responsibilities of how the international community should respond. dr. waldman, ron, give me your experiences both working in the u.s. government and internationally. welcome your sense of where we are now, but also particularly what lessons do we draw from this experience in terms of going forward, in terms of health systems that we've heard so much about but also the international response capacity. >> thanks, josh. thanks, john. is the microphone on? >> it is. >> thanks, john. i'd like to address the problem in two parts. one is what we can do about this horrible outbreak now, and then where we can go from here: i want to start by saying that in regard to dr. kim's statement, i would just -- every time she used the word probably too late, i would just take off probably. [laughter] i don't think it's really an issue that the world did respond too late. we allowed the outbreak to spread, and we allowed the number of cases to grow to a point where it's very, very difficult to contain. the outbreak probably began as long ago as december, and the first instance -- the first cases were reported in the forests of guinea. doctors without borders announced in june that their resources had been overwhelmed and that they could no longer each try to contain -- even try to contain the outbreak from spreading. and the world health organization responded in august. the u.s. government announced its first major foray last week. so, yeah, we responded too late. there's no point -- at this time pointing fingers, that be be done as part of the case study that the president suggested. but at this point for all kinds of reasons ranging from the humanitarian to the very, very, very practical, political, social and economic consequences that are yet to fully be seen, we need to do as much as we can. so let me just say i think that many of you if you're following this outbreak, maybe you saw a article in "the washington post" this morning that reports on a newly-evolving strategy that may or may not be able to have an impact on the situation. let me just go over very briefly the pranks of -- the planks of the strategy that most of the department, most of the partners now agree on. number one is the management of cases of ebola virus disease. basically, this revolves around getting people off the streets and isolating them for the duration of their illness. we to not want to allow people to have any opportunity whatsoever to transmitt the virus to others. it's a highly infectious disease. fortunately, it's not spread by the, through the air a, by the respiratory route. one has to come in contact with surfaces contaminated by the body fluids of a sick person or with those fluids themselves. but still, when people are exposed, when they develop illness after an incubation period that can vary from a few days to a few weeks, the proportion of people who come down with this disease who die is scary. it's well over 50%. and as a result and the worst case scenario might have been mentioned earlier this morning that are going to be released by the cdc this week, the cdc is saying without further intervention, as president sirleaf said, the number of cases is estimated the surpass 500,000 which means we're very likely to see between 300,000-400,000 over these three countries. it's just phenomenal. they're numbers that are so big for an infectious disease outbreak that it's hard to get a grip on them. so one area of intervention are the hospitals, called ebola treatment centers. steve mentioned that president obama had pledged to liberia 17 100-bed hospitals. i want to come back to whether or not that's the best strategy, what proportion of the overall strategy those hospitals need to play, it's up in the air. i'll come back to it. we've been pushing at save the children very hard to have an intermediate layer of care developed closer to the community with a little bit less strict isolation procedures so we know that what we're proposing in terms of facilities will be leaky and will be part of the problem of transmission. but we hope that they will be a bigger part of the solution of getting people out of their homes, off the streets and in places where transmission can be restricted to an absolute minimum. but president sirleaf so right on -- is so right on. she stole my thunder, i'm sorry to say. this won't work unless the communities are convinced to take ownership of this situation and of the problem. and for all the reasons that the president mentioned, this is proving to be extremely difficult to do. but there are many people who are keeping their ill family members home, becoming exposed themselves. they are, if their family members or village neighbors should die, they're conducting burials in a very up safe manner -- unsafe manner. burials are kind of a superspreading event where people because of the traditional burial rites put themselves at particular exposure. crowds come, they touch the dead body, and these need to be carefully supervised. so community action, attempts at behavior change, these are really the only things that will bring about relatively rapid end to the epidemic if that's even feasible at this time. president sirleaf also emphasized the fact that many people in liberia are dying of non-ebola disease because there are no health facilities that are currently functioning. so common diseases like malaria, diarrheal diseases, pneumonia, complications of pregnancy, people are dying because they have no place to go. and if there are facilities that are functioning, then mixed in with all of those people with those conditions are also people with the early symptoms of ebola virus disease because the symptoms are nondescript. in the early days of a person ill with ebola, it's characterized by diarrhea or a cough or a fever, the same things that are the characteristics, the symptoms of the most common potentially fatal decides. so this is a real disaster and a difficult problem to overcome. triage needs to be done. ebola patients need to be separated from non-ebola patients. but our science isn't advanced enough to allow us to do that very quickly. there's no rapid test for the detection of ebola virus. there's only taking some blood, sending it from a peripheral area to a laboratory wherever it might be, doing a test that takes 4-6 hours to complete, getting the results back. in the meantime, all of the mixing of ebola and non-ebola patients has occurred, and health facilities also -- where are they functioning -- would be also super-spreading sites or amplifying sites of the outbreak. so we're really looking at some major challenges, and we're not sure how to overcome it. two other quick things. one has to do with the protection of children. there's a growing number of orphans, there's a growing number of chirp in the streets. -- children in the streets. they're very vulnerable, and they need to be cared for and protected. it's very difficult to to convince people to foster, to take in children whose relatives had ebola and the children may be exposed. and finally, and this will tie in some with what steve is going to say, there are real hardships in terms of people's inability to pursue their livelihoods. there's no money coming in to households, and without money, there's no purchasing power even for the basic things like food. so food distribution is becoming a growing issue, a growing area of concern. of course, food, water and basic needs will be provided at the health facilities, the hospitals, the ebola care centers, but even now within the villages and communities people are having difficulty. as you might know, there was a lockdown for three days in sierra leone this weekend, and the biggest complaint that i've heard from the population was their ip ability to store enough food to carry them through those days. people live from hand to mouth and don't have large reserves. the same is true in liberia, and foodstocks need to be supplemented either by the distribution of food itself or by other systems whether they're voucher systems or cash transfers. so i just wanted to say what are the constraints, we might be able to figure out what to do, but there are very severe constraints, and just in one minute, there's not enough money in this response yet. the response is okay. it's big, it's getting bigger. the world health organization, the u.n. have called for over a billion dollars in funding. that's not yet available. and i know from what's coming through the ngos so far that there really isn't that much money. and if we concentrate on the high level facilities, the 100-bed treatment centers that president obama promised, the budgets for those right now that are being submitted to the government call for more than a million, million and a half dollars a month for their operating costs. so whatever money has been pledged is going to be exhausted all too rapidly. secondly, human resources. this is by far the biggest constraint that all of the responders are facing. there are no people available for this response. neither ex-pats who may not want to go there because president sirleaf said they're not sure would they be able to get out should they get ill, if there's a dangerous situation. but local staff also is very reluctant to sign up to work on this. and in any event, the numbers of health personnel and support personnel required are really high when we're talking about the needs for isolation, for water and sanitation, for disinfection, for burial purposes. these aren't good jobs to have. they're not nice. and people don't really want to rush up and volunteer. and the final constraint -- we don't know very much about what's going on. these are uncharted waters. there have been ebola outbreaks in the past, but the responses have been more rapid than expected, and we've been able to contain them very early on. here we've never dealt with anything like this. even proposals like the one i mentioned of having the intermediate level, close-to-community care, we have no idea if that would be part of the solution or part of the problem. every action that's taken needs to be carefully evaluated in realtime so we can see the impact that it's having, and we can see whether or not we want to pursue that line of work. so i guess i'm coming across as not being quite as optimistic as president sirleaf. and by nature, i'm fairly cynical begin with, so that's not a good thing. [laughter] but the outbreak as the director of the cdc, the director general of the who, theup special representative for ebola viruses, we've heard all of these people say the situation is out of control. it is out of control. it's going to take a gargantuan effort just to bring it back, just to bring it back to a situation that can be controlled. and that's what we're shooting for now. not even bringing an end to it in the immediate future, but rather, just getting a handle on what's going on, reducing transmission to the point where there's no more growth of the outbreak or only slow growth of the outbreak so some of our more traditional means of containment can be more effective. >> ron, thank you. it's sobering. and, steve, turn to you. i mean, i think ron's message is clear. as he said, it's been reiterated by global health leaders. the epidemic is out of control, and the control measures that we are bringing in, putting in place or are being put into place by various partners are really in uncharted space right now. people are going to have to learn. we don't know what works in this context. so with that, it'd be terrific if you could build on the conversation you started with the president. but also where do you see the economic impact here, for the three countries, for the region, even more broadly for the continue innocent, and also how do we think about the kind of investment that's going to be needed to sustain economies while public health measures are brought to bear which will undoubtedly take a considerable period of time? so, steve? >> thanks, john. the first point i want to make is that this is an epidemic of poverty. this is not strictly a disease of poverty. anybody can get it, but it's an epidemic of poverty. just as low incomes and lack of food and lack of water are all manifestations of poverty as is illiteracy and many other manifestations of poverty. the weaknesses and lack of capacity in institutions to be able to respond to a public health crisis is just as strong an indication of poverty. and through that, unfortunately, there's a self-reinforcing negative cycle that we're beginning to see here. that is, that as the disease worsens, that undermines capacity and undermines finances and economic ability and political systems and legal systems which in turn further weaken the entire economic and social system which are cutting incomes and leading to more poverty. so it's a horrible crisis because for the last nine years, since the elections in 2005, liberia has been in more of a positive reinforcing cycle. that improvements in economic and political systems are leading to higher incomes, less poverty, increases in school enrollments, strengthening of democracy which in turn are reinforcing each other or had been reinforcing each other. positive steps in one area were reinforcing positive steps in another. and there had been so much progress since the end of the conflict in 2003 and the elections in 2005 in liberia, also in sierra leone. a little bitless of an extent in guinea because the political system just began to change more recently, in 2008. but we're seeing a sad reversal from a positive reinforcing cycle back to a negative reinforcement cycle. and since this is an epidemic of poverty, one of the things that's really made me, quite frankly, angry is the blame the victim sip dream that had been around -- syndrome that has been around for the last several months. the problem is that these people are stupid in terms of their cultural practices or that the government doesn't have the competence or the capacity and, or, you know, they make dumb mistakes that this retrospect, you know, we can all see that these are mistakes, and if they just took things more seriously or were able to treat people, this would all end. and it's really quite sad that once again we see the kind of blame the victim kind of situation. this was not anyone's fault. this is ap act of nature. an act of nature. the deep unfortune is that it came into a region of the world that was very fragile in terms of its very promising recovery and was overwhelmed very quickly. scott taylor said it, dr. bump said it earlier, who would have expected, who could have expected that they would have had the systems in place to respond in -- to respond? there is, as several people have said and ronnie just said, there are big lessons here for the future of the international system and its ability or inability to respond, because this isn't going to be the last ebola crisis, and this has really exposed enormous weaknesses in the global ability to respond to emerging disease threats. i'm not an expert on that, and others will comment op that, but i think there's a huge lesson going forward. in terms of a couple of comments on the economics and politics, president sirleaf outlined a lot of the devastation that's going on. it's really quite enormous. among many other things, i'll just highlight one she didn't touch on which is the impact on the budget, which you might not think of. but the government revenue is way down because they rely very heavily on import tariffs, and trade is down, so import tariffs are down can. the mines are shut down, so their payments to the government are down. there's a big question as to whether the government's going to be able to make its payroll this year. if they wanted to reopen schools, are they going to have the money to reopen them? court systems and all the other kinds of thing that is government normally does. and among many other things, they need a big infusion of cash which, just to keep the government operations running, which the international community is generally very reluctant to provide. generally for good reasons in other circumstances. but we don't have the flexibility to respond in a set of circumstances like this when one of the things they need is cash and figuring out how to do that. usaid is providing $5 million in cash, and they were twisted in pretzels to figure out how they were going to provide $5 million in cash. the imf is actually going to step up in the next two weeks or so and provide around $50 million cash to the liberian government and similar smaller amounts to guinea if sierra leone. so the imf, in of all situations, is going to be one of the first to step up in the crisis. but i do worry about the longer term impacts on the economy and the impact on investment going forward because i think it's going to be -- the longer this drags out, the more of a dark shadow is going to be cast on west africa in general, and the harder it's going to be to attract investors going forward. and this is having huge impacts on individual people. people are out of jobs, poor people are not being able to work on construction sites and retail shops as taxi drivers, working in hotels and restaurants. they're not working anymore. a lot of them have lost their jobs. so anger is rising both in terms of the disease and etch's worried about that -- everyone's worried about that, but on top of that, people's incomes are down, and they're not able to provide for their family. so anger is on the rise. and alongside the economic implications, i worry that there are going to be longer term political implications and ramifications. all three of these countries are young and fragile democracies, quite promising democratses, and they had begun to deliver the goods. and i worry that among many other casualties one of them will be a lack of -- a loss of faith in the ability of democracies to provide, provide the goods. and already in liberia we're seeing former warlords and associates standing up and saying, you see? they can't actually do it. i should be in power. and with elections coming up in a couple of years, we'll have to see how that, how that takes shape. but i do believe that there are much bigger implications here on economic and political systems and people's belief in those economic and political systems, not to mention their belief in the world order and international systems and their ability to respond. president sirleaf outlined the steps going forward. it doesn't have to all end in catastrophe. we're running out of time, but there sill is some time -- there still is some time. the key will be not just for the people in liberia to given to -- not to begin, they have been stepping up in a big way, to continue to step up, but for the international community to provide the cash, the people, the health experts, the other experts that can help turn this around and begin to make those investments in agriculture through the u.s. feed the future program to get farmers back to work, through trade to make sure there are trade concessions that outside investors will be somewhat more open to investing in these countries going forward, to investing in infrastructure -- roads and power systems which will have a long-term benefit but which will get people back to work quickly. there's going to have to be another prong to this effort which so far isn't really happening in order to get people back to work to be able to care for their families and get these economic systems back going in a more process direction. >> steve, thank you. and -- okay. if it's okay, i'd like to follow up directly with you on the last point because it does seem to me that we've seep seen -- seen the global public health community responding slowly to this crisis. what you're laying out, though, is an economic agenda for these three countries, but for the region. and, again, the imf is to be credit with the the initial steps it's taken. but it seems to me the president also laid out a much broader aweapon is da around trade and around investment. who could take that lead? do we have a global architecture to take the lead? that's for you but, also, all the panel its. who should be -- is this the u.s.' role? who needs to be the lead in this? >> so we have an insufficient global architecture on these issues. it's slightly different in each cub -- in each country. in liberia it's united states, in sierra leone, it's historically the united kingdom, and in guinea, it's the french government. that's not going the change, and the reality is that the united states is going to focus primarily on liberia and not so much on guinea. we might not like that, we might all hope there's a regional response. there should be, but it's not going to happen. we're going to need -- so all three of those governments are going to have to step up. and then several key international organizations. the international monetary fund, as i mentioned. who would have guessed, you know, darth vadar himself, you know, the age-old nemesis. [laughter] that's long other, but they still have this reputation. far from the old, out-of-date image of strong conditionality and we'll never do it unless you do it our way, they're going to be the ones that are going to step up as part of existing programs and existing commitments that had already been made and that the governments were all in compliance with and will go to their board -- you'll see, it's going to be october 23rd, it'll be page 26, column c of the newspapers that the board will approve, i think it's going the to be about $48 million for liberia and other amounts. so the imf is a big piece of this. the world bank is going to have to step up. they have made many commitments so far. they sound like quite encouraging commitments. as far as i can tell, there's less actually happening on ground. and the bank is going to have to step up on the infrastructure side in particular and on power and roads as well as some of the cash to supplement the imf stuff. bilaterally, the u.s. response so far is certainly good, as ronnie said, it's a step up. but if you look at what the president said in the white house press release last week, there's nothing on the economic side. now, what they are saying is that'll come, okay? fine. i hope it comes fast. but the united states -- and there have to be similar efforts by the united kingdom and france, they're going to have to support farmers getting back to work through feed the future, infrastructure investments. i hope the millennium challenge corporation is a bit flexibility in sierra leone and liberia, two of its partner countries, to move forward on infrastructure investments. we're going to need the ustr and commerce to step up on trade and think very creatively about the kinds of things that we can to to encourage trade; remove tariffs, open up the door cans. so it's going to take efforts from are a number -- from a number of actors, and there isn't an overall coordinator to do it. it's different piece that are going to have to fit together in a puzzle to make this work and to get the economic response that we need as quickly as possible. >> steve, that's very helpful. i was going to turn to the public health response. super, or ron -- super, or ron -- susan or ron, do you want to -- if that's the case from the stand point of the global economic architecture, i'd like to go a little bit back to where with we started. susan, you laid out -- and i would agree with ron, i think you could drop the "probably." i think that people are -- and that's not a, there are people who are working in all these organizations incredibly hard to respond. it's just a question of whether we as a global community have the instruments and the to respond. -- and the infrastructure to respond. and it seems in this case we've responded too slowly and ineffectively. but i guess the question i would ask you, your analysis, susan, is this a situation where the ihr legal instruments are essentially sound but in this case we didn't use them to their full potential? or is there -- are you beginning to see lessons emerge where we need to rethink the global legal infrastructure in which public health responses like this will be conducted? >> so overall, i think the ihr is, you know, in principle, a legally-sound instrument. i think it is sort of the execution and implementation of it. and i think it was said very well, it's very difficult to think about sort of what is the process and execution of how do you address a heart attack when you're in the midst of a heart attack? so i think dr. cameron mentioned this morning in the 201 assessment of whether countries had implement inned mare core capacity, there was around 20%, i believe, in the region. if 2013 report, i think, is more positive, but these are based on self-reports, and for those of you who do surveys, take that as you will. also i think part of it is, you know, the institute was engaged, for example, in terms of resource allocation in a training course for folks on the implementation of the ihr. and these were primarily for middle and lower income countries to think about, well, what exactly are the core capacity requirements, how do you implement this treaty? but that was stopped a few years ago. so really, i think, what we found in doing that course is very few, i think, lower and middle income countries had sort of a lawyer at all in the my industry of health to sort of explain what are the requirements, how do you implement them. and it doesn't have to be a lawyer. a few of them had sort of anyone in the my industry of health that could actually explain, you know, what are we required to do? so when you think about do these countries have effective, you know, is the ihr an effective mechanism? yes, if it's implemented correctly. has it been implemented correctly? no. [laughter] and i think, you know, with something like, for example, i said a public health emergency of international concern has been e declared three times. the first one was with h1n1. and i think the who assessed whether that had been working effectively. at the time overall they said yes, but one of the things they raised wuss, you know, we got a little lucky because it may have been diffuse and spread, but it didn't have sort of, you know, morbidity and mortality of sort of what could happen in a pandemic. and i think one of the questions is what would happen with sort of a disease outbreak that would have senate morbidity and mortality? and i think you see the consequences of that now. >> so, ron, if i could, i mean, if we -- even if we have legal instruments that describe roles and responsibilities, it still requires institutions and capacity to do so. and i know we focused a lot on the countries, and i want to be cognizant of steve's caution that this is not about blaming the victim. i'd like -- given your experience, ron, in public health or global public health responses, what lessons do you see here that we can begin to think about in terms of the international system, including who? what do we need to be thinking about? because, obviously, we need to be thinking how do we avoid being in the situation again? >> yeah. i think who's made a number of proannouncements regarding the fact that they were underfunded in this particular area which may or may not be true. i think if you start at the macro crow level, we're seeing a shift in the global health priorities as countries are growing economically. we're going through something called the epidemiological transition which means that the disease profile in many low, low-middle countries are starting to shift from one dominated by ip february white house diseases to one that has to put great or priority on the diseases that occur when people live longer and are healthier and societies are healthier. so people are trying to put a greater emphasis on cardiovascular diseases, cancer, mental disorders, so on is and so forth, and that means that the money is shifting from one area to another. so there has been some decline in attention to ip february white house disease -- ip february white house disease control in the global level, certainly like in the wealthier countries like our own. you don't have to learn far into the newspapers to learn about epidemics occurring in this country because we've taken our eye off that ball. but on the global scene as well, parts of who like the global outbreak alert and response network and the areas concerned we merging pandemic threats, they don't have the same funding now as when we really had the imminent threat of not only h1n1, but at the time it was the h5n1. and because of that threat, in fact, there had been a lot of preparedness activities in a lot of countries in a lot of parts of the world. the u.s. was haley engaged -- heavily engaged as was the who. at that time, it was in the late 2000s, there really was a whole-of-society approach adopted to the control of these emerging pandemic threats. interestingly, the one part of the world where there was the least preparedness activity taking place was in this part of the world where this is occurring now. it just wasn't seen to be a very vulnerable area for the emergence of these pathogens. .. and we are responding to the problem as it existed in june. as if we are doing what they should have been then we are doing it now and it's too late. we need to be responding now to the situation as it will exist in october and november. we need to get ahead of the curve and every time we spend is going to be another day that we fall behind alternately. so there are some fairly drastic solutions being proposed and we are starting to hear them but we don't know the legality of them both as an individual, community and national level and i hope it doesn't come to that, but for the control of the disease risk, who knows what happens. i tell my students they ought to watch the movie contagion which i think is a picture of what might, although i hasten to add and i might repeat that there's really no threat. i want to build on what steve said actually. there is extremely little or no threat to the wealthy countries of the world. they have systems that can deal with it and we will know when the first case arrives in the united states and our public health service will be able to contain it very rapidly and that is the situation with most countries is an epidemic of poverty. but we have an obligation on many levels i think to continue to do our best to bring this under control now and back to the point where they are more conservative and traditional measures of containment that can be put into reverse the tide. >> did he want to the law to comment on the human rights? in the midst of an emergency, you know, the intervening story has the ability to enact what can be extraordinary and coercive measures at the individual and the regional level. we send to the regional and global level this is permissible. it depends on the balancing and i think for those of you familiar with public of the law it is the notion of the power and restraint. the powder and the duty to react but they must also do so and i think these are outlined in the a. hr and international human rights instruments which is the principal principle and really i think with not just ebola is looking at when they are directed at this directive and necessary to achieve the objective based on the scientific evidence and limited duration and most importantly the least intrusive and restrictive measure to achieve the overall objective. i think one of the questions folks have now and the experts are more knowledgeable of it but whether the regional quarantines is appropriate and i think even if it is completely possible to put someone in isolation and quarantine if it isn't the ghost restrictive measure to achieve the objective which is to prevent the case it might not be lawful to do so. >> i'm just going through some of the questions that we've got here but before we switch to these i do think this is an epidemic of poverty. i do like that. it's the political will and the global community and we saw some actions last week in the u.s. security conference that's something that does not typically doing this kind of case that you can argue that the just a revolution. but it is likely that the future epidemics are going to have been in poor countries with fewer resources into the global and international community needs to be mobilized politically to respond if you are going to hope to be a head of this or in sync with it as an emergency. i don't know if the three of you want to share my think the u.s. has taken some lead later this weekend beginning of the local health security agenda but how do we fill the dialog that says this is a global public good, this capacity and is also something that is helpful, particularly to people in poverty but also something we need to be globally. i think that is going to be necessary to whatever we do. >> part of the trick is to stop the fear mongering but at the same time continue to be serious about the potential impact of the epidemic not just in west africa but more broadly especially as it gets to spread. the fear mongering i think some people do it with the intention of we've got to wake people up to realize how challenging the situation is and it reminds me a little bit about, you know, i think some of that proclamation about the threats to international security were overdone in the years after 9/11 and frankly as a mechanism to get people to act on various issues. the trick is to get the balance where we are not just scaremongering that we are getting the message out in clear ways that the threat of not just the immediate public health threat that to the international systems views on democracy and views on the international economic order and the others that have been taking a hit since the 2008 financial crisis and the invasion of iraq and we are seeing democratic recessions in a number of country and the beginning of the questions of the effectiveness of democracy and the minister of hungary calling for the liberal bloggers he for example and i wondered if this feeds into that part of what we have to do is to get get the narrative out of that can convince people of the seriousness of this issue without fear mongering. but i do think that for all of the pessimism and challenges these are matters of choice. as much as this is a national disaster that comes out of nowhere that we cannot completely stop, there is a collective choice in the international of the international community to make over the coming weeks and months. you use the phrase political will. but we have the collective ability to at least begin to bring this under control if not to stop it in the months to come. before that happens there will be much more suffering that we have choices to make. can we get to a place where this is at least under control and stabilizing? yes. we've done it with hiv. it's not over by any shot but it is stabilized. we've done it with malaria after escalating for decades the following very sharply because of international decisions to fight it and fight it harder. people finally made the choices, we did it with pouliot where it is almost eradicated but not quite there yet. this is similar to those. i remember in the early '90s i'd been thinking about the days when people are were finally recognizing the severity of the hiv crisis and it took the international community way too long to step up but when we did it have a big bag into the question for me now is whether we will collectively make that choice. and a lot of this goes to the united states not only by latter really because of its leadership in the united nations and the world bank and in the ins and other places imf and other places people still do look to the united states. i worry a little bit because there are retired generals out there saying this is a bad use of that u.s. troops. obama is putting them in harms way and all that stuff .-full-stop don't recognize the bigger issues that are at stake. but the good news is that this is a choice and that we do have the brains and the resources and people to type this and to bring it under control. we are beginning to imagine a direction and we need to nudge more aggressively in the months to come and if we do that we can bring it together collectively we can bring this under control i think. i'm going to go to some of the questions now. let me start with one that we have been focusing on this question asks really if we are in a situation where this spread to surrounding countries where it is synagogue -- can you describe do you think we will see more of what we have seen in the three countries that are impacted or are there greater and more dynamics involved if we see this spreading dramatically in the nearby countries? it is speculative. i'm a little bit surprised and i do not fully understand why the disease is not spread to other countries. one case in senegal basically traveled the length of the country to reach the capital city. a number of cases in nigeria and at least two sides we don't know what is going on with them. maybe it has spread to other countries but it hasn't yet reached the point of disability. i know there are people looking on the alert in the other neighboring countries as well. i know that usaid is conducting regional preparedness workshops in the countries as we speak taking lessons from the pandemic preparedness plan that has had been developed for influenza. i don't think that we entirely understand the dynamics of the epidemic or how it spreads. i don't think that we heard the term's exponential growth. we've heard accelerated growth. i don't exactly -- it's really hard to model the spread of the outbreak even when we observe it up close because then bought even every county in the country before the cases. so the way that it moves isn't really clear it seems to move in spurts that it will reach a particular area and affect a lot of people in that area and that we won't see it again and then it will occur in another area and it contributed to the lateness of the response that although we knew that the ebola virus was spreading in new guinea as far as december into january of this year there was a pure code that it became quite absent and they didn't react because if it appeared to be on the waiting end and many few cases were being reported and that it was an explosion again. so it isn't clear what the dynamics are. i can't answer that question except to say that it doesn't start affecting other countries and there is a chain of transmission that is payroll to the ones that we are seeing now, then all of the things that steve said about the economic consequences and the potential for the consequences will affect other countries as well. >> next question gets to the issue of medical countermeasures and the question is what do you all the lever is there an appropriate economic investment as a global resource for this pandemic particularly of treatment and vaccines and also looking down the road and i know you've given some thought to this issue of how we create the right conditions for making therapies available for something that allows them to be available to address some of these issues. this is a question whether it should be a worldwide or global activity write-down to a great extent it is done by the united states and a few other countries >> of these types of things should be done, but i think that as doctor can attest to, when things are framed in that they have to be in the local context, that requires as you pointed out that the hoa caldwell objects on investment but it's really not even just about the money but where is the money going to come from in terms of if these things are done, you know, how do you figure out the appropriate application and it really requires people like you to think about it before hand. so, absolutely. i think there is a place to think about making future investments in the medical countermeasures that folks need to give serious consideration into what to what that framework will look like. >> i just want to say one thing and to get it off my chest. the sad part of the outbreak is that we wait until these events occurred and then we start talking about how we ought to throw a lot of money into developing drugs and vaccines for ebola or worse the failure not so much of the outbreak response community as it is in the development vanity into the real case study is what is the development agency has been doing for the last 60 years if we would have had stronger health systems in countries in the first place we wouldn't be where we are now but now i went to usaid very early on in the outbreak and they were talking about putting massive amounts of money into strengthening the health system in nigeria, which is fine and that ought to be done maybe not now, it should have been done maybe this is the right time to do it but i hope we learn a lesson and we don't have to wait for the next catastrophe to occur before we decide that we need to make the appropriate investments and development. >> want to ask you a question. >> we have all been involved and applauded the u.s. government efforts in the last ten years to build responses on hiv, primarily malaria to a lesser extent tb. you know where my question is going. in terms of vertical responses to disease. and it's not just the executive branch. but the honest truth is that the congress loves it and the american people love it because we can explain that we are providing and antiretrovirals to agnes or whoever the person is is and we can actually bring agnes to testify in front of the senate foreign relations committee and say your money is keeping her alive and we can prove it because we are providing her with antiretrovirals. it's a very compelling case and we can do the same with a bad back bed nets. children live and weeks of the campaign's children in high school contribute $10 someone will buy a bed net. so the political economy at its best level and is sometimes understanding the american people want a specific actions on specific diseases. jesse laid out very well and we all talked about the impotence of the health systems. you've been more involved in this than any of us. how do we square that circle of the congress is imperative they want results measurable knowledge of the need to build systems over time. >> that's the question that has been haunting me for the last several years. i've spent quite a bit of time on the bilateral response program that is focused to fight aids and malaria, three diseases. we had a considerable debate in the global fund about the extent to which countries should be supported to build the health systems and opposed to the systems to deliver responses to those three diseases. they outlined exactly why it is so much more politically attractive to make the argument that an investment of u.s. tax dollars leads to a specific outcome with a specific person. i don't think that if the conversation is only going to be about a direct bilateral program versus a relatively nebulous investment in the health system i frankly don't see how that argument is going to be persuasive over time. i think you have to change the conversation and so one thing that this crisis provides is an opportunity to think about health systems as a protection for the world as well as for these countries that ebola illustrates because i do think there is an argument. people here in the united united states united states to invest do invest and we do want public-health infrastructure. we may not think about it from day to day but we sure want the cbc functioning per example in 2009 with h. one and one. before we didn't know that it was a serious flu pandemic we forget about the constant news beat on cnn, the lines in the parking lot, all those issues. there was a demand for public action. can we change that and make that argument that the argument that we are going to be safer as a country if the world is safer and so i'm wondering if one would change the conversation. number two and i think this is the long-standing hope can you make the diagonal argument rather than the series of the vertical programs competing against an argument for war is awful, is there an argument that we can actually invest in systems with accountable countries such that when you come back -- a strong health system should treat people with hiv, tb, malaria, ebola etc. effectively and then every other and better in life we know the systems that are well organized and share basic cost of operating. businesses don't operate -- wal-mart doesn't have a separate company for each product on its shelf so it makes sense to have institutions that are well organized. so if we can make the case that broad-based investments with performance measures that could give you the kind of maybe not exact way but something close to that specificity i think is the way that he would engage congress in and the executive branch into changing the conversation. i fear that that would be a much more difficult case to make. >> we are near the end. i didn't mean to speak. that wasn't the plan. [laughter] >> it was my plan. >> i had a sense you are being so nice earlier that something was up. [laughter] but i do want to offer anyone a chance for a brief concluding thought since i ate up the last question. >> i have said plenty >> i guess i just wanted to say i would urge everyone to continue to follow this outbreak closely. it is a really important events. there are event. there are other things happening in the world but also extremely important, and sometimes those things get a little bit more coverage and attention because they are easier to understand and sometimes they have been there before. this is a very unusual events that is occurring and one of major importance. for people that do the kind of work i do for a living living it's like an invasion from outer space and it really does require everyone's full attention and the maximum amount of cooperation as well. we are all under threat and have to rise to the occasion. >> i would like to ask everyone in the audience to thank the panel. [applause] i would like to invite dean anderson to come out and give the final remarks. >> i would open a session by saying that i observed that those of us have tried to teach that have tried to teach international affairs at the school of the foreign service we have come out of a period that is particularly i think enhanced by the cold war and post-cold war era in which we thought of international affairs as a matter of relations between human beings. it's been the organization of the state, the threats to the state of about the alliance between the state that has made up the stuff of international affairs and we need to veto beyond the brink in which the questions become less of relations between human beings and relations between all human beings and the challenges that have come from global climate change, food shortages, water shortages and things like infectious diseases. as our panelists have observed today. the reality may be upon the recognition and ability to respond to that change. but i'm pleased to say that the community at georgetown and in the wider circle have come together today to deal with that issue in a way that the school of the foreign service is not equipped to deal with and so i very some i very much appreciate those of our communities who have joined us particularly john and wednesday in helping us to think about international affairs in a way that may be more appropriate for the 21st century and i finally, want to thank all of you for being such an appreciative audience. so thank you very much. next on c-span2,, health and human services secretary sylvia on implementing the affordable care act. that illegals the eagles colors discuss the upcoming supreme court term. >> with the second enrollment. the beginning november 15 for those applying for health care coverage under the affordable care act, health and human services secretary sylvia burwell spoke at the brookings institution about the rollout of the law and the healthcare website. this is a half-hour. >> good afternoon. i welcome you to the brookings institution and an even more delighted to welcome sylvia burwell, secretary sylvia burwell to this event at brookings. i don't sylvia some time, over 20 years. when i first encountered the sya sylvia in the clinton i ou administration, i thought of her as a friendly competent youngcon woman whot worked for bob at td national economic council. i learned that sylvia was the and the can-do person and that was a useful kind of person to have around. and she likes to keep in touch with real people out around america not just in washington. and she grew up in west virginia. one day i found myself in a hard hat deep underground in west virginia in a cool line. but i wasn't the only one that noticed that sylvia was competent and levelheaded choose the office of management and budget. she had a distinguished career in philanthropy where she had major responsibilities in not one but two big foundations. and then president obama had the good sense in bringing her back to washington to be the director of the omd. i was divided. i have a strong affection for the office of management and budget and i always feel better when i know that the agency is in its strong hands. i also have a deep respect for the difficulties that this thing that i ever did but apparently it wasn't tough enough for sylvia because she let the president talk her into an even tougher one. the department of health and human services is a vital agency of the government that literally affects every single american that some time in their lives often many times at anytime in history, any time in history, running the hhs effectively is a huge strategic and managerial challenge. but this may be the most challenging time of all because it includes implementing the portable care act. it's a far-reaching piece of legislation that's already providing millions of people with affordable health insurance and will impact the way that americans interact with their health care system for decades to come. it will play out differently in different parts of the country as we gain experience with what works and what needs fixing. the people in the academic world often imagine that the hard job in government is making policy as the political battles are fought and the compromises are made, after the bills are passed and signed, the hard job is to implement the policy on the ground. and that is the sylvia burwell's job right now to make the affordable care act work. someone i've known and followed for so long i'm sure most of you know that alice was the director of the budget office as well as the first woman to head the office of management and budget and as i aspired to follow the footsteps literally and figuratively for those that know her and for whatever reason i decided to climb mount kilimanjaro. brookings is a place that has a special place in the household. we like to read it to our children that are six and four at a morning and it's a morning ritual after household over breakfast and sometimes we read the magic treehouse and other times we read the brookings institution's report. i do have a message for my six-year-old and that is the fact that on the whole aggregate gdp being a less good measure of economic progress she doesn't disagree. while i'm not -- i do want to skip to the fact that i have great respect for brookings as an institution and the work they do and examining all issues it takes a long and and the short term view to think about and analyze trends over time, conduct as part systemic and period research and serve as three words on the motto those are quality come independence and impact. and as a former omb director, those words are music to my ears. and i want to take this opportunity to apply back the analytical framework to the issue of health care. and as we think about the question of how the affordable care act is working and then how i'm thinking about the steps as we go forward. i come to believe strongly in important measurable impact and when it comes to the affordable care act i think there are three basic measures. access, affordability and quality. our more people getting covered? access and affordability. or middle-class similes shielded from the bills of the fertility? are we spending our dollars more widely. when you consider the wall in the lands of the affordable access and quality the evidence points to the conclusion the affordable care act is working and family businesses and taxpayers are better off as a result. four years after president obama signed a law, middle-class families have more security and many who already have insurance had better coverage. fewer americans are uninsured and at the same time, we are spending our healthcare dollars more wisely and starting to receive higher-quality care. as we walk through the evidence i think it might be helpful to add a little historical context. as a country we've been wrestling with these questions of how to cover the insured as long as the brookings institution has been here as a matter of fact even longer. in 1912 teddy roosevelt's party platform called for universal health care a long with priorities like women's suffrage and the national highway system. in the 1920s women got the right to vote and in the 1950s president eisenhower delivered the nation a highway system. 80 years ago president franklin delano roosevelt succeeded in creating social security but was unable to make progress on the issue of a national healthcare system. 65 years ago president truman asked congress for a fair deal, a deal that included things like the cool rights for all and an increase in the minimum wage and universal healthcare. the congress passed the minimum wage. 50 years ago president johnson signed medicare and medicaid into law. they told the congress come equipped with a comprehensive health insurance is an idea whose time has come in america there has been the need to assure every americans financial access to high-quality health care. that's president was richard nixon. and in the 40 years since his address to congress, the country is paid a hefty price for an action on health care even to president ford, carter, bush and clinton made this issue a priori. the cost spiral out of control and health care healthcare became unaffordable for millions of families and businesses alike. taxpayers help the affected as well do you have those that were not priced out of the healthcare market many were locked out because of pre-existing conditions and many who were fortunate enough to have insurance that did not receive a very high quality of care. by the time president obama took the oath of office or system had broken down to such a degree that we were spending far more as an economy on health care and both gross and per capita terms than all the other developed countries. in 2009 were spending $2 trillion a year on health care which was almost 50% more per person than the next most costly nation. the driving cost to their toll on family budgets. in 2007, a harvard study led by a certain professor with a very bright future, elizabeth warren found that 62% of the personal bankruptcy was due to medical problems. what were we getting for the higher healthcare costs that we shouldered? in 2010 the commonwealth fund benchmarked against the six advanced industrialized nations. they looked at quality quality, access, efficiency, equity and healthy lives. we were dead last. we still were not scoring well in these benchmarks we are doing a lot better on some measures of quality. by the time the affordable care act was passed, tens of millions of americans were uninsured. millions more have coverage that wasn't there when the needed they needed it and every one felt the impact. too many americans relied on the emergency room for the most basic ethical care. uninsured children were more likely to have fewer immunizations and go without prescriptions. uninsured adults were more likely to have chronic health conditions many of which went undiagnosed. the system wasn't working for millions of americans who have insurance. 78% of people who went bankrupt due to medical bills actually have health insurance. just because you happen to have an insurance card coming your care isn't necessarily affordable. if you are charged several thousand dollars for an ambulance ride that wasn't covered. having an insurance card not guarantee that you have access to the services needed. having an insurance card didn't mean your doctors were effectively coordinating so that you wouldn't end up taking tests twice were getting procedures that you might not need. thanks to the affordable care act, things are changing for the better. let's consider the evidence on the uninsured but we are making historical progress. the affordable care act addresses quality, a port authority and access. it expanded medicaid. it looked at the barriers to coverage like pre-existing conditions as well as annual and lifetime caps. it allows young adults to stay on their appearance policy until they are each 26 and it created the hope insurance marketplace. and insurance companies now can provide affordable coverage to consumers through the marketplace. during the last open enrollment, consumers chose from an average of nearly 50 plans and i have news for you when it comes to choice and competition. today we are able to announce that in 2015, there's been a 25% increase in the total on the issue were selling insurance in the marketplace. there is already real evidence that these plans are affordable. just last week the commonwealth fund released a study showing 70% of americans with marketplace insurance plans field they can now afford their care. the premiums are affordable. it is no surprise therefore that when the folks evaluate the success of the law of the marketplace receives much of the attention. back in march, news reports suggested that it would take something close to a miracle to reach 6 million people. last week we announced that 17.3 million people signed up for marketplace plans, paid their premiums and have access to affordable care. 7.3 million people to borrow a phrase from the vice president is a big deal. but i'm here to tell you i don't think that's the number that we should focus on. yesterday we released another number from a significant brand that is 8 million people enrolled in medicaid or s. chip since the enrollment date and that is an increase of nearly 14% in terms of the monthly increases before that time. that is a significant number. but again, i don't think that is the most important number that we should focus on. the number that is even more important is that in just one year, we have reduced the number of uninsured by 26%. to translate that, since 2013, 10.3 million adults are no longer uninsured. i firmly believe this is the key measure. we should look at it because it represents historic progress on something that has eluded our country for over a century. there isn't a business in america that wouldn't be ecstatic with that kind of growth. ultimately, every number tells the story and i want to share with you the story is robert junior a floridian who was uninsured. roberts coverage he signed up for the marketplace and it took an effect on january 1. on january 2 coming he went to see went to see about a growth that he had on his todd olson and i'm afraid that the diagnosis was bad. it was late stage cancer. after prayer, perseverance, radiation and chemotherapy, robert is now cancer free. without health insurance, those treatments that saved his life would be $200,000. under the affordable care act for robert, what we saw is he paid a $2,000 deductible, $1,500 in copayments and what was his monthly premium wax $118. i want to read some words directly in his own words i wasn't in favor of obamacare he said. last year i wasn't going to get health insurance and i was going to pay the penalty. i'm grateful to the air i am now. i'm one of the luckiest people in the world. i'm going to live and work and be productive. i would say that his story isn't a story about politics. it's not the story of the left and it's not a story of the right. it's a story about affordability, access and quality. when it comes to americans who already had insurance i will be straightforward with you, those of us who support the affordable care act hasn't done a very good job at making the case that this was something that helped those people. if you think of a mom or dad is sitting at their kitchen table working on a family budget, it's a big deal that they are actually saving money, still getting better coverage and have financial security. many middle-class americans have more money in their budgets because their insurance company is now required to spend at least 80% of the premium on their healthcare. families have saved an average of $80 that they can put on their electric bill or back in their grocery budget. meanwhile, millions of seniors are saving billions of dollars on their prescriptions as we phase out the doughnut hole. more than 8.2 million seniors have saved $11.5 billion. middle-class families are also benefiting from a security that comes from knowing your health coverage will be there when you need it. families no longer have to worry about losing their homes were having their hard-earned savings wiped away by an accident or unexpected diagnosis. there is security in knowing that if you lose your job you can purchase marketplace coverage even if you have a pre-existing condition and that you won't lose your insurance just because you get sick or get cut off or if you need chemotherapy or some life-saving operation. a healthier and more financially secure middle-class is good for business who benefit from the healthy workforce and consumers with more disposable income. they reported last week the businesses lose $576 billion each year because of an unhealthy population. some of the biggest impact for businesses and tax payers feel from the law are in the area of cost. since president obama find the affordable care act others evidence that we have bent the cost curve when it comes to healthcare. we have now held down health care price inflation the healthcare price inflation to the lowest level in 50 years. premiums for the employer-based coverage have been driven down as well. earlier this month, kaiser gore did that this year's cost growth is the lowest on record. it's been projected about had the premiums grow at a rate that the rate that we saw in the previous decade instead of the slow rate in the past four years, the employer coverage would be $1,800 more today. if you are an employee or come of this means you need to hire workers if you're an employee it means you could be keeping or of having your paycheck tomorrow. if you are a taxpayer, it means a healthier economy. and prove to our health delivery system are also having an impact on costs to taxpayers as we we stand dollars more wisely. we save taxpayers $116 billion in spending medicare dollars more wisely and by improving the quality of healthcare. or in a further example, the accountable care organization models we are testing for medicare are saving $370 million counting. taken together i believe the evidence points to a clear conclusion. the affordable care act is working. my job as a secretary is to lead our efforts to keep it working, and to help it work better. like anyone in business, we want to learn from the things we got right into the things we got wrong. we are taking that approach and we have a four-part strategy moving forward. first is improving access and affordability through the marketplace. in order to make sure that americans continue to get access and affordable choices, we have to get health care ... right. to me the formula for this is technology, management and prioritization. we are checking of the outstanding items from last years year's to do list, checking out the functionality and adding functionality for renewing and enrolling in the coverage. we are prioritizing the most important issues in the area to improve consistent with our deadlines. we are focusing on giving ourselves the appropriate amount of time for testing and we are very focused on security. anyone who could ever manage manage to large-scale technology project knows that these projects are challenging and often require tough choices. we are prepared to meet those choices and so that we can deliver the best consumer experience. second is improving the quality for patients and spending every dollar wisely. we are testing medicare and medicaid and reaching out to the business immunity to find solutions that we can all benefit from. changing incentives to move from volume-based two more impact-based systems. investing in tools that can expand our capacity for change in the health care delivery system. improving the flow of information so doctors can spend time with patients and less time doing paperwork so they can coordinate more effectively with one another. third is expanding access by expanding medicaid. one of the first meetings i did was a bipartisan meeting with governors and decided to all the governors we want to work with you to be flexible, we want to work with you to expand access to medicaid. in the time i've been there we've added pennsylvania, the state with the a republican governor and we are hopeful that we can more to work together in that space. for this helping them understand how to use their more coverage including the role of the prevention as well as bonus. many of the folks that are newly covered have been cut health insurance in years and some of them even met her before. we want to make sure folks know how to use their coverage and we are part and with organizations of organizations across the country to help them do so. i would like to close with a final thought as we work through this issue i think we need a bit of a course correction when it comes to how we talk about these issues and it starts with collectively turning the volume down. surely we can all agree that the back and forth has not really helped those that we are trying to serve in terms of delivering for the hard-working families that we all try to serve. i prefer a brookings approach, quality come independents and impact. a small-business owner from texas wrote a blog and what she talked about is what it was like to be uninsured. she's a small-business owner then she talked about what it was like to be uninsured but not having a regular family covered because her son had a pre-existing condition. and she wrote about how poor her family the affordable care act is working and i want to read a few of her own words. recently i was able to enroll my family, my entire family, she wrote. not only is my son finally covered, but the premium is only half of what we were paying before. i was shocked to learn that my prescriptions which were $280 a month now cost $5. my family now has the financial security and a tremendous piece of mind that comes with coverage. i don't have to work for someone else just because the health benefits anymore. i launched my small-business and i can focus on expanding it. betsy, robert, moms and dads across the country are counting on us. they deserve for this to work so let's move beyond the back and forth and let's move forward together. thank you. [applause] >> i'm happy to take some questions. yes? i'm from the american cancer society and people have been touched by cancer and other disease. they know how valuable insurance is that i think the challenge for all of us has been making sure that people that haven't been touched by the disease but may be at risk for it though how the law can help them as well as people that they have coverage through work how the law bolsters that. what are they doing to help educate the importance of the law? >> i think that when i talked about how we need to talk about coverage of the issue of how to use the coverage the point that you raise is one not just for the newly insured that across all because i think many people don't realize the extension of benefits for prevention and wellness and i think that's probably what you are referring to specifically. and so, one of the things we will do as we do our education for the uninsured is to do that more broadly. the other thing is in our conversations with the employers as a place that we are having a lot of conversation. the good news is that many employers are ready to talk about issues of wellness and prevention. and so, what we want to do is use our own research and conversations but i think that we actually know that in this case things will move more to the partners and stakeholders on the ground. people like your own organization who are delivering that message in our trusted sources. so whether that is the trusted employer like yours we will partner with all to try to move that message out and it's important in the points that i need as well as the points i made earlier that i don't think that we've done a very good job of helping people understand for the insured with the affordable care act. yes? >> thank you for the remarks. with the catholic health association a lot of our hospitals were deeply involved in getting people enrolled and educating them about new coverage options. for hospitals that were not yet engaged in it or hesitated because they are in states where it isn't as popular do you have any guidance in terms of how they can work in their community and get people signed up? >> first come to think you for all of the support and help. with regards to the states it isn't as popular. i think one of the things is making sure those states reach out to us. there are regional offices all across the country for the hhs and where there are those hospitals whether it is coming through the business organization here in washington, d.c. or through the region that might be a little more familiar with the challenges that you are articulating. we want to work with folks so that they can do what they would like to do in the context in which they are in. i think there's another point we are hopeful about. now people can see -- last year at this time we didn't have something to point to. we didn't have the story, we didn't have those stories. and i think we are hopeful that that also will be an element that can create a better environment that even where the environment is tough, we want to work and work in ways that will work for the context of these hospitals are in. we are working with hospitals, insurers, stakeholders in terms of the groups. this is an all hands on deck effort. >> yes? >> one of the thing the number of latinos that were signing up for the law could be improved and i'm just wondering your thoughts on how we could make a more concerted effort to get to that community and make sure the communities are covered. >> i think it is a very important place and we do believe that we can make progress on even more progress this year. i think one of the things that we need to do is listen, listen to the feedback that we received last year about a number of challenges. some of the challenges of technological. some of them came another form. what we are trying to do is work through and make sure whether it is through the navigators and how we share information through language issues that there are a whole sweep of things we are working on to make things easier to engage in the system and a second, to make sure that we are sharing the information so people can understand what it means in terms of the benefit and work with the stakeholders that are closest to these organizations to make sure how we'd raise some in and explain something to it often does kind of things are making a difference. the thing that i think is important and we have heard from probably some of you here on the issues that we are challenging. please keep letting us know. what we can do to fix we are going to do that as quickly as we can. >> hutchinson with the national center for transgender equal. and with all of the great thing that has been done for years and we still don't have implementing rules for the civil rights provisions and i think most people still haven't heard of those provisions including most providers that i talked to. we've delivered hundreds of stories of healthcare discrimination to the department and i would like to know are we going to see section 1567 implementing the rules this year? >> with regards to the timetable and the rules, that is something i think what we are most focused on is making sure that as we are getting the system up and running that if there are issues of discrimination that we are working through those. if there are cases folks should let us know. thank you for doing that with regards to the specific timing of the rule. it's not something that at this point i'm ready to commit to a specific timetable on where we are on that. consider the issue extremely important. i think you know the administration's commitment on a number of fronts to the issues about making sure that there is access and that the access is not discriminatory. that cuts across a wide range of issues. we want to continue to work to make sure that we are enforcing the law and understand the importance of the issue of with specific provision. thank you. >> on behalf of brookings, i want to thank secretary burwell and thank all of you for coming and listening out there. and good luck. we need this thing to work at hh s, and we are counting on you to make it work. thank you. [captions copyright national cable satellite corp. 2014] [captioning performed by national captioning institute]

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