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tv   Politics and Public Policy Today  CSPAN  March 14, 2016 3:00pm-5:01pm EDT

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that's empowering people such as athletic trainers. the athletic trainers are probably the single-most important person that could be on siter to any sort of contact collision event. it's important even in this country, for example, in the state of california, athletic trainers are not even regulated, so anyone can hold up a shingle and say i'm an athletic trainer or in new york city, 35,000 members of of the school athletic league and there's not one athletic trainer. they're the people that need to be empowered. we passed legislation, we defined providers as athletic trainers and team physicians. i think if we can get t signatories to the american development model, coaches education, em bower athletic trainers, those three combines will shift the safety in youth sport than anything i know of. >> thank you, mr. chairman. thank you for convening this group. i want to echo a fair a of what
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dr. hainline said. about trainers, a work on the policy and educational initiatives, 37% of schools have trained. this is the easiest way to protect kids from injuries associated with competitive sports, whether football, which i know is a contact sport, or any other sport. both on prevention and treatment side. when you have kids suffering injuries, including catastrophic injuries, the fact we can't invest further in public health trainers is something we have to address. the league have added several hundred trainers in high schools just in the last couple of years and we'll have an announcement on this point again tomorrow. it is a dramatic way absent all of the scientific questions that remain unanswered to improve the public health around sports for
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both boys and girls in those high school ages. and that's something we're going to continue to work on. let me add, we spent some time a couple years ago, the nfl did, with a number of other supporters around the country, traveling around state to state getting youth concussion laws passed. this came from zachary liestat who suffered traumatic brain injury from football and returned too soon. we spent four years getting 50 state laws passed and they're pretty simplistic around identifying an injury and insuring a child duridn't retur to play. there's a baseline that can be done from policy and education perspective to raise awareness of people participating in youth sports. more needs to be done in this regard. it's the first time that's been done. i think that might be a model we can talk about as we go forward for improving youth sports.
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the third point, dr. gioia was humble around usa heads of football program, the design was educate youth coaches as david mentioneded 150,000 coaches have been trained on concussion identification as well as ways to teach the game appropriately, which is essential in football, when to introduce contact and teach tackling. but that's 150,000 coaches representing well more than 1 million kids who didn't flow anything about concussion. so, these are huge challenges but not insurmountable ones and if the wise group of people here, more expert in the science that i would be, can think through the science initiativeses you can make progress while harder scientific questions are being addressed. >> burgess, screen, hudson. taking the order you raise your hands. go ahead. >> thank you, mr. chairman. i actually have two questions for mr. miller, then i'd like to
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ask miss mckee -- sorry, mckayla a question. 35 years ago this month roger staubach retired, i recall the press conference. the story around the retirement he suffered a number of concussions that season and somehow determined that he could not tolerate one more concussion or there would be big trouble. i did not know what metric was used, i did not know what test was used but i assumed there was a metric or there was a test where you could tell that's enough. so in the league today, what is the state-of-the-art, if you will, for someone who has had repetitive episodes of head trauma? >> first, in the particular case of roger staubach, terrific that he's gone on to a terrifically successful post -- he was great in football but his post-football successes have been terrific. the question is a medical
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question. and with each team physician and in the case of the nfl, we've added unaffiliated doctors in terms of diagnostics of the injurieses, unaffiliated doctors on each sideline and further independent experts who have to clear a player before allowed to play in addition to the team physician. the standard is whatever the team medical staff in consultation with the unaffiliated independent doctors comes to for that particular individual. there is no concrete answer to that question. for the reasons why, i defer to some of the people around the table who are going to know more about diagnostic is and treatment. >> again, that was 36 years ago. i would have expected the science to have advanced more than it has because of the investment that the envelope has. i did not see the movie, i did read the book, the description in the book of i guess the
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indekts case for chronic traumatic enaccept pa lop think, mike webster, pittsburgh steelers, a case spending for compensation for his long-term injuries. he was eventually awarded compensation three years after his death. so, i guess the question is, is that process better now than it was ten years ago that a player has for applying for benefits from the disability part of the league? >> yeah, disability benefit question is an important one. i'm sure miss mckayla has an answer to this. she does work as an advocate and important work for retired players and their families. >> i think the answer is in our most recent cba, most recent collective bargaining agreement, we allocated additional $1 billion towards retired players programs. that's of course, for those who played in the years before the
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modern age defined as pre-1993. in addition a number of programs in place for retired player care which includes programs associated with players who may have been diagnosed with dementia called 88 plan, any neu neurodegenerative disease, parkinson's, without causation, if you received diagnosis -- more than 300 players in the scope of the program received benefits -- you'll get care on an annual basis in terms of the payment. >> we'll get into the future carings. i wanted to see if we can focus on the scientific things with the concussions. do you have another question in that area? >> let me ask, you obviously have a perspective on this. as i read about this illness, yes, it's devastating for the individual who contracts it but devastating for the family, et cetera strangement from families, there's an ongoing continuum with which the family has to deal. can you give us insight from the
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family's perspective? >> if i can contribute nothing more today, because i'm not a doctor, but i hope that i can impress upon you all how difficult and tragic a disease this is. not just for the sufficient -- i -- i hesitate to think of what they go through, particularly in the day when my husband died he had no idea what was happening. i think for those that suffer today, at least they have the benefit of knowing there's a neurological cause for what they're struggling with and probably beat themselves up less than my husband probably did mentally, blaming himself for his failure just to be the man that he had been. but for the family, it's devastating. i can't overstate the capacity for this disease to rip families apart. you know, we've seen, i get, i was doctoring dr. mckee if she knows what the total number is, she said around 180, 190.
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we know all of the families, we know the clinical histories, each and every one of those, donations and individuals who passed away with the devastating disease. very often there are widows or ex-wives, very often ex-wives who feel very guilty for not holding things together. i in all honesty say i'm more surprised when the family's intact than when it's not. you know, i think that there are -- there are some benefits that the nfl is able to provide to their former players and thank goodness for that. part of the problem with these things is that, even for former players to access them unless things have changed, that i'm unaware of, those players have to be vested which means you have had to play four years in the league. we cannot forget this disease issing diagnosed in people who never played in the nfl for whom there are no benefits, there are
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no places to turn, both for treatment and compensation in terms where they're going to fund this treatment. i can tell you that families are in very, very dire straits and there are a lot of individuals really, really struggling. >> appreciate your observations. i want to ask you, probably a larger discussion, a year and a half ago the committee got involved in the question of domestic abuse and the national football league and it strikes me, looking at the continuum of this disease that that may be an aspect of while we focused on that as an issue where the nfl needed to foe cut, but also perhaps it's an index where it needs to be studied perhaps there is already a component of chronic traumatic encephalopathy making itself apparent. >> i would think unfortunately that's very much the case. my husband passed away at 45. he was a very, very different man from the man i had known, but he passed away young, and it's almost -- it's a very
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strange thing for me to consider that we may have almost gotten off easy because a lot of the families that i speak with do see a lot of ugliness, a lot of scariness. talked to women whose husbands are young as 38 years old coming in and the baby's cries are making him irritable and setting him off, and they're afraid of their own safety and how long -- i think absolutely it's an issue that has to be looked at. and there's a lot of potential. when you think of the areas of the brain affected that they lack the ability to control impulses, their emotional liability is compromised and you know, this irritability and rage is a volatile combination. i would think absolutely it would be a concern. >> discuss it from the military standpoint. similar symptoms in military and suicide rates. move close to the mike. >> absolutely. in d.o.d. one of the things that we struggle with is the way that
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patients -- >> move close to the mike. >> sorry. the way patients come to us. we're mostly male, 85% male, 18 to 30year-olds, physically active, the thing is, is that as a psychiatrist and many people in primary care clinics we're not seeing people right after they've had a concussion. we're seeing people downstream. as i psychiatrist, for me i need to tease out concussive illness with ptsd, pain disorder, any number of other things and folks don't just come to you saying i had a concussion and here's what happened. diagnostic clarification is a huge issue. i've heard disability brought up in a couple of places. v.a. schedule has specific items of ptsd but ascertaining the nexus between the insult and what happened downstream is very hard for us. certainly augers policy issues and the like. >> help me understanding, discussing this ace fellow navy
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provider, too, many of people diagnosed in the past with ptsd had similar symptoms to what miss mchale is saying, nightmares, troubles in social relationships and realizing a lot of that is from concussions. >> absolutely. it's very, very challenging to ascertain. it's tempting in d.o.d. to use the sports medicine model for prevention and treatment but we can't. we can't do that and meet patients where they are. so a lot more to learn. as a physician, i have a 2-year-old, he's been walking 300 days and hit his head 300 times. before i tell him to walk it off and rub some dirt in it, i want to say, how can i possibly assess this 2-year-old because he doesn't give me a history. it strikes me a lot of mire patients can't give me a history about what happened, when it happened, what happened downstream and that's why we need to move the research so much. >> i just want to add, because i think we're getting mixing a
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couple of things, there's the issue of a concussive incident. this is what i was trying to say before. one concussion, how you treat that? when do people go back on to the field or wherever they're going, and the second question is cte question, which is repeated -- and it's not -- i mean it could be repeated concussions but it can also be a long history of repetition for sort of, okay, i'm not a doctor but sort of subconcussive, you know, i'm not sure we have -- we have scientific data to support all of that. >> let me ask this. take a pause here for identification. i want someone in this room to identify how you -- what you look at in an mri, before i go to you, what you're looking at, p.e.t. scan, tell me what you're looking for. the movie was all about the --
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ask someone describe what you see, what you're looking for? describe that. >> not exactly what you like to hear. we can't see what we want to see. let me just go make it as simple as i can. in the end stage condition, so in stage iv disease, the brain is severely degenerated and that will show up on an mri scan as severe atrophy. and the culprit, we think, is aggregation of the tal protein in the serve cells and that is the signature of cte, it is also very important in alzheimer's disease, dementia, psp. multiple different diseases with think the tile protein aggregation is a bad actor.
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now the trouble is, as you move back in time to people who are not severely demented, then it becomes trickier to know what the differences are. so what we have funded is research that will look at the brain because now you can only make the diagnosis in a brain after someone dies, then image those brains for tal or mri signature, and then the next stage, another grant we're funding, to move into longitudinal study to follow people at risk to find out when the imaging signatures or a syndrome, characteristic clinical syndrome appears we can say this is an accurate diagnosis, if x, y, and z are occurring. that's the situation we're in now. we're really unfortunately stuck with the problem we need to examine the brain to know if somebody has it. >> but we shouldn't shy away -- >> let me finish up. i know you're going to go for a while. i know this guy.
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so, the problem is, which i think we've got to throw out on the table, we nshly -- i don't know about ann thought this would be a rare event. we knew it happened in boxers. to find out it happened to people who have 1,000 hits in a season, it's not that much of a revelation. but to find it in people who have high school or college exposures or to find it in a brain bank, doctor, you mentioned the brain bank, look at the mayo clinic to find it in 30% of people who have played sports, we now don't know how common this is. we don't know whether everyone is going to progress. we doubt it. so we really are desperate to try and figure out way to diagnose this in people. we have a couple of clues but we have to work those out. >> yeah, there are lots of ways to diagnose early cognitive deficits or early behavior dysfunction.
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plenty of ways to diagnose acute brain imrajry. they don't involve imaging at the present time and may not in the short term. >> not specific? >> right. we have physical exam. we have neuropsychological testing. physiologic measures, physical eye tracking, and posturology, dr. collins a leader in. plenty of ways to diagnosis. if we believe this sky's falling we need to create a multimodal approach to assessment. it's never going to be a single test. it's never going to be $1,000 mri or dti, it's not in the short term. but we have clinicians that know how to do this. and researchers around the table that can put together and have put together multimodal assessments. that's what my research is. that's what my research is. that's what everybody's research is. >> that's not cte. >> for cte as well, absolutely for cte. that's how we diagnose alzheimer's we can wait until the person expires and look at
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their brain or late stage ct or mri scan. researchers are looking at early evidence of dementia, you know. and that does not involve imaging. it involves other testing which we all do. >> i would add there have been a number of points of interests raised i think in the last 10 or 15 minutes that start to converge around a common theme. and the unfortunate reality is the common theme is the lesson we've taken 30 years to learn and represents the dilemma that we currently face. we have been fascinated with some discovery, some magical discovery of a single solution theory that would explain and predict outcome across individuals. one of the burning questions in the scientific community, it's no wonder if is in households, the same question is, how can it be two individuals with seemingly the same injury have much different short-term outcomes? and now the narrative has turned
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to how could it be that two individuals with seemingly very similar exposure profiles have -- lead much drastically different lives? it has to be a complex matrix of input channels that predicts risk. it's not -- this condition short term and long term is far too heterogenius there's a single predictor variable. with respect to long-term outcome, the burning question is what are the risks? how prevalent are they? who is at risk and why? what are the factors that predict risk? how could we interrupt or prevent those risks? and it -- the parallel question at the same time is, is exposure or what we oftentimes say how many, meaning number of total concussions or how much total exposure, is it necessary,
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sufficie sufficient or neither or both in predicting long-term risk of neurologic health problems. all of those questions remain unanswered. >> i want to make sure everybody has a chance to ask questions. go ahead, jan. >> i'm concerned the nfl has a troubling record of denying scientific ininquiry into the risks of playing football. when a doctor published evidence of cte in the brain, and former player mike webster, nfl doctors went on a campaign to discredit and undermine both the doctor and his, who. the doctors went so far as to demand retraction of the doctor's peer-reviewed resent. for the next 14 years the nfl pursued a strategy vehemently denying the evidence of cte and
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former playerers the league began producing biased nonpeer reviewed research. that routine repetitive hits in football are linked to chronic brain damage. the nfl suppressed critical information for current and future players about the long-term health implications of playing tackle football. yƱ 4, 2 three days before the super bowl, dr. mitchell burger, a member of ed 4, neck and spine committee denied there was a, quote, link, unquote between fnl and cte. dr. burger grudgingly admitted only, quote, can be, unquote, association between football and cte because some former players have developed the disease. to hear an nfl affiliated physician waffle and obfuscate about a basic scientifically established connection is truly
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astonishing. some may want to claim the league has turned a corner, they may highlight the nfl's rule change and the neurotrauma specialists on the sidelines at every game. they point to funding the nfl has committed toward reducing and managing concussions. i want to ask about that, too. espn said there was some change in that. as laud ibl such initiatives may be by focusing on concussions, the envelope is pedalling a false sense of security. football is a high risk sport because of the routine hits, not just diagnosable concussions. what the american public needs now is honesty about the health risks, clearly more research, the risks inherent in popular sports like football. so i just want to ask what i think is an -- a yes or no question from both dr. miller and dr. mccrea.
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let me ask dr. mccrea, do you think there is a link between football and degenerative brain disorders like cte. >> i think there is a link between playing football and cte. we've seen it 90 out of 94 nfl players whose brain we asked, 45 out of 55 college players and 6 out of 26 high school players. i don't think this represents how common this disease is in the living population. but the fact that over five years, i've been able to accumulate this number of cases in football players, it cannot be rare. in fact, i think we are going to be surprised at how common it is. and the other thing i really want to emphasize in this discussion is it's not about concussions. it's about limiting head injury. head injury that occurs on every single play of the game at every single level of this game. we have to eliminate somehow the
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cumulative head impacts. we need to have sensors or accelerometers, some way of gauging the number of impacts and limiting them so we can maintain safety for athletes, especially at youth level when they don't intend to make their life about football. we have seen many times, lisa and i, amateur athletes come down with the disease. it's devastating when you see this disease in a 25-year-old. i don't think it's common, but we've seen it over and over and over. it cannot be rare. to me what our job is, as american citizens, to maintain the health of these young athletes for the entirety of their life, and if there's something we can do to limit this risk it needs to be done immediately. >> thank you. mr. miller, do you think there is a link between football and degenerative brain disorders like cte. >> certainly dr. me key's research shows a number of retired nfl players are
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diagnosed with cte. the answer is certainly yes. but there are a number of questions that come with that. >> i guess i just -- >> right. >> is there a link. >> yes. >> because we have seen -- i feel that you know, that was not the unequivocal answer three days before the super bowl by dr. mitchell burger. >> i'm not going to speak for dr. burger. >> you're speakinger to the nfl, right? >> you asked a question whether i thought there was a link, and i think certainly based on dr. mckee's research there's a link because she's found cte in a number of retired football players. the broader point and the one your question gets to, what does that mean, where do we go from here with the information. when we talk about a link or the incidents or prevalence, i think that some of the medical experts around the table -- for the record, i'm not a medical physician, i feel limited or
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scientist -- i defer to the people around the table what the science means around the question that you're asking. >> i have another -- another issue i want to bring up. saturday's tribune brandy class taken, famous soccer player, they had that famous picture of her taking off -- anyway, talked -- she is donating her brain to science because obviously she wants more research. plus, she has -- she's acknowledged that she may have suffered several concussions. but this article also says that "the new york times," the no foe mail athletes found to have cte, "the new york times" reports, which i found strange, but it also talked -- this article talks about female athletes suffer greater rates of concussion, report more symptoms after concussions and demonstrate greater impairment
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during neuropsychological testing for experiencing concussions when compared with their male counterparts. and the idea that there needs to be more research and nih actually just now, 2016, said that gender has to be a consideration in all pretrial and in clinical trials. difference as well as the clinical trials. and so i -- i just want to put that out there. i want to ask, do we need to reconsider whether or not sports need to change for minors? should we, for example, e-lum nate headers in soccer? should we be considering whether children, minors, ought to be playing tackle football at all throughout their lives? do we need to have a more comprehensive view of whether or
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not we should subject our children to these kinds of sports? you know, adults who want to play professional athletics and want to risk this kind of thing, it seems to me that's their decision. as long as they know the risks. but children, should we change sports? >> from the standpoint of what you're asking about gender issues and at-risk populations and bringing this back to scientific level, can someone respond? first, dr. gioia and hainline. >> a confriend at georgetown a few weeks ago looked at the issue of gender and concussion in particular. one of the things i presented at that meeting was that it's -- it actually is age and your gender. we in fact, in our work, have found that boys and girls are not different either in terms of their symptom expression when preadolescent, but when they're
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adolescents we see big differences between boys and girls and symptom expression. we don't know why. but that also -- when boys and girls are not injured, whether young or adolescent, we don't see them talking about nonconcussive symptoms differently. so there's something about concussion in adolescents that is an issue here. i'll go back to kind of the point i made earlier, which that is we don't understand enough about girls in this kind -- >> what direction are girls different than boys? >> higher symptoms. adolescent girls are reporting more symptoms and taking relatively longer to recover than boys. >> is it true that no female athletes have been found to have cte? >> that's true. we've only had four female brain donors and they weren't all athletes. it has been twice described in literature, one was a domestic abuse situation where she had been abused for many years by her husband. another one was autistic woman
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banged her head, repetitive led banger. the demographic of sports in military service favor men. we expect this to change because of the recent increase of women in contact sports and certainly in the military. but we are actively trying to recruit female brain donors to answer this very important question, is there a gender difference in the outcome from repetitive head injury. >> doctor, do you have an answer? >> yeah. i think the main issue here is we're talking about complicated injury in the most complicated organ in the body. we don't have a natural history study from the time that a kid gets injured or somebody has repetitive injuries through the course of the development of something like cte. for example a colleague, cardio author raftic surgery, it completely changed the way we've looked at it. what we need today is a longitudinal study of the problem to understand what is the incident of this.
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we need better diagnostic tools. we don't have beyond a clinical exam objective biomarker or blood-based biomarker we need better ways to predict who are those people who aren't going to do well. it comes down to funding your famili pam /* pamphlet nih is spending $93 million to understand a problem that costs over $70 billion a year. professional athletes make more money in a single contract than the doctor had to fund research that we're asking questions about today. in many ways the gap can be closed by better care, better follow-up, better screening and unfortunately we have to make a bigger investment in the problem to understand this. again, i'm overjoyed that the american public has turned a problem that as a neurosurgeon working in level i trauma center in urban environment i've seen this and consequences of traumatic injury for decades.
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i appreciate you're interested in this. but there's got to be a more sustained and powerful investment to understand the problem. >> dr. hainline? >> so i want to speak with some cautious optimism about where we may be. so the ncaa and the department of defense joined forces, a little more than a year and a half ago. we have begun a study, and we're going to be getting results real-time. so this is a study that is involving 30 schools. at each school every single student athlete, whether female tennis player or male football player undergoes rigorous multimodal examination. if they're concussed it's repeat the six hours, 48 hours, onward in six months. seven sports, three women's sports, women's soccer, lacrosse, ice hockey, the same for men, and men's football. also getting genetic testing, kids are wearing sensors and
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getting brain mris. just in a year and a half, we've done studies on 18,000 student athletes and tracked over 700 concussions. a large study before that may have been upwards around 20 concussions i'm happy to say to people at table, mickey collins is a participant, mike mccrea is a principal developer, the colonel and i spent a year putting this together. geoff manly and i met, we're working in a cross functional way that has never happened before in concussion research. there are so man q. people that are invested just in the study alone. what we're going -- what we're doing, and dr. mccrea can speak to this, i'm not allowed to evaluate the results firsthand because that would be a conflict of interest. walter and i and dallas, we're on the executive committee of the study. we have oversight but we don't have voting power. it's set up in a way that that
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it's a nonconflict of interest study. we will be having a few things. the study's going to provide definitive evidence. in the short term, within two years, on what is the natural history of concussion. just concussion. we're also going to be defining neurobiological recovery in concussion. which is exceptionally important. that's different than symptom recovery. we will have that data. mike mccrea can speak better to it. but closer than another year we'll have definitive data on what it does mean to be neurobiologically recovered. coming back to washington in three days, laying foundation dozs to put this into a five-year study and make this the framingham study of concussion. it doesn't mean we're waiting 35 years. it means in very, very active five-year increments we're coming in with new tools
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including p.e.t. scans and advanced brain imaging to understand what are we seeing in increments. are we seeing problems for certain groups of populations. it's not just ncaa athletes every cadet at west point is enrolled and we're studying these individuals as well. in addition for everyone concussed, they have a control and their contact collision sport and noncontact sport. for the first time we're going to have real data on those who have had repetitive head contact but haven't been concussed. so that's something that we're actively looking at. so that's ongoing. it's very real. and the first wave of analysis is going to be report the some time -- not going to hold you to to, mike -- late spring. >> june. >> and it's going on after that. even while we're waiting for these results, so just two weeks ago there were 15 of the most prominent medical organizations in sports medical organizations in the country, and we looked at
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first round of the results, including very, very detailed head sensor data. i'm not putting out a specific date, but you're going to see, coming probably within the next three months, very new recommendations that are called inner association guidelines. not ncaa specific but equally endorses by the american medical society for sports medicine, congress of neurologic surgeons, american academy of neurology on concussion diagnosis and management. with regard to our football practice, the ivy league was in the room with us, their information was leaked earlier than they wanted. but there's going to be a whole new emphasis on absolute recovery, which is something that's been overlooked as well. i am just a little optimistic that we do have something very, very hot in the pipeline, it's very real, and we're getting active results. >> does anybody here think anybody at this table think we should change the rules of the sports for our student athletes? that's what i want to know.
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should headers in soccer -- my grandchildren play soccer -- eliminated or any way change football? >> i feel, and brian you've brought so much to the field, with the research you're overseeing and managing, i think we need science to lead the way. and i think it really behooves us to put science first in understanding these issues because if we make sweeping changes on sports without having science there could be unintended consequences that i see every day in clinic. >> correct. >> i want to make a pitch for science so lead the way. >> if we don't fund this for longer than the two or five years, we'll be back in here five years. this longitudinal needs to go on. headers are not the problem in soccer. >> richard hudson has a question. then paul tonka. >> did you want to say something, too? i didn't see your hand. >> yeah. i would just say, i hesitate to want to wait on the science when
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we know that simple changes to a game can have such a tremendous impact on the safety of children. i would say absolutely there could be changes in youth sports and absolutely we should be having a conversation about the wisdom of putting our kids in activities where their heads are getting hit repeatedly over and over, when we know for some individuals those consequences can be very, very dire. and we don't know yet about the risk factors. we don't know yet about those that are going to ultimately be -- have the consequences of something like cte but we absolutely know that no head trauma's good head trauma. i believe there are weighed that we can absolutely make games save favor without toying with the fundamentals of the game. soccer, absolutely, they raided the age at which they will introduce heading in soccer. the usa hockey raising the age of checking, all of those will make tremendous differents in
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terms of making kids safer. we should explore every opportunity to make every sport safer in ways that don't change the game, but absolutely that conversation should be had. >> i want to make sure we get our members' questions in. mr. hudson. >> thank you, mr. chairman. i represent the home of the carolina panthers, and i did marry a girl from denver. representative, i a have to accept you on the super bowl victory. >> i'll accept your congratulations. >> appreciate the panther blue jacket today. sorry. i have become interested in the issue of pediatric trauma. my interest was piqued by the children's institute at wake forest center in north carolina. they're doing a lot of work in trying to look at some of the questions. for example, studies where they put sensors in helmets to look at not just big hits but constant hits and the outcomes of that would be. one of the things that struck me
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the disparity of care. if your child suffers a trauma incident and you live near a level i pediatric trauma center your kid's got a great chance of surviving and being healthy. if you live in a part of the country that doesn't have close proximity, a lot of problems. that's one of the things that nags at me. the chairman and chairman upton have help immediate get a gao study to look at this issue across the spectrum of how care is delivered. it was interesting to me when you brought the issue of awareness but also how do we take the research and understanding that you all are developing and then have it available and where the rubber meets the road, where the care is actually happening? maybe i'll throw that open. >> a couple of comments. i mentioned mild traumatic brain injury guidelines. including clinical decisions support tools within electronic health records, children's
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hospital of philadelphia has been leading the way in this area where they're integrating across -- moshing across their health care settings from their eds to primary cares to urgent cares. all of the clinicians whether or not advanced medical education in concussion management. protocols are built in to their clinical decision support. the care, regard office the setting they show up for care in, is identical or near identic identical. i think that's critical. the other thing i wanted to mention another active area of inquiry for cdc, mr. miller mentioned earlier all 50 stated having return to play laws. we're very much interested in the best practices within the return to play laws as well as return to learn protocols. we're actively evaluating go they work, how they work, what are the components of laws that need to be in place. those are a couple of thins. >> dr. gioia? >> to recognize what brian and
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ncaa, mike and others are doing with the d.o.d. i this is laudable and it's 18 years to advance. we need to do that with kids. we need the same focused research for um for kids below 18, below college levels. and part of the reason that we have it is because we haven't really had both advocacy but organized advocacy and research systems that are set up to some extent by the way ncaa and d.o.d. have them. the children's institute is part of a consortium that we're developing on pediatric brain injury called four corners consortium. dallas knows about this as well. trying to model what is happening the collegiate and above level really for kids. really to look at that question, what are the risk exposures, what are not? how do we understand epidemiology of this as well as treatment. i do think that some priorities need to be reset, not just to
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start with the collegiate athletes but start with our youngest kids and moving that forward it can link with what is going into the ncaa, into the d.o.d., that means the cdc, nih and others need that funding support to really make that happen. >> one of the things that happened in youth sports over the last 120 years has made this more difficult, and there's ways to overcome that, the participation in school-based sports is actually declined while club-based sports increased dramatically. but that's the wild west out there. and we need to have some way that even if the club-based sports, they get incorporated into the systems that were developed. >> just wanted to clarify one point that dr. gioia said. nih we have looked at the portfolio and we agree that what this issue of understanding the
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effects in children is a gap and that seems to have been currently highest priority of trying to fill the gap with further research. thanks toer that. >> to that point, i appreciate brian mentioning care consort m consortium. all of these things start to hang together with the mentioning of track tbi and four corners initiative that jerry's heading up within a year, the care consortium will have 25,000 collegiate athletes enrolled. we estimate over 1200 concussed athlete whose have arguably represent the most richly characterized cohort of injured athletes ever enrolled in a study. that provides a unique opportunity. you know, i hate to keep coming back to this point, but the reason we're sitting here debating a number of very fundamental issues about long-term risk and outcome is
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because in large part, there has never been a truly population-based prospective longitudinal study of outcome after traumatic brain injury. the military and the v.v. has invested in to do exactly that in military service members and veterans but to date we've never done that in the civilian setting and track tbi provides the most richly characterized cohort of civilians affected by traumatic brain injury. care represents the largest and richly characterized cohort of athletes affected. we not only have detailed data on clinical recovery but we have blood biomarkers, genetics, imaging that tells us about the neurobiology of the injury, as the doctor was pointing out earlier. the fact of the matter is, again, i keep preaching to the choir here, the likelihood that a single variable, whether it's injury or exposure predicts
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outcome, i think, has already fall. on failure because, again, we look at two individuals with seemingly the same profile of exposure or injury with drastically different outcomes even in the short range over ten days and over an entire lifetime. it's going to talk a monumental effort, and there are some low hanging fruit that we can grab early on here that would answer some of the fundamental questions. in terms of what is the risk associated with exposure, whether it's subconcussive or injury, but what's the multiple -- multidimensional mat trix of factors that predict outcome in we've been chasing the single solution for decades and it's destined to failure and that's the lesson learned and dilemma we face at present. >> dr. manly, you had something? >> yes. one of the thinnize want to make sure we don't miss, and we're all very passionate about youth
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sports, very passionate about what happens with kids, we've talked about the community impact but i don't want to forget about the elderly. the fastest growing population of concussion and brain injury is the elderly. there's a 50% increase. in california it's higher than that. less than 1% of the literature has spoken to this. we've excluded these people from prior clinical trials. as best i can tell, knowing a lot of the people overs the year we're all moving in this direction, and the cancer doctors and heart doctors have done a wonderful job. and this is going to be an ongoing problem. and i know this is a big problem, there's a lot to chew and i'm glad we're talking about this. i don't want to forget the elderly. this is a population we need to be very mindful of. >> thank you for redigging us. incredibly important. paul tonk coof new york. >> thank you, mr. chair. all of the talk of cte and i'd like to take a step back and
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focus on that for a moment and dr. mckee, whomever around the room, when was it recognized as a unique disease? and is there a distinct quality to it that separates it from alzheimer's disease or other neu neurodegenerative diseases? what likely is the biggest cause? i heard, you know, you talking about extending beyond concussions and also just head injuries. final item i'd throw out as a question or oh, there's talk of clusters of depression and suicide. are there things that we're already learning about the impact as it relates to suicide or mental health -- mental elt
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i illness or health disorders? >> so cte, i can't say when it exactly was identified as a unique disease because it's been known since the 1920s. there was advances in 1970s in about the neur pathological and clinical characteristics. but actually i do think it was the consensus conference held just a year ago that established, this is a unique disease. it can be distinguished path logically from alzheimer's disease. it can be distinguished from aging or all these other unusual tile-based diseases like progressive super nuclear palsey. er with we are blinded to all of the information with these slides. they went through these slides pb they sifted through them. took them about a hundred hours each. in over 90% of the cases correctly identified cte.
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they even went further and said there was a characteristic lesion in cte that they have never seen in any other disorder. and this panel of experts also said that in their combined experience they've never seen this disease in anyone who hasn't experienced trauma, typically multiple episodes of trauma. that's about as distinctive a disease as can you hope for. at least path logically. what we're struggling with is where are the specific clinical characteristics. it has a lot of evoverlaps with alzheimer's disease and when it presents early life in the 30s, it can be depression. it can be personality disorders. it can be a lot of rage, aggression, domestic violence and suicidality. it is very hard to sift through those symptoms because they are nonspecific but we are certainly seeing that in many of the individuals with cte found at postmortem when we look at their
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clinical characteristics during life. so depression, very common. suicidality, common. aggression, violent behave your, short fuse, explosivity and memory problems are the most common clinical disturbances. >> thank you. thank you. and the advance research that would come or additional research that goes forward. what's the most critical step as you go forward with the -- >> well, i think the new funding of the long-term perspective cohorts, following former nfl and i believe some college athletes over time they will be serial evaluating them. yearly evaluations. yearly imaging. doing blood tests. and then they will follow them to death. and hopefully we will be able to develop a way to image the disease with certainty so we can diagnose it during life. that's probably the most important thing we can do at this point. diagnose it during life. if we could identify it in these
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young athletes, we could pull them out of the game or have a very good shot of treating it. so we really want early identification during life. and i think this seven-year nih study will go a long way towards answering some of these questions. >> thank you very much. >> do you have follow-up you want to ask? then i will ask a question here. >> very brief. you mentioned some of it. diagnostically, what are blood tests out there that you can help diagnose acute brain injury. obviously, cardiac disease, i was heart surgeon, you know. you get a cpk, you can tell right away that there's, you know, that in combination with radio graphic studies, but i'm not aware of what there is as it relates to the brain. can anybody comment on that? >> i defined most of the work in that field when i was dod. there is nothing approved at this point. there are more than 20 different potential targets, two of which
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have actually been through the pivotal trials are now analyzed and hope to be submitted to the fda by the end of this year for approval. the data i've seen looks very good on it. the idea that you could in fact measure in the blood, something that happened in the brain, is denied for most of history until about 12, 15 years ago. and blood-brain barrier was an issue we couldn't cross. what was actually shown, with very high sensitive instruments, there are break down products from brain injury that seem to get into the blood and i have a strong hope that in the next year we'll see a test and that will get better in brain injury just like it got better in heart disease. >> or cerebral spinal fluid. >> just as in heart disease and stroke, awareness for clinicians about how to make the diagnosis when they come in without using
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a blood test is a lot cheaper and a lot easier. so i truly hope with years of dedication and funding will result in blood tests but we actually have tests now, just when a person comes in, in the er or on the field, battlefield or ball field, we can diagnose them now. >> we do think that as they do research, they should take blood and try to develop it. >> sure. if that's part of the protocol and done correctly, of course. and we do. but in the meantime, the rest of the world is actually just treating these people and we've been doing it with pretty good rigor for years. we are trying to refine that and obje on /* object fie them. >> i have a question that i want everybody to answer as part of this panel. this is the oversight and investigation subcommittee. our job is to gather information and be forwarded to make legislative recommendations.
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this can be anything from the budget issues to this has jurisdiction over health, jurisdiction over nih, professional sports, wide range here. so i'm going to ask this question and i want each of you to answer it in whatever realm you want it come from, but what do we need to know? the key committee that will deal with this, what does congress need to know, with whether it is a recommendation or information that we have to have in the areas of causes, prevention, diagnosis and treatment? what is your take away that you want it make sure that this committee knows? i will start here, doctor, you can start. >> thank you. >> make sure your mike is on. >> so i would say in terms -- >> do this in about 30 seconds. >> in terms of causes i think we need a dose response curve. given the individual, what is their risk, almost like a risk score that the framing has. so we can advise parents, advise
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people, whether nfl players or others, the list of long-term. i think that will take a while. before i lose my chance, i will stay one other thing which is we should put on the table trying to understand the effects of last injury. many people around the table are looking at sports injury. they won't look at blast unless there is that type of injury. we have hundreds of thousands of veterans exposed to blast. we know very little if anything about what happened to their brains. >>. >> before brae? >> think there are questions unanswered. the positive position is we are not starting from scratch wp we have strides over the past 20 years that put us in the position and a people in the room and colleagues around the
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world can he did ziesign the st to directly answer the fundamental questions. but the studies will be major undertakings that require a significant investment on the part of both public and private partnerships. then we can come back to the table and answer the critical questions that the public domain wants to know now. and we can answer those with science. >> thank you. dr. heck? >> what we need are successful clinical trials to do something about this. we have 30-something failed clinical trials. we added multiple analcys and why those failed and yet we keep doing them the same way. as much as i am the strongest add vericate of the studies and those kinds of things, that is more admiring the problem. we need to find treatments for this. we need to get at the fundamental issues of why the studies have failed. i hand it over to jeff, because i think the tag team here,
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because he will say what i would have said. >> so yeah. we have 40-something definitions of concussion. that means no one knows. what we need is we know that there's multiple forms of injury here and we need better diagnostic tools, whether they are imaging, blood-based biomarkers. the heart is a great model. like mike said, more than one thing. not just a clinical exam, it is several things. until we have a diagnosis, we cannot have a target of treatment. until we have target of treatment, we will never have a good outcome. i think the work that we've been doing and the good news story is a lot of us are working together based upon common data and elements and data bases we are all sharing. we all know one person won't solve this institution. we are working to the in public-private partnerships. bringing in industry in a competitive environment to figure out how to make a difference here. one of the things we need is we need more funding. $94 million is not going to cut this. this is a very, very big problem in the united states. there's lots of money floating around in different places and i
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know there's a lot of problems. but we've heard from everybody here that this is a major public health issue and the awareness is here now. it is now time to really, you know, put some money where the mouth is here. and fund some of this stuff so we can make a difference for our patients and their families. >> we're going to go around. i have a hard-stop time, so i have to come back. >> far too modest. what we have fail trials, we don't enroll the right patients in the trials. tbi is just like cancer. it is not one single entity. and right now we treat it like one entity. it is multiple diseases in one. so we don't enroll the right patients in the trials. and measures currently used to assess whether there is a difference in the patients is fundamentally flawed. it is based upon measures that have very little to do with the patho physiology of what is going on in the disease. we need to solve the problems at clinical trials and as jeff is leading a big effort to do part of that.
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>> ms. mckale, what does the committee need to know? >> it is clear there is a lot that is known. there is certainly a lot that needs to be learned about concussion. but of that that is known, you know, it occurs to me that had this tragedy never occurred to my husband i would be very much in the dark about cannot kugss in general. and i find that i deal everyday with parents whose children's lives have been derailed when concussion treatment and what not goes wrong. there is so much more prevention that could happen by just this issue of awareness. so much needs to be done about getting this critical information into the hands of the people where it will make a difference and that includes not just the coaches, not just the athletic trainers, but absolutely the parents and the athletes themselves. >> dr. keen? >> thank you.
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we need a blood test for concussion. monitor the brain injury until it's recovered then let the kids go back and play safely. in an ideal world, diagnosis for concussion we need to measure the number of hits our kids are getting. somehow address the aaccumulative head impact and measure it so we can establish the dose response curve. we need to diagnose cte during life. blood test, cfs test, or maybe the pet scanning. but we need to be able to make the diagnosis during life. that will give us our best chance to monitor a treatment and develop a treatment. and then lastly, we need to follow our youth athletes from youth until middle age and maybe beyond to really understand all of the multiple variables that play into risks of contact sports. we all know sports are extremely important. we want our kids to play sports. but we need to understand the risks. >> thank you. >> around this table there are five massive studies going on that have all these questions
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imbedded in them. all of them. and they overlap and the studies are actually integrated. we actually talk to each other. most of us are on all of the studies together. we need those studies to just continue and finish and you know, as they are. we don't need 12 studies, 5,000 new questions. all these questions, we have heard at every meeting. we are all aware of them. we have little mice with helmets on getting injuryed. we're asking the same questions. but they go from children to elders and everything in between. and so what we need is just to raise awareness, raisedcation, because a lot of us actually are managing these folks effectively but we need to continue with the path of science we're doing and not overreact or underrepangt but really if we could just kind of have the folks that are all linked into these studies, just work on this for at least the next five years, if not longer. we will actually have the answers. and then we don't have to have
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this fantastic meeting again with the same level of basic questions. so i just think we need to steady as she goes and push forward with what we're doing. in the military, ncaa, nfl, children, elders. >> thank you. >> dr. headline? >> yes. with regard to studies, i'll reiterate, i think we are getting the answers and the funding will be important moving forward in five-year increments. i think what the world needs to hear and i truly believe this, is that there is unparallel collaboration amongst sports medicine organizations working with the cdc, with the national governing bodies. i've been in sports medicine publicly for over 25 years. i've never seen this degree of collaboration before and it leads me to be somewhat optimistic. and again as public health advocate for sport and i truly
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do believe in sport, it is much different than exercise, we need to focus back on youth and understand where they are most vulnerable is the lack of coaching education. it is great to empower parents but coaches need to be empowered as well. we aren't doing that in our country. and i truly do believe we need athletic trainers. we need to empower them and make sure they are a part of every, especially contact collision sporting event. thank you for this opportunity. >> thank you. >> dr. collins? >> i would like to echo at lot of what i heard here. i would like to echo dr. hailine. we are more collaborate than we have ever been right now. we need the science before we make any rash decisions on the issues. i think the science is coming from soon in terms of helping to answer the questiones. i want it stress in pittsburgh we see 20,000 patients year and very few kids i see that don't
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get back to play safely and enjoy the sports that they love. we don't see the morbidity that is being discussed here. i think there is a big kass em between that and what we hear in terms of cte. i think we need more research in cte and bet are understand that construct as well as bring this all together. i think more work needs to be done. we have never been more collaborative. science is maturing. i think we need more time before we make any large scale decision. >> mr. miller? >> as the only nonph.d on the panel, we take our information from where we need to do our research. we collaborate with people here too. so it won't be surprising that
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my answer will be what many others have suggested. we put our research dollars into a few buckets. one is diagnostic to treatment. as we sit here now, we have a research portfolio with public and private collaborators in excess of $100 million and those things can drive change. but it's the people who are here and many people like them who do the hard work who are going to move the science forward. so i guess i would suggest some of the things i've heard today like perspective longitudinal study. like more money being invested in the treatment. better education and advocacy. all these things this fine group of people is doing. and maybe just more of the same is going to get us to a better place relatively soon. >> thank you. dr. joyo? >> last but not least are the kids. i will reinforce, reemphasize that collaborations that are
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happening right now are largely if you are in your teens and beyond. we need to understand the risk and forces that go with it. do we refresh, do we not? keep the kids having fun, and is it a full development spectrum injury that we have to understand. >> thank you. >> thank you, representative murphy. i say clinicians say we balance risk and benefit. anything we come up with for universal prevention strategy needs to balance those risk and benefits. not moving is bad for your brain. not moving is bad for your cardiovascular system. which is also bad for your brain. right now my 2-year-old is not hanging out in his crib. not wearing a football helmet around the house, he is moving.
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because that's where i believe the science is right now. also we need to move the science. i don't think we can answer the questions about traumatic brain injury and cte without studies. we have a handful of papers in the first five years and then it exploded. and i think that you know, certain we've got our research priorities in order. i know my colleagues in dod are very atune to this problem. and i think we're going to move in these next -- in the next decade or so. thank you. >> dr. mullen? >> thank you for invite meg here as well. i think from cdc's perspective we need better info. as i mentioned earlier, across mechanism, life span, understanding context and circumstances. outcomes, including disability. and of course recovery. that will help us do two things. understand the problem better. even at the state level and understand if all of the prevention efforts we are talking about are actually making a difference. thank you.
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>> a statement? >> thank you. well mr. miller, i'm an doctor either, but that never stops me from giving my opinion. i want to thank all of the -- all of you for coming here today and sharing your knowledge with us. it's really instructive and that's why we like to do these roundtables from time to time. as somebody who works a lot in my career, on issues of biomedical research, i'm really shocked at how little evidence that we have for something that we've known of -- geez, i've known about it since i was a little kid and it is really shocking and i also happen to be a person who thinks that we shouldn't be doing public policy unless it's evidenced based. i look forward -- i'm glad you're all working together on research studies and i look forward to getting the results of that research. i just want to say one last thing as a mom though, we don't
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have a lot of moms that inherit this table at this moment -- i mean, at this table. and what i want to say is if i had a 5-year-old who was thinking about, and i'll confess i did try to get my two daughters to play ice hockey, but they decided to take ballet instead. not a lot of -- you can probably still get a concussion in ballet, but if i had a 5-year-old that i was, girl or boy, who i was trying to get to do peewee hockey, having people come in and say, you know, we need to get more data before we can tell you, mom, about what kinds of -- what kinds of play they should be having, and when should they start checking and all of that. so don't worry. in seven to ten years we're going to have some data from our longitudinal studies, that
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wouldn't satisfy me as a mother. as i say, i really hear what you're saying about the studies and i agree with it. but at the same time, i think it's important that we take some of the initial data that we have and start to at least put some protocols in place for kids. just like the nfl has with its players. to try to prevent some of these concussive injuries that really can have long-lasting effects. i guess my sense would be, better to error on the front end for prevention of something while at the same time you're studying so that you can really drill down for both diagnosis treatment and development of protocols. thanks, mr. chairman. >> thank you. i want to thank everyone for beg here today. this is quite a bit we learned. i fell like we should have gotten continuing education credits for this.
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i'm sure you will continue to work in collaborative ways as you proceed. from a standpoint here within we are calling, although we focused on sports and military on some other things, whether people are watching this on c-span or what members are taking with us, remember that most cases are from falls. that's the leading cause of death, for a person 65 years or older. motor vehicle crashes, leading cause no are children and young adults. 5 to 24 years. assaults, leading results for death to children 0 to 4. we have a lot to learn here. especially as mr. hudson pointed out, being near a pediatric trauma un it make a big difference. being around a stroke unit makes a big difference. i did see the movie "concussion." it is one of the strange things i know just about everybody in it being from pittsburgh. but also i know how much has changed in the last few years.
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having talked to dr. joe ma row, things were entirely different, just ten years ago and protocols and even such things as moving where you kick the ball on a kick off has made a tremendous difference in tbis in sports. but also working on a ptsd unit at walter reed hospital wrb i was there today, and what struck me about this whole thing is about how we know so little about this in the military. and how we need to know more. playing sport is a close. sunday is football day opposed to church day. with the 1% who volunteer to wear the uniform and take the oath, thank you for your service, doctor, it is amazing. and to watch how while wars have wound down and special forces are still there and patients, whether air force or green berets or s.e.a.l.s, they are still out there and coming in. and people who have been
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breechers and close air support of 1,000 and 2,000 pound bombs and the way the concussive shock wave continues to go through them. for the longest time we would get back results from neuro raid ologists enwo say, they must be faking it. and they are doing what you describe at home, lisa. temper, depression, suicide. you are helping us along those lines. we deal with things in the committee. but some things lead to life-saving efforts. this is helpful. we want you to stay in touch with us. with a series of hearings, where we good. whether it is making sure the brain initiative is fully-funded. a lot of this is in the air yf mental illness. we will talk about funding shortfalls. and spend half a trillion aier on problems. we are trying to find 1 billion
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or $2 billion a year to take care of it. that almost disgusts me that that's the level we are at, trying to find funding, when we could save a lot of lives. i think that's where unit of opinions do do this, but where there is a will, we have to find a way. please stay in touch with all of us. with that, this particular forum is closed. thank you.
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you can find all the briefings and hearings we've cover owned c-span concerning head injuries and recovery on-line on the c-span library, c-span.org. ahead of the primary there tomorrow, john kasich will be joined by former presidential
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candidate mitt romney. and ohio senator rob portman. live coverage here on c-span 3 at 6:00 eastern time. campaign 2016 on tuesday. with swing states. candidate speeches and viewer reaction begins at 7:00 p.m. eastern p.m. taking you on the road to the white house on c-span, c-span radio and c-span.org.p.m. taking you on t road to the white house on c-span, c-span radio and c-span.org..m. taking you on th road to the white house on c-span, c-span radio and c-span.org.m. taking you on thed to the white house on c-span, c-span radio and c-span.org.. t to the white house on c-span, c-span radio and c-span.org. ta white house on c-span, c-span radio and c-span.org. the aleph institute is heaping veterans and other groups and have sentencing federal laws including judge webs state advocates and state attorneys general. this summit ran about an hour and a half.
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>> you want it introduce the speakers? oh, right. sometimes they say people need no introduction, which would be true as well. it's really a great honor to be here with two attorney generals. i think one of the most exciting things we've seen in the area of criminal justice is more and more law enforcement leaders, sheriffs and in this case attorney generals. not only being interested and engaged but really taking such positive steps in the area of criminal justice reform. and of course we have a democrat and republican here so it also illustrates the bipartisan nature of this and in an age when so many issues are partisan. so i wanted to pose a number of questions here today and then we'll hopefully have time to hear from those of you in the audience. and about some different areas of criminal justice where one or both of you have really made a
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positive difference in your states. so first of all, i know we heard earlier today about justice reinvestment which is a daily-driven process that has gone on in more than two thirds of states to look at who is going into the prison system. what the programs are working. which programs aren't. what the various outcomes are. and bring together various stake holders from prosecutors to victims advocates, judges, experts on criminology, look at this date wa and from that highlight solutions. georgia has been very successful and is adding forms to it sessions and maryland is in a reinvestment process with the governor leading the way and of course with attorney general frosh. i want to turn to you and see if you know what is going on with maryland in that regard? >> sure. we actually use georgia as a model. because it's done such good
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work. but number of of about three years ago, maryland kicked off a series of efforts. we decriminalized possession of small amounts of marijuana. if you have less than 10 grams, if you possess less than 10 grams of marijuana, the first time it is not a criminal offense. there's a civil fine that's applicable. that relates to about 31,000 arrests per year in our state. so it took a huge load, we believe at least going forward, it will take a huge load off the criminal justice system. we have this year as a result of a task force that was put together over the past year, a series of recommendations em boba embodies making their way through the general assembly and there is general optimism that this measure which encompasses a number of different initiatives
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will pass in tact. because as you said a minute ago, marc, it's an initiative sponsored by the governor, by myself, by prosecutors, public defender. and it does a number of different things. it revises drug possession penalties downward for drugs other than marijuana it does across the board reductions in penalties. trying to minimize prison time and minimize incarceration. it also requires for folks who have drug addiction problems, prompt placement in residential treatment beds. there will be additional money available for it. instead of sending people to jail, they will be diverted, get drug treatment. it eliminates the disparities and sentencing between crack and
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cocaine. it raises the felony theft threshold. so that people who steal relatively small amounts of money or value of goods don't end up spending time additional time in jail, don't get convicted of felonies. it expands in prison good behavior program and incentive credits. so if you're in prison and you are doing what you're supposed to be doing, we have the opportunity to earn time or credits that will get you out earlier. we passed last year legislation that created a safety valve for mandatory minimum sentences. it applied prospectively. and it allowed people who are the subject mandatory minimum sentences to get those sentences
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reviewed by a three-judge panel. this year's legislation is going to apply that rule retroacti retroactively. so folks now in jail can get those reviews. it expands the alternatives to incarceration in sentencing guidelines and includes, includes suspended sentences in calculating the guideline compliance. that's important in keeping prison time down. the legislation also identifies best practices and alternative dispute resolutions. we will try to -- we have great success in the civil arena in maryland with alternative dispute resolution and we will try to turn that to the criminal arena. i'm sorry i'm going on so long. but it is a multifaceted approach. let me just give you a couple more. we have a risk needs assessment
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tool and when people are released and use swift and certain and proportional sanctions for violation of probation and parole. so it is -- there are, i think, nine other things that this legislation does. it is a broad-based and i think holistic approach to alternatives to just sending people away and locking them up. >> great. could you talk a little bit about georgia's experience and i know some of those things georgia has implemented as well. >> yes. so candidly, i'm go tock reing really short with this question. we heard from judge bogs an he was the coauthor in the first panel. and i would simply say that key here as was alluded to was the collaborative translucent transparent nature. when you have the aclu and the tea party both in the room, you're able to come to a discussion that creates a great
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bill. which limits the political after effect. which was alluded to earlier. so we've done a bunch of those things. we have also spent a lot of time on both revising parole and probation. we're now at the point where if it was a sale of drugs over x number of years, there needs to be a process to determine whether the individual has already served too much time and should be released. with this year's legislation, if they serve more than x number of years for possession, they have that automatic right for a hearing to be released from prison because as brian said, you've got to go retroactively back or you are only solving a small piece of the problem at a time. >> great. one of the other issues i wanted to bring up as i know you made a high priority of assisting victims of crime which contain a variety of forms from victim services, victim notification, compensation. sometimes of course in texas we have victims compensation fund
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that the attorney general runs. the first and best thing is if the offender can play restitution, of course if they are working, maybe they could do it. but otherwise as a back stop we have crime victims compensation fund. whether it is domestic violence or other types of crime, can you touch on other things you have done in that area? >> clearly, there is a whole list of fees and fines that defendants pay. queerry whether they should be paying many of them. many relates it pensions rather than relate to the crime. but restitution is number one. to the extent the defendant is able to pay first moneys go towards restitution for the victim. and thats really, really important. and then we have a whole bunch of services to decrease the recidivism rate and increase the potential that they succeed. everything from other issues such as banning the box to one
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of the neat things we really do in that regard is also a certificate. but with specific reference to the victims, just as you are taking extra time to figure out the sentences, you need to take extra time to figure out how to help the victims and let's face it, for too long, that's last on the list of things to do and it's been moved considerably up. and many of our district attorneys now have specific staff that are full-time specific to that issue. >> greg, did you want to anything on that? in different states roles can differ as far as whether the attorney general is involved or not. >> right. we do have a person in our office who works full-time on assisting victims and on policy for victims services. sam said it, for too long, as been at the back end and the legislation that we've got this year also focuses on victims services. i will say, one of the problems, we want it make sure victims get
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restitution. one thing that is with our folks in maryland and across the country is adding fees to sentences. and there was an article in the washington post a couple weeks ago about a woman who was sentenced as a juvenile to detention managed to get her ged, gone out of detention, she had no family. found herself a job. gainfully employed. and yet was getting yanked back to court weekly almost or once a month because she was unable to pay the $400 or $500 she had accumulated in fines in fees apart from restitution. she was getting pulled back by the court to a account for the fact she could not afford to pay
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these moneys. and that's a very, very serious problem. she was in danger of losing her job because she was performing at work and having to take time off to go back and account for these fees. >> sort after different question at the end but i think it is worth mentioning to the extent we can. for too long the answer we thought with the inmates is you let them get through the day. that's a pufrny issue. puny issue. so we have charter schools in the prisons, youth prisons and adult prisons, the government went up to a superintendent and said i want you to retire from your position and i'm going to make you the vice commissioner for corrections. and he's in charge of the programming it make sure there is educational programming. another thing that we do in addition to not only giving them a ged but giving them classes and having them walk out where they can get a good paying job rather than a minimal paying
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job, is we now have a system a where like in our technical colleges, we have a shortage of welders. we have a shortage of plumbers. god for bid if you need a plumber because they certainly charge enough. so in our technical colleges, if you good for a wedding degree, it is a hundred percent paid under the state's program. we are doing the same program in the prisons. now we have these folks who are released from prison with a welder's degree where they are going to be making more than my son who got out with a journalism degree. so not only are you helping those that have good behavior in the prison system, but you're actually giving them the ability to have a really good-paying job. >> that's terrific. one of the things we did in texas is occupational licensing, to get a provisional license to go into these jobs that would have disqualified them because
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of their conviction. on the fines, we would like people discharge them through community service. and again prior advertise the victim restitution for sure.adv victim restitution for sure. those are excellent points. and the charter school model is great too. we have seen when the school district sends some over they send the ones they want to get rid of. so having the principal there on campus is important. other issue is addiction. that is something we saw in new hampshire,i huge issue of opiat abuse. came up on both the democratic and republican side. combatting addiction whether it is pill mills or making sure that treatment is available. we have seen a number of states for example, emphasizing nonnarcotic treatments for opioid things to block the receptors in the brain that trigger that craving. also good samaritan laws and
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other things. so if you could touch on a little of what you have been involved with, both not just as attorney general but previously as legislator in dealing with addiction. >> sure. first, i don't know -- i apologize if someone put it in context already this morning, but let me try to do that. the price of heroin plummeted over the past several decades. i think in the '80s up around $1200 per gram. it is now down around $400 per gram. the purity of heroin on the street has tripled. and folks who receive prescriptions for opioid medication often find that they become addicted and can't get off it, turn to heroin, because it is a much cheaper alternative. from a law enforcement
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perspective, maryland joined a task force that runs from our state all the way up to the state of maine. i'm not sure we've made it quite down to georgia yet. but the folks who are trafficking in heroin don't respect state boundaries and we are the attorneys general from maryland to maine are able to share information and we think do a more effective job of addressing heroin trafficking. at the same time, you have to address the drug treatment problems that arise from heroin use from opioid abuse and one of the things that is making its way through our general assembly this year is greater input into the prescription drug monitoring program run by our state. new york has done an excellent job here. they require e-prescriptions. if you are writing a prescription for opioid
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medication, it has to be done electronically. no one can steal your prescription pad and forge one. in maryland we hope to get to the point where every time somebody prescribes an opioid medication, it'll be in in our data base. the doctor can check to see whether the patient has been to three other doctors before, been turned down, gotten prescription, and help doctors make better choices when they're prescribing opioid medications. finally, i guess i would say, like all attorney generals, we have a medicative fraud unit that looks at doctors who are overprescribin overprescribing. looks at pill mills. looks to see if the rate of prescription of opioid medication is so high from one particular practice that it raises suspicious about either fraud in terms of medicaid
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reimbursement or criminal activity. >> so in 2012 we wrote a bill to go after the pill mills. actually, we wrote it in '11. it government passed in'12, likg else, there's an education process before you can pass the legislati legislation. florida passed theirs in '11, and as soon as florida passed theirs, folks that were i think at the time florida had something like 95 of the top 100 doctors for prescribing opioids and there weren't that many wrecks on 95 or 4. as soon as florida passed their bill, they started to moving to south georgia. my favorite was the "wall street journal" did a story before our legislative session where used car lot dealer talked about pride how he immediately moved a facility into georgia to sell the drugs. he knew all about oxycontin. so we passed the bill, had a
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huge effect. we had gone up to about -- in one year we went from about 40 clinics, well, that's not the right word -- charlatons to 125, we're closer to the original number with pill mills but we did see a significant uptick in cost of pills, oxy, hydro, et cetera $30 a bill on the plaque market. and in contrast, as brian talked about, heroin is $10. that's created a huge, huge problem in that rartd. additionally. ags steal programs from each other. i always provide attribution. so the former kentucky ag, jack conway started going to talk to schools about prescription drug abuse. we took jack's program, and i added something to it which was a psa contest, 30-second psa
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from a mentor level. so i go into anywhere from 30 to 50 schools every fall and i bring with me local accountability court judges, sometimes the sheriff or law enforcement, more importantly, i bring with me a girl or boy who is about 22, 23, who is a recovering addict so that there is a minuter to level for them to hear the dangers of how addictive these drugs are and how hard it is to get off the drugs. if i walk into a high school and start talking abo to kids they' snoring if i have a 22-year-old with me who takes majority of the time they're paying attention. i frankly prefer to have a female speaker because with a female speaker the girls will immediately go up to her after the session, either disclose that they're in recovery or need to go into recovery. the boys generally aren't that bright at that age to go up to a
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boy, so i get a further benefit from the girl speakers. and it's been very well received. it is a interive process. when you go into a school and say you want to talk about drugs you're waiting for the phone to hang up. the more successful it gets and growth of accountability courts it's easier for me to now get into the schools. if we can play one of the winning videos from our contest. >> it's okay, don't worry. grab the pills and go. no one's going to notice that they're gone. besides, a few little pills can't hurt, right?
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>> so that was the winning video from 2014, and i have an association with the georgia association of broadcasters and one of the pharmacy distribution soebiations. they pay to have the winning video shown on tv for three months after our contest. so the kids can get to see their videos shown all over the state on nbc, abc, cbs, et cetera, and the whole idea here is to provide that education. we also give them a check, frankly. my office can't give a check, but the medical association of georgia, the georgia pharmacy association helped me in that effort. and the whole idea is to teach these kids how dangerous drugs are. we also have a 911 bill that you just mentioned. for instance, if these kids are at a party and someone falls to
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the floor, many times kids will think that it's okay, they're sleeping, they'll sleep it off. no, because once you get regurgitation, it then stops oxygen in the brain. that's called death. so we tell these kids that you call 911, if you're the person who calls and the person who you think is having the over dose, there will be no arrest unless the person who calls was a dealer. short of the dealer, there's automatic amnesty, 100% amnesty. also relates, for instance, to alcohol. so we now have the same scenario in college campuses, for instance, so the whole idea is we're saying you don't need to go to your friend's funeral. let have them get the narcan and have their life saved. so we now have a bunch of sheriffs and police departments that just as they carry an epi pen, they carry narcan, a nasal spray, so when they come to the call, they can immediately administer the spray to stop
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the -- start the reversal of the narcotic to, once again, save these kids' lives. >> that's terrific. you mentioned accountability courts and that's something both of you have in your states, whether it's drug courts, mental health courts, veterans courts. so georgia's expanded them greatly. did you want to add anything? >> prior to a.g. i was county executive or county chairman of a county of 700,000 folks, and before this was vogue statewide, before we had talked to pew and bga, my county had a dui court, my county had a drug court, my county had a juvenile drug court. for a couple of us that had it, you immediately saw the gain. you immediately saw the benefit. and then, of course, it became statewide and our governors put in a bunch of money, millions every year.
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one thing that was interesting that wasn't mentioned earlier, how do you get judged to agree to hard work it takes to have an accountability court? let's face it, you expect failure. you expect, you know, 18-month program here, it takes additional time for the court to have these cases in front of them. so last year the judges were requesting a pay raise. so what the governor did is he said that, if your judicial circuit has an accountability court each judge will get an extra $6,000. if your circuit doesn't have an accountability court, say good-bye to the six grand. it worked. >> let me turn to you on that. also, since you mentioned juvenile drug courts, juvenile justice, georgia did a bill, house bill 242, in 2013, reserving state juvenile custody for those violent and serious
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use. maryland in 2015, used to be for 33 sentences, kids 14 to 17 automatically tried as adults. but now after the bill it's discretionary. what you might add about the courts and juvenile justice as well. >> well, all of the problems discussed here this morning relating to intercourseration apply with greater course to juveniles. in maryland, i think we have reached a point where there's general agreement on that. if i can digress and tell you a story. there's a crew team and they've got big guys but they stink. they lose every race. the coach finally gets fed up. and le pulls assistant coach aside. he said, look, i want you to go over and see what harvard's doing. why do we keep losing to these guys? the assistant coach goes over, hides behind a bush, watches
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harvard. coach, i got it figured out, at harvard they've got eight guys rowing and one guy yelling. now, we -- we -- we -- i think are moving together in the right direction. republicans and democrats on all of these justice issues, especially with respect to juveniles, are headed in the right direction. we've had controversy after controversy through the '80s, '90s and early 0s should somebody go straight to adult court if they commit a serious offense. we still have juvenile life without parole in maryland. but, frankly, i think that's a mistake. but i think we do have a general consensus that for most juvenile offenses, a community setting is the appropriate place. when we send kids to a locked
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facility they learn how to criminals more quickly and end up being in trouble for the rest of their lives. we're, i think, moving in the right direction. we still have a very long way to go. >> another issue you wanted to address as pretrial justice, over half of the people in our count jails or city jails, there are more initials in city jail, not due to you, but over half of the people are waiting in trial and people lose their jobs and so forth even if not convicted and there's various issues, not having prompt representation. interested in your thoughts how to address that. >> well, when i was in the maryland senate i was chairman of the judicial proceedings committee, tried to get reform of maryland's pretrial justice system and failed. it's -- it's

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