>> GOOD MORNING. APPRECIATE AS ALWAYS YOUR PRESENCE AND ASSEMBLING OF THE BRAIN TRUST HERE. WE KNOW YOUR TIME IS PRECIOUS AND WE APPRECIATE YOU SHARING IN THIS PERIOD OF SERVICE. TO YOUR (INAUDIBLE) COMMUNITY. AND WITH NO FURTHER ADIEU LET MEGA L IN THE 206TH THE MEETING OF THE NATIONAL ADVISORY COUNCIL, NHLBI. . I'LL TURN IT OVER TO (INAUDIBLE). >> AS DR. GIBBONS SAID WELCOME, THANK YOU AGAIN FOR MAKING YOUR PRESENCE AVAILABLE TO ALL OF US. WE DEPEND ON EVERY SINGLE ONE OF YOU AND I THINK YOU KNOW FROM YOUR SERVICE ON THE COUNCIL HOW IMPORTANT THAT IS. TWO MEMBERS WHO THOUGHT THEY WERE LEAVING NOW PARTICULARLY HOW IMPORTANT THEIR PRESENCE IS BECAUSE THEY THOUGHT THEY WERE DONE IN OCTOBER BUT THEY'RE BACK. DR.S NUGENT AND SMITH WHITLY, THANK YOU AGAIN FOR COMING ONE MORE TIME. THIS PROBABLY REALLY IS THE LAST TIME WE NEED YOU IN THIS PARTICULAR OFFICIAL CAPACITY. BUT AS I MENTIONED BEFORE IN OCTOBER, NEVER SAY NEVER. YOU ARE NEVER REALLY DONE, WE ARE NEVER GOING TO PART WAYS PERMANENTLY. WE KNOW WHERE YOU ARE. WE A CURRENTLY WORKING TO ON BOARD NEW MEMBERS, DON'T WORRY, WE ARE IDENTIFYING NEW NOMINEES FOR THOSE SUPPOSED TO ROTATE OFF IN OCTOBER, THIS YEAR, WE ARE WORKING TO IDENTIFY THE NEXT PEOPLE. SO THINGS ARE PROCEEDING AS THEY SHOULD. I HAVE SOME ADMINISTRATIVE ANNOUNCEMENTS THAT IS NECESSARY -- ARE NECESSARY TO COVER BEFORE WE CONTINUE WITH THE MEETING. ONE THING I WANT TO ASK EVERYBODY TO DO IS IF YOU HAVE A CELL PHONE, PLEASE DO ME A FAVOR AND SET IT TO VIBRATE OR MUTE SO WE DON'T GET RHAPSODY PLAYING IN THE MIDST OF SOMEBODY'S SPEECH OR TALK. I HAVE ALREADY TAKEN MY OWN ADVICE AND SILENCED MINE. THIS MEETING HAS BEEN ADVERTISED WITH NOTICE OF THE SCHEDULED MEETING PUBLISHED IN FEDERAL REGISTER REQUIRED BY LAW. CONFLICT OF INTEREST, I WANT TO REMIND EVERYBODY COUNCIL MEMBERS ARE REQUIRED TO ABSENT THEMSELVES THE ROOM DURING THE REVIEW OF ANY APPLICATION IF THEIR PRESENCE CONSTITUTE OR APPEAR TO CONSTITUTE A CONFLICT OF INTEREST. ACCORDING TO FEDERAL LAW COUNCIL MEMBERS MAY NOT ENGAGE IN ANY LOBBYING ACTIVITIES WHILE ATTENDING COUNCIL MEETINGS OR SPONSORED EVENTS. FURTHER INFORMATION REGARDING CONFLICT OF INTEREST REGULATIONS ARE INCLUDED IN THE ELECTRONIC COUNCIL BOOK, I THINK YOU ARE ALL FAMILIAR WITH THOSE POLICIES BUT REMINDING YOU BECAUSE WE TAKE THIS SERIOUSLY. YOU HAVE A CONFLICT OF INTEREST FORM WE ASK IMMEDIATELY FOLLOWING TODAY'S MEETING EACH OF YOU SIGN THE CONFLICT OF INTEREST FORM THISES THAT ARE AT YOUR SEAT AND GIVE IT TO KIM OR COLLEAGUES, KIM AND WENDY IN THE BACK ARE HAPPY TO ASSIST YOU. I WANT TO REMIND YOU THAT THE OPEN SESSION OF TODAY'S MEETING IS BEING WEBCAST AND RECORDED. THE VIDEO WILL BE ARCHIVED AND REMAIN AVAILABLE TO THE PUBLIC AND NIH COLLEAGUES. FOR COUNCIL MEMBERS ON THE PHONE, WE ASK THAT YOU ALSO MUTE YOUR PHONES WHILE YOU ARE LISTENING SO THAT WE DON'T GET ANY FEEDBACK. REMEMBER TO UNMUTE WHEN YOU WOULD LIKE TO TALK AND MUTE AGAIN WHEN FINISHED. THOSE AT THE TABLE WHEN YOU SPEAK WE HAVE THESE WONDERFUL MICROPHONE DEVICES. I KNOW YOU ARE FAMILIAR WITH THEM. DO REMEMBER TO TURN ON WHEN SPEAKING, IT'S PARTICULARLY IMPORTANT TODAY BECAUSE WE HAVE THE ADDED BENEFIT OF CONSTRUCTION NOISE THAT IS GOING TO AUGMENT OUR COUNCIL MEETING TODAY. MORE IMPORTANT TO MINIMIZE DISTRACTIONS PROVIDING OURSELVES. SO WHEN YOU SPEAK TURN ON YOUR MICROPHONE SO THAT THE WRITERS CAN CAPTURE WHAT YOU ARE SAYING IN THE WEBCAST WILL CAPTURE IT. AND BE SURE TO TURN OFF WHEN FINISHED. EVERYBODY IS HERE WITH US IN PERSON EXCEPT FOR GRACE ANN SHE WILL BE JOINING US BY PHONE IF SHE'S NOT ALREADY THERE, I BELIEVE SHE STILL HAS YET TO JOIN. OF COURSE DR. RICHARD SCOFIELD IS ON THE PHONE, GOOD MORNING. OKAY. FUTURE MEETING DATES. THE FUTURE MEETING DATES THROUGH 2021 NOR NATIONAL HEART LUNG AND BLOOD ADVISORY COUNCIL HAVE BEEN PROVIDED TO YOU AND ARE LISTED ON THE AGENDA TO FACILITATE YOUR ATTENDANCE. PLEASE BE SURE YOU MAKE A NOTE OF THOSE DATES ESPECIALLY THE ONES FOR UPCOMING COUNCIL MEETINGS THAT YOU NEED ON YOUR CALENDAR TO MINIMIZE POTENTIAL FOR A CONFLICT WHICH WOULD CAUSE YOU TO HAVE TO MISS THE MEETING. WE WOULD REALLY HATE IT IF YOU HAD TO MISS THE MEETING. IF YOU HAVE AN ADMINISTRATIVE ASSISTANT SHARE THOSE DATES WITH THEM TO GET ON YOUR CALENDAR AS NEEDED. YOUR PRESENCE IS REALLY APPRECIATED IN PARTICULAR IN THE AFTERNOON OR IN THE CLOSED SESSION WHEN WE REQUIRE QUORUM TO CONDUCT GRANT REVIEW BUSINESS REQUIRED BY LAW. WE APPRECIATE YOU STAYING TO THE END OF THE MEETING. QUICK REVIEW OF THE AGENDA TO GIVE YOU A PREVIEW OF COMING ATTRACTIONS SO YOU KNOW WHAT'S HAPPENING. WE'LL START WITH DR. GIBBONS DIRECTORS REPORT AND AFTERWARDS WE WILL HAVE A PRESENTATION FROM DR. CLAYTON, NIH ASSOCIATE DIRECTOR FOR RESEARCH ON WOMEN'S HEALTH AND DIRECTOR NIH OFFICE OF RESEARCH ON WOMEN'S HEALTH AND DR. STEVEN WOOLF, DIRECTOR EMERITUS AND PROFESSOR OF THE DEPARTMENT OF FAMILY MEDICINE AND POPULATION HEALTH AND THE C KENNETH AND DIANE WRIGHT DISTINGUISHED CHAIR POPULATION HEALTH AND HEALTH EQUITY AT VIRGINIA COMMONWEALTH UNIVERSITY. FORTUNATELY WE DIDN'T HAVE A SNOWSTORM TODAY THOUGH YOU MAY HAVE HAD TO SWIM UP I 64 TO GET HERE BUT HE'S HERE. THAT WOULD BE FOLLOWED BY A DISCUSSION WHERE I'LL REMIND YOU THE AUTHORITIES YOU DELEGATESSED TO ME AS THE EXECUTIVE SECRETARY OF OUR COUNCIL. IN RECOGNITION OF HEART MONTH WE WANT TO TAKE A GROUP PHOTO OF OUR COUNCIL MEMBERS. WE WILL DO THIS RIGHT BEFORE THE BREAK FOR LUNCH. THOSE OF YOU THAT WERE READ GOOD FOR YOU BUT IF YOU DIDN'T WE LOVE YOU ANYWAY, YOU CAN STILL BE IN THE PICTURE. FOLLOWING LUNCH WEAL START THE CLOSED SESSION FOR GRANTS REVIEW FOLLOWED BY ADJOURNMENT. WITH THOSE PLANS IN MIND I'LL TURN IT BACK TO DR. GIBBONS TO HEAR HIS REPORT AND LET EVERYTHING GET STARTED. THANK YOU ALL AGAIN. WE'LL START WITH THE REPORT. AND AS PART OF THE ONGOING FEEDBACK OF HOW THINGS ARE GOING IN OUR FISCAL STEWARDSHIP, WE ALWAYS STARTS WITH THE INSIDE STORY. AND THEIR STAFF MEMBERS THAT HAVE ARE IN TRANSITION AND I'LL START OFF WITH DR. COOK OUR CHIEF OF STAFF AND SENIOR SCIENTIFIC OFFICER. SHE HAS BEEN APPOINTED AS THE NEXT EXECUTIVE DIRECTOR OF PCORI. AND SO IT ALWAYS GIVES US GREATS PRIDE, WHEN WE SEE SOMEONE WHO ACTUALLY I THINK I MET AT COUNCIL MEETING WHEN I WAS SERVING ON COUNCIL AND LATER ON WHEN I JOINED NHLBI, SHE WAS A GS 14 PROGRAM OFFICER IN DCBS AND SHE'S KIND OF GOING UP THE RANKS HERE. TAKING ON LEADERSHIP POSITIONS, VARIOUS SORTS, A KEY SPEARHEAD OF STRATEGIC VISION AND NUMBER OF INITIATIVES, SHE HAS BACKGROUND HEALTH SERVICES RESEARCH AND SO PARTICULARLY LEANED IN ACTUALLY ON MAJOR TOPIC TODAY THAT RELATES TO WOMEN'S HEALTH AND PROVIDE GREAT LEADERSHIP AS PART OF THE OVERSIGHT OF THAT WORKING GROUP AND SO BEFORE I BREAK INTO TEARS, LET ME JUST MOVE ON AND JUST ASK THAT YOU RECOGNIZE AND APPRECIATE THE SERVICE THAT SHE'S DONE FOR THE NHLBI. [APPLAUSE] YOU CAN TELL WHO THE REAL BOSS IS, YOU DIDN'T SEE ME GET THAT KIND OF AICALLYMATION BUT IT'S WELL DESERVED, A CLEARLY BELOVED SERVANT LEADER. IN ADDITION, WE ALSO WANT TO ACKNOWLEDGE AND CELEBRATE THE SERVICE BY THE DEPUTY OF DBDR, DR. DONNA DEMICELI, WHO PLAYED AN IMPORTANT ROLE IN LEADERSHIP IN MANY WAYS ACTUALLY ALSO HAS BEEN WOMEN'S HEALTH REALM AND REPRESENTING THE INSTITUTE. BUT IS ALSO IS IN THAT KEEP THIS LEADER CLUB AS ALWAYS PASSIONATE ABOUT THAT. CERTAINLY SHE'S MADE A MARK IN TERMS OF OUR EXTENSIVE PORTFOLIO IN HEMOPHILIA. AND WHAT I APPRECIATE MOST ABOUT DONNA WAS HER PASSION FOR CLINICIAN SCIENTISTS AND ENSURING WE MAINTAIN A ROBUST WORK FORCE. SHE WAS VERY FORCEFUL IN ENSURING WE DO WHATEVER WE COULD IN INNOVATIVE WAYS TO ENSURE THAT. SOME OF THAT IS PROBABLY ACTUALLY IN YOUR PORTFOLIO TODAY IN TERMS OF CLINICIAN SCIENCES RO1 OTHER PROGRAMS THAT SHE WAS A MAJOR DRIVING FORCE. SO AGAIN WE APPRECIATE DONNA'S SERVICE AS WELL. AS WAS ALLUDED TO, FEBRUARY IS AMERICAN HEART MONTH SO WE LOOK FORWARD TO Y'ALL PARTICIPATING AND DISSEMINATING OUR MESSAGE THAT OUR HEARTS ARE HEALTHIER TOGETHER ACKNOWLEDGMENT THAT INDEED THE LIFESTYLE CHANGES WE CAN MAKE ARE BEST INFORMED AND SUSTAINED MAINTAINED BY THE SOCIAL SUPPORT, THE PEER NETWORKS WITH EACH OTHER TO PROMOTE THE HEALTHIER LIVING. IT'S BEEN PART OF OUR EMPHASIS AND POINT OF EMPHASIS THIS MONTH, APPRECIATE THE WORK THAT OUR TEAM HAS BEEN DOING IN PROMOTING THAT MESSAGE. LET ME NOW SHIFT TO THE FISCAL STEWARDSHIP COME POINT. Y'ALL KNOW THE BUDGET OF THE PRESIDENT WAS RELEASED YESTERDAY. THIS IS THE SEASON WHEN APPROPRIATIONS START TO COME TOGETHER. WE ARE VERY FORTUNATE AND BLESSED THAT FOR THE LAST FIVE YEARS CONGRESS HAS SEEN FIT TO PLUS UP THE NIH. WE ARE HOPEFUL THAT TREND WILL CONTINUE THOUGH WE KNOW THESE ARE CHALLENGING TIMES AND PLUS UP WAS NOT REFLECTED IN THE PRESIDENT'S BUDGET. THAT IS OFTEN JUST THE START OF THE NEGOTIATION SO WE REMAIN HOPEFUL THAT THAT WILL WORK OUT. IN THE MEANTIME FOR FY 20 WE ARE DOING WHAT WE CAN TO BE GOOD FISCAL STEWARDS OF THE 4.1% INCREASE WE RECEIVED. IT'S NOTABLE THERE WAS SPECIFIC LANGUAGE IN THAT 2020 APPROPRIATION THAT ENCOURAGED THE INSTITUTE TO PURSUE WHAT IS ALREADY IMPLICIT AND EXPLICIT IN STRATEGIC VISION AROUND GENERAL AREA OF CHRONIC DISEASE AND PRECISION MEDICINE PATHWAY, OBVIOUSLY WE HAVE BEEN COMMITTED TO. AND IN ADDITION WE WILL BE PURSUING THE PRIORITIES THAT WE HAVE OUTLINED WITH YOU BE IT COUNCIL AS PARTS OF OUR STRATEGIC PRIORITIES CERTAINLY INVESTIGATOR INITIATED DISCOVERY SCIENCE, THE NEXT GENERATION, CERTAIN STRATEGIC PRIORITIES, SOME WHICH EMERGED OVER THE LAST FEW YEARS WITH RECENT TRENDS IN eCIGARETTES AND VAPING, PUBLIC HEALTH THREAT, WHAT YOU WILL HEAR TODAY IN TERMS OF INTERNAL HEALTH ONGOING HEALTH DISPARITIES PARTICULARLY GEOGRAPHIC ONES AND BY RACE ETHNICITY BY MAJOR PROGRAM ANYBODY KNIVES PRECISION MEDICINE ON SICKLE CELL DISEASE AND COPD. THAT IS THE HIGH LEVEL OVERVIEW. THESE ARE THE CURVES YOU ARE NOW FAMILIAR WITH AND IN WHICH WE BELIEVE NOW THAT WE BEGIN TO CLOSE OUT FY 19 HOPEFULLY IS STARTING TO FILL IN AS WHERE WE ENDED UP WITH THE SUCCESS RATES OVERALL FOR RO1s. FOR OUR ESIs. AGAIN BOUNCING AROUND 30% SUCCESS RATE WITH THEIR 10 PERCENTILE BONUS. THE K AWARDS, AGAIN, BOUNCING AROUND THAT 40% SUCCESS RATE RANGE. SO THIS IS REALLY THE FRUIT OF THOSE PLUS UPS IN OUR BUDGET THAT WE HAVE BEEN ABLE TO MAINTAIN THOSE INVESTMENTS IN THOSE KEY AREAS. I LAST COUNCIL I STARTED TO UNVEIL A LITTLE BIT OF THE DIGGING THAT OUR STAFF HAS BEEN DOING RELATED TO PROMOTING CULTURE OF DIVERSITY AND INCLUSIVE EXCELLENCE. AND REVIEWING AND TRACKING HOW THAT'S PLAYING OUT IN THE FUNDING PORTFOLIO. THIS AGAIN IS A SNAP SHOT OF EARLY DATA ANALYSIS RELATED TO BOTH SEX GENDER AS WELL AS RACE ETHNICITY ACROSS SOME OF OUR MAJOR MECHANISMS. YOU CAN SEE ON THE LEFT THE GRADIANT OF THE ESTABLISHED RO1s WHERE WOMEN ARE ABOUT 35% OF THOSE ESTABLISHED RO1s ON THE RIGHT. CLEARLY NOT QUITE REACHING THE POPULATION SCALE PARODY, GUESS WHAT GIVES SOME GLIMMER OF HOPE IS THAT AS YOU LOOK AT THE PIPELINE OF EARLY ESTABLISHED INVESTIGATORS K AWARD AND F AWARDS YOU CAN SEE THERE IS A BETTER SEX GENDER BALANCE AS YOU GO FROM 71% MALE DOWN TO 4050s SO WE HOPE AS THOSE COHORTS MOVE THROUGH WE WILL BE ABLE TO RETAIN THEM SCIENCE AND THEY WILL GET POSITIONS AT YOUR INSTITUTIONS. BECOME SUSTAINED RO1 PARTS -- PIs WITHIN OUR WORK FORCE. THE RACE ETHNICITY DATA. OBVIOUSLY THIS IS A LITTLE MORE SPARSE. THERE IS CONFIDENCE INTERVALS THAT ARE PROBABLY WIDER ON THIS DATA. BUT YOU CAN SEE AGAIN A SIMILAR GRADIANT AT THE ESTABLISHED INVESTIGATOR RO1 LEVEL AND AGAIN, A GLIMMER OF HOPE THAT AT LEAST IN THE TRAINEE AND CAREER DEVELOPMENT AREAS, THERE APPEARS TO BE LITTLE BIT MORE DIVERTSTY AS PART OF HOPEFULLY A WAVE THAT WE CAN AGAIN RETAIN AS PART OF OUR BIOMEDICAL WORK FORCE. ONE OF THE THINGS YOU ARE AWARE OF AND WE ARE PROUD OF AT THE NHLBI LEGACY THAT I CERTAINLY AND BETSY MAY HAVE BEEN EARLY RUNS OF THIS IS THAT A NUMBER OF INSTITUTE CENTERS HAS A BONUS FOR ESTABLISHED INVESTIGATORS ABOUT FIVE POINTS NHLBI MAINTAINED ONE OF TEN. ONE OF THE THINGS AGAIN PRELIMINARY ANALYSIS OF OUR PORTFOLIO IS TO LOOK AT IT OVER THE RANGE OF OUR PAY LINE ROUGHLY AND POINTS ABOVE THAT. YOU CAN SEE THESE ARE FROM LAST YEAR, AGAIN ONE SNAP SHOT, THERE'S PROBABLY VARIANTS ACROSS THE TREND PERIOD BUT YOU CAN SEE THAT THERE APPEARS TO BE AT LEAST A TREND TOWARD THAT UPPER RANGE STILL CONTRIBUTING TO EXTENDING OUR DIVERSITY OF OUR POOL BOTH FOR WOMEN AND FOR UNDER-REPRESENTED MINORITIES. SO THAT BY HAVING THAT ADDITIONAL FIVE PLUS FIVE POINTS ABOVE THE PAY LINE, AGAIN, MAYBE GIVING US AN OPPORTUNITY TO EXPLAIN SOME OF THE EXPANDED DIVERSITY OF OUR ESI A AWARDEE POOL. THAT SECOND 5% PROBABLY DOES CONTRIBUTE A SUBSTANTIAL NUMBER OF OUR ESIs ON A GIVEN AWARD CYCLE BASIS. WE ARE STILL ANALYZING THIS DATA œAT LEAST SOME SENSE OF WHY THAT EXTRA FIVE IN THE TOTAL TEN POINT BONUS MAY BE A PARTICULAR VALUE, PARTICULARLY WITH REGARD TO EXTENDING THE DIVERSITY OF THE NEXT GENERATION. IN ADDITION, THIS ANALYSIS HAS BEEN EXTENDED A LITTLE BIT, WE SHOWED YOU THE Ss Ks, RO1s, SO THE STAFF TEAM THEN DID A BIT OF A DIVE ON OUR T 32s IN PARTICULAR IN EXPLORING THEIR DIVERSITY AND PROGRESS IN INCLUSIVE EXCELLENCE ON THE LEFT SEX AND GENDER AND YOU CAN SEE THAT BOTH FOR PRE-DOCS AND POST DOCS, I THINK SOME SENSE OF PARODY THERE AMONG MALES AND FEMALES WHICH AGAIN IS HOPEFUL. PROBABLY REFLECTIVE OF WOMEN IN Ph.D. PROGRAMS AND POST DOCS. SO THAT'S ENCOURAGING AS EARLY PART OF OUR PIPELINE. ON THE RIGHTS WITH RACE ETHNICITY, I HADN'T SEEN REPORTED PREVIOUSLY THIS KIND OF DATA SO YOU CAN SEE THERE FOR BOTH PRE-DOCS AND POST DOCS AMONG OUR T 32s THAT THEY SEEM TO BE FAIRLY ALIGNED WITH OUR F AWARDS. AGAIN, NUMBERS ARE SMALL SO YOU WANT TO BE CAUTIOUS HERE BUT AGAIN, RELATIVELY GOOD DATA SET FOR SINGLE INSTITUTE RELATIVE TO THE WHOLE NIH ENTERPRISE. SUGGESTING AGAIN SOME PROGRESS BEING MADE. I MIGHT MENTION THERE MIGHT BE A BIT OF A CAVEAT, NOT A MAJOR ONE, THAT THE INSTITUTE ACTUALLY HAS T 32 PROGRAMS THAT HAVE AS A PRIMARY POINT OF EMPHASIS AND FOCUS DIVERSITY. SO IF YOU DRILL DOWN TO THOSE T 32s MY FORMER LIFE I HAD ONE OF THOSE AS WELL, THAT THEY HAVE A MAJORITY OFTEN OF THEIR TRAINEES FROM UNDER-REPRESENTED GROUPS. SO THAT CONTRIBUTES I THINK TO OUR AGGREGATE NUMBERS THAT WE HAVE DIVERSITY T 32s AS WELL AS CLASSIC INSTITUTIONAL ONES SOME OF WHICH HAVE BEEN AROUND FOR 30, 40 YEARS. AGAIN, THIS GIVES YOU A SENSE OF HOW WE ARE TRYING TO TRACK HOW WE ARE AS A COLLECTIVE DOING IN TERMS OF CREATING A DIVERSE NEXT GENERATION OF LEADERS. IN THE BIOMEDICAL WORK FORCE. THIS IS SOMETHING THAT WE SEE AS A COLLECTIVE RESPONSIBILITY ALONG WITH YOU AS LEADERS IN THIS FIELD AND I KNOW WE HAVE DEANS AND CHAIRS AROUND THE TABLE AND I THINK WE ALL ARE WELL SERVED OUR NATION IS WELL SERVED BY HAVING DIVERSE INCLUSIVE -- AS WELL AS BIOMEDICAL WORK FORCE. OUR DATA FROM THE Fs AND Ts AND THIS AGGREGATE DATA IN TERMS OF NUMBER OF UNDER-REPRESENTED MINORITY Ph.D.s SUGGESTS THAT WE ARE GOING TO BREAK THE TREND LINE IN TERMS OF PIPELINE. I THINK THE CHALLENGE COLLECTIVELY IS FOR US TO NURTURE THAT PIPELINE, TO RETAIN THEM IN SCIENCE AND ULTIMATELY GIVE THEM A JOB. SO THAT THEY INDEED CAN JOIN THE PROFISORY, HAD TO STARTUP PACKAGES THEY NEED TO LAUNCH A CAREER, GET A K, GET AN ESI AWARD. SO I THINK THAT'S THE NEXT TASK FOR US ALL TO DO TOGETHER. WE CERTAINLY ARE WORKING HARD, OUR STAFF IS DEVELOPING INNOVATIVE STRATEGIES TO CONTINUE TO LOOK FOR OPPORTUNITIES TO PRIME THE PUMP HERE, RETAIN AND NURTURE THE NEXT GENERATION. WITH YOUR HELP WILL CONTINUE TO INNOVATE IN THIS SPACE. ALSO AS PART OF OUR FISCAL STEWARDSHIP Y'ALL ARE AWARE NOW THAT THE NHLBI HAS THIS OTHER TRANSACTION AUTHORITY IN WHICH WE AWARD AND MAKE INVESTMENTS IN RESEARCH PROGRAMS THAT ARE KIND OF NEITHER FISH NOR FOUL, NEITHER GRANT OR CONTRACT BUT THAT ARE NIMBLE FUNDING INSTRUMENTS AND WE HAVE THIS AUTHORITY TO MAKE STRATEGC INVESTMENTS, SOMETHING WE TRY TO USE VERY TARGETED FASHION, THROUGHOUT OUR PORTFOLIO, FOR EVERY PROGRAM BUT WHEN INDEED IT REALLY IS CRITICALLY IMPORTANT TO BE INNOVATIVE, NIMBLE AND STRATEGIC. I THINK AS PART OF OUR FISCAL STEWARDSHIP AND TRANSPARENCY TO UPDATE YOU ON A REGULAR BASIS AS TO STATUS OF THESE THINGS, WE TEND TO FOCUS THEM ON CERTAIN PROGRAM MA TICK AREAS. THIS IS SICKLE CELL ON THE LEFT, IN WHICH YOU CAN SEE SOME OF THE MULTI-YEAR FUNDING INVESTMENTS THAT ARE BEING MADE IN THE VARIOUS AREAS OF THE CURE SICKLE CELL INITIATIVE INVOLVING CLINICAL STRATEGIES SO THIS MIGHT INVOLVE EARLY PHASE OR PRE-CLINICAL IND ENABLING MOVEMENT ALONG THE DEVELOPMENTAL PATHWAY. SIMILARLY IN CASES OF GENE EDITING AND GENETIC ENGINEERING, BIOMANUFACTURING WHICH IS ACTUALLY QUITE -- ONE OF THE CHALLENGE IN THIS SPACE, INNOVATIVE AND SIMILARLY LOOKING AT PATIENT OUTCOME MODELING, DATA MANAGEMENT, ET CETERA. SO THESE ARE SOME OF THE INVESTMENTS WE ARE MAKING. SIMILARLY ON THE OTHER SIDE IS BIODATA CATALYST, SOMETHING THAT WILL BE UPDATING YOU WITH. I WILL SEE -- I DON'T SEE DR. KAUFFMAN BUT HOPEFULLY JUNE COUNCIL HE SHOULD BE READY TO DAZZLE YOU WITH NO PRESSURE JOHN, DAZZLE YOU WITH THE RESOURCES THAT ARE BEING GENERATED THERE THAT ARE LEVERAGING TOP MED CREATING A CLOUD BASED RESOURCE THAT WE THINK WILL BE DISTINCT AND UNIQUE AND POWERFUL. THAT IS TAKING AN INVESTMENT TO MAKE SURE THE DATA IS HARMONIZED, THE ANALYTIC TOOLS ARE THERE SO THAT WHEN INVESTIGATORS GO TO THE DATA, RATHER THAN DOWNLOAD THE DATA, THEY WILL BE ABLE TO PURSUE THEIR DISCOVERIES IN THAT SPACE IN WHICH AGAIN IT WILL LINK IN AN INTEROPERABLE FASHION WITH OTHER DATA RESOURCES AND WILL BE AMENABLE TO NEW TECHNOLOGIES AND MACHINE LEARNING ANALYTICS. WE ALSO SEE THIS AS A GREAT TRAINING OPPORTUNITY TO PUSH FORWARD DATA SCIENCE AND INTEGRATIVE AND HEART LUNG BLOOD SCIENCE, WE LOOK FORWARD TO ROLLING THAT OUT, AGAIN, THESE ARE THE OTHER TRANSACTION AUTHORITY HAS BEEN REALLY CRITICAL IN THAT FAST PACED TECHNOLOGY DRIVEN AREA. THAT'S THE FISCAL MANAGEMENTS. LET ME JUST TOUCH ON SOME OF THE SCIENTIFIC OPPORTUNITIES EMERGING THAT WE SHOULD UPDATE YOU ON THAT RELATE TO OUR IMPLEMENTATION OF STRATEGIC VISION YOU HELPED US CRAFT. FIRST, ONGOING UPDATE WHERE WE ARE RELATED TO VAPING AND THE LUNG INJURY RELATED TO ECIGARETTES AND THAT CRISIS. NOW THAT WE HAVE A CORONA VIRUS, PEOPLE HAVE FORGOTTEN ABOUT BUT SOME REASON JIM IT COMES BACK TO THE LUNG. SO WHAT CAN YOU SAY. BUT CLEARLY WE HAVE A LOT OF WORK TO DO IN PROVIDING AN EVIDENCE BASE THAT HOPEFULLY WILL UNDERPIN POLICY AND PUBLIC HEALTH PRACTICE RELATED TO ECIGARETTES AND VAPING AND WE AGAIN APPRECIATE THE STAFF LEADERS THAT HAVE MOVED VERY QUICKLY SWIFTLY NIMBLY TO ALREADY BE IN THE PROCESS OF O SOLICITING RECEIVING AND STARTING TO REVIEW SOME PROJECTS THAT CAN GIVE US GREATER INSIGHT INTO THE CONSTITUENTS OF THE ELIQUIDS AS WELL AS MIXTURES, ET CETERA, THAT INCLUDE FLAVORINGS AND OTHER CONSTITUENTS THAT MAY IMPACT ON LUNG HEALTH AND REALLY UNDERSTANDING THAT BOTH SHORT TERM AND IN THE LONG TERM. SO AGAIN WE APPRECIATE THE WORK CERTAINLY DOD AND OTHER PARTS OF THE INSTITUTE THAT HAVE BEEN WORKING ON RAPID RESPONSE TEAM TO ADDRESS THIS PUBLIC HEALTH THREAT. SO STAY TUNED FOR THAT. YOU WILL BE SEEING THE ROLL OUT OF A NUMBER OF PROGRAMS OF WHICH THE MOST IMMEDIATE WAS THIS NOTICE ABOUT SUPPLEMENTS TO ADDRESS THIS EMERGING CRISIS THAT WHICH WE PARTNERED WITH OTHER INSTITUTES, WITH SIMILAR EQUITIES AS WELL AS WORKING SHOULDER TO SHOULDER WITH OUR COLLEAGUES AT FDA AND CDC AS WE JUMP ON ENSURING THAT THE PUBLIC HEALTH IS PRESERVED. LET ME SHIFT TO ANOTHER AREA IN WHICH WE ARE -- HAVE HAD PERSISTENT STRATEGIC VISION IMPLEMENTATION RELATED TO HEALTH DISPARITIES IN VARIOUS POPULATIONS AND AGAIN, THE RECENT JAMA ARTICLE CAUGHT OUR EYE RELATED TO INCREASE IN MID LIFE MORTALITY AND REALLY A STALLING IF YOU WILL OF THE LIFE EXPECTANCY IN THE UNITED STATES WHICH I THINK SERVES AS A WAKE UP CALL FOR US ALL AND A REMINDER THAT THERE ARE PARTS OF THIS COUNTRY THAT FROM A PUBLIC HEALTH PERSPECTIVE, HEADED IN THEIR OWN DIRECTION. IT SEEMS SOMETIMES LIKE THE CDC JUST COPIES THE SAME MAP OVER AND OVER AGAIN, BECAUSE IT SEEMS LIKE THE THINGS THAT RELATE TO OUR PORTFOLIO KEEP HITTING THOSE SAME AREAS. OF THE COUNTRY, THOSE SAME REGIONS OF THE COUNTRY. IN DEED BECAUSE OF OUR PORTFOLIO AND IT'S IMPORTANT ON LITERALLY LIFE AND VITALITY, IT'S GOING TO INFLUENCE HOW THIS INSTITUTE RESPONDS TO THESE PUBLIC HEALTH TRENDS. SO WE ARE GRATEDFUL TO HAVE DR. WOOLF PRESENT SOME OF IN THIS WORK AND HIS INSIGHTS RELATED TO THIS CHALLENGE. WE DON'T NEED TO REMIND THIS AUDIENCE THAT CONSISTENT WITH THE WORK FROM HIS GROUP ARE OTHER STUDIES THAT INDICATE IN PARTICULAR FOR CARDIOVASCULAR DISEASE SIMILAR GEOGRAPHIC DISPARITY PATTERNS. CERTAIN CALL OUT SPECIAL POPULATIONS AFRICAN AMERICANS AND RURAL AMERICANS PARTICULARLY LOW SES RURAL AMERICANS, AMERICAN INDIAN, NATIVE AMERICANS, ALASKA NATIVES AS ADDITIONAL POCKETS AND POPULATIONS IN WHICH THEY ARE NOT EXPERIENCING THE FRUITS OF OUR DISCOVERY SCIENCE, THAT IS BENEFITING AND REDUCING CARDIOVASCULAR DEATH OVERALL. WE ARE HOPEFUL THAT OUR COMMUNITY WILL RISE TO THIS CHALLENGE, ENCOURAGE BY RECENT ROLL OUT OF THE RURAL COHORT STUDY. SOMETHING WE ARE LOOKING TO FURTHER ENHANCE IN WAYS THAT CAN HELP UNDERSTAND A LOT OF DRIVERS OF THIS ADVERSE PATTERN OF CARDIOVASCULAR DISEASE, IT WILL BE INCLUSIVE OF A VARIETY OF POTENTIAL MEDIATORS BUT CERTAINLY WILL HAVE CLEAR ELEMENT OF UNDERSTANDING THE SOCIAL DETERMINANTS OF HEALTH THAT CLEARLY MAY BE A TREE DRIVER AS WELL AS PSYCHOSOCIAL ELEMENTS AS WELL. SO LOOKING FORWARD TO THOSE STUDIES AND WHAT THEY CAN DO TO INFORM HOW WE CAN BEND THE CURVE ON THOSE OUTCOMES. WE SEE THIS AS PART OF OUR SYSTEM APPROACH THAT TRYING TO SPAN FROM NUCLEOTIDES TO NEIGHBORHOODS AND APPRECIATING ALL THE VARIOUS INPUTS INTO PROMOTING RISK AND OUTCOMES AND POTENTIAL MEANS OF INTERVENTION, TO PREVENT IF NOT PREEMPT CHRONIC DISEASE AS WE GET GREATER UNDERSTANDING AND FIDELITY IN THAT. ONE OF THE KEYS TO THAT IS TO CAPTURE DATA AND USE NEW TOOLS AND APPROACHES OF ANALYTICS AND WE HAVE A NUMBER OF ELEMENTS TOWARD THAT END. DR. B EMS PRESENTED TO YOU BEFORE WHAT WE ARE TRYING TO DO AT POPULATION REVEL, COUNTY LEVEL AND WITH GREAT GRANULARITY TO CAPTURE SOME OF THESE SYSTEMS-BASED DATA POINTS. BUT WANT TO HIGHLIGHT ANALYSIS DONE BY DCBS COLLEAGUES IN WHICH THE LEVEL OF DATA SCIENCE WE ARE FUNDING IN OUR PORTFOLIO T. THE MAIN TAKE AWAY HERE IS THAT IT'S RELATIVELY MODEST. AND I BELIEVE THIS IS AN AREA THAT IS HIGHLIGHTED IN THE STRATEGIC VISION, CLEARLY IT'S A FRONT BURNER ELEMENT OF OUR IMPLEMENTATION PLAN. IT'S AN AREA THAT WE COULD BE EVEN MORE STRATEGIC AND PROMOTING AND ACCELERATING GREATER EMPHASIS IN THIS SPACE PARTICULARLY GIVEN EMERGENCE OF TOOLS AND MACHINE LEARNING, AI, BIG DATA TO BRING TO BARE ON SOME OF THESE CHALLENGE. IN THAT REGARD, WE APPRECIATE THE ADVISORY COUNCIL FEEDBACK IN THIS SPACE TO REALLY ADDRESS ONE OF THE CRITICAL CHALLENGES RELATES TO TRAINING IN THIS AREA . SO CHALLENGED OUR STAFF TO COME UP WITH INNOVATIVE WAYS TO PROMOTE GREATER UPTAKE OF THESE NEW TOOLS AND TECHNIQUES, FACILITATED BY CREATING RESOURCES LIKE BIODATA CATALYST BUT ALSO WORKING WITH YOU TO BE SURE THE NEXT GENERATION HAS THESE CAPABILITIES AND TOOLS AND MAYBE EVEN SOME TRAINING OPPORTUNITY FOR THOSE OF US WITH GRAY BEARDS TO AGAIN ADAPT AND LEARN SOME OF THESE NEW TOOLS AND TECHNOLOGIES. MOREOVER THIS IS AN OPPORTUNITY FOR US WHO HAVE EXPERTISE IN HEART LUNG BLOOD SLEEP SCIENCE TO COLLABORATE SHOULDER TO SHOULDER IN CROSS DISCIPLINARY WAY IN NEW SCIENTIFIC TEAMS THAN INTEGRATE DATA SCIENTISTS COMPUTATIONAL BIOLOGISTS, SYSTEMS MEDICINE PEOPLE, TO REALLY AGAIN TACKLE HEART LUNG BLOOD SLEEP SCIENCE. SO I THINK WE WANT TO CREATE A NEW SET OF MULTI-LINGUAL SCIENTISTS THAT SPEAK IN ALGORITHMS AS MUCH AS WE CAN IN MOLECULAR PATHWAYS. SO THAT IS ONE OF THE EMERGING CHALLENGES AND OPPORTUNITIES FOR THE INSTITUTE. FINALLY WANTS TO TOUCH ON A KEY TOPIC THIS MORNING THAT RELATES TO TRENDS NIH EFFORT TO IMPROVE -- TRANS-NIH EFFORT TO IMPROVE WOMEN'S HEALTH, PARTICULARLY ADDRESS AGAIN DISTURBING STATISTICS IN THE RISE OF MATERNAL MORBIDITY MORTALITY, WE HAVE DR. JANINE CLAYTON, LEADER OF OFFICE OF RESEARCH WOMEN'S HEALTH AND AT THE FOREFRONT OF THIS TRANS-NIH EFFORT. WE APPRECIATE THE OPPORTUNITY TO HEAR FROM HER ABOUT FORMATIVE BUT RAPIDLY MOVING PLANS FOR A TRANS-NIH EFFORT IN THIS SPACE THIS IS SOMETHING THAT IS QUITE GERMANE TO NHLBI GIVEN CARDIOVASCULAR AND COAGULATION BLEEDING COMPLICATIONS ARE A HUGE CONSTITUENT OF A LOT OF THAT MATERNAL MORBIDITY MORTALITY, IT COMES TO OUR PORTFOLIO IN ADDITION OUR PORTFOLIO IS REVEALED NEW MOMS TO BE AND OTHER DATA, A LOT OF SLEEP DISTURBANCES AS PART OF PREGNANCY. AND AGAIN, IS AN OPPORTUNITY FOR THIS INSTITUTE TO LEAN IN AND MAKE A DIFFERENCE ON THIS DISTURBING PUBLIC HEALTH CHALLENGE AND PATTERN. IT PARTICULARLY EFFECTS CERTAIN COMMUNITIES, CERTAINLY AFRICAN AMERICAN WOMEN ARE HIGH RISK AND THIS AGAIN ALLIANCE WITH A LOT OF OUR INTERESTS IN SPECIAL POPULATIONS, HEALTH DISPARITIES, BOTH RACE ETHNICITY AND GEOGRAPHY AS WELL AS LEANING IN WITH SOCIAL DETERMINANTS OF HEALTH IN WAYS THAT AFFECT CHRONIC DISEASE EARLY IN THE LIFE STAGES OF WOMEN THAT MAY HAVE LONG TERM CONSEQUENCES. SO WE ARE INTRIGUED THAT THIS IS AN AREA OF PUBLIC HEALTH THREAT THAT IS DRAWING THE ATTENTION OF NUMBER OF PEOPLE OF CONGRESS, WEAPON HAD THE OPPORTUNITY TO DO SOME BRIEFINGS ON THE HILL RELATED TO THIS TOPIC. AND AGAIN, I SWEAR THIS IS A DIFFERENT MAP BUT YOU CAN SEE HERE AGAIN WHERE THERE ARE CHALLENGES IN MATERNAL MORTALITY IN UNITED STATES STILL AFFECTING THAT OHIO RIVER VALLEY, THAT HEART LAND DOWN THE MISSISSIPPI RIVER, THE SOUTHEAST, THIS ONE ALSO REALLY HIGHLIGHTS TEXAS IN THE SPACE OF MATERNAL HEALTH THAT IS A KEY PROBLEM. AND INDEED ON THE RIGHT HAND PANEL IS PREECLAMPSIA, A MAJOR PART OF THE MORBIDITY MORTALITY WHICH YOU CAN SEE DIFFERENCES BY RACE ETHNICITY, WHERE AFRICAN AMERICAN WOMEN THIS IS A MAJOR PROBLEM SO BOTH GEOGRAPHIC AND RACE DISPARITIES. THIS IS AN OPPORTUNITY THAT AGAIN AFFECTS OUR INSTITUTE. SINCE A LOT OF THESE ADVERSE PREGNANCY OUTCOMES RELATE TO CARDIOVASCULAR AND HEMATOLOGIC COMPLICATIONS AND OUR STAFF HAS BEEN VERY PROACTIVE IN DEVELOPING A PORTFOLIO DRESSING THIS ON MULTIPLE LEVELS. COHORTS STUDIES LIKE NEW MOMS TO BE HELPING US APPRECIATE RISK FACTORS THAT PRE-DISPOSE AND PERHAPS MORE IMPORTANTLY HOW THIS IS PART OF A WHOLE LIFE TRAJECTORY THAT BEGINS REALLY PRECONCEPTION OF WOMEN AND CHILD BARING YEARS, WHO ALREADY ARE ON A PATHWAY OF INCREASED CARDIOVASCULAR RISK DUE TO GROWING PREVALENCE OF OBESITY AND EARLY SIGNS OF HYPERTENSION IN THIS POPULATION. THAT THEN IS JUST ACCENTUATED BY THE STRESS TEST IF YOU WILL OF PREGNANCY AND IS CALLING OUT A HIGH RISK GROUP THAT WHEN FOLLOWED AS NEW MOMS TO BE HAS DONE OVER THE YEARS, CLEARLY CONFERS INCREASE RISK THAT PROBABLY PERSISTS FOR DECADES, NOT ONLY IN MOM BUT IN THE BABY. SO INDEED, THIS IS REALLY A WOMEN'S HEALTH ACROSS THE LIFE SPANISH SHOE AT THE END OF THE DAY THAT HAPPENS TO BE SO WEDDED IF YOU WILL BY THE PREGNANCY EXPERIENCE. THIS IS -- PROVIDES AN OPPORTUNITY FOR US TO DO INTERVENTIONS IN CLINICAL TRIALS WHERE STAFF PUT TOGETHER ROBUST PORTFOLIO. YOU CAN SEE SOME OF THEM ALREADY ON GOING TRYING TO ADDRESS PREECLAMPSIA SLEEP HYPERTENSION IN THIS CONTEXT WITH VARIOUS PHARMACOLOGIC BUT ALSO BEHAVIORAL INTERVENTIONS. ULTIMATELY IT IS LIKELY THIS WILL REQUIRE APPROACH TO IMPLEMENTATION SCIENCE THAT CAN ADDRESS WOMEN'S HEALTH OR DURING -- BEFORE DURING AND AFTER PREGNANCY IN A MORE CONTINUOUS LIFE STAGE PATTERN. PART OF THE REASON WE THINK THIS MAYBE OF PARTICULAR RELEVANCE, AGAIN COMES FROM NHLBI COHORT DATA, THIS FROM CARDIA I THOUGHT PARTICULARLY NOTABLE THAT YOU CAN SEE CUMULATIVE INCIDENCE OF HYPERTENSION AND OFTEN WE CLASSICALLY FOCUSED IN ON MIDDLE AGE IN OUR COHORT STUDIES AND CLEARLY THERE IS A VERY HIGH PREVALENCE OF HYPERTENSION, AT TIME YEAR 55 WHICH THE AFRICAN AMERICANS ARE MUCH HIGHER THAN WHITES. WHAT I WILL POINT TO YOU IS THE DOTTED LINES THAT CONTRAST AFRICAN AMERICAN WOMEN RELATIVE TO WHITE WOMEN. AND YOU CAN SEE THAT THE SHIFT IN THAT CURVE AND HOW YOU CAN SEE THAT MORE RAPID ASSENT REALLY MEANS AFRICAN AMERICAN WOMEN AT 35 ALREADY HAVING A VASCULAR PATTERN OF ACCELERATION THAT IS EQUIVALENT TO WHITE WOMEN DECADES OF 15 YEARS OLDER. SO THIS SORT OF ACCELERATION OF THAT RISK THAT FALLS NOW RIGHT IN THEIR CHILD BARING YEARS IS CONTRIBUTING TO THEIR CHRONIC PROFILE, EVEN PRECONCEPTION IN THIS CONTEXT. SO THAT IS INSIGHTFUL DATA COMING FROM CARDIA. IT RAISES THE QUESTION AS TO HOW WE MIGHT BE ABLE TO TURN THAT CURVE, IS IT ACTUALLY POSSIBLE TO SHIFT THAT BACK WHERE AFRICAN AMERICAN WOMEN START TO HAVE A MORE CURVE MORE REMINISCENT OF WHITE WOMEN IN THOSE CHILD BARING YEARS. I DON'T KNOW THAT WE HAVE A STRATEGY, WILL HAVE TO ASK MY COLLEAGUES, DR. GOFF OR LARRY OR SOMEBODY, THAT IT WOULD BE NOTEWORTHY IF WE CAN START THAT PRIMORDIAL PREVENTION MUCH EARLIER ON IN THE ONSET OF THESE RISKS THAT MIGHT HAVE BENEFITS THAT LAST DECADES. AND I WAS REMINDED OF THIS PAPER BY STEVE JULIUS, THE TROPHY TRIAL WHICH THEY RANDOMIZED GROUPS OF PLACEBO GETTING AN ANGIOTEN SIN RECEPTOR FOR A PERIOD OF TIME AND FOLLOW THOSE INDIVIDUALS LATER. THIS APPEARED TO DELAY THESE PRE-HYPOTENSIVES EVENTUALLY HITTING THE DIAGNOSIS OF HYPERTENSION. ONE OF THE QUESTIONS THAT THIS RAISES IS, IS THERE A BENEFIT OF BEING UNDER THAT AREA UNDER THE CURVE FOR A WHILE? IN HA DISEASE THAT TAKES DECADES , WHAT'S THE EFFECT OF CHANGING THAT TRAJECTORY FOR YEARS AND DECADES, DO YOU BENEFIT FROM THAT OVER A LONG PERIOD OF TIME, IS THAT IN A SENSE BUILT INTO THE MEMORY OF YOUR BLOOD VESSELS AND CARDIOVASCULAR TREE YOU ARE PROTECTED DURING THAT PERIOD. I WOULD SUGGEST WE MIGHT HAVE HINTS OF THAT FROM THE OLD DPP TRIAL, NHLBI DATA WITH DDK IN TERMS OF DOING INTERVENTION. IN THAT CASE WITH METFORMIN OR LIFESTYLE ON PRE-DIABETICS. AND HERE IT'S HIGHLIGHTING THE DATA ON WOMEN. WHICH THERE APPEAR TO BE A SIGNAL IF YOU FOLLOWED THEM UP 15 YEARS LATER THE WOMEN STILL HAD A SUSTAINED REDUCTION IN MICROVASCULAR OUTCOMES. AND BENEFIT FROM THE EARLY INTERVENTION PERSISTENT AND MEASURABLE 15 YEARS LATER. AGAIN, POTENTIALLY CONSISTENT WITH THIS NOTION OF PREVENTION AD PREYES, SIR OF CHRONIC DISEASE AND RAISES THIS WHAT IF CIRCUMSTANCE WHERE EPIDEMIOLOGIC STUDIES SUGGEST OBSERVATIONALLY THERE COULD BE THOSE HIGH RISK SHOWN BY -- PAPER GENETIC RISK BUT THAT COULD BE AMELIORATED WITH THOSE WHO ADOPTED A HEALTHY LIFESTYLE DESPITE HIGH GENETIC BURDEN OF RISK AND PRE-DISPOSITIONS CBD. SIMILARLY IN THE MIDDLE PANEL HERE SHOWN THE DPP TRIAL AGAIN FOLLOW-UP WHERE YOU SEE PLACEBO GROUP STILL AT THE TOP IN TERMS OF CUMULATIVE INCIDENCE OF DIABETES BUT PERSISTENT EFFECT OF THE LIFESTYLE INTERVENTION, AGAIN WELL OVER A DECADE LATER, SO IT RAISES THE QUESTION WHETHER WE COULD HAVE SOMETHING ANALOGOUS, A DPP-LIKE INTERVENTION TRIAL THAT THEN FOCUSES IN ON THESE HIGH RISK WOMEN THAT WE SEE DYING AND HAVING MORBID COMPLICATIONS AT MANY FOLD RATES THAN MOST COUNTRIES LIKE OURSELF OURS AROUND THE WORLD. CAN WE DO SOMETHING THAT CAN HAVE A ROBUST SCALABLE SORT OF PATHWAY AND IMPACT THAT COULD TURN THAT CURVE. AGAIN, I WILL PUT THAT OUT AS A CHALLENGE AS TO THOSE IN OUR STAFF HERE WHO ARE THE EXPERT TRIALISTS AS WELL AS THE IMMUNITY. COMMUNITY. I'M GETTING THE HOOK. LAURA, PUSH THE BUTTON FOR NOISE. >> I DIDN'T HAVE ANYTHING TO DO WITH THAT. >> THAT WAS THE RESPONSE TO MY CHALLENGE. OKAY. FAIR ENOUGH. IT WOULD BE I THINK NOTEWORTHY AND TIMELY IF WE COULD DEVELOP AND LISTEN WHETHER IT'S ADVISABLE OR FEASIBLE TO THINK ABOUT A ROBUST INTERVENTION STUDY, IT'S BEEN OVER 30 YEARS SINCE WOMEN'S HEALTH INITIATIVE DID DEFINITIVE CLINICAL TRIALS IN WOMEN IN THEIR MENOPAUSAL YEARS. WHAT IF WE DID WOMEN'S HEALTH INITIATIVE LIKE INTERVENTION AT SCALE AND SCOPE AND ROBUSTNESS AND IMPACT FOR THESE WOMEN IN CHILD BARING YEARS. IS SOMETHING THAT I WOULD LIKE FOR THE TEAMS TO CONTEMPLATE, A CONCEPT IDEA THAT I HOPE WE WILL HEAR FROM OUR COUNCIL ABOUT AS WE WORK THROUGH HOW CAN WE BEST ADDRESS THIS PUBLIC HEALTH TREND THAT THREATENS YOUNG WOMEN IN THIS COUNTRY. AND AGAIN, WE WILL BE ENGAGED IN BRAINSTORMING ABOUT HOW THIS INSTITUTE MIGHT PARTICIPATE IN THAT TRANS-NIH EFFORT AND THINGS THAT RELATE TO OUR PARTICULAR PORTFOLIO WHICH CLEARLY IS AT THE CORE DRIVING THIS MATERNAL MORBIDITY MORTALITY, THIS SHOWS YOU SOME OF THE OPPORTUNITIES WE MIGHT BRAINSTORM AND CONTEMPLATE, BECAUSE I THINK THERE WILL BE A CALL TO ACTION QUITE SOON IN THIS SPACE. I WANT US TO BE AHEAD OF THE CURVE. WITH THAT, AND GIVEN THE CONSTRUCTION NOISE, I'LL CALL IT A WRAP THERE AND AGAIN, EXPRESS OUR APPRECIATION FOR ALL THAT YOU ARE DOING AS PART OF OUR CIRCLE OF PARTNERS. TO HELP US CREATE THIS DIVERSE ECOSYSTEM OF INCLUSIVE EXCELLENE IN WHICH WE ARE TAKING ON SOME OF THE EMERGING CHALLENGES OUR COUNTRY FACES AND REALLY GOING AT THOSE WHO ARE MOST AT RISK AND WHERE WE -- I BELIEVE CAN HAVE GREATEST IMPACT THAT COULD BE TRANSFORMATIVE TO THESE COMMUNITIES. THANK YOU FOR YOUR ATTENTION. [APPLAUSE] >> ANY QUESTIONS OR COMMENTS? DID EVERYBODY HAVE THEIR COFFEE THIS MORN SOMETHING NOT SEEING ANY QUESTIONS OR COMMENTS FROM OUR COUNCIL MEMBERS, I'M GOING TO PROCEED WITH INTRODUCING OUR NEXT SPEAKER, THIS MORNING, DR. JANINE CLAYTON, SHE WILL BE SPEAKING TO AT THIS ABOUT MATERNAL MORTALITY, WHAT DO WE KNOW AND HOW IS THE NIH ADDRESSING IT. DR. CLAYTON IS THE NIH ASSOCIATE DIRECTOR FOR RESEARCH ON WOMEN'S HEALTH AND DIRECTOR OF THE NIH OFFICE OF RESEARCH ON WOMEN'S HEALTH WHERE SHE SERVED SINCE 2012. CHEF IS A BOARD CERTIFIED OPHTHALMOLOGIST AND PREVIOUSLY SERVED DEPUTY CLINICAL DIRECTOR OF THE NATIONAL EYE INSTITUTE. HER RESEARCH INTERESTS INCLUDE OCULAR SURFACE DISEASE AND ROLE OF SEX AND GENDER IN HEALTH AND DISEASE. DR. CLAYTON ALSO STRENGTHENED NIH SUPPORT FOR RESEARCH ON DISEASE DISORDERS AND CONDITIONS THAT AFFECT WOMEN. SHE'S ARCHITECT OF THE NIH POLICY REQUIRING SCIENTISTS TO CONSIDER SEX AS A BIOLOGICAL VARIABLE, ACROSS THE RESEARCH SPECTRUM. A PART OF THE NIH INITIATIVE TO ENHANCE REPRODUCIBILITY RIGOR AND TRANSPARENCY. AS CO-CHAIR OF THE NIH WORKING GROUP ON WOMEN IN BIOMEDICAL CAREERS WITH NIH DIRECTOR DR. COLLINS, DR. CLAYTON LEADS NIH EFFORTS TO ADVANCE WOMEN IN SCIENCE CAREERS. DR. CLAYTON IS IN MUCH DEMAND THIS MORNING AND WE ARE GRATEFUL WE WAS ABLE TO MAKE TIME IN HER SCHEDULE TO SPEAK TO US. WELCOME, DR. CLAYTON. >> GOOD MORNING, THANK YOU. THIS IS THE FIRST TIME I HAVE HAD TO SPEAK AT TWO COUNCILS IN THE SAME MORNING BUT THAT MEANS EVERYBODY IS THINKING ABOUT THE HEALTH OF WOMEN SO THAT IS IMPORTANT TO ME SO THANK YOU, DR. GIBBONS AND ENTIRE NHLBI FOR INCLUDING AND INVITING ME. SORRY I MISSED THE BEING OF YOUR COMMENTS BUT I DID HEAR A SHOUT OUT AND YOUR LAST SLIDES JUST WERE PERFECT TO RIDE ME INTO WHAT WE ARE GOING TO TALK ABOUT HERE T A REALLY DISTURBING IMPORTANT ISSUE, MATERNAL MORTALITY IN THIS COUNTRY, IS REACHING LEVELS THAT ARE UNHEARD OF. AND EXCEED THOSE OF ALL OF OUR PEER COUNTRIES. LET ME START WITH RECENT NEWS, LAST WEEK OR A NEW WEEKS AGO THE NATIONAL CENTER FOR HEALTH STATISTICS RELEASED THREE REPORTS ON MATERNAL MORE IT WILLTY, THESE ARE IMPORTANT BECAUSE THEY REPRESENT AN EXSENTIVE REVIEW OF HIGH QUALITY DATA AND ENHANCEMENT OF THE DATA QUALITY REFLECTED BY NEW CODING PROCEDURES RELATED TO THE PREGNANCY CHECK BOX, DEATH CERTIFICATES AND MORE STANDARDIZATION ACROSS THE STATES, SO THAT WE CAN HAVE MORE CONFIDENCE IN THE NUMBERS THAT ARE BEING REPORTED. THAT SAID, THE NUMBERS ARE STILL VERY DISTURBING. THOSE REPORTS TO ME THEY JUST MAKE US EVEN MORE CONFIDENT IN THE NUMBERS AND COMPELLED TO DO SOMETHING ABOUT IT. HERE IS WHAT THE NUMBERS LOOK LIKE IN TERMS OF MATERNAL MORTALITY STATISTICSES IN RACIAL ETHNIC GAPS YOU SEE ON THE LEFT WITH EXTREMELY DISTURBING RATE AND NON-HISPANIC BLACKS. NA FEEDS THE RATE OF NON-HISPANIC WHITES AND ALSO EQUALLY DISTURBING RATE IN AMERICAN INDIAN ALASKA NATIVE WOMEN WHICH DOESN'T GET AS MUCH DISCUSSION, THAT'S IMPORTANT FOR US ESPECIALLY ACROSS THE BOARD TO THINK ABOUT ALL THE MANY DIFFERENT FACTORS AND ALL OF THE WOMEN WHO ARE AFFECTED, ALL THE MOTHERS WHO P WE ARE LOSING AND ALL THE FAMILIES THAT ARE AFFECTED. THIS IS ALSO IMPORTANT TO CONSIDER WHAT ABOUT THE HISPANIC PARADOX? I DON'T KNOW IF DR. WOOLF WILL TALK ABOUT THIS LATER BUT THAT IS SOMETHING WE SEE IN OTHER HEALTH OUTCOMES AS WELL, IF WE CAN BETTER UNDERSTAND THAT MIGHT WE BE ABLE TO USE THAT INFORMATION OR IS THAT GOING TO BE CHANGING TOO. SO WE NEED TO KEEP AN EYE ON ALL OF THOSE DIFFERENCES. AND THIS IS WHY. I THINK I SHARED THIS SLIDE MAYBE THE LAST TIME I VISITED WHETHER THIS NUMBER IS EXACTLY WHAT THE NUMBER S THE IMPORTANT THING IT FAR EXCEEDS THE HIGH INCOME PEER COUNTRIES IS AT A LEVEL WITH COUNTRIES THAT HAVE A VERY DIFFERENT HEALTH SYSTEM THAN WE DO WITH OUR HIGH QUALITY HEALTH SYSTEM HAVING RATES LIKE THIS JUST DOESN'T MESH. IT DOESN'T WORK. HOW DOES THIS HAPPEN AND WHAT ARE WE GOING TO DO ABOUT IT MORE IMPORTANTLY. SO THINK ABOUT THE LEADING CAUSES OF MATERNAL MORTALITY, IT'S IMPORTANT TO THINK ABOUT THEM IN CONTEXT OF TIME PERIOD, IS IT DURING PREGNANCY, DAY OF DELIVERY, FIRST TO SIX DAYS POST PARTUM OR LATE FOURTH TRIMESTER, YOU ARE LOOKING MORE EQUAL BREAK DOWN BETWEEN INFECTION AND NON-CARDIOVASCULAR CONDITIONS, DAY OF DELIVERY NOT SURPRISING THAT HEMORRHAGE IS LEADING CAUSE OF MATERNAL MORTALITY AND GLOBALLY IS A HUGE ISSUE. AMNIOTIC FLUID EMBOLISM AND CARDIOVASCULAR CONDITIONS. ONE TO SIX DAYS POST PARTEM HEM RIDGE IS UP THERE AT LEADING CAUSE BUT HYPERFENSIVE INFECTION COMES INTO PLAY AND IN THAT LATE UP TO ONE YEAR AFTER DELIVERY I WANT TO DRAW YOUR ATTENTION TO THIS NUMBER. AND THIS ISSUE OF CARDIO MYOP THINK WHICH IS APPEARING TO BE A BIGGER ISSUE FOR AFRICAN AMERICAN WOMEN SO WE SEE DIFFERENCES AMONG RACE ETHNICITY IN THESE PARTICULAR CAUSES AS WELL. BOTTOM LINE, 50 TO 60% ARE PREVENTABLE. SO WHAT CAN WE DO TO GET THOSE INTERVENTIONS THAT WE KNOW WORK FOR SOME WOMEN AND SOME CONTEXT SO WE CAN PREVENT THOSE DISEASES AND CONDITIONS AND DEATHS THAT ARE PREVENTABLE. I KNOW MANY OF YOU HEARD THIS TERM THAT PREGNANCY IS A STRESS TEST. IT IS A STRESS TEST. ANYBODY WHO HAS BEEN PREGNANT IT WILL TELL YOU IT'S A STRESS TEST BUT I WOULD SUBMIT IT'S A TEST FOR US. AND WE ARE FAILING THE TEST BECAUSE OF THOSE NUMBERS. BECAUSE OF WHAT WE ARE SEEING. SO IF YOU THINK ABOUT THE LIFE SPAN AND DR. GIBBONS HAD A LIFE COURSE IN ONE OF HIS SLIDES BUT THE LEFT GOING IN UTERO EXPOSURE TO THE OLDEST YEARS HERE, WE NEED TO THINK ABOUT PREGNANCY NOT AS A SOLITARY EVENT THAT OCCURS ONCE OR TWICE OR SEVERAL TIMES IN A WOMAN'S LIFETIME BUT AS PART OF THE ENTIRE TRAJECTORY OF HER LIFE. BECAUSE IT INFLUENCES THE HEALTHS OF WOMEN THROUGHOUT THEIR ENTIRE TRAJECTORY AND THEIR HEALTH STATUS GOING INTO THAT PREGNANCY IS A REALLY IMPORTANT PARAMETER. SO WE KNOW FOR EXAMPLE FOR WOMEN THAT EXPERIENCE DEPRESSION IN ADOLESCENCE ARE INCREASED RISK FOR DEPRESSION IN THE PERIMENOPAUSAL PERIOD. WE KNOW THAT, I'M NOT SURE WE DO ANYTHING ABOUT THAT KNOWING THAT WHAT ARE DO WE CHANGE HAS BEEN THOSE WOMEN WHO IDENTIFY AS HIGH RISK? IN TERMS OF DR. GIBBONS CHALLENGE TO THE GROUP HERE, WE KNOW WOMEN EXPERIENCE PRE-ECLAMPSIA DURING PREGNANCY OR GESTATIONAL DIABETES DURING PREGNANCY ARE AT FAR INCREASE RISK FOR DEVELOPING HYPERTENSION AND THE STUDY SHOWED IN ONE CASE PREECLAMPSIA WITHIN THREE YEARS ALSO INCREASE RISK FOR TYPE 2 DIABETES AND CARDIOVASCULAR DISEASE INCLUDING CHRONIC KIDNEY DISEASE. IF WE KNOW THIS IS THE ARC WHAT ARE WE DOING TO INTERRUPT THAT? HOW CAN WE PUT ON OUR PREVENTION HAT NOT PRIMARY PREVENTION BUT HOW PUT ON PREVENTION HAT TO CHANGE THIS TRAJECTORY AND CHANGE THIS COURSE. WE KNOW WOMEN ARE CARED FOR, BY MANY DIFFERENT PEOPLE ALONG THE WAY. OUR CARE IS FRAGMENTED. HOW WE DO RESEARCH IN SOME CASES IS DISPARATE. WE DON'T ALWAYS COME TOGETHER AROUND A PARTICULAR CAUSE ECAUSE WE ARE GOING DEEP. ON A PARTICULAR ASPECT. AND YOU HAVE TO DO THAT. YOU NEED THAT DEPTH OF RESEARCH AT THE BASIC LEVEL TO MAKE DISCOVERIES BUT YOU NEED TO BRING THAT UP TO THE LEVEL OF INDIVIDUAL WOMEN AND I WOULD SUBMIT WE CAN INTEGRATE ACROSS OUR RESEARCH AND WE MUST TO BE ABLE TO ADDRESS AN ISSUE LIKE THIS. ONE OFF APPROACHES JUST WON'T WORK. SO I WOULD SAY MATERNAL MORTALITY IS A TIP OF THE ICEBERG AND MORBIDITY AND SEVERE MORBIDITY AND THE NEAR MESSES EVERY WOMAN THAT DIES THERE SEVEN OR TEN YEAR MESSES FOR THAT WOMAN AND WHAT'S -- MISSES FOR THAT WOMAN AND WHAT'S UNDERNEATH THAT. YOU HEARD THAT BEFORE ARESOME DETERMINANTS OF HEALTH. HOW CAN WE ADDRESS IN IN A COORDINATED SEQUENTIAL APPROPRIATE WAY TO HAVE THE MAXIMUM IMPACT AND HAVE THAT EVIDENCE THAT WE ARE GENERATING BE IMPLEMENTED IN THE RIGHT CONTEXT TO MAKE A DIFFERENCE. SO NIH INVESTED SIGNIFICANTLY IN ISSUE OF MATERNAL HEALTH, MANY INSTITUTES AND CENTERS HERE AT NIH, WITH NICHD BEING THE LEAD FOR THAT WITH REPRESENTING FOR EXAMPLE FY 19 OVER $324,000,000 IN THAT SPACE. THIS GRAPHIC HIGHLIGHTS SOME OF THE AREASNA ARE A DRESS BUD THINK ABOUT THAT HOW THAT GRAPHIC LOOKS FOR A COMMENT I MAKE IN THE FUTURE. THERE'S OBVIOUSLY INVESTMENTS IN VERY IMPORTANT AREAS. TESTIFY 21ST CENTURY EXCUSER ACT HIGHLIGHTED THAT THE ISSUE OF RESEARCH IN PREGNANT WOMEN AND LACK AT A TIMING WOMEN, AND UNDERSTANDING HOW SCIENCE WORKS IN THOSE CONTEXT, HOW MEDICATIONS WORK, HOW WE NEED TO TREAT PREGNANT WOMEN WHO GET SICK AND SICK WOMEN WHO GET PREGNANT, BECAUSE OF THAT THEY CREATEDDED THE TASK FORCE FOR PREGNANT AND LACK AT A TIMING WOMEN, RENEWED RECENTLY FOR TWO YEARS. THAT GROUP MET VERY RECENTLY LAST WEEK AND THEY ARE ADDRESSING IMPLEMENTATION PLANS FOR 15 RECOMMENDATIONS, THAT THIS GROUP CREATED, IT'S A VERY BROAD GROUP, TRANSAGENCY EVEN, CHAIRED BY DR. BIANCI DIRECTOR OF NICHD WITH REPRESENTATION FROM OTHER FEDERAL AGENCIES AND SECTORS, A VARIETY OF INDUSTRY REPRESENTATIVES INCLUDING AS WELL AS MEDICAL SOCIETIES AND NPOs. I WILL HIGHLIGHT THREE AREAS THAT THEY TALKED ABOUT LAST WEEK. I SUBMIT TO YOU THAT THAT LINK HAS RECOMMENDATIONS FOR ALL -- IMPLEMENTATION STRATEGIES FOR ALL 15 RECOMMENDATIONS. SOME OF THE HIGHLIGHTS FOR YOU ARE TO CREATE A SEPARATE PRIORITIZATION PROCESS OF PREGNANT AND LACK AT A TIMING WOMEN. WE NEED TO THINK ABOUT WHAT ARE THE MOST IMPORTANT COMPELLING RESEARCH QUESTIONS THAT NEED TO BE ASKED FOR DIFFERENT POPULATIONS AND FOR DIFFERENT CONDITIONS AND DISEASES. WHAT ABOUT FOR PREGNANT LACK AT A TIMING WOMEN WHICH IS A SLIGHTLY DIFFERENT PERSPECTIVE. WE NEED TO ADDRESS HOW TO -- WE NEED TO ADDRESS CURRENT BARRIERS INCLUDING PREGNANT AND LACK AT A TIMING WOMEN IN CLINICAL TRIALS WHICH WE KNOW THERE ARE MANY BUT HOW WE'LL ADDRESS THOSE BARRIERS, MOVE BEYOND TALKING ABOUT THEM AND DOING SOMETHING ABOUT THEM. ONE PARTICULAR STRATEGY ADVOCATED FOR IS DESIGNING HEALTH RECORD SYSTEMS THAT ALLOW YOU TO LINK MOTHER AND INFANT HEALTH RECORDS SO WE CAN BETTER DELINEATE COURSES OF BOTH CHILD INFANT AND MOTHER. THAT'S IMPORTANT AND ONE PARTICULAR STRATEGY, AS YOU IMAGINE THERE ARE MANY DIFFERENT ELECTRONIC HEALTH SYSTEMS, HEALTH RECORD SYSTEMS, HEALTH SYSTEMS, VENDORS, THERE'S ISSUES AROUND THAT, I KNOW YOU CAN IMAGINE THAT THAT WOULDN'T BE EASY BUT AN IMPORTANT THING TO DO. NIH IS TAKING THESE ISSUES VERY SERIOUSLY, BOTH IN TERMS OF RESEARCH INVESTMENTS, AS IN TERMS OF DISCUSSIONS HERE AT NIH AND GAT INJURIES FOR US TO MOVE FORWARD IN WAYS THAT ARE GOING TO BEND THAT CURVE THAT I SHOWED YOU. NIH LEADERSHIP CREATED A MATERNAL MORTALITY TASK FORCE, I'M PRIVILEGED TO CO-CHAIR THAT WITH DR. BIANCI AND DR. SWEATS, NIH ASSOCIATE DEPUTY DIRECTOR, THAT GROUP IS CONVENING A SHORT PERIOD OF TIME BUT WE WERE ABLE TO PUT OUT AN RFI THAT I WANT TO MAKE SURE THAT ALL OF YOU KNOW ABOUT. THIS REQUEST FOR INFORMATION IS ASKING FOR FEEDBACK ON A POTENTIAL STRATEGY THAT WOULD INVOLVE TWO PRONGED APPROACH LOOKING AT COMMUNITY FOCUSED SOCIAL BEHAVIORAL FACTORS AND ALL THOSE ISSUES THAT WOULD ALLOW US TO BE POTENTIALLY STUDY AND EVALUATE TOOLS AT STATE LEVEL OR TAILORED TO PARTICULAR COMMUNITY USING THE RECOGNITION ARE SO IMPORTANT IN MATERNAL MORTALITY AND MORBIDITY AND AN EFFORT BIOLOGICALLY FOCUSED LOOKING AT THE UNDERPINNINGS OF RISK INCLUDING PRIORITIZING CARDIOVASCULAR DISEASE, MATERNAL INFECTION AND MENTAL HEALTH. THERE ARE MANY ISSUES THAT ARE IMPORTANT SO WE REALLY WOULD LIKE TO GET AS MUCH INPUT AS POSSIBLE ON THIS RFI, PLEASE SHARE THIS WIDELY WITH YOUR STAKEHOLDERS AND WE WOULD LOVE TO HEAR FROM YOU IN TERMS OF YOUR FEEDBACK ON THESE POTENTIAL STRATEGIES. DEADLINE FOR RESPONSE IS FEBRUARY 21ST. IN ADDITION WE HAVE BEEN WORKING ALONG WITH MEMBERS OF THE INSTITUTE, RATS TWO LEVELS RATS THE DEPARTMENT. MATERNAL MORTALITY MORBIDITY STEERING COMMITTEE AND THE WORKING GROUP WHERE INSTITUTES AND CENTERS ARE WELL REPRESENTED, NHLBI AND MINORITY LEVEL AND HEALTH DISPARITIES AND OTHERS REPRESENTED THERE, WE ARE COORDINATING ACROSS THE DEPARTMENT IN TERMS OF WHERE ISSUES ARRIVE IMPORTANT FOR RESEARCH, SPECIFIC DELIVERY OF CARE ISSUES OR MEDICAL HEALTHCARE PROFESSIONAL EDUCATION ISSUE, GAPS IN UNDERSTANDING, WHAT ARE THE MOST IMPORTANT FACTORS THAT WE NEED TO PRIORITY. THOSE DISCUSSIONS -- PRIORITIZE. THOSE DISCUSSIONS ARE ONGOING AND YOU SHOULD STAY TUNED AND KEEP AN EYE OUT FOR SOMETHING THERE SOON. IN MAY Z WHICH IS VERY IMPORTANT MONTH FOR WOMEN, NATIONAL WOMEN'S HEALTH IN THAT SECOND WEEK, IN PARTNERSHIP WITH NICHD AND NHLBI AND NICHD ARE REPRESENTED THERE, A WORKSHOP ONCO MORBID CONDITIONS. WOMEN ARE MORE LIKELY TO BE OLDER, MORE LIKELY TO BE MORE ILL, MORE LIKELY TO BE HYPERTENSIVE. THEY ARE MORE LIKELY TO BE OBESE, MORE LIKELY TO ALREADY HAVE TYPE 2 DIABETES BEFORE THEY BECOME PREGNANT. ALL THOSE FACTORS CRYPT TO THESE OUTCOMES AMONG OTHERS SO WE WILL TALK ABOUT THAT CONSTELLATION OF CORE MORBIDITIES AND WHAT THAT -- CO-MORBIDITIES AND WHAT THAT MEANS NOR REPRODUCTIVE HEALTH IN 2020. WOMEN ARE HAVING BABIES SEVEN TO TEN YEARS LATER THAN THEY WERE IN 1970s. THAT HAS CONSEQUENCES. WHAT HAVE WE DONE TO BE ABLE TO MITIGATE THOSE RISKS THAT OLDER WOMEN -- WOMEN HAVING CHILDREN OLDER AGES HAVE. OF COURSE WE LIKE FOR ALL OF THIS INFORMATION TO INFORM THE DEVELOPMENT OF A RESEARCH AGENDA IN THE FUTURE THAT'S COORDINATED, AND THAT IS ALIGND WITH A TRANS-NIH STRATEGIC PLAN FOR WOMEN'S HEALTH RESEARCH. IT WAS MY PRIVILEGE A YEAR AGO TO WORK WITH THE INSTITUTES AND SENT AND SCIENTISTS AND OUTSIDE STAKEHOLDERS AND ADVOCACY GROUPS AND OTHERS TO DEVELOP THIS TRANS-NIH STRATEGIC PLAN AND THE ULTIMATE GOAL OF THIS PLAN IS ADVANCE RIGOROUS RESEARCH RELEVANT TO THE HEALTH OF WOMEN AND OF COURSE IMPROVING MATERNAL HEALTH AND ADDRESSING DISTURBING TRENDS D MATERNAL MORTALITY IS RELEVANT TO HEALTH OF WOMEN. HERE ARE THE OTHER WAYS WE ARE DOING THAT. I WANT TO SHARE A COUPLE OF PIECES OF INFORMATION ABOUT THE OFFICE OF RESEARCH WOMEN'S HEALTH AND NEW PROGRAMS. IN A DIGS TO MENTORED CAREER DEVELOPMENT PROGRAMS, NIH IS ONLY SPECIALIZED CENTER OF CENTER OF EXCELLENCE OF SEX DIFFERENCES, A DISEASE AGNOSTIC PROGRAM, SEX AND GENDER ADMINISTRATIVE SUPPLEMENTS WHERE WE WORKED WITH VIRTUALLY EVERY INSTITUTE AND CENTER OVER THE LAST SIX YEARS, FUNDING OVER 340 INVESTIGATORS AT ALMOST $40,000,000 FOR THEM TO ADD OPPOSITE SEX TO BASIC SCIENCE STUDIES TO ADD BOTH SEXES MORE SUBJECTS TO INCREASE POWER, TO DO SECONDARY DATA ANALYSIS, THAT'S OUR SEX AND GENDER ADMINISTRATIVE SUPPLEMENT PROGRAM. A VERY IMPORTANT PROGRAM FOR THIS ISSUE UNDERSTUDIED UNDERREPORTED OR UNDER-REPRESENTED POPULATIONS OF WOMEN ACROSS THE U.S. WHICH COULD BE AFRICAN AMERICAN WOMEN AND PARTICULAR SETTING, LATIN WOMEN IN PARTICULAR SETTING OR WHITE WOMEN IN LAY SHAH, IT'S -- IN APPROXIMATE LAY SHAH, A VERY BROAD DEFINITION AND ALLOWS US TO LOOK SPECIFICALLY AT POPULATIONS OF WOMEN AND STUDY INTERVENTIONS OR CONTEXT OR NATURAL HISTORY THAT ARE HIGHLY RELEVANT TO THEM AND OUR NEWEST PROGRAM NIH FIRST EVER RO1 THAT IS FOCUSING ON SEX AND GENDER, BOTH BIOLOGICAL ASPECT AS WELL AS SOCIAL ASPECT WITH GENDER, THE INVESTIGATORS MUST ADDRESS BOTH -- AT LEAST ONE ASPECT OF SEX AND GENDER AND THEY MUST ADDRESS ONE OF THE FIVE OBJECTIVES IN STRATEGIC GOAL ONE OF THE TRANS-NIH STRATEGIC PLAN. WE ARE EXCITED TO HAVE RECEIVED A ROBUST RESPONSE. FOR THAT. RO1 FOA AND WE LOOK FORWARD TO TALKING WITH YOU MORE AND THAT ONE IN THE FUTURE WHEN WE ARE FUNDED A FEW OF THOSE. I MENTIONED THE U 3 PROGRAM. I WANT STOW SHARE WITH YOU THAT THE INTERSEXUALITY OF SEX GENDER AND HOW THAT INTERFACES AND INTERSECTS AND INTERACTS WITH OTHER IMPORTANT ASPECTS OF HEALTH RACE AND ETHNICITY BUT SOCIAL DETERMINANTS OF HEALTH PLAY SPACE URBAN LOCATION RURAL LOCATION AND OTHERS IS AN ISSUE THAT WE HAVE BEEN TRYING TO HIGHLIGHT THAT'S BEEN PICKED UP BY MANY INSTITUTES ESPECIALLY NHLBI WHICH HAS A ROBUST INCLUSION OF WOMEN'S HEALTH IN THEIR STRATEGIC PLAN IN THEIR STRATEGIC VISION AND IN THEIR EFFORTS. SO THE LAST YEAR WE WERE ABLE TO PUT FORWARD $4.7 MILLION TO 21 AWARDS TO INVESTIGATORS FUNNED BY TEN INSTITUTES AND CENTERS HERE AT NIH AND THREE OF THEM TO CUTS ON REPRODUCTIVE HEALTH AND MATERNAL HEALTH SPACE. ONE IS RELATED TO LOW INCOME AFRICAN AMERICAN AND LAT MOW KNOW WOMEN LIVING WITH HIV IN THE HOE LATINO WOMEN LIVING WITH HIV IN THE LAST TRIMESTER AND VERY IMPORTANT TRANSITION. THERE'S A LOT OF ATTENTION TO BABY ONCE BORN, THERE NEEDS TO BE JUST AS MUCH ATTENTION GIVEN TO THE HEALTH OF THE MOTHER. WHETHER PLACENTAL MICROEXPRESSION FOUR ADIPOSITY GROUPS IS AFFECTED BY MATERNAL RACE ETHNICITY IS ANOTHER TOPIC AND ANOTHER SUPPLEENT ADDRESSES PEER SUPPORT AND PEER LED INTERVENTIONS TO IMPROVE POST PARTEM RETENTION OF STUDY PARTICIPANTS IN HIV CARE. WE HAVE SEEN THAT PRE-NATAL GROUP COUNSELING IS VERY EFFECTIVE IN SOME POPULATIONS AND WE WANT TO SEE MORE OF LOOKING AT THAT PEER SUPPORT AND HOW WE CAN LEVERAGE THAT IN OUR INTERVENTIONS. NHLBI HAS MANY EFFORTS THAT ARE HIGHLY RELEVANT IN MATERNAL HEALTH SPACE AND WE ARE PLEASED TO BE ABLE TO SUPPORT SEVERAL OF THOSE HERE I'M HIGHLIGHTING A FEW OF THEM TO GIVE YOU A SENSE OF THE RANGE OF THEM BUT THIS IS JUST THE TIP OF THE ICEBERG, THERE IS A LARGE NUMBER OF INVESTMENTS AS YOU MIGHT IMAGINE. AS THEY COME AROUND TO THE END HERE I WANT TO SHARE WITH YOU THIS MULTI DIMENSIONAL FRAMEWORK AND THINK IN THE CONTEXT OF THAT EARLIER SLIDE THAT I SHOWED YOU WITH THE EKG TRACING AND HOW WE HAVE TO THINK OF THESE ISSUES IN THE CONTEXT OF THE LIVES WOMEN LEAD AND IN THE LIFE COURSE ALONG THEIR LIFE COURSE. SO OBVIOUSLY HERE IS THE LIFE COURSE IN THE MIDDLE, WE THINK OF HEALTH AS THESE BIOLOGICAL FACTORS OR THESE INTERNAL FACTORS, FROM OUR PERSPECTIVE FIRST AND FOREMOST SEX HAVING INFLUENCE THERE, INFLUENCING LITS RALLY THE GENE EXPRESSION OF EVERY SINGLE CELL IN YOUR BODY, EVERY ORGAN SYSTEM, AND OBVIOUSLY THAT HAS AFFECTS AT THE ORGANISM PERSON LEVEL. SO THOSE GENETIC MOLECULAR AFFECTS ARE HAVING A ROLE TO PLAY S THAT DOES INFLUENCE HEALTH BUT ALSO WOMEN IN CONTEXT, THESE EXTERNAL FACTORS FIRST AND FOREMOST FROM OUR PERSPECTIVE, GENDER HOW THE CARE GIVING ROLES, THOSE RESPONSIBILITIES, THOSE DYNAMICS ALL OF THOSE EXPECTATIONS AND NORMS THAT MAY AFFECT HEALTH. SOCIAL DETERMINANTS OF HEALTH, INCREDIBLE. OUR GENETIC RISK ACCOUNTS FOR 20, 30% OF OUR HEALTH OUTCOMES. WHAT ABOUT THE OTHER 70%? IT'S ALL THESE OTHER FACTORS, HEALTH BEHAVIORS OUR ENVIRONMENTAL EXPOSURE SO THAT'S ENVIRONMENT WITH A BIG E, SO IT COULD BE TOXIC EXPOSURE TO CHEMICALS OR BPA BUT ALSO EXPOSURE TO STRESS. ADVERSE CHILDHOOD EXPERIENCES THAT YOU HAD AT AGE 3 THAT ARE AFFECTING YOUR HEALTHS RISK AT 55. WE NEED TO BETTER UNDERSTAND ALL OF THESE FACTORS ALL THESE ISSUES, HOW THEY INTERACT, HOW THEY INTERSECT, IN THE CONTEXT OF THE LIFE COURSE SO WE CAN BETTER ADDRESS THE HEALTH OF WOMEN. IT'S VERY CLEAR WOMEN ARE -- HAD A VERY DIFFERENT HEALTH STATUS, WHEN THEY ARE BECOMING PREGNANT THAN EVER BEFORE. SO TO ADDRESS THE ISSUES OF MATERNAL HEALTH, WE NEED TO ADDRESS THE HEALTH OF WOMEN, BEFORE THEY BECOME PREGNANT AS YOU SAW FROM DR. GIBBONS SLIDE DURING PREGNANCY AND AFTER PREGNANCY, IT WAS REALLY WARMED MY HEART WHEN HE MENTIONED WHI AND LEGACY OF THE WHI, A LAND MARK STUDY THAT LOOKED AT ISSUES RELATED TO THE HEALTH OF WOMEN IN A PARTICULAR LIFE STAGE, I LITERALLY WROTE DOWN NOTES ALMOST EXACTLY WHAT GARY SAID ABOUT WE NEED A WHI STRATEGY LIKE STRATEGY FOR HEALTH OF WOMEN OF REPRODUCTIVE AGE, BY THAT A COMPREHENSIVE STRATEGY TO ADDRESS IN A COORDINATED WAY, WHAT ARE THE MOST COMPELLING QUESTIONS BUT EQUALLY IMPORTANT WE HAVE SCIENCE AN TECHNOLOGY TODAY WE CAN APPLY TO THIS PROBLEM IN WAYSES THAT WE HAVEN'T YET. AND THE BENEFIT WILL BE REAPED NOT JUST AROUND MATERNAL MORTALITY AND MATERNAL HEALTH, THE BENEFIT WILL BE TO HEALTH O WOMEN BROADLY. WE KNOW WHEN HEALTH OF WOMEN IMPROVES IN ANY COMMUNITY, ANY SOCIETY, THE ENTIRE HEALTH OF THE COMMUNITY IMPROVES. SO THIS IS I WOULD SAY AN INVESTMENT AND STRATEGY THAT IS IMPORTANT FOR EVERYBODY'S HEALTH. I WOULD BE REMISS IF I DIDN'T MENTION AN AREA THAT'S ALSO IMPORTANT TO US AT ORWH, THE ISSUE OF WOMEN AND CAREERS. WE ARTICULATED IN THAT TRANS-NIH STRATEGIC PLAN FOR THE FIRST TIME, A VISION FOR WOMEN, THAT VISION SAYS WE WANTS ALL WOMEN TO REACH THEIR FULL POTENTIAL IN SCIENCE. IN ORDER TO DO THAT, WE ARE TRYING TO DEVELOP STRATEGIES TO SUPPORT WOMEN IN PARTICULAR AT TRANSITION POINTS WHERE WE KNOW WOMEN TEND TO LEAVED SCIENTIFIC BIOMEDICAL WORK FORCE. SO WE TALKED ABOUT AT OUR COUNCIL A CONCEPTS OF HOW TO RECOGNIZE TRANSFORMATIVE APPROACHES THAT HAVE ACTUALLY PROMOTED FACULTY GENDER DIVERSITY INSTITUTION SO WE CAN SEE WHAT HAS WORKED FOR SOME INSTITUTIONS FOR SOME DISCIPLINES AND FOR SOME CONTEXT. AND WE PUT OUT AN RFI FOR THAT AND COMPILING THAT INFORMATION. WE ARE ALSO PLEASED ALONG WITH O 26 INSTITUTES AND CENTERS TO HAVE SUPPORTED NEW NOTICES OF SPECIAL INTEREST, THAT ARE ADDRESSING CAREER RETENTION OF CONSIDER AWARDEES WHICH PROVIDE TIME AND MONEY FOR INVESTIGATORS WHO ARE EXPERIENCING PA QUALIFYING LIFE EVENT INCLUDING CHILDBIRTH, TO BE ABLE TO HAVE CONTINUE THEIR WORK AND WE ARE VERY FLEXIBLE IN OUR STRATEGIES TO DO THAT. A COMPANION OC THAT ADDRESSES FIRST TIME RO1 EQUIVALENT RECIPIENT FORS THE SAME REASON, QUALIFYING LIFE EPIEVENT, THE GOAL IS TO KEEP INVESTIGATORS IN SCIENCE, KEEP THE SCIENCE GOING, KEEP THEM IN SCIENCE TO REACH POTENTIAL AND THE GUIDE NOTICES ARE LISTED THERE. NINDS AND OTHERS HAVE ANNOUNCED ELIGIBILITY WINDOW FOR PATHWAYS TO INDEPENDENCE AWARDS, K-9 9 R 00, BE SURE YOU ARE WARE OF THAT. WE ARE WORKING WITH POST DOCS THE POST ARE NATIONAL POST DOC ASSOCIATION AND OTHER GROUPS OF POST DOCS TO TRY TO GET THIS INFORMATION OUT. TO AS MANY PEOPLE AS POSSIBLE INTO THE SCIENTIFIC COMMUNITIES. AND SEVERAL OF THE INSTITUTES DIRECTORS HAVE BLOGGED ABOUT THIS AND ARE TALKING ABOUT THAT IN THEIR PRESENTATION. EDUCATION AROUND THESE ISSUES OF HOW SEX AND GENDER INFLUENCE HEALTH AND DISEASE ARE PARTICULARLY IMPORTANT TO ORWH AND I WANT TO SHARE WITH YOU THE LAUNCH OF ONE OF OUR NEWEST SEX AND GENDER COURSES BENCH TO BEDSIDE INTEGRATING SEX AND GENDER TO IMPROVE HUMAN HEALTH. WE UPDATED THIS COURSE, IT'S A COMPLETE UPDATE, IT'S A COLLABORATION WITH OFFICE OF WOMEN'S HEALTH AD FOOD AND DRUG ADMINISTRATION. THE FIRST MODULE IS AVAILABLE ON IMMUNOLOGY, THE NEXT MODULE IS CARDIOVASCULAR DISEASE. SO THAT WILL BE COMING OUT SOON. AND WE ALSO HAVE A NEW SABV PRIMER THAT WILL BE COMING IN A COUPLE OF MONTHS AS WELL. SO AS I COLLECT MY THOUGHTS HERE FOR OUR SUMMARY, I WANT TO BRING IT TOGETHER TO SHARE WITH YOU THE OVERALL STRATEGY THAT WE ARE EMPLOYING, SO WE BELIEVE INTEGRATING CONSIDERATIONS OF SEX BIOLOGICAL FACTORS AND GENDER, SOCIAL FACTORS, AT EVERY STAGE OF THIS RESEARCH CONTINUUM, FROM THE MOST BASIC STUDY WHERE SEX DOES PLAY A ROLE THROUGH THAT TRANSLATION TO CLINIC, ALONG THE WHICH IN PAUL PHASES, SEX DISSIGNATURE GATING RESULTS AND REPORTING THAT ALL THESE STEPS NEED TO TAKE PLACE, THAT SHOULD INFORM EDUCATION INTERPERSONAL COMMUNICATION WORKING ONLINE MODULES TO INFORM HEALTH AND SCIENCE POLICY, THE APPROACHES WE TAKE IN THAT SPACE AND ULTIMATELY DELIVER SEX AND GENDER INFORMED EVIDENCE BASED CARE TO EVERY INDIVIDUAL, THAT'S THE ULTIMATE GOAL AND INTEGRATING THESE PERSPECTIVES THROUGHOUT THIS CONTINUUM STRENGTHENS THE CONTINUUM AND ALLOWS IT TO BE MORE LIKELY TO LEAD TO HEALTHY OUTCOMES FOR EVERYBODY. SO WE -- EVERY YEAR, SO CELEBRATE ACROSS THE COUNTRY, EVERYBODY NEEDS TO WEAR RED, WE ARE CREATIVE IN OUR REDS, IF YOU CAN HAVE A LITTLE PIECE OF RED& ON WITH A SCARF SO HERE IS ONE FUN PHOTO FROM JUST THIS YEAR, WHERE WE BROUGHT ATTENTION TO THIS ISSUE. U I THINK WE AGREE HERE IN THIS ROOM AND ORWH, BRINGING ATTENTION TO ISSUE IS THE FIRST STEP, MOVING FORWARD APPLYING KNOWLEDGE IS ANOTHER STEP, DATA ISN'T KNOWLEDGE UNLESS YOU INTERPRET AND APPLY IT AND IT DOESN'T GET TO HAVE ITS FULL IMPACT. WE DON'T REAP THE BENEFIT OF INVESTMENTS UNTIL WE TURN DISCOVERY INTO HEALTH. FOR EVERYONE. THANK YOU SO MUCH FOR INVITING ME DR. GIBBONS AND THE ENTIRE NHLBI TEAM AND I LOOK FORWARD TO HAVING A FEW QUESTIONS AND ANSWERS WITH YOU NOW. [APPLAUSE] DR. CRAFT HAD A QUESTION FIRST. PUSH THE BUTTON. OTHER ONE. THE ONE THAT LOOKS LIKE A LITTLE VOICE. >> GOT IT. THANK YOU. VERY COMPLICATED. THANK YOU SO MUCH, THAT WAS INCREDIBLY INFORMATIVE TALK. I DID HAVE A QUESTION ABOUT SOME OF THE DATA YOU SHOWED INITIALLY. I AGREE WITH YOU, I THINK ADVANCE MATERNAL AGE ISSUE IS VERY REAL. HOW MUCH DATA HAS YOU SHOWED INVOLVE WOMEN THAT HAD YOU USE OTHER TECHNIQUES TO BECOME PREGNANT? IVF, EXCEED THOSE TYPESES OF THINGS AND HOW DOES THAT IMPACT THE DATA YOU SHOWED WITH REGARDS TO COMPLICATIONS MORTALITY? >> GREAT QUESTION. THE SHORT ANSWER IS, A BIG PIECE OF THAT IS AS YOU MENTION ADVANCE MATERNAL AGE, THAT NEW CDC DTA REPORTED THE RATES OF MATERNAL MORTALITY FOR WOMEN 40 AND ABOVE IS EIGHT TIMES GREATER THAN FOR WOMEN 25 AND BELOW. SO I WOULD SAY THAT'S THE NEW PIECE OF INFORMATION, IT DOESN'T PARSE OUT BUT YOU CAN IMAGINE WOMEN OVER 40, THERE IS A SIGNIFICANT PROPORTION FOR WHICH OTHER METHODS HAVE BEEN EMPLOYED. THE CDC TO MY KNOWLEDGE DOES NOT PROVIDE THAT INFORMATION THAT GRANULARITY BUT NOW THAT YOU HAVE ASKED ME I'LL GO BACK TO FULL THAT OUT. I THINK THAT AGE ISSUE IS REALLY IMPORTANT. SO IT'S NOT JUST THE AGE, IT'S ALL THE HEALTH THINGS THAT HAPPENED TO YOU BEFORE YOU BECAME THAT AGE, THE NUMBER IS A PIECE BUT THAT'S PASSAGE OF TIME GIVEN YOU INCREASE RISK OF DEVELOPING CHRONIC DISEASE. ALSO WHETHER THAT'S FIRST PREGNANCY NORTH IS IMPORTANT ADS YOU KNOW. SO I THINK THAT AS WE ARE SEEING WOMEN BEING OLDER, 7 TO 10 YEARS OLDER AS I MENTIONED COMPARED TO CAN 1907s HAVING A FIRST CHILD, -- 1970s, NEED -- WE NEED TO PARSE OUT AGE AS IT PERTAINS TO THAT QUESTION. >> DR. ARNETTE. >> THANK YOU FOR THIS GREAT PRESENTATION. INTERESTINGLY ON OUR RIDE HOME FROM THE LAST COUNCIL MEETING A BUNCH OF US WERE DISCUSSING THIS ISSUE AND HOW WORRIED WE ARE ABOUT WOMEN. AND THIS -- THESE PREGNANCY OUTCOMES. SO I'M FROM APPALACIAN REGION OF KENTUCKY AND WE HAVE EPIDEMIC OF MORTALITY RATES, CARDIO MOPATHY, IT DOESN'T FALL ON RACE OR STATUS, JUST EMERGING AS THIS VERY INTERESTING PHENOMENON, ANY CLUE ABOUT THE CARDIO MYOPATHY AND WHAT'S CAUSING THAT? >> GREAT QUESTION. THANK YOU FOR SHARING YOUR EXPERIENCE. SO MY UNDERSTANDING FROM MY COLLEAGUES IN THE CARDIOVASCULAR FIELD, THERE'S GENETIC RISK FOR CARDIO MYOPATHY BUT THAT DOESN'T EXPLAIN WHAT WE ARE SEEING SO THERE'S SOMETHING ELSE GOING ON. THAT IS AN AREA WE SEE RIPE FOR FURTHER INVESTIGATION. IN PARTICULAR YOU SHARED YOUR EXPERIENCE IN APPALACIAN COMMUNITIES AS WELL AS AFRICAN AMERICAN COMMUNITIES AND UNDERSTAND WHAT DIFFERENCES OR SIMILARITIES MAYBE AND THIS IS NOT ALL ABOUT RACE AND ETHNICITY THOUGH YOU MENTIONED SES AND WE RECOGNIZE THAT SES DOES NOT ACCOUNT FOR SOME OF THE DIFFERENCES WE SEE IN PARTICULAR IN AFRICAN AMERICAN WOMEN AS WELL. IF THAT IS NOT THE CASE EVERY OTHER HEALTH PARAMETER OUTCOME WHEN YOU CORRECT SES YOU CAN SEE A CHANGE. WE DON'T SEE THAT. THAT MEANS WE ARE MISSING A BIG PIECE OF THIS PUZZLE. WE DON'T LIKE MISSING PIECES OF THE PUDS L. THAT IS A CHALLENGE FOR US TO BETTER UNDERSTAND WHAT IS DIFFERENT NOW THAN 30 YEARS AGO, WHAT IS SIMILAR AND MORE IMPORTANTLY WHAT CAN WE DO ABOUT IT. >> DR. SHEPHERD THEN DR. SMITH WHITLEY AND DR. WETSEL. >> SURELY YOU CAN CORRECT FOR MATERNAL AGE AND COMPARISONS TO OTHER INDUSTRIALIZED SOCIETIES T. AND WHEN YOU DO THAT DOES THAT MAKE A BIG DIFFERENCE D HOW DIFFERENT THE U.S. LOOKS FROM THESE OTHER COUNTRIES? >> OUR DATA ARE WORSE THAN EVERY OTHER COUNTRY THAT IS COME PROGRAM INCOME NO MATTER WHAT YOU CORRECT FOR. >> THAT'S -- THE REASON I'M ASKING, SEEMS EASY TO FOCUS ON THE DIFFERENCE IN MATERNAL AGE BUT SEEMS LIKE THAT'S NOT GOING TO REALLY GET TO THE ROOT OF THE PROBLEM. OLDER WOMEN ARE HAVING BABIES IN EUROPE TOO BUT THE DIFFERENCES ARE ENORMOUS. >> THEIR HEALTH STATUS, THE THEORY IS THEIR HEALTH STATUS GOING INTO PREGNANCY IS DIFFERENT THAN THE HEALTH STATUS OF WOMEN IN U.S. GOING INTO PREGNANCY AND THERE ARE DIFFERENT HEALTH SYSTEM ISSUES, MORE LIKELY TO HAVE ROUTINE CARE PROVIDED AND ACCESS. THERE ARE -- THE POPULATIONS IN SOME CASES ARE NOT ADS DIVERSE. SO MAYBE DIFFERENCES THERE. I THINK WHAT THIS POINTS TO, THERE HAVE BEEN BRILLIANT PEOPLE WORKING ON THIS PROBLEM AND I WANT TO ACKNOWLEDGE ALL THAT ATTENTION FROM EPIDEMIOLOGISTS AND OTHERS IN PUBLIC HEALTH OFFICIALS, THIS IS CALLING FOR A MORE MULTI-DISCIPLINARY APPROACH WE CAN LOOK AT THESE ISSUES ON A DIFFERENT WAY. LIKE LOOKING AT THAT VASE ON YOUR COFFEE TABLE ALL YEAR BUT WHEN YOU TURN IT UPSIDE DOWN IT LOOKS TOTALLY DIFFERENT. IT'S GOING TO REQUIRE FRESH EYES AND NEW TEAMS TO REALLY FARCE THIS OUT. HANKS -- PARSE THIS OUT. THANKS FOR YOUR QUESTION. >> EXCELLENT PRESENTATION. YOU HAVE GIVEN US A LOT OF FOOD FOR THOUGHT THIS MORNING. I WONDER IF IN LOOKING AT THAT VASE ON THE TABLE AND THINKING ABOUT ANOTHER APPROACH, OTHERS HAVE CONSIDERED LOOKING AT WOMEN WITH A RARE CHRONIC ILLNESS AND WHAT THEY CAN INFORM. CALIFORNIA DATA SHOWS WOMEN WITH SICKLE CELL DISEASE HAVE EIGHT TIMES MORE LIKELY CHANCE OF MORTALITY DURING PREGNANCY. AND I WONDER ABOUT WHETHER OR NOT THERE'S AN EFFORT TO LOOK AT WHETHER THE RENAL DISEASE, WHETHER THE THROMBOTIC COMPLICATIONS, SOMETHING UNIQUE ABOUT THAT VULNERABLE POPULATION. THAT COULD INFORM THE HEALTH OF OTHER AFRICAN AMERICAN WOMEN OR WOMEN IN GENERAL. WONDER IF THERE'S BEEN CONSIDERATION INCLUDING STUDIES ON WOMEN WHO GO INTO PREGNANCY WITH A RARE CHRONIC DISEASE. >> THANK YOU SO MUCH FOR THAT QUESTION. I FORGET TO MENTION SICKLE CELL DISEASE IS A REALLY IMPORTANT PIECE OF THIS PUZZLE. BOTH FOR TISSUES THAT YOU HIGHLIGHTED FOR THOSE WOMEN THEMSELVES AND ALSO WHAT WE CAN LEARN ABOUT PREGNANCY RISK AND POOR YOU COMES. IT HAS BEEN UNDER DISCUSSION AS PARTICULAR AREA OF FOCUS AND IS SUPER IMPORTANT ONE FOR THE AFRICAN AMERICAN COMMUNITY. WHETHER IT'S THE ISSUE OF NOT BEING ABLE TO TAKE HYDROXY UREA OR OTHER THINGS DURING PREGNANCY OR SOMETHING ABOUT THE VASCULATURE WHICH WE ARE SEEING, ALL OVER THE PLACE FOR THESE RISK PLACENTAL HEALTH AND WHAT IS HAPPENING EARLY IN THE FIRST TRIMERSER, WE KNOW WE SEE WOMEN IN LATE THIRD TRIMESTER BUT ALL SET UP BY FIRST TRIMESTER, WE HAVEN'T IMAGED IT IN THE PAST. WE HAVEN'T HAD THE PARAMETERS AND BIOMARKERS TO BE ABLE TO LOOK AT THAT BUT YOU ARE ABSOLUTELY CORRECT, SO CALLED RARE DISEASES NOT RARE FOR SOME CONTEXT ARE IMPORTANT AS WELL. SO WE NEED TO DEVELOP STRATEGIES THAT WILL BOTH ADDRESS SPECIFIC CONCERNS OF POPULATIONS LIKE THE POPULATION YOU IDENTIFIED AND YOU HAVE IDENTIFIED INDIVIDUALLY. SO WE NEED TO TEST INTERVENTIONS APPROPRIATE THERE. YOU MENTION CALIFORNIA. INTERESTING, THEY HAVE DONE INCREDIBLE WORK WITH IDENTIFYING A COUPLE OF SPECIFIC PARAMETERS LIKE HEMORRHAGE THAT THEY WANTED TO IMPROVE QUALITY OF CARE ON IN THEIR HOSPITALS AND THEY HAVE DONE THAT BY POLICE DEPARTMENTING STANDARDIZED -- BY IMPLEMENTING STANDARDIZEED SAFETY LEVELS. THE DISPARITY BETWEEN AFRICAN AMERICANS AND WHAT IT WOMEN DIDN'T CHANGE. WHICH TELLS US WE ARE MISSING PART OF THE PICTURE. SO WE WANT TO BE ABLE TO UNDERSTAND ARE SOME OF THOSE INTERVENTIONS THAT WORKED IN CALIFORNIA, IN THAT CONTEXT MIGHT THEY WORK IN OTHER PLACES OR DO OTHER PLACES AND POPULATION AND CIRCUMSTANCES OF CARE REQUIRE DIFFERENT SOLUTIONS? IT'S DEFINITELY NOT A ONE SIZE FITS ALL STRATEGY BUT NICE TO HAVE OPTIONS OF WHOM THESE THINGS WORK WHERE AND WHEN SO WE INTERVENE IN A MORE PROACTIVE WAY. AND PERSONALIZED WAY. WOULDN'T IT BE NICE IF THERE WAS A PERSONALIZED PREGNANCY INTERVENTION WHERE YOUR PREGNANCY, THIS IS WHAT YOU NEED, THE EVIDENCE SHOWS THAT YOU NEED BLAH BLAH, YOUR FREQUENCY, OF GLUCOSE TESTS NEED TO BE X Y Z BASED ON THIS DATA SO WE CAN INDIVIDUALIZE AND PERSONALIZE YOUR PREGNANCY PROFILE. WE KNOW IT'S DIFFERENT AND WE SHOULD BE ABLE TO DO THAT FOR EVERY SINGLE WOMAN. >> DR. WENTZELL. >> GREAT THOUGHT PROVOKING TALK. I THOUGHT ONE OF YOUR EARLY SLIDES YOU BROKE DOWN MORBIDITY AND MORTALITY, BY ININTO FOUR CATEGORIES OF EARLY PREGNANCY AND THEN POST DELIVERY. I WASN'T CLEAR WHEN YOU PRESENTED THAT WHERE HIGHEST PERCENTAGES OF DEATHS WERE AMONG THOSE FOUR QUADRANTS AND THEN THAT WAS I BELIEVE IN AFRICAN AMERICANS IF YOU APPLY THAT TO OTHER GROUPS DOES THE PORTION CHANGE AND DOES IT GIVE US CLUES AS FAR AS WHAT MIGHT BE THE MOST IMPORTANT CATEGORIESES TO GOOF? >> THANK YOU FOR THAT. THAT WAS -- TO GO AFTER? >> ITS PIECE ABOUT A THIRD, A THIRD ARE EARLY PREGNANCY, SAW THIRD AROUND DELIVERY AND A THIRD LATE. THE RULE OF THIRDS SO THAT DOESN'T HELP TOO MUCH. IN TERMS OF DIFFERENCES, BY RACE, ONE BIG DIFFERENCE REPORTED IS THAT RATED OF CARDIO MYOPATHY IN LATE DEATH WHICH IS PARTICULARLY HIGH IN AFRICAN AMERICANS BUT YOU REPORTED TO ME SOME NEW INFORMATION THAT WILL MAKE ME GO LOOK AND SEE WHETHER THERE'S DATA THAT I CAN FIND ON THAT. IF THERE NOT, THAT'S A NEW PERSPECTIVE THAT HASN'T BEEN REALLY ELEVATED. SO THERE ARE SOME DIFFERENCES, BY TIME AND BY RACE, THEY ARE NOT BIG EXCEPT FOR THE CARDIOMYOPATHY ONE. ANYBODY ELSE? OKAY. DR. GRAHAM, DR. KNEW GENT. >> IF YOU HAD A MAGIC WAND AND YOU CONTROLLED ALL THE VARIOUS HEALTHCARE RESOURCES, -- I I KNOW THIS IS YOUR OPPORTUNITY, THERE'S SO MUCH DEBATE ON THIS TOPIC AND SO MUCH PARTICIPATE IN THE DIFFERENT DYNAMICS. I WAS AT A QUORUM THE OTHER DAY AT HOPKINS TO HONOR A YOUNG LADY WHO PASSED, SHE WAS A RESEARCHER AND HAD -- EXACTLY. SO AMAZING STORY LINE THAT SHOWS HOW THIS PERSEVERANCE THROUGH ECONOMIC CLASSES PARTICULARLY MINORITY WOMAN. WHAT'S VEXING ABOUT THIS CHALLENGE IS I THINK THERE DOESN'T SEEM TO BE EVEN THE TEN DENSE OF WHAT WOULD BE AN EFFECTIVE STRATEGY GIVEN THE MULTIPLE NATURE OF THIS. BACK TO MY WAND QUESTION, WITHOUT -- BUT HAD YOUR MAGIC WAND, WHAT TWO AREAS WOULD YOU TARGET TO GIVE THE MOST IMPACT TO TRY TO CREATE SOME DEGREE OF CHANGE? >> TOUGHEST QUESTION AT THE END. OH, BOY. THANK YOU SO FOR THAT, DR. EVERYBODYING. I HAVE INCLUDED -- IRVING I INCLUDED HER STORIES IN MY PUBLICATIONS SHE'S A PUBLIC HEALTH SERVICE OFFICER STUDYING HEALTH DISPARITIES WHOSE HERSELF PASSED AWAY FROM -- ONE OF OUR UNFORTUNATE MOTHERS WE HAVE LST. AND BRINGS THAT ISSUE HOME FOR US. IN TERMS OF I WOULD LOVE TO HAVE THE POWER TO DO THAT. BUT IN TERMS OF ALL SERIOUSNESS HOW TO LOOK AT THAT ISSUE, I THINK THAT -- AND I DIDN'T TALK MUCH ABOUT THIS, BUT IT IS AN ISSUE AND THAT IS STRUCTURAL RACISM IS AN ISSUE AND A CONCERN BECAUSE WE KNOW THAT SOME OF THESE EXPERIENCES THAT AFRICAN AMERICAN WOMEN AND OTHER WOMEN OF COLOR HAVE HAD BEFORE THEY BECOME PREGNANT ARE AFFECTING THEIR HEALTH STATUS. THEIR EXPERIENCES DURING PREGNANCY AND INTERACTION WITH THE HEALTHCARE SYSTEM ARE AFFECTING OUTCOMES. SO WE HAVE DATA ON PIECES OFNA. BUT IT'S NOT BEEN PUT TOGETHER BUT MORE IMPORTANTLY WE WANT TO MAKE SURE EVERY WOMAN GETS EVIDENCE BASED CARE AT EVERY INTERVENTION AND THERAPEUTIC INTERACTION. ONE WAY TO DO THAT IS THROUGH STANDARDIZATION. AL EXAMPLE COMES IN MIND, YOU PICK A PROBLEM PARSE OUT IF WE EXPERIENCE HEMORRHAGE WHERE ARE WE -- HOW ARE WE DEFICIENT? WE ARE NOT CHARACTER RIDING THE COMPLETE VALUE OF BLOOD LOSS. SO WE NEED TO AUTOMATE THINGS SO IT'S NOT JUST A HUMAN BEING COUNTING SOMETHING, IT IS A SYSTEM, YOU GET CHECKS AND BALANCES IN YOUR SYSTEM, SO THAT WE CAN USE ALL THESE ELEGANT ELECTRONIC HEALTH RECORD TOOLS AND APPROACHES THAT WIFE TO HELP US. SO PAYING THIS PERSON GAINED 20 POUNDS OVER TWO VISITS YOU NEED TO LOOK FOR THIS. THOSE KIND OF DECISION MAKING TOOLS AND ASSISTANCE FOR HEALTHCARE PROVIDERS IF WE CAN DO THAT IN A MOTHER INTEGRATED WAY ACROSS THE HEALTH SYSTEM IT'S NOT BOILING THE OCEAN, IT IS DOABLE. HEALTH SYSTEMS CAN MAKE CHANGE, THEY CONTROL THE HEALTH SYSTEM, NOT ENOUGH BECAUSE WE WANT TO ADDRESS WOMEN EVERYWHERE AND EVERYBODY ISN'T IN THAT KIND OF A SYSTEM. SO IN THAT CASE I THINK YOU NEED TO GO TO THE COMMUNITY WHERE WOMEN LIVE. SO I WOULD SAY BOTH STANDARDIZATION OF APPROACHES THAT IS INTEGRATEDDED WITH LEVERAGING ELECTRONIC HEALTH RECORDS AND OTHER DATA, THAT WE HAVE PULLING TOGETHER TO IDENTIFY WOMEN WHO ARE AT RISK AND INTERVENE WITHOUT IT BEING ONLY SUBJECT TO HUMAN. GOING TO THE COMMUNITIES WOMEN ARE LIVING. AND ASKINGS THOSE WOMEN WHAT DO WE NEED WHAT SUPPORTS YOU WHAT IS YOUR EXPERIENCE. WE KNOW WE ARE SEEING POCKETS OF POSITIVE EXPERIENCES FOR EXAMPLE, WITH PATIENT NAVIGATORS, AND OTHERS IN CERTAIN COMMUNITIES BUT WE NEED TO DATA SO WE WANT TO BE ABLE TO DESIGN THOSE IN A COMMUNITY BASED PARTICIPATORY WAY SO WE CAN COME TO SOLUTIONS TOGETHER BUT RIGOROUS, WE NEED TO DATA. WE WILL IMPLEMENT A PARTICULAR STRATEGY FROM THE BEGINNING. WITH THE COMMUNITY SO THOSE ARE TWO STRATEGIES. YOU CAN'T TAKE AWAY THAT BASIC DISCOVERY SCIENCE. I WANT TO IMAGE THAT PLACENTA AND IDENTIFY NEW BIOMARKER FOR POST PARTEM DEPRESSION. THAT BASIC DISCOVERY SCIENCE IS NECESSARY FOR THAT TOO. YOU SAID I COULD CONTROL THE WORLD. I GOD A MILLION MILLION DOLLARS, I CAN DO THAT, RIGHT? >> I WISH WE COULD WHATEVER -- EMBOLDEN YOUR IDEA, THAT WAS SO ON POINT, YOUR COMMENT AND FRAMING THIS IN CONTEXT OF STRUCTURAL RACISM IS HOW ANYONE N MY WIFE IS PREGNANT AT THE SAME TIME SHE LOST HER LIFE AND IT WAS THAT SAME SOCIAL CLASS OF -- SHE WAS AT HOPKINS TOO IN THAT SAME COHORT. WHATs FRIGHTENING TO A LOT OF THOSE WOMEN THEY THOUGHT THEY HAD GONE THROUGH MEDICAL SCHOOL, THROUGH THESE THINGS AND THE THINGS SHE EXPERIENCED WAS QUITE FRANKLY A COMPONENT OF RACISM AND HEALTHCARE AND I THINK FRIGHTENED ME AND FREAKED ME OUT BUT YOU ARE RIGHT, IT'S A BEAUTIFUL ANSWER. >> WE HAVE TIME FOR ONE LAST QUESTION. >> CAN I ASK YOU TO GO BACK TO THE SLIDE THAT SHOWS YOU -- WHEN WE REALLY TAKE OFF THE U.S. MATERNAL MORTALITY. I'M A RETURNEE TO THIS COMMITTEE. YOU JUST PASSED IT. THE NEXT ONE. THAT SLIDE YOU SHOWED HERE, I THINK IT WAS TWO OR THREE ICER AGO, IT WAS SO MIND BOGGLING TO ME, BUT EVERYTHING WE TALK ABOUT, RESEARCHING, SOMETHING HAPPENED IN THE 1990s, THIS IS NOT SOMETHING -- THIS HAPPENED IN TWO DECADES, 20 YEARS OR SO, MAYBE 30. WE HAVE TO I THINK ASK OURSELVES WHAT THE HELL HAPPENED TWO US AS A NATION IN 1990? THERE WAS MATERNAL DEATH THEN. WE HAD THE SAME RACIAL DIVERSITY THAT WE HAVE NOW. BUT I THINK WHAT'S REALLY HAPPENING, I'M GOING TO CALL THIS OUT, AND THAT IS THAT WE WENT FROM WOMEN BEING ABLE TO GO TO A TEACHING HOSPITAL, NO MATTER WHAT THEIR ECONOMIC STATUS WAS, THEY COULD GO TO A UNIVERSITY O. WHAT'S HAPPENED IN THIS TIME FRAME IS THE INDUSTRIALIZATION, THE BUSINESS OF HEALTHCARE. IF WE DON'T ADDRESS THAT, THE FACT THAT WE ARE PAYING SO MUCH MORE FOR HEALTHCARE NOW AND GETTING HORRIBLE OUTCOMES, THEN IT DOESN'T MATTER HOW MANY PLACENTAS WE LOOK AT, IT DOESN'T MATTER ALL THE OTHER GREAT RESEARCH THAT IS HAPPENING. IF PATIENTS CAN'T GET ACCESS TO CARE. I THINK THE OUR THING, OUR INSTITUTE, NIH, I WAS AT HHS LAST WEEK, TALKING TO ADMIRAL JIROR, IF WE DON'T PUT FUNDING INTO THE CONTINUUM, WE CAN'T START ADS WE HAVE DONE IN SICKLE CELL. WE CAN'T START PAYING FOR A CONTINUUM STUDY AND THEN THREE YEARS SAYING OKAY WE DON'T HAVE MONEY TO DO THIS ANY MORE. WE HAVE GOT TO REALLY LOOK AT OURSELVES HONESTLY AND SAY WHAT ALL THESE OTHER GROUPS HAVE, WE WERE IN THE GRAY FOR A LONG TIME. AND WE DECIDED TO MAKE BUSINESS -- HEALTHCARE A BUSINESS. THAT HAS TO BE PART OF THIS DISCUSSION. BECAUSE I THINK THE GREAT SCIENCE THAT'S GOING ON IS FANTASTIC. I JUST DON'T WANT TO HEAR ABOUT ANOTHER WOMAN LOSING HER LIFE BECAUSE SHE CAN'T GET AXIS TO HEALTHCARE. -- ACCESS TO HEALTHCARE. I AM -- I LIVE IN CALIFORNIA. I KNOW THERE ARE BIG, BIG PROBLEMS AND ONE ANOTHER -- IT COULD BE THE FIFTH RICHEST COUNTRY IN THE WORLD, RIGHT? AND OUR HEALTHCARE IS TERRIBLE. IT HAS TO DO WITH ACCESS. WE HAVE GOT TO ADDRESS THAT. WE DANCE AROUND IT ALL THE TIME. I'M SORRY THAT WAS NOT A QUESTION. >> IT WAS A COMMENT. >> BUT THIS IS MY LAST TIME HERE. >> I THINK MAYBE WE'LL HAVE TO INVITES YOU BACK. >> I WANT TO SAY THIS SLIDE MADE A HUGE IMPACT AND I THINK EVERYBODY NEEDS TO THINK ABOUT THAT. GOD BLESS YOU FOR THE WORK YOU DO. >> I SAY THERE ARE SOME -- NOT TO MINUTE GLIDES COMMENT, THERE'S CONCERNS ABOUT DATA QUALITY AND AS CERTAINING MORE DEATH BECAUSE OF DATA QUALITY. THAT BEING SAID THE RATES AREN'T ACCEPTABLE. MU MENTIONED ACCESS TO CARE, CLEARLY NEEDED BUT WHEN YOU ACCESS CARE WE NEED THE MAKE SURE EVERYBODY IS GETTING HIGH STANDARD QUALITY CARE AS WELL. MY UNDERSTANDING IS THE RACIAL AND ETHNIC DISPARITIES GO FAR BACK BEFORE 19 90. IS IT 1900 I THINK. THERE'S VERY OLD DATA THAT SHOW RACIAL ETHNIC DISPARITIES HAVE EXIST FOR LONG TIME. (OFF MIC) >> I DON'T KNOW THE ANSWER TO THAT. I MENTIONED THE HISPANIC PARADOX. ALSO HISPANIC CULTURAL ISSUES MAYBE PLAYING A ROLE THERE THAT ARE FUNCTIONING BEING OPERATIONALLIZED DIFFERENT THAN OTHER CULTURES. WE WON'T KNOW THAT UNTIL WE DO THE RESEARCH. OF COURSE WE WANT TO UNDERSTAND DISEASES BETTER, BUT THE BOTTOM LINE, WE ARE DOING THIS TO IMPROVE THE HEALTH OF PEOPLE. SO UNTIL WE CAN DO THAT, EVERYTHING WE ARE DOING IS GOOD BUT NOT GOOD ENOUGH. >> THANK YOU VERY MUCH AGAIN, DR. CLAYTON. [APPLAUSE] >> WE ARE GOING TO TAKE A BREAK FOR ANOTHER 15 MINUTES. PLEASE BE BACK IN YOUR SEAT BY 5 AFTER 10:00. IF YOU ARE NOT, YOU WILL TURN INTO A PUMPKIN. I WOULD LIKE TO INTRODUCE OUR SECOND SPEAKER THIS MORNING. DR. STEVEN WOOLF IS DIRECTOR EMERITUS AT THE VIRGINIA COMMONWEALTH UNIVERSITY CENTER ON SOCIETY AND HEALTH AND HE'S PROFESSOR OF FAMILY MEDICINE AND POPULATION HEALTH AT VIRGINIA COMMONWEALTH UNIVERSITY. HE IS BOARD CERTIFIED IN FAMILY MEDICINE AND PREVENTIVE MEDICINE AND PUBLIC HEALTH, DR. WOOLF PUBLISHED MORE THAN 200 ARTICLES AND EDITED THREE BOOKS AND CAREER FOCUSED ON PROMOTING THE MOST EFFECTIVE HEALTHCARE SERVICES AND ADVOCATING HEALTH PROMOTION AND DISEASE PREVENTION AND NEED TO I DRESSSOME DETERMINANTS OF HEALTH. IN ADDITION TO SCIENTIFIC PUBLICATIONS, HE IS EMPHASIZED OUTREACH TO POLICY MAKERS THE PUBLIC AND THE MEDIA TO RAISE WARENESS ABOUT THE FACTORS OUTSIDE OF HEALTHCARE THAT SHAPE HEALTH OUTCOMES. HE'S GOING TO SPEAK TO US TODAY ABOUT THE DECLINE IN U.S. LIFE EXPECTANCY AND INCREASE IN MID LIFE MORTALITY. POTENTIAL EXPLANATIONS AND RESEARCH PRIORITIES. DR. WOOLF. >> GOOD MORNING. IT'S ANEMONE NOR TO HAVE BEEN INVITED TO TALK ABOUT THIS. THIS IS THE FEEL GOOD PORTION OF THE MORNING TALKING DECLINE IN U.S. LIFE EXPECTANCY. I DON'T SEE DR. KNEW GENT THERE BUT I THINK I LIKE HER TITLE BETTER WHAT THE HELL HAPPENED IN THE 1990s. YOU WILL SEE WHY ACTUALLY. SHE WAS EXACTLY ON POINT AND WE WILL COME BACK TO THAT. LET ME GET STARTED. WHAT I'M GOING TO DO IS BASICALLY TRY TO UNPACK A LITTLE BIT ABOUT WHAT'S GOING ON WITH U.S. LIFE EXPECTANCY AND AS THE TITLE HINTS AT THE ANSWER LIES IN THE MIDDLE AGE GROUP YOUNG AND MIDDLE AGE ADULTS. WE WILL WALK THROUGH THE DATA AND THEN HOPEFULLY HAVE PLENTY OF TIME TO TALK ABOUT THIS AND GET YOUR FEEDBACK. FIRST OF ALL THE ISSUE HAS BEEN IN THE NEWS, THIS IS -- THERE WAS A PERIOD OF THREE CONSECUTIVE YEARS WHERE U.S. LIFE EXPECTANCY DECLINED AND THAT GARNERED A FAIR AMOUNT OF PRESS COVERAGE. IT'S IMPORTANT TO PUT THIS IN A LONG TERM PERSPECTIVE, SO GOING BACK IN TIME THIS IS A GRAPH FROM 1960s. YOU CAN SEE THESE TWO LIVES ONE REPRESENTS THE U.S. LIFE EXPECTANCY AND THE OTHER IS OECD AVERAGE, ORGANIZATION FOR ECONOMIC COOPERATION AND DEVELOPMENT AND WHEN I WAS A KID THE U.S. LIFE EXPECTANCY EXCEEDED THAT OF THE OECD COUNTRIES. IN THE 1980s THIS SLOPE STARTED CHANGING. THE PACE OF INCREASE IN U.S. BEGAN TO FALL OFF RELATIVE TO OTHER COUNTRIES, 1998 IS WHEN THE LINES CROSSED SO DURING THE -- DR. KNEW GENT, I MENTIONED YOUR -- YOUR TITLE WHAT THE HELL HAPPENED IN THE 1990s IS I WANT TO CHANGE MY TALK TO THAT. SO IN 1998 IS WHEN WE FELL BELOW THE AVERAGE AND WE PLATEAUED IN 2011 AND DECLINE HAPPENED. SO IT'S REALLY IMPORTANT THOUGH WE ARE FOCUSED ON WHAT JUST HAPPENED IN THE LAST FEW YEARS TO HAVE A LONG TERM PERSPECTIVE TO UNDERSTAND THIS IS A PROCESS UNDERWAY FOR A WHILE. THIS ZOOMS IN A LITTLE BIT ON THE 1995 FORWARD PERIOD. YOU CAN SEE GOING UP TO 2016 DATA HOW WE WERE FALLING OFF. THERE WAS JUST NEWS A FEW WEEKS AGO, THE CDC ANNOUNCED THERE'S BEEN SOME GOOD NEWS WHICH IS THAT LIFE EXPECTANCY INCREASED. IT GUIDE. THERE IS INTERRUPTION IN THIS THREE YEAR FALL BUT WHEN I WAS INTERVIEWED BY THE WASHINGTON POST ABOUT THIS I WANTED TO MAKE SURE THEY THOUGHT ABOUT THIS LONG TERM PERSPECTIVE AND THEY WERE KIND ENOUGH TO INDULGE ME AND INTRODUCE THIS DATA THAT I GAVE THEM, THIS IS AN INFO GRAPHIC FROM THE WASHINGTON POST BUT ON THE LEFT YOU CAN SEE U.S. LIFE EXPECTANCY RELATIVE TO THE OTHER COUNTRIES AND THEN OF COURSE ON THE RIGHT ARE HEALTHCARE SPENDING WHICH I THINK SPEAKS VOLUMES JUST THE TWO PICTURES. SO IN 2013 I HAD THE PLEASURE OF CHAIRING A NATIONAL -- IT WAS THE INSTITUTE OF MEDICINE THEN NATIONAL ACADEMY OF MEDICINE NOW, COMMITTEE THAT NIH ACTUALLY FUNDED. TO LOOK AT THE U.S. HEALTH DISADVANTAGE RELATIVE TO OTHER COUNTRIES. THE REPORT BASICALLY TOLD IT ALL, SHORTER LIVES POORER HEALTH, WE DID A DETAILED ANALYSIS AND DOCUMENTED THAT U.S. HEALTH RELATIVE TO 16 OTHER HIGH INCOME COUNTRIES WAS WORSE IN MULTIPLE DIMENSIONS, TOO SMALL A FONT TO READ BUT THIS IS A TABLE OF MORTALITY RATES. MOST CAUSES OF DEATH FROM HERE AIL THE WAY UP, ARE ONES WHERE U.S. MORTALITY RATES EXCEED THOSE PEER COUNTRIES THE SMALLEST AT THE BOTTOM ARE ONES WHERE WE HAVE BETTER SORRY LET ME BACK UP. ONES ON THE BOTTOM IS WHERE WE ARE BETTER SO GOOD NEWS IN TERMS& OF -- THIS POINTER IS TRICKY, CANCER MORTALITY, STROKE MORTALITY, THAT'S AN AREA WE CAN BE PROUD OF DOING BETTER THAN PEER COUNTRIES BUT FOR THE ABOUT PREGNANCY AND CHILDBIRTH, HIGHER MORTALITY RATES IN THE U.S. THAN OTHER COUNTRIES SO ONE IMPORTANT POINT AS WE GO OFF DR. CLAYTON'S TALK IS THAT IF THAT IS THE ISSUE IS, THIS IS A BIGGER ISSUE, U.S. HEALTH DISADVANTAGE CUTS ACROSS BODY SYSTEMS, ACROSS INSTITUTES AND ORGAN SYSTEMS AS YOU WILL SEE. THIS IS A GRAPH THAT FOLLOWS DR. CLAYTON'S TALK SURVIVING TO AGE 50, THE RED DOTS ARE U.S., THE GRAY DOTS ARE COMPARISON COUNTRIES ON THE LEFT IS MEN, RIGHT ARE WOMEN. YOU CAN SEE IN 1980s, MEN WERE IN THE BOTTOM END OF THE RANGE AND FELL TO THE BOTTOM BUT LOOK AT WOMEN. THE U.S. IS OFF THE CHARTS. THE PROCT OF AGE SURVIVING TO 50 IS LOWEST AS AMERICAN WOMAN. WE NEED TO COME BACK TO, I'LL HAVE IT ON MY FINAL SLIDE AS RESEARCH PRIORITY, WHAT'S GOING ON WITH WOMEN IN THE US. THERE'S SOMETHING SPECIAL AND ADVERSE GOING ON SUBJECTING THE HEALTH OF WOMEN NOT JUST PREGNANCY AND CHILDBIRTH BY ACROSS BODY SYSTEMS. I WON'T REPEAT THIS POINT. SO I WAS ASKED TO COME HERE TO DISCUSS THE STUDY THAT WAS PUBLISHED IN JAMA IN NOVEMBER WITH WE DID INTENSIVE ANALYSIS TO TRY TO UNDERSTAND WHAT'S BEHIND THIS RECENT DECLINE IN LIFE EXPECTANCY AND AS I SAID IT'S NOT A RECENT EVENT, IT'S LONG TERM TREND. WHAT WE FOUND IS THAT THERE IS SOME GOOD NEWS, WHEN YOU START LOOKING MORTALITY RATES OVER THIS TIME PERIOD BY AGE GROUP WE CAN REPORT FOR INFANT MORTALITY, CHILDREN AND AT LEAST EARLY TEENS MORTALITY RATES ARE DECLINING THE WAY WE WOULD LIKE THEM TO. ALSO OLDER ADULTS IN AMERICA MORTALITY RATES ARE DECLINING, IT'S MIDDLE AGE GROUP, 25 TO 64 WHERE WE ARE SEEING THE DIFFERENT PATTERN. A QUICK WORD ABOUT METHOD, HAPPY TO GO INTO MORE DETAIL DURING THE DISCUSSION IF YOU WANT BUT WE DID A SYSTEMATIC ANALYSIS OF VITAL STATISTICS AND INCLUDED A DETAILED ANALYSIS OF CAUSES OF DEATH ICD 10 CODES SO FORTH TO DRILL DOWN ANGEL PEEL BACK THE ONION TO UNDERSTAND WHAT IS BEHIND THIS AND WE ANALYZE DATA FOR ALL 50 STATES SO WE CAN GEOGRAPHICALLY LOCATE WHERE TREND WAS HAPPENING. YOU CAN SEE WHAT I'M TALKING ABOUT WITH THE SO CALLED MID LIFE MORTALITY TREND, MID LIFE MEANS YOUNG ADULTSES AND MIDDLE AGE ADULTS AND AROUND 2010 A PERIOD OF DECLINING ALL CAUSE MORTALITY IN THIS AGE GROUP ENDED AND WE BEGAN DECLINING. SO SIT'S IMPORTANT FOR YOU NOT TO COME FROM THAT SLIDE THINKING THIS PROBLEM STARTED IN 2010, IT STARTED IN 1990s. IT'S GIST THAT DURING THE 1990s WHEN CAUSE SPECIFIC MORTALITY RATES FROM CERTAIN CAUSES WHICH WE'LL GET INTO LIKE DRUG OVERDOSES AND OTHERS BEGAN CLIMBING THEY WERE OFFSET BY THE PROGRESS WE WERE MAKING, SUDDENLY COMING OUT OF NHLBI IN ISCHEMIC HEART DISEASE MORTALITY, DECLINES IN HIV MORTALITY AND DECLINES FROM CAR ACCIDENTS WHERE HELPING ALL CAUSE MORTALITY BUT THEY WERE BEING OFFSET SLOWLY BY SURELY BY STEADY RISE IN OTHER CAUSES OF DEATH; IT WAS FINALLY 2010 WE REACHED THE TIPPING POINT, ALL CAUSE MORTALITY INCREASED BUT IT'S IMPORTANT TO KNOW THIS IS A TREND UNDERWAY FOR A WHILE. IF WE DISAGGREGATE BY RACE, I THINK THIS GRAPH WAS SHOWN EARLIER BUT I THINK IT WAS MISS LABELED ON THE PREVIOUS VERSION, LET'S START WITH THE U.S. AVERAGE. THIS BOLD LINE HERE IS THE U.S.. I CAN SEE MORTALITY RATE DECLINING THERE. THIS IS THE NON-HISPANIC WHITE POPULATION HERE. HERE IS -- YOU CAN SEE THE NATIVE AMERICAN POPULATION. SO THIS LONG TERM INCREASE IN MIDLINE MORTALITY WAS UNDERWAY IN THE AMERICAN INDIAN NATIVE AMERICAN POPULATION SINCE THE 1990s. THERE WAS SOME GOOD NEWS, FOR THE AFRICAN AMERICAN MORTALITY RATE NON-HISPANIC BLACKS WE HAD GREAT PROGRESS IN LOWERING ALL CAUSE MORTALITY. BUT LOOK CLOSELY, WE WILL GET INTO THIS MORE IN A MINUTE, THAT NOW IS ALSO -- SO THE PROGRESS MADE NARROWING THE BLACK WHITE MORTALITY GAP IS NOW GETTING REVERSED. THERE IS AN INITIAL REPORT CASE AND DATEON A FEW YEARS AGO THAT MADE THIS LOOK LIKE A PROBLEM HITTING WHITE PEOPLE, WHITE MIDDLE AGE ADULTS BUT THE MAIN TAKE AWAY FROM THIS STUDY AND OTHERS LIKE IT IS THAT THIS PHENOMENON IS EFFECTING ALL RACIAL ETHNIC GROUPS. HISPANIC POPULATION YOU CAN'T SEE IT HERE IN THIS GRAPH BUT MORTALITY RATES HAVE BEEN GOING UP SINCE 2014. AND EVEN THE ASIAN POPULATION WITH THE BEST HEALTH IS ALSO INCREASING. WHAT ARE SPECIFIC CAUSES OF DEATH? DEPENDS WHICH AGE GROUP YOU ARE LOOKING AT BUT IF YOU HAVE BEEN FOLLOWING THIS TOPIC YOU KNOW THAT THERE'S TALK ABOUT DEATH OF DESPAIR, BECAUSE THE PRIMARY CAUSES OF DEATH FIRST REPORTED OUT AS BEING RESPONSIBLE FOR THIS TREND WAS DRUG OVERDOSES, MAJOR CONTRIBUTOR, DRAMATIC INCREASE IN DEATH FROM ACCIDENTAL DRUG OVERDOSES BUT DEATH FROM ALCOHOLISM, FOR EXAMPLE, SIR ROTTIC LIVER DISEASE AND SUICIDE. AND THOSE THREE GOT ATTENTION AND THAT'S WHAT GOT THIS LABEL DEATH OF DESPAIR, LED MANY POLICY MAKERS AND REPORTERS AND OTHERS TO PIGEON HOLE THIS PHENOMENON AS ONE OF PSYCHOSOCIAL DISTRESS. THAT IS A BIG PIECE OF IT. THE IMPORTANT -- FINALLY EMPHASIZE THE SLIDE HERE, IT'S BROADER THAN THIS, IN OUR JAMA STUDY WE DOCUMENTED 35 CAUSES OF DEATH MORTALITY RATES INCREASED FOR THIS AGE GROUP, IT TRANSCENDS THOSE THREE PARTICULAR THAT WERE FEATURED. IT DOES VARY BY AGE GROUP SO THIS IS YOUNG ADULTS, 25 TO 34, THIS IS THE AGE GROUP EXPERIENCED THE LARGEST RELATIVE INCREASE IN DEATH RATES DURING THIS TIME. 19% INCREASE IN MORTALITY RATES SINCE THE 1990s. THE LINE STANDING OUT HERE IS DRUG OVERDOSES BUT YOU CAN ALSO SEE ICREASES IN DEATH FROM MENTAL AND BEHAVIORAL DISORDERS, HOMICIDES AND OTHER CONDITIONS AS WELL. AS YOU GET TO OLDER AGE GROUPS THE AGE WHERE CHRONIC DISEASE STARTS SETTING IN, YOU WILL SEE THERE'S BEEN INCREASE IN CAUSES OF DEATH FROM CHRONIC DISEASE AS WELL. THE ONE I WANT TO CALL OUT BECAUSE OF WHERE WE ARE RIGHT NOW IS HYPERTENSIVE HEART DISEASE MORTALITY. A BIG CONTRIBUTOR SO THIS IS THE GRAY LINE HERE IN THE GRAPH, A BIG CONTRIBUTOR TO THE INCREASE IN MORTALITY RATES IN THIS AGE GROUP IS HYPERTENSIVE DISEASE MORTALITY. THERE'S ALSO BEEN AS YOU KNOW DESPITE GREAT SUCCESS IN LOWERING ISCHEMIC HEART DISEASE MORTALITY, A LEVELING OFF OF THAT PROGRESS AND IN SOME STUDIES A REPORT OF INCREASING CARDIOVASCULAR MORTALITY RATE. WHEN WE DUG INTO THE ICD CODES TO UNPACK THAT OUR SENSE IS BEING INTERESTED IN YOUR THOUGHTS. THAT LEVELING OFF IS BEING CAUSED BY FIRST THIS HYPERTENSIVE HEART DISEASE MORTALITY, INCREASING DEATH FOR CONGESTIVE HEART FAILURE AND VALVE HEART DISEASE. I THINK THAT'S REALLY THE AREA FOR INVESTIGATION IN TERMS OF WHAT'S GOING ON TO OFFSET THE PROGRESS THAT WE HAVE BEEN MAKING WITH ISCHEMIC HEART DISEASE BUT YOU NOTICE SINCE THIS IS NHLBI WE ARE TALKING ABOUT, THERE'S INCREASE IN CHRONIC LUNG DISEASE COPD, YOU DON'T SEE IT IN THIS GRAPH, IN THE GEOGRAPHIC DATA I CAN TALK TO YOU ABOUT DURING THE DISCUSSION WHERE WE ANALYZE THE DATA BY 50 STATES N MANY STATES COPD MORTALITY RATES ARE CLIMBING. IN THIS AGE GROUP. MY POINT HERE IS JUST A PROBLEM CLEARLY BEING DRIVEN IN LARGE PART BY THE OPIOID EPIDEMIC NOT EXCLUSIVELY AND THERE'S SOMETHING MORE SYSTEMIC GOING ON AFFECTING MORTALITY RATES FOR MULTIPLE BODY SYSTEMS IN THIS AGE GROUP ACROSS ALL RACIAL AND ETHNIC GROUPS. I DON'T EXPECT YOU TO READ THE SLIDE BUT YOU CAN SEE IT ONLINE IF YOU ARE INTERESTED, JUST TO EMPHASIZE MULTIPLE CAUSES OF DEATH, THIS IS A CHART SHOWING THE ROWS HERE DIFFERENCE CAUSES OF DEATH, THIS IS AGE GROUP INFANCY TO 85 PLUS, AND THE RED ARE -- THE RED ARE AGE GROUPS EXPERIENCED IN INCREASING MORTALITY RATES AND YOU CAN SIGH THIS VISUAL CLUSTERING OF MID LIFE PERIOD WHERE MORTALITY RATES INCREASE. AS I SAID, WE DIG AGGRAVATED THE DATA BY STATE TO SEE WHERE THIS IMPACT IS HAPPENING THE MOST, THIS CHART IS SHOWING RELATIVE INCREASE IN MORTALITY IN THIS AGE GROUP. ON THE LEFT YOU CAN SEE NEW HAMPSHIRE WEST VIRGINIA OHIO, EXPERIENCING LARGE INCREASE IN MID LIFE MORTALITY DURING THIS TIME PERIOD AND STATES HERE ON THE RIGHT LIKE NEW YORK AND WYOMING CALIFORNIA EXPERIENCE RELATIVELY LITTLE IMPACT. THE PROBLEM THOUGH IS IF YOU ARE TRYING TO ASK THE QUESTION WHICH STATE HAS EXPERIENCED LARGEST RELATIVE INCREASE A GRAPH LIKE THIS IS FINE BUT TRYING TO STEP BACK AND SAY THIS PROBLEM THE UNITED STATES IS HAVING, THE DECLINE IN LIFE EXPECTANCY RELATIVE TO OTHER COUNTRIES, WHAT STATES ARE DRIVING US? YOU HAVE TO MULTIPLY THE RELATIVE INCREASE BY THE POPULATION SIZE. SO STATE LIKE NEW HAMPSHIRE EXPERIENCING LARGE RELATIVE INCREASE BECAUSE OF SMALL POPULATION, DOESN'T CONTRIBUTE QUANTITATIVELY AS MUCH TO THE TREND. SO WE DID ANALYSIS THAT SORT OF LOOKED AT THE ACTUAL ABSOLUTE RATE IN TERMS OF EXCESS DEATH. SO THIS MAP IS SHOWING RELATIVE INCREASE IN TERMS OF WHICH STATES, YOU CAN SEE IN NORTHERN NEW ENGLAND, THIS LARGE RELATIVE INCREASE IN MORTALITY BUT LOOK AT ACTUAL ABSOLUTE DEATH IT LOOKS LIKE THIS. I DO WANT TO -- I WAS CHUCKLING WHEN THE COMMENT WAS MADE EARLIER THIS LOOKS LIKE THE MAPS YOU SEE; BUT I WANT TO POINT OUT A DIFFERENCE HERE, IT'S NOT EXACTLY LIKE THE MAPS YOU SEE. WHEN WE WENT INTO STUDY AND REPORTERS ASKED ARE THERE SURPRISES THERE WAS A SURPRISE, THE SURPRISE WAS THAT IN MOST MAPS OF MORTALITY, PATTERNS BY CARDIOVASCULAR DISEASE OR WHATEVER, WE TEND TO FIND THE WORST RATES IN THE DEEP SOUTH, MISSISSIPPI, ALABAMA, GEORGIA. THAT WAS NOT THE -- THAT WAS NOT THE REGION THAT EXPERIENCED THE LARGEST RELATIVE INCREASES IN MORTALITY. IT'S AREA THE OHIO VALLEY, THIS REGION HERE IS GROUND ZERO FOR IN PHENOMENON. WHAT WE FOUND, WHEN WE DID THE MATH IS THERE WERE FOUR OHIO VALLEY STATES SHOWN ON THIS MAP THAT ACCOUNTED FOR ONE-THIRD OF ALL U.S. DEATH CAUSED BY THIS INCREASE. IN TERMS OF UNDERSTANDING ITOLOGY, THAT'S A CLUE. WHATEVER IS RESPONSIBLE FOR THIS TREND IS CONCENTRATED IN CERTAIN PARTS OF THE COUNTRY. TURNS OUT ONE-THIRD OF EXCESS DEATHS ARE IN THESE FOUR STATES AND HALF OF THE EXCESS DEATHS ARE IN THE 13 APPALACIAN STATES SO THAT SOUNDS LIKE WHAT WE TYPICALLY THINK ABOUT BUT MORE CENTRAL APPALACIA NORTHERN AND CENTRAL REGIONS WHERE WE SEE BIGGEST RELATIVE INCREASES THAT THE DEEP SOUTH HAVE HIGHEST ABSOLUTE MORTALITY RATES, TO BE CLEAR I'M NOT GLOSSING OVER THE FACT THAT THERE ARE DISPROPORTIONATELY HIGH MORTALITY RATES IN THE DEEP SOUTH, JUST SAYING THIS BUMP IS HAPPENING MORE IN THIS NORTHERN AREA. I WANT TO CALL ATTENTION TO ANOTHER PHENOMENON WHICH GETS BACK TO DR. KNEW GENT'S POINT. NEW YORK HAS THE THIRD HIGHEST LIFE EXPECTANCY IN THE COUNTRY. AND I THROUGH MOST OF MY CAREER HAD THIS IMAGE OF HAVING GREAT HEALTH OUTCOMES BUT THAT WAS NOT ALWAYS THE CASE. YOU CAN SEE HERE UP UNTIL 1990 THERE WERE TIMES WHERE IT HAD A LOWER LIFE EXPECTANCY THAN BUT THEN SOMETHING HAPPENED IN THE 1990s. YOU SEE THIS SEPARATION. THIS PART OF OUR FINING EMERGED BECAUSE OF TEMPORAL LONGITUDINAL ANALYSIS SPANNING DECADES AND EXPOSED PHENOMENON IN THE 1990s WE STARTED TO SEE A SEPARATION IN STATE HEALTH TRAJECTORIES THAT WE HAVEN'T SEEN BEFORE. YOU CAN SEE THIS COMPARISON AND SAY YOU ARE COMPARING APPLES AND ORANGES, NEW YORK AND OKLAHOMA, DIFFERENT GEOGRAPHIC REGIONS DIFFERENT ECONOMIES, A LOT HAPPENED IN OKLAHOMA FOR EXAMPLE AND OTHER CHANGES IN INDUSTRIES IN NEW YORK AND FRANKLY CHANGES IN DEMOGRAPHIC COMPOSITION YOU MAY BE MAKING UNFAIR COMPARISON THERE. EVEN WHEN YOU TAKE ADJACENT CITIES. COLORADO AND KANSAS, SIDE BY SIDE YOU CAN SEE THE SEPARATION BETWEEN THEM IN LIFE EXPECTANCY. ALABAMA AND GEORGIA. SIDE BY SIDE IN THE DEEP SOUTH. BUT AGAIN IN THE 1990s SOMETHING HAPPENED. SO I WANT TO TALK MORE ABOUT THAT. DR. NUGENT PUT OUT A HYPOTHESIS, I WANT O TO EXPLORE THE OTHERS IN MINUTE OR TWO BUT THIS IS SOMETHING INTRIGUING BOTH BECAUSE WE WANT TO UNDERSTAND WHAT'S BEHIND IT BUT ALSO RAISES SOME TESTABLE HYPOTHESES FOR RESEARCH IN TERMS OF UNDERSTANDING WHAT'S CAUSING THIS. SO GETTING BACK TO THE LARGEST QUESTION OF WHY THIS IS HAPPENING, IT'S IMPORTANT TO GO BACK TO BASICS AND THINK ABOUT THE SOCIO ECOLOGICAL FRAMEWORK YOU HAVE SEEN DIFFERENT SLIDES THIS MORNING GETTING AROUND THE SAME ISSUE THAT ARE HEALTH SHAPED BY MORE THAN HEALTHCARE. THIS PARTICULAR GRAPHIC COMES FROM OUR SHORTER LIVES POOR HEALTH REPORT, TRYING TO PROVIDE A SIMPLIFIED SKI MATTIC FOR WHAT SHAPES HEALTH. IF WE THINK OF HEALTH OUTCOMES ON THE RIGHT, HEALTHCARE IS AN IMPORTANT FACTOR BUT STUDIES SHOW THAT IT ONLY ACCOUNTS FOR 10 TO 20% HEALTH OUTCOMES. INDIVIDUAL BEHAVIORS, WE KNOW ARE A MAJOR FACTOR, SMOKING DIET, PHYSICAL ACTIVITY. WE NOW RECOGNIZE THAT BOTH HEALTHCARE AND INDIVIDUAL BEHAVIORS ARE SHAPED BY SOCIO ECONOMIC STATUS EDUCATION AND INCOME AND EMPLOYMENT AND SO FORTH AND ALSO ENVIRONMENT. DO WE LIVE IN A COMMUNITY THAT MAKES IT EASY TO BE PHYSICALLY ACTIVE AND EAT WELL, PEOPLE HAVE TALKED ABOUT ACES AND SOCIAL ENVIRONMENT HOW MUCH TRAUMA, HOW MUCH RACISM ARE WE EXPOSED TO AD HOW DOES IT SHAPE OUR HEALTH AND WE BELIEVE POLICIES AND SPENDING ACT AS WHAT ACADEMICS CALL A MACRO STRUCTURAL DETERMINANT OF HEALTH. INFLUENCE THOSE OTHER BOXES SO IF YOU WANT TO UNDERSTAND THE U.S. LIFE EXPECTANCY IS FALLING OFF WHILE INCREASING IN OTHER COUNTRIES WE HAVE TO THINK IN A SYSTEMATIC WAY THROUGH THE BOXES AND ASK WHAT ARE THEY DOING THERE. THAT ISN'T HAPPENING HERE, I WANT TO DISPENSE WITH ONE PARTICULAR THEORY ABOUT THE U.S. HEALTH DISADVANTAGE WHICH IS THAT WE ARE A MORE DIVERSE POPULATION. SO ONE OF THE PUSH BACKS YOU GET IS PEOPLE SAY WELL, YOU ARE COMPARING US WITH FINLAND AND JAPAN, WE ARE A VERY DIVERSE POPULATION. WE KNOW WE HAVE RACIAL ETHNIC DISPARITY, PEOPLE WHO HAVE HIGH POVERTY RATES HAVE WORSE OUTCOMES, THAT'S WHY THE U.S. LOOKS THE WAY IT DOES BUT IN OUR ANALYSIS, THIS IS BACK IN 2013 REPORT STRATIFY OUR COMPARISON BY WHITES, BLACKS AND SO FORTH, RICH, POOR, PEOPLE WITH HEALTH INSURANCE, WITHOUT HEALTH INSURANCE, ACROSS DIMENSIONS THE U.S. FAIRS POORLY. RICH AMERICANS DIE EARLIER THAN RICH PEOPLE IN OTHER COUNTRIES. WHITE AMERICANS DIE EARLIER THAN WHITE PEOPLE IN OTHER COUNTRIES SO IT'S TRUE THAT OBVIOUSLY WE HAVE BIG HEALTH INEQUITIES IN THIS COUNTRY BUT IT'S TOO SIMPLE AN EXPLANATION TO SAY THE REASON AMERICA IS FAIRING POORLY BECAUSE OF THE RACIAL COMPOSITION AND IN FACT THE LARGEST INCREASE IN MID LIFE MORTALITY THAT'S BEHIND US IS HAPPENING IN THE WHITE POPULATION. NON-HISPANIC WHITES EXPERIENCING THE LARGEST INCREASE. WE HAVE TO UNDERSTAND WHAT IS IT IN THESE BOXES IS CAUSING THE U.S. TO DO SO POORLY RELATIVE TO OTHER COUNTRIES. S IN THINKING THROUGH THE THEORIES ABOUT WHAT'S BEHIND THIS, HERE ARE SOME OF THE POPULAR CONTENDERS. OBVIOUS LIZ THE FIRST ONE IS THE DRUG ABUSE PROBLEM, THE OPIOID EPIDEMIC IS A HUGE FACTOR. INCREASE IN IN DEATH RATES FROM DRUG OVERDOSES IS ASTONISHING THE PACE OF INCREASE. THIS IS NOT HAPPENED IN OTHER COUNTRIES NOTHING TO THIS SCALE. THE EPIDEMIC IS -- I DON'T WANT TO SAY UNIQUELY AMERICAN PHENOMENON BUT CLEARLY STANDS OUS AS DISPROPORTIONATE IN THE US. ALSO INCREASE DEATH FROM ALCOHOL, NOT ENOUGH ATTENTION TO THAT BUT SIGNIFICANT INCREASE IN DEATH RATES FROM ALCOHOLIC LIVER DISEASE, BING DRINKING AND ANOTHER NUMBER OF OTHER COMPLICATIONS FROM ALCOHOLISM. BOTH FALL UNDER CATEGORY OF SELF-MEDICATING FOR REASONS WE CAN GET INTO. TOBACCO AND OBESITY IN MEANS LEADING CAUSE OF DEATH IN THE UNITED STATES WHETHER RESPONSIBLE FOR THIS INCREASE IN MORE THAT WILLTY IS NOT CLEAR BECAUSE WE ARE IN A PERIOD WHERE WE HAVE HAD VERY POSITIVE PROGRESS IN REDUCING SMOKING RATES, THE AGE GROUP THAT WAS MOST EFFECTED BY INCREASE IN SMOKING IN LAST CENTURY IS NOT IN THE RIGHT AGE GROUP TO EXPLAIN THIS INCREASE IN YOUNG AND MIDDLE AGE ADULTS, OBESITY ON THE OTHER HAND IS PROBABLY PLAYING INFLUENCE ON THIS, THERE'S A FAIR BODY OF EVIDENCE TO SUGGEST THAT OBESE CAUSES MAYBE CONTRIBUTING TO SOME OF THIS BUT EVEN IF YOU SAID DRUGS AND OBESITY, THAT'S NOTS ENOUGH TO EXPLAIN INCREASES IN 35 CAUSES OF DEATH. IT REALLY -- WE CAN TAKE THE THEOR THERE'S 35 INDEPENDENT COINCIDENCES HAPPENED, CAUSES INCREASES OR ENTERTAIN POSSIBILITY OF SYSTEMIC CAUSE, THAT'S RESPONSIBLE. SO WHAT MIGHT THE SYSTEMIC CAUSE BE? ONE (INAUDIBLE) IS MENTIONED DEFICIENCIES IN THE HEALTHCARE SYSTEM, SO THE U.S. STANDS OUT FROM THE OTHER COUNTRIES BECAUSE YOU DON'T HAVE UNIVERSAL HEALTHCARE, THERE ARE GAPS IN HEALTHCARE, ONE OF THE REASONS WHY PEOPLE SOMETIMES ARE DRAWN TO THIS THEORY EXPLAINING INCREASE IN MID LIFE MORTALITY IS THE FACT THAT AS I MENTIONED AT THE BEGINNING WE ARE DOING WELL WITH KIDS AND OLDER ADULTS, TWO GROUPS THAT HAVE STRONGER HEALTH INSURANCE PROTECTIONS IN THE US. THE CHIP PROGRAM IN KIDS, MEDICARE IN OLDER ADULTS, AND THIS MIDDLE WORKING AGE POPULATION IS THE ONE THAT FALLS THROUGH THE YAKS WITH GAPS IN EMPLOYMENT AND SO FORTH. MAYBE THAT IS PART OF IT. THE PROBLEM THOUGH IS THAT WE CAN'T HANG EVERYTHING ON THAT. WITH MATERNAL MORTALITY I CAN SORT OF BUY THE ARGUMENT THAT IF WE DID A BETTER JOB WITH HEALTHCARE DELIVERY, WE MIGHT MAKE SOME GOOD PROGRESS WITH CLOSING THAT GAP BUT YOU CAN'T BLAME THE HEALTHCARE SYSTEM FOR OPIOID EPIDEMIC. ARE PEOPLE SELF-MEDICATING WITH DRUGS AND ALCOHOL, OBVIOUSLY HEALTHCARE HAS A ROLE TO PLAY IN DEALING WITH THAT PROBLEM. OBVIOUSLY HEALTHCARE PLAYED A ROLE IN CONTRIBUTING TO THE OPIOID EPIDEMIC BUT ANY CASE THE LARGER SYSTEMIC SOCIETAL PROBLEM IS CAUSING PEOPLE TO TURN TO DRUGS AND ALCOHOL IS BEYOND HEALTHCARE. SO THEN PEOPLE TALKED ABOUT THIS NOTION OF PSYCHOLOGICAL DISTRESS, DESPAIR WAS THE CLOAKIAL JARGON THE MEDIA PICKED UP BUT IS IT DEPRESSION, STRESS, ANXIETY, THAT IS CONTRIBUTING TO TIS, THERE'S GOT TO BE SOME ELEMENT OF THAT. CLEARLY THE INCREASE IN SUICIDE RATES DOCUMENTED IN THE U.S. CLEARLY REFLECTS AN INCREASING POPULATION THAT'S FEELING A SENSE OF DESPERATION THERE. MAYBE SOME ELEMENT OF THEM HAVING GREATER ACCESS TO LETHAL INSTRUMENTS FOR SUICIDE LIKE FIREARMS BUT THE COMBINATION OF FACTORS THAT WE ARE SEEING DOES SUGGEST THERE'S SOMETHING ABOUT LIFE IN AMERICA THAT IS CAUSING ENOUGH DISTRESS TO CAUSE THESE BEHAVIORS. WE THINK ABOUT CHRONIC STRESS FOR WHATEVER CAUSE, I WILL GET TO A THEORY IN A MINUTE WHAT ARE THE CAUSES MIGHT BE, WE KNOW THAT CHRONIC STRESS IS BAD FOR YOUR HEALTH, WE HAVE BIOLOGICAL RESEARCH TO SHOW THE EFFECTS ON NEUROENDOCRINE SYSTEM, THE END ORGAN DAMAGE CAUSED BY EXPOSURE TO CHRONIC DEATH, RACISM WAS MENTIONED EARLIER TODAY AND THERE'S A GROWING BODY OF RESEARCH, JENNIFER AND I WERE TALKING AN'T THIS DURING THE BREAK ABOUT THE GROWING BODY OF RESEARCH ABOUT THE BIOLOGICAL EFFECTS OF DAILY EXPOSURE TO DISCRIMINATION AND SO FORTH AND HOW THAT AFFECTS OUR BODY. AND EPIGENETIC EFFECTS THAT ACCUMULATED TRANSGENERATIONALLY OVER TIME. THAT WE ALSO KNOW ARE HARMFUL. PEOPLE EXPOSED TO CHRONIC STRESS TURNED TO UNHEALTHY COPING BEHAVIORS SO THEY MAY START INCREASE SMOKING MAY OVEREAT WHICH CONTRIBUTE TO THE OBESITY, THEY MAY SELF-MEDICATE WITH DRUGS AND ALCOHOL, MAY TURN INWARD AND BECOME DEPRESSED AND POTENTIALLY COMMIT SUICIDE, MAY ACT OUT AND BECOME MORE VIOLENT WHICH MIGHT EXPLAIN INCREASE IN HOMICIDE. BUT IF THEY -- THE ROOT OF IT ALL IS THE STRESS. UNDERSTANDING WHAT'S CAUSIN THAT. FOR THAT I WANT TO POINT TO THE POSSIBILITY OF SOCIO ECONOMIC CONDITIONS IN OUR COUNTRY BEING IMPORTANT FACTOR. THINK OF THE MAP I SHOWED OF WHERE IN THE U.S. WE ARE SEEING THE LARGEST INCREASES IN MORTALITY, IT'S THE RUST BELT. IT'S CENTRAL APPALACIA. THINK ABOUT THE MIDWEST RUST BELT, WHAT HAPPENED IN THE '90s? THERE WERE CHANGES IN DELIVERY OF THE HEALTHCARE SYSTEM BUT OTHER THINGS CHANGE. WE HAD IN THE 1970s AND 1980s A MASSIVE CHANGE IN OUR ECONOMY. LOSS OF MANUFACTURING DRUGS, AUTO PLANTS CLOSING. THE AREA SINGLE LARGEST INCREASE OFFER MORTALITY IS WHERE PEOPLE IN COMMUNITIES HAVE BEEN DEALING A LONG TERM PERIOD OF CHRONIC UNEMPLOYMENT, STAGNANT WAGES WIDENING INCOME AND EQUALITY, GREATER SENSE OF LACK OF SOCIAL MOBILITY THEIR KIDS CAN'T GET AHEAD. THERE IS AN IMPORTANT SOCIETAL BACK STORY HERE THAT I THINK IS POTENTIALLY DRIVING THIS. I ALSO WANT TO MENTION THE STATE TRAJECTOR TORRY CHANGENING THE '90s. REMEMBER THE GRAPH SHOWING OKLAHOMA ALABAMA GEORGIA SO ORTHO. THINK ABOUT YOUR HISTORY. DURING THE REGAIN ADMINISTRATION, THIS WAS A TIME WHEN CONCERTED DECISIONS WERE MADE TO SHIFT POWERS TO THE STATES. BLOCK GRANTS MOVED TO THE STATES, LEGAL AUTHORITIES WERE MOVED FROM FEDERAL GOVERNMENT TO STATES, PARTLY TO DECREASE SIZE OF FEDERAL GOVERNMENT AND GIVE POWER TO THE STATES. ONE OF THE CONSEQUENCES IS STATES HAVE MORE POWER TO MAKE DECISIONS AROUND A RANGE OF POLICIES SOME WHICH AFFECT HEALTH SO YOU HAVE THE POTENTIAL FOR STATES TO START PARTING COMPANY IN TERMS OF CHOICES THEY MAKE. SO SOME OF THAT DIVERGENCE BETWEEN NEW YORK AN OKLAHOMA MIGHT REPRESENT DIFFERENCES IN DEMOGRAPHIC COMPOSITION BUT SOME MAY REFLECT POLICIES THAT& DIFFERENT STATES PURSUE WHICH AFFECT THEIR HEALTH OF THEIR POPULATION. AMONG OTHER THINGS. SO THERE'S A EMERGING EVIDENCE TO SUGGEST THAT WE NEED TO BE THINKING MORE ABOUT THIS, THIS IS A STUDY THAT CAME OUT A FEW WEEKS AGO SHOWING IN THIS PARTICULAR COMPARISON MORTALITY RATES FROM OPIOID OVERDOSES IN MANUFACTURING COUNTIES WHERE THE COMPARISON WAS BETWEEN MANUFACTURING COUNTIES THAT HAD AUDIT PLAN CLOSE AND ONES IN CONTROL GROUP THAT DIDN'T HAVE AUTO PLANT CLOSE. YOU CAN SEE THE GRAPH ON THE RIGHT. THERE'S TWO MORE STUDIES THAT HAVE COME OUT WITH SIMILAR MESSAGES. SO WHEN WE THINK ABOUT WHAT'S BEHIND THIS, IT'S NOT WHAT WE WERE TRAINED IN MEDICAL SCHOOL AND WE DIDN'T LEARN ANYTHING ABOUT THIS THERE. THESE FACTORS THAT ARE ON THIS SLIDE ARE PART OF THE ITOLOGY, PART OF THE NATURAL HISTORY OF THE DISEASE, AS MUCH AS GENETICS AND BIOLOGY ARE. IN ORDER HAVE A HOLISTIC THEORY ABOUT WHAT'S GOING ON WE HAVE TO PULL INTO EXPLANATORY MODEL. SO BEING HERE AT NIH I WANTED TO THROW IN JUST A SMALL NUMBER OF RESEARCH PRIORITIES THAT I WANTED TO ENCOURAGE. SO THE FIRST ONE IS HOW AM I DOING ON TIME? I'M NOT GOING TO TAKE LONG WITH THIS, I WANT TO QUICKLY BLAST THROUGH, THE FIRST IS WE NEED TO UNDERSTAND WHAT IS CAUSING INCREASE CAUSE SPECIFIC MORTALITY RATES, IT'S NOT INDUSTRY WIDE OVERDOSE RATES GOING UP, THAT'S EASY, BUT WHY HYPERTENSIVE HEART DISEASE RATES GOING UP, VALLECULAR HEART DISEASE AND CONGESTIVE HEART FAILURE AND WHY ISCHEMIC HEART DISEASE DOWN AND OTHERS ARE GOING UP HOW MUCH IS ART FACTUAL DUE TO CHANGES IN CODING ON DEATH CERTIFICATES, HOW MUCH IS REAL AND WHY IS IT HAPPENING, WHAT IS THE CONTRIBUTION OF OBESITY, COULD ALCOHOL BE CONTRIBUTING. SOME WONDER WHETHER THE DRUG EPIDEMIC IS CONTRIBUTING TO CARDIOVASCULAR COMPLICATIONS. I GAVE THIS TALK TO A NEUROLOGICAL SOCIETY A COUPLE OF WEEKS AGO BECAUSE MORTALITY RATE FROM NEUROLOGIC DISEASE IS INCREASING IN THIS AGE GROUP NOT OLDER ADULTS, AGE GROUP YOU EXPECT TO SEE INCREASES FROM ALZHEIMERS BUT IN YOUNG AND MIDDLE AGE ADULTS, DEATH FROM NEUROLOGIC DISEASE, FROM EACH THERE'S 35 CAUSES OF DEATH, WE NEED TO DO RESEARCH TO UNDERSTAND WHY ARE YOUNG AND MIDDLE AGE PEOPLE DYING AT HIGHER RATES FROM THOSE CONDITIONS. WE ARE ABANDONING OUR -- THE AMERICAN PUBLIC IF WE DON'T FIND ANSWERS TO THIS BECAUSE THEY ARE DYING PREMATURELY, THIS INCREASE IN WORKING AGE MORTALITY MEANS THAT AMERICANS MORE LIKELY TO DIE BEFORE AGE 65 THAN THEY WERE JUST A FEW YEARS AGO. MORTALITY RATES, THIS NEEDS TO EXPAND TO LOOK AT PREVALENCE OF DISEASE IN PHYSICAL AND MENTAL AREAS. THIS IS A FRUITSFUL AREA I WOULD ENCOURAGE NHLBI TO FUND LOOKING AT COHORT STUDIES TO UNDERSTAND WHAT HAPPENED IN THESE AGE COHORTS, SOME LIMITED AMOUNT OF COHORT STUDIES DONE TO SUGGEST IT WAS PEOPLE BORN IN THE 1940s AND 50s WHO EXPERIENCE A CERTAIN PATTERN HERE AND THEY ARE THE ONES NOW EXPERIENCING INCREASING MORTALITY IN OLDER AGE GROUPS BUT WHAT HAPPENED TO THE PEOPLE THAT WERE BORN IN 1990s? THE ONES YOUNGER ADULTS DYING HIGHER RATES, WHAT ARE THE DIFFERENT EXPOSURES THEY HAD, AGE PERIOD COHORT ANALYSES UNPACK THAT. AND THERE'S NOT ENOUGH OF THOSE. THE WOMEN'S HEALTH DISADVANTAGE DIMENSION MULTIPLE TIMES TODAY, IT'S IMPORTANT TO EMPHASIZE ALONG WITH THE OTHER EVIDENCE WE PRESENTED WITH THIS MORNING I WILL ADD THIS, THE REGULARTIVE INCREASE IN MID LIFE MORTALITY I SHOWEDDED YOU I DIDN'T STRATIFY BY SEX, THE RELATIVE INCREASE HAS BEEN HIGHER IN WOMEN THAN MEN. . ABSOLUTE RATES HIGHER THAN IN WOMEN, OBVIOUSLY BUT RELATIVE INCREASE FROM DRUG OVERDOSE IS SUICIDE, ALCOHOL RELATED DEATH HIGHER IN AMERICAN WOMEN THAN MEN. SOMEONE SHARED A SLIDE TO SAY THIS IS A RURAL PROBLEM, IT IS A LARGER PROBLEM IN RURAL AREAS AND RELATIVE TERMS. BUT IS HAPPENING IN LARGE CITIES, HAPPENING IN SUBURBS, IN SMALL AND MEDIUM SIZE CITIES AND BECAUSE POPULATION CENTER ARE THERE, THAT'S WHERE THE ACTION IS IN TERMS OF ABSOLUTE IMPACT ON POPULATION TRENDS. SO WE DON'T WANT TO TO THINK OF THIS AS A RURAL PROBLEM BUT IT'S A MULTI-SETTING. WOMEN ARE DYING AT HIGHER RATES IN EACH OF THOSE SETTINGS SO WE NEED TO UNDERSTAND WHAT THAT IS ABOUT. AND I JUST WANT TO DIGRESS QUICKLY ON THAT TO SAY THAT MAYBE WE CAN TALK MORE DURING THE DISCUSSION THAT THE ANSWER HAS TO DO MORE WITH BIOLOGY OF WOMEN, BE GIVEN THE CONTEXT OF WHAT I WAS TALKING ABOUT IN TERMS OF HOW OUR ECONOMY HAS CHANGED AND THE SOCIAL ECONOMIC CIRCUMSTANCE OF THE AREAS MOST DEEPLY IMPACTED, WE HAVE TO THINK ABOUT HOW AMERICAN WOMEN HAVE BEEN AFFECTED IN A WAY THAT'S DIFFERENT THAN AMERICAN WOMEN IN OTHER COUNTRY -- THAN WOMEN IN OTHER COUNTRIES. HOW DOES THIS ECONOMY SELECTIVELY DISADVANTAGED WOMEN AND MAKE THEM MORE VULNERABLE TO THEIR HEALTH BEING AFFECTED. IT'S A LARGER CONVERSATION. THE TIMING OF THE RACIAL ETHNIC TRENDS, THE PHENOMENON OF THE WHITE POPULATION AND IS NOW AFFECTING THE AFRICAN AMERICAN HISPANIC POPULATION. IT'S ALSO AFFECTING THE AFRICAN AMERICAN AND HISPANIC POPULATION IN A DIFFERENT WAY, SO TO USE AN EXAMPLE THAT YOU ARE FAMILIAR WITH, THE OPIOID EPIDEMIC LED IN THE WHITE POPULATION WITH PRESCRIPTION DRUGS BUT THE CURRENT PHASE OF FENTANYL RELATED DEATH IS INCREASING FASTER THAN THE AMERICAN THAN THE -- SO DISAGGREGATING THE -- THE THEORY THAT WE ARE HAVING INCREASING DESPAIR, THIS IS MORE THAN NIMH THING THAN NHLBI IS IT TRUE WE ARE HAVING INCREASING DESPAIR, WHAT IS THE EVIDENCE PREVALENCE OF DEPRESSION ANXIETY OR DESPAIR WHATEVER TERM YOU WANT TO USE HAS TRULY INCREASED. THERE'S CONTROVERSY IN THE LITERATURE AND THERE'S NOT GREAT STUDIES TO DOCUMENT HOW THIS IS TRUE BUT IF IN FACT INCREASE NO MORTALITY IS DUE TO DEPTH OR DESPAIR WE SHOULD BE ABLE TO DISPROVE WHETHER THAT'S INCREASED. I TALKED THE ROLE OF SOCIO ECONOMIC STRESS, THAT NEEDS TO BE EXAMINED. I ALSO TALKED ABOUT THIS GEOGRAPHIC PATTERNING OF THE DIFFERENCES, SO IF YOU THINK ABOUT GEORGIA AND ALABAMA, I'LL USE THAT EXAMPLE, THERE'S THREE DIFFERENT REASONS WHY GEORGIA AND ALABAMA SEPARATED. ONE IS COMPOSITIONAL CHANGE. THINK ABOUT GROWTH OF ATLANTA. MAYBE THE POPULATION THAT CAME INTO ATLANTA MAYBE MORE EDUCATED POPULATION, MAYBE MORE IMMIGRANTS, IMMIGRANTS HAVE BETTER HEALTH THAN U.S. BORN ADULTS DO. ARE THERE ECONOMIC AND OTHER FIXED EFFECTS THAT MIGHT EXPLAIN THOSE DIFFERENCES AND THE THIRD ONE THAT I HAD MENTIONED TO WHAT EXTENT IS THE POLICY CHOICES. THAT GETS TO MY LAST POINT PROBABLY HARDEST TO THINK ABOUT AT NIH. I USED TO WORK AT NIH, IT WAS 35 YEARS AGO BUT THIS PARTICULAR ASPECT HASN'T CHANGED, THE REAL ANSWER TO THIS THE RESEARCH THAT NEEDS TO HAS BEEN HAS TOTARAS SEN NOT ONLY BODY SYSTEMS, IT MEANS NOT ONLY WORKING ACROSS CAMPUS AT NIH TO WORK THROUGH THE AFFECTS HAPPENING ACROSS ORGAN SYSTEMS BUT BECAUSE OF WHAT I JUST TALKED ABOUT WE HAVE TO UNDERSTAND THE HISTORY OF WHAT HAPPENED TO THESE PLACES, THE COMMITTEE, THE SOCIO LOGICAL PATTERNS POLITICAL SCIENCE AND SO FORTH. SO THERE ARE RESEARCH TEAMS, I'M INVOLVED WITH ONE OF THEM, WHERE PEOPLE IN THESE OTHER DISCIPLINES ARE COMING TOGETHER. THE LAW, JOURNALISM, COMING TOGETHER TO UNDERSTAND WHAT HAPPENED TO EXPLAIN THIS, YOU HAVE TO INTEGRATE WHAT WE KNOW IN MEDICINE AND PUBLIC HEALTH WITH THOSE OTHER SCIENCES, SHARE DATA AND THROUGH THAT COME UP WITH A COMPREHENSIVE UNDERSTANDING OF WHAT'S RESPONSIBLE FOR IT. YOU KNOW BETTER THAN ME HOW NIH AND NHLBI IN PARTICULAR CAN STIMULATE THAT INTERDISCIPLINARY RESEARCH BUT I WOULD ARGUE UNLESS WE DO THAT WE ARE NOT GOING TO MOVE THE NEEDLE UNDERSTANDING THIS PROBLEM, THE KNOWLEDGE BASE FOR SOLVING THIS REQUIRES US TO GET OUTSIDE THAT BOX. I WILL STOP HERE IN THE INTEREST OF TIME, THIS IS A SUMMARY OF WHAT WE HAVE SAID AND OPEN UP FOR DISCUSSION. [APPLAUSE] >> DR. ARNETTE THEN DR. ABLE AND DR. CRAFT. >> THANK YOU, STEVE FOR ALL THAT AND CALLING OUT THE HIGHER REGION AND HOW DEVASTATED THAT REGION HAS BEEN. I'LL REFER YOU TO A WONDERFUL BOOK I JUST FINISHED CALLED "INVISIBLE WOMEN" LOOKING HOW WOMEN DATA RELATED TO WOMEN ARE SYSTEMATICALLY UNDERINVESTIGATED, IN ALMOST EVER DOMAIN OF LIFE INCLUDING DU MANY,MC CAR CRASHES WHERE WOMEN ARE 1.7 TIMES MORE ABLE TO DIE IN BECAUSE THEY ARE WOMEN. FASCINATING BOOK. I ENCOURAGE YOU TO OPEN AREAS WE HAVEN'T THOUGHT ABOUT THAT COULD BE CONTRIBUTETOLOGY THE DIFFERENCES IN WOMEN. BUT YOU ARE -- YOUR RESULTS ARE STRIKING. >> THANK YOU. I WILL LACK FOR THAT BOOK. >> SO DR. GRAHAM GAVE DR. CLAYTON THE MAGIC WAND TO DESIGN OUR HEALTHCARE SYSTEM, I WANT TO GIVE YOU THE WAND AND ASK YOU HOW TO REDESIGN THE PREMIER INSTITUTES DEVOTED TO HELP NHLBI BEING ONE OF THEM, NIH LOTS OF MONEY IS GOING INTO OUR RESEARCH ENTERPRISE. IMAGINE WE DON'T HAVE THE EXISTING INSTITUTES OR PARADIGM, HOW WOULD YOU REDESIGN STRUCTURE IN THE 21ST CENTURY TO FOCUS ON HEALTH. >> I HATE TO DO THIS ON DAY OF NEW HAMPSHIRE PRIMARY BUT TENSION BETWEEN WHAT YOU WOULD LIKE TO DO AND WHAT IS REALISTIC. IN A PERFECT WORLD IF WE START FROM SCRATCH, KNOWING WHAT WE KNOW ABOUT SOCIO ECOLOGICAL MODEL WE WOULD DESIGN OUR RESEARCH INSTITUTIONS AROUND THOSE COMPONENTS. WE CERTAINLY -- WE WOULDN'T NECESSARILY BE CONSTRAINED BY BODY SYSTEMS. WE WOULD BE THINKING CROSS CUTTING IN TERMS OF PRIMARY CARE, COMMUNITY CONDITIONS AND THE ROLE OF POLICY AT EACH LEVEL SO HEALTH IS SHAPED FROM THE SUB CELLULAR LEVEL TO OUR NEIGHBORHOODS. AS WE JUST SAW, EVEN AT THE STATE AND NATIONAL LEVEL, SO WE WANT TO HAVE AN APPROACH TO RESEARCH ABOUT QUESTIONS LIKE HYPERTENSIVE HEART DISEASE THAT SPANNED ALL OF THOSE LEVELS IN AN INTEGRATED WAY. BUT I GUESS WE GOT TO GET REAL. BUT I THINK IT IS WORTHYING CREATIVELY AND I'M NOT QUALIFIED TO ADVISE YOU ON HOW TO DO THIS. I THINK IT IS WE ARE THINKING CREATIVELY ABOUT WHETHER THERE ARE RFAs OR OTHER KINDS OF FUNDING MECHANISMS THAT ENCOURAGE THIS COMING TOGETHER OF DISCIPLINES THAT HAVE NOT SEEN LAID EYES ON HEALTH STATISTICS BUT HAVE THE ANSWERS TO OUR QUESTIONS, GIVEN ANECDOTAL EXAMPLE ONE RESEARCH TEAM I'M ON I WAS LOOKING AT PECULIAR RESULTS FOR KANSAS MORTALITY RATES AND I WAS SEEING A PARTICULAR PATTERN WITH THE DATA. POLITICAL SCIENTIST FROM PRINCETON WAS ON THE CALL AND I SAID I DON'T UNDERSTAND WHAT HAPPENED WITH THESE DATA IN KANSAS AND HE SAID I CAN TELL YOU WHAT HAPPENED. THAT LED TO AN ENTIRE CONVERSATION WHERE HE HAD NOT EVER SEEN THE KANSAS HEALTH STATISTICS, HE KNEW PLENTY OF KANSAS BUT NEVER SEEN HEALTH STATISTICS BUT HE KNEW PLENTY TO ANSWER OUR QUESTIONS SO COMING UP WITH FUNDING MECHANISMS THAT ENCOURAGE THIS INTERDISCIPLINARY COLLABORATION I THINK WOULD BE VERY FRUITFUL IN TRYING TO GET AT THESE ANSWERS. >> DR. ABLE. >> SEEMS LIKE THE ELEPHANT IN THE ROOM ARE POLITICIANS AND POLICY MAKERS. SO MY QUESTION IS, YOU TALKED ABOUT THIS AS A PREVIOUS COUNCIL MEETING IS A LOT OF THOUGHT AROUND HOW DO YOU ACTUALLY CHANGE AND INFLUENCE HUMAN BEHAVIOR, HOW DO YOU CHANGE AND INFLUENCE THE BEHAVIOR OF THOSE WHO ACTUALLY ARE DECISION MAKERS AND I WOULD CURIOUS THE HEAR YOUR THOUGHTS RESEARCH IN OR APPROACHES TO INFLUENCING THOSE WHO ULTIMATELY ARE THE MAKERS OF SOME OF THESE DECISIONS THAT HAVE UNINTENDED CONSEQUENCES THAT WE SEE AS DIVERGING CURVES. >> WE KNOW FROM PATIENT CARE, EDUCATION IS NOT ENOUGH BUT IT IS CERTAINLY A PREREQUISITE. ONE OF THE FIRST STEPS IS TO MAKE PEOPLE AWARE THIS IS HAPPENING. SO MY SENSE IS THAT POLICY MAKERS AND FRANKLY THE AMERICAN PUBLIC DOES NOT KNOW. THEY ARE LESS LIKELY TO REACH AGE 65. THEIR CHILDREN ARE GOING TO LIVE SHORTER LIVES THAN THEY ARE. AND THAT THE AMERICAN HEALTHCARE SYSTEM IS NOT ONLY NOT THE BEST HEALTHCARE SYSTEM BUT YOUR HEALTH ACROSS MULTIPLE METRICS IN THE UNITED STATES IS INFERIOR TO OTHER COUNTRIES AND GETTING WORSE. THAT'S NOT I THINK PUBLIC KNOWLEDGE. SO I THINK WE NEED TO DO A BETTER JOB RAISING AWARENESS ABOUT THIS. IT'S SOMETHING I CAN WORKING ON FOR MANY YEARS, THE FACT THIS JAMA STUDY ENDED ON THE FRONT PAGE OF THE NEW YORK TIMES WASHINGTON POST NBC NEWS AND SO FORTH WAS GRATIFYING TO ME, NOT JUST BECAUSE MY PAPER GOT VISIBILITY BUT BECAUSE FINALLY FELT LIKE SOMEBODY PAYING ATTENTION TO THIS ISSUE. WE NEED TO CAPITALIZE ON THAT BRING THE INFORMATION TO CAPITOL HILL TO THE EXTENT THEY CAN GET ANYTHING DONE BUT ALSO TO STATE POLICY OFFICIAL WHO ALSO MAY NOT BE AWARE OF THESE STATE HEALTH TRENDS AND WHERE THEIR STATES ARE GOING. WE HAVE STATE HEALTH RANKINGS THAT COME OUT EVERY YEAR. AND THE STATES ARE OFFICIALS ARE PROBABLY SICK OF SEEING THOSE BECAUSE IF YOU ARE IN MISSISSIPPI OR ALABAMA, IT'S -- FEELS >> MR. ROSS: FORCEMENT OF THE SAME MESSAGE. THE TRENDS ARE VERY INSTRUCTIVE, WHERE YOU ARE MAKING PROGRESS AND WHERE YOU ARE DOING WORSE SO WE NEED A BEAR JOB OF EDUCATION. BUT TO GET AT THE CRUX OF YOUR QUESTION, THE LARGER ISSUES INCENTIVES AND MOTIVATION AND WE HAVE -- FRANKLY I GUESS I CAN SAY THIS BECAUSE I AM NOT A FED, WE HAVE A SITUATION WHERE WE HAVE SPECIAL INTERESTS THAT ARE SHAPING OUR POLICY DECISIONS. AND DECISIONS ARE BEING MADE THAT SERVE AS THOSE SPECIAL INTERESTS AND NOT NECESSARILY PUBLIC HEALTH SO THE CHOICES THAT MAYBE GOOD FOR CERTAIN CORPORATIONS OR INDUSTRIES THAT ARE ACTUALLY HARMING AUTO WORKERS FOR EXAMPLE, LEAVING THEM WITHOUT SOURCES OF JOBS, NOT BRINGING 21ST CENTURY JOBS TO COMMUNITIES THAT HAVE BEEN ABANDON BY INDUSTRIES THAT ARE FAILING THEM. THE WAY TO SOLVE THAT IS TO CHANGE INCENTIVES. ONE PART COULD COME FROM THE PUBLIC, BEING MORE PROACTIVE IN DEMANDING THOSE CHANGES. VOTERS AND SO FORTH. BUT ALSO CHANGING THE BUSINESS MODEL. I THINK WHAT WE -- IT'S A LONG DISCUSSION TO GET INTO BUT WE ARE IN A SITUATION WHERE CORPORATE AMERICA IS FINDING THAT THEY CAN'T CONTINUE TO AFFORD THIS PROBLEM. THE DATA I HAVE SHOWN YOU IS WORKING AGE POPULATION. SO THIS MEANS AMERICAN WORKERS ARE SICKER AND DYING EARLIER THAN WORKERS IN OTHER COUNTRIES. THE U.S. BUSINESS COMMUNITY CANNOT COMPETE WELL AGAINST OTHER COUNTRIES. AS LONG AS THIS CONTINUES. SO INCREASING BUSINESS INTEREST GETTING THIS PROBLEM SOLVED THAT MAY CLASH WITH OTHER BUSINESS INTERESTS THAT BENEFIT FROM THE STATUS QUO. WE'LL HAVE TO SEE HOW THAT SHAKES OUT. >> DR. CRAFT AND THOMAS, ANOTHER COMPELLING TALK. THANK YOU VERY MUCH. ADS YOU MENTIONED A BOOK YOU REMEMBER I ALSO REMEMBER THIS BOOK HILL BILLY -- HE TALKS HIS STRUGGLE TO GET OUT OF THE CYCLE OF AN EMPLOYMENT POVERTY DRUG ADDICTION DESPAIR, OHIO AND KENTUCKY, IT IS A COMPELLING STORY. THINKING ABOUT STATE POLICIES AS YOU MENTION, YOU MAY HAVE SAID THIS AND I MISSED IT, WITH THE EXPANSION OF MEDICAID IN PARTICULAR STATES AND NOT ACROSS THE BOARD, HOW HAS THAT IMPACTED THESE STATE TO STATE DIFFERENCES? I REALIZE SOME DATA ARE RECENT SINCE THIS REALLY JUST HAPPENED THE LAST FEW YEARS SO I DON'T KNOW IF YOU CAN SAY MUCH YET BUT CURIOUS IF YOU HAVE BEEN ABLE TO LOOK AT THE DATA FROM THAT PERSPECTIVE. >> THERE HAVE BEEN ENOUGH YEARS NOW WE HAVE EVIDENCE COMING OUT THAT'S DOCUMENTING THE HEALTH BENEFITS OF MEDICAID EXPANSION. SO STATES CLEARLY EXPANDING MEDICAID HAVE SEEN IMPROVEMENTS IN HEALTH OUTCOMES ACROSS SEVERAL DI MENTIONS THAT HAVE BEEN DOCUMENTED EMPIRICALLY. WHETHER YOU ARE TALKING THAT, CIGARETTE TAXES MOTORCYCLE HELMET LAWS AND OTHERS. WE CAN THINK OF MANY EXAMPLES LIKE THE FLINT MICHIGAN INCIDENT WITH WATER WHERE POLICY MAKERS HAVE MADE CHOICES AFFECTED HEALTH OUTCOMES DISPROPORTIONATELY FROM THEIR POPULATION NOT EXPERIENCED BY OTHERS. WE HAVE A GOOD BODY OF EVIDENCE IN LITERATURE AROUND PUBLIC HEALTH RELATED POLICIES THAT WE KNOW AFFECTING STATE HEALTH OUTCOMES. PROBABLY FOR EXAMPLE ARE INCREASING AREA OF CONCERN, STATES TO OVERRIDE LOCAL AUTHORITIES SO IF YOUR CITY IS WANTING TO CRACK DOWN TOBACCO CONTROL AND HAVE MORE BANS ON INDOOR SMOKING THE STATE GOVERNMENT CAN OVERRIDE YOU AND PREVENT YOU FROM ENFORCING THOSE LAWS. SO STATES HAVE BEEN MORE FORCEFUL WITH PROBABLY POLICIES HAVE ALSO SEEN CHANGES IN HEALTH TRENDS. BUT I WANT TO EMPHASIZE, IT'S NOT JUST PUBLIC HEALTH RELATED POLICIES, POLICIES ABOUT EDUCATION, SOCIAL SERVICES, SUPPORT FOR MANUFACTURING DIFFERENTLY ACROSS THE STATES. IT'S POSSIBLE THOSE ARE HAVING AS MUCH IMPACT ON HEALTH TRENDS AS THE ONES WE TYPICALLY THINK OF AS HEALTH POLICIES. >> DR. THOMAS AND LAST QUESTION >> THANK YOU VERY MUCH. VERY PROVOCATIVE. I THINK IT'S EQUALLY STRIKING AS THE LIFE EXPECTANCY CHANGE IS THE COST BEING SPENT. HOW WE THINK ABOUT THAT, SPECIFICALLY DO WE UNDERSTAND THAT EXORBITANT COST BEING SPENT HOW MUCH IS BEING SPENT RELATIVE TO EACH DIFFERENT AGE COHORT? IS IT -- MOST OF THAT EXPENSE COMING FROM ELDERLY INDIVIDUALS? THE MIDDLE AGE FOLKS? OTHER OPPORTUNITIES? ALL THE SOLUTIONS WE ARE TALKING ABOUT REQUIRE RESOURCES BUT WHERE ARE THOSE RESOURCES GOING TO COME FROM. ONE OBVIOUS INTERVENTION IS CURVE HEALTHCARE COSTS. SO BEGINNING TO UNDERSTAND THAT AND WHAT THAT DIRECT RELATIONSHIP IS WOULD BE VERY IMPORTANT. THAT WILL REQUIRE DIFFERENT SKILL SETS, USING ECONOMISTS AND THINGS LIKE THAT, PARSE THAT OUT TO TRY TO UNDERSTAND THAT. >> HOW MUCH TIME DO WE HAVE? NOT BEING FACETIOUS BECAUSE WE DON'T HAVE ENOUGH TIME TO TALK ISSUE OF HEALTHCARE COSTS. I WILL SAY MANY YEARS ABOUT THIS RIDICULOUS MISMATCH WHERE RESOURCES GO AND WHERE THEY OUGHT TO BE GOING SO IT'S COMPLETELY TURNED ON ITS HEAD. ONE REASON WHY THE U.S. MAY BE DOING SO POORLY RELATIVE TO OTHER COUNTRIES, WHY THEY SPENT LESS PER CAPITA ON THEIR GDP ON HEALTHCARE MAY HAVE SOMETHING TO RESOURCES, MORE RATIONAL APPROACH TO HOW THEY MAKE THOSE INVESTMENTS. WE DON'T HAVE TIME TO GET INTO THE DETAILS BUT FUND MINUTE TALL THESIS IS OURS IS PERVERSELY BACKWARDS, IT'S BEEN THAT WAY FOR A LONG TIME. >> DR. MENSA. >> STEVE, THANK YOU VERY MUCH. A FANTASTIC TALK. APPRECIATE IT. I ALSO WANT TO THANK YOU BECAUSE YOU HAVE BEEN ONE OF THE VERY FEW PEOPLE OVER THE LAST 20, 30 YEARS PRODUCING RIGOROUS ANALYSIS AND SCIENTIFIC JOURNALS AS WELL AS WASHINGTON POST AND NEW YORK TIMES. AS YOU KNOW, OUR MISSION HERE IS TO PROVIDE GLOBAL LEADERSHIP IN RESEARCH TRAINING AND EDUCATION SO PEOPLE LIVE LONGER HEALTHIER LIVES. I'M REMINDED OF A PAPER ON THE WASHINGTON POST 15 YEARS AGO, I LOOK IT UP NOW WHERE YOU CALLED UNHEALTHY MEDICINE, ALL BREAK THROUGHS AND NO FOLLOW THROUGH. œTHROUGHS WE HAVE BEEN ABLE TO CHAMPION AND SUPPORT AND ALL THESE ADVERSE TRENDS WE HEARD THIS MORNING HAVE HAPPENED AT TIMES WHERE WE CONTINUE TO HAVE MORE BREAK THROUGHS SO WHAT IS YOUR GUIDANCE TO US YOUR SUGGESTION, YOUR ADVICE SONA WE CAN MAINTAIN THE BREAK THROUGHS BUT ALSO ADVANCE FOLLOW THROUGHS. >> LIKE DR. CLAYTON SAID WE DON'T WANT THE DISCOVERY PROCESS, WE WANT TO MAKE THOSE ADVANCES SO CERTAINLY THAT'S IMPORTANT. BUT THAT ON ED WAS WRITTEN AFTER SOME YEARS OF RESEARCH DOCUMENTING TO SAVE MORE LIVES. EVEN IF WE DIDN'T OFFER NEWER DRUGS. ANTI-PLATELET AGENTS VERSUS ASPIRIN, POINT IS IF WE CAN DO A BETTER JOB DELIVERING BASICS TO PATIENTS WERE APPROPRIATE FOR THOSE TREATMENTS, IN CLOSING THAT GAP BETWEEN WHAT THE GUIDELINES SAY WE ARE SUPPOSED TO BE DOING AND WHAT WE ARE ACTUALLY DOING, TO SAVE MORE LIVES THAN THE INCREMENTAL BENEFIT THAT COMES FROM THE NEW CLASSIC DRUGS. UNFORTUNATELY THAT PROBLEM IS IS NOT GONE AWAY. WE CONTINUE TO HAVE A REAL DELIVERY GAP IN QUALITY OF CARE AMERICANS ARE GETTING. WE HAVE NIH AND A NUMBER OF OTHER STRENGTHS WE CAN BE PROUD OF IN THE U.S. COMPARED TO THE OTHER COMPARISON COUNTRIES. BUT WE ARE FALLING SHORT PEOPLE DON'T HAVE ACCESS TO NOT ONLY ADVANCE LEVELS OF CARE BUT BASIC LEVELS OF CARE, AND FOR DISADVANTAGED POPULATIONS UNDERSERVED POPULATIONS, LOW INCOME POPULATION, RURAL POPULATIONS THE GAP AFTER COURSE IS EVEN GREATER SO THAT UNFORTUNATELY IS NOT SO MUCH BENCH SCIENCE BUT SYSTEMS SCIENCE AND DELIVERY AND IMPLEMENTATION SCIENCE THAT REALLY NEEDS TO BE A PRIORITY, MORE OF WHAT AHRQ WOULD BE CONSIDERING ITS TREATMENT BUT WHETHER IT'S NIH OR AHRQ I DON'T THINK WE ARE PUTTING ENOUGH MONEY HOW TO CLOSE IMPLEMENTATION GAPS. THAT WOULD SAVE MORE LIVES. >> SO WE HAVE TIME FOR ANOTHER QUESTION FROM DR. WENTZELL AND POSSIBLY DR. GRANT. >> WONDERFUL TALK, I LIVE IN SOUTHWEST PENNSYLVANIA SO CLEARLY WE HAVE A LOT OF SHIRE US IN THAT REGION INCLUDING -- ISSUES IN THAT REGION INCLUDING DISPARITIES IN THE VALLEY AND PITTSBURG WHICH IS A TEN YEAR DIFFERENCE SPACE OF TEN MILES BASICALLY. WITH MULTI-VARIANT ANALYSIS REQUIRED TO FIGURE OUT THE REASONS BECAUSE THE STEEL MILLS ARE STILL OPEN. THIS GOES BACK TO SOMETHING WE AS A COUNTRY INVEST IN STARTING IN CHILDHOOD. WITH EDUCATION. WITH PRE-SCHOOL, EDGE CHARACTERS ET CETERA, BECAUSE CHANGING BEHAVIORS AND PEOPLE AND CHANGING AD TUESDAYS DOES REQUIRE SOME EDUCATIONAL ELEMENTS TO THIS TOO. I THINK HARKEN BACK TO FACT WE ARE THE ONLY EDUCATED COUNTRY IN THE WORLD THAT DOESN'T USE THE METRIC SYSTEM. WE ARE A DIFFICULT COUNTRY TO CHANGE. WHICH IS TO OUR WORSENING OUTCOMES BECAUSE WE CAN'T DO THAT. BUT I THINK FOR PEOPLE WHO TALK CHALLENGES GETTING PEOPLE TO STOP SMOKING AND NO WAY TO GET PEOPLE TOLL STOP SMOKING ONCE PEOPLE START DOWN THE PATH IT'S HARD TO BREAK THAT PATHWAY. SO YOU HAVE TO PREVENT GOING DOWN THAT PATHWAY REALLY AT A VERY EARLY STAGE. LOTS OF MONEY WE ARE INVESTING IN HEALTHCARE MAY BE SHOULD BE INVESTED IN EARLY CHILDHOOD EDUCATION PRE-SCHOOL, ET CETERA BUT WITH AN APPROACH YOU ARE GOING TO HOPEFULLY CHANGE PEOPLE'S LIVES. >> COULDN'T AGREE MORE. THIS IS ANOTHER SET OF ISSUES THE U.S. AND OTHER COUNTRIES MADE MORE INVESTMENT IN CHILDREN, MORE INVESTMENT IN YOUNG FAMILIES, CHILDHOOD, EDUCATION, NUMBERS ARE BETTER IN THOSE OTHER COUNTRIES. DIDN'T ALWAYS USED TO BE LIKE THAT, THE U.S. USED TO BE OUTPERFORMING THEM BUT NOT SINCE THE '80s. BUT WE HAVE TO DIG BELOW THAT, WHY IS THAT? I THINK A LOT OF IT GETS TO SOME DEEP SOCIETAL ISSUES ABOUT THE BELIEF IN INDIVIDUALISM. RUGGED INDIVIDUALISM. PEOPLE NEED TO MAKE THE BEST FOR THEMSELVES, IT'S NOT GOVERNMENT RESPONSIBILITY TO INVEST IN THOSE THINGS. AND IN OTHER COUNTRY THERE'S A SOCIAL COMPACT AND ATTITUDE OF WE ARE IN THIS TOGETHER. THERE'S POLITICS THAT SWIRLS AROUND THOSE ISSUES. BUT THE FACT OF THE MATTER, WITHOUT GETTING POLITICAL IS IF WE DON'T MAKE THOSE INVESTMENTS, WE ARE GOING TO CONTINUE TO SEE MORTALITY RATES CLIMB AND LIFE EXPECTANCY DECLINE. SORRY TO END ON A SAD NOTE. >> I THINK WE HAVE TIME FOR YOUR QUESTION DR. GRAHAM THEN WE HAVE TO CONCLUDE. >> I HAVE BEEN FOLLOWING YOUR WORK A LONG TIME, I WILL BE USING YOUR SLIDES BOSTON AS RESIDENT OF MASS GENERAL, ONE THING I WANT TO CAUTION IN THESE DISCUSSIONS THOUGH IS BECAUSE WE ARE TALKING TRENDS SOMETIMES WE FORGET CHALLENGES THAT ARE STILL CONSISTENT IN AFRICAN AMERICAN COMMUNITIES. WHEN I NOTICE IS THIS CONVERSATION OCCURRED AROUND DATA IS SENSE THINGS ARE BETTER IN THE AFRICAN AMERICAN COMMUNITIES BECAUSE THESE ARE TRENDS, ABSOLUTE -- BLACK UNEMPLOYMENT RATE IS STILL TWO TO THREE TIMES HIGHER. DECIMATED BLACK COMMUNITIES BEFORE WE SAW SOME OF THE CHALLENGES WE SAW EVOLVING, THAT LACK OF EMPLOYMENT FOR BLACK MEN IS STILL PRESENT AN PERSISTENT. SO I WANT TO CAUTION THE TONE AND TENNER WHEN WE SO TREND PARTICULARLY AFRICAN AMERICAN COMMUNITY HOW THINGS WERE GETTING A LOT BETTER, BECAUSE KIND OF BUT NOT REALLY. THINGS WERE A BIT CHALLENGING AND ALL THESE THINGS PERSISTENT FOR A LONG TIME. SO TO SOME DEGREE I WANT TO EMPHASIZE THAT THINGS WE ARE TALKING ABOUT IN PARTICULAR BLACK COMMUNITIES ARE TRENDS BUT THAT NUMBERS ARE STILL TERRIBLE AND UNACCEPTABLE. >> IN MANY WAYS THE PROBLEM HAS NOT GOTTEN BETTER. WE HAVE SEEN THIS DECLINE. I OFTEN GO BACK AND SHOW STUDENTS SLIDE OF JOHN KENNEDY CIVIL RIGHT'S SPEECH IN 1963. ON LIVE TV AND REPORTED THAT AFRICAN AMERICAN INFANTS WERE TWICE AS LIKELY TO DIE AS WHITE INFANTS IN THE FIRST YEAR OF LIFE. THAT WAS IN HIS SPEECH AND THAT WAS 1963. STILL THAT WAY. THE RATIO IS PRETTY MUCH THE SAME, IT'S NOT IMPROVED. YOU GO BACK TO THE BOOK ON PHILADELPHIA NEGRO IS THE STATE OF THE BOOK IN THE 1800S DOCUMENTING THE HOUSING BLOCK THE SAME DISPARITY SO THIS IS A LONG HISTORY. WHAT DISTRESSED ME ABOUT THE CASE IN DEE TON WORK AND THE WAY IT WAS COVERED IN MEDIA IS BECAUSE IT WAS FIRST REPORTED IN THE WHITE POPULATION, IT WAS PORTRAYED AS ALARMING ISSUE OBVIOUSLY IN TERMS OF ABSOLUTE NUMBERS, MORE WHITE AMERICANS. THE INCREASE DOES -- IS NOT EVER REACHED CLOSE TO WHAT THE MORTALITY IS IN THE AFRICAN AMERICAN POPULATION. YOU ARE RIGHT TO REINFORCE THAT WE ARE KEEP THAT ALWAYS FRONT AND CENTER. I WOULD ADD NATIVE AMERICAN POPULATION. RATES WERE CLIMBING AND ARE STILL EXCEPTIONALLY HIGH BACK WHEN WHITE MORTALITY RATES INCREASE. THANK YOU SO MUCH FOR YOUR TIME. I APPRECIATE YOUR INTEREST IN THIS. [APPLAUSE] >> THANK YOU, DR. WOOLF. >> WE HAVE A LOT OF FOOD FOR THOUGHT Z NOW TO SWITCH TO SOMETHING COMPLETELY MUNDANE. I'LL REMIND YOU OF DELEGATED AUTHORITIES YOU REMINDED ME WITH AT THE INSTITUTE NHLBI FOR MAKING DECISIONS FOR THE COUNCIL. COULD WE GO TO THE NEXT SLIGHTED PLEASE. WE BRINGING FOR YOUR ACCORDANCE AT THE COUNCIL THE ANNUAL RENEWAL OF THE DELEGATED AUTHORITY, REQUIRED TO DO THIS EVERY YEAR. DELEGATED AUTHORITY ALLOW NHLBI STAFF TO PERFORM SPECIFIC FUNCTIONS WITHOUT COUNCIL INVOLVEMENT THERE BY ADDING FLEXIBILITY AND DECREASING THE BURDEN ON THE COUNCIL. WE SEEK YOUR APPROVAL OF THE DELEGATED AUTHORITIES FOR 2020 WHICH ARE -- WHICH WERE AVAILABLE IN THE ELECTRONIC COUNCIL BOOK AND SUMMARIZED ON THIS SLIDE THAT YOU SEE ON THE SCREEN. THESE REMAIN UNCHANGED FOR THOSE APPROVED FOR 2019. I WOULD LIKE TO ASK IF ANY COUNCIL MEMBERS HAVE QUESTIONS WHICH TO DISCUSS THESE DELEGATED AUTHORITY. I SEE EVERYBODY COMPLETELY TRUSTS US TO DO THE RIGHT THING. I UNDERSTAND THAT WITH GREAT POWER COMES GREAT RESPONSIBILITY AND WE SHALL DO THAT. I'M GOING TO TAKE THIS AS APPROVAL TO MOVE FORWARD WITH DELEGATED AUTHORITIES FOR 2020. THIS CONCLUDES THE TECHNICALLY OPEN PART OF THE SESSION FOR NATIONAL HEART LUNG AND BLOOD ADVISORY COUNCIL THAT PRIOR TO BREAKING FOR LUNCH AS I MENTION TO ALL OF YOU WE WILL HAVE A COUNCIL MEMBER PHOTO. IT'S GOING TO BE PART OF OUR CONTINUATION OF HASH TAG OUR HEARTS ARE HEALTHIER TOGETHER THEME FOR HEART MONTH AND GOING TO FOCUS ON THE ROLE OF SORT SUPPORT PLAYS IN MAINTAINING LIFESTYLE HABITS, SOMETHING WE CAN APPRECIATE OFF THE TALKS WE HEARD THIS MORNING. I WILL TELL YOU THAT IN YOUR FOLDERS EVERY COUNCIL MEMBER SHOULD HAVE DISCLOSURE FOR THE PHOTO, IF YOU COULD MAKE SURE THAT YOU SIGN THOSE DISCLOSURES SO THAT WE CAN GO AHEAD AND DISSEMINATE THE PHOTOGRAPH AND IF YOU WISH NOT TO BE INCLUDEDDED IN THE PHOTO, YOU DON'T HAVE TO BE. I WON'T TWIST ANYBODY'S HARM BUT HOPE YOU WILL PARTICIPATE. AFTER THE PHOTO WE WILL HAVE A BREAK FOR LUNCH AND I THINK THAT I'M GOING TO ASK YOU TO BE BACK HERE BY 12:20.