WE'RE READY TO START OUR OPEN SESSION FOR THE NATIONAL ADVISORY COUNCIL ON MINORITY HEALTH AND HEALTH DISPARITIES. SO I'M CALLING THIS MEETING TO ORDER. IF I COULD START WITH INTRODUCTIONS, I'M ELISEO PEREZ-STABLE, DIRECTOR OF NIMHD. >> NATHAN SIMPSON, DIRECTOR DIVISION OF SCIENTIFIC PROGRAMS NIMHD. >> U.T. HEALTH, SAN ANTONIO. >> SPERO MANSON, UNIVERSITY OF COLORADO. >> GISELLE CORBIE-SMITH. >> CARMEN, UNIVERSITY OF PUERTO RICO SWANN. >> GOOD MORNING, BRIAN RIVERS, MOREHOUSE SCHOOL OF MEDICINE. >> UNIVERSITY OF CALIFORNIA SAN DIEGO. >> BRIAN MUSE TAN SKI, NORTHWESTERN. >> JOSEPH KAHOLOKULA, UNIVERSITY OF HAWAII. >> LINDA GREENE, UNIVERSITY UNIVERSITY OF WISCONSIN. >> MARSHAL CHEN, UNIVERSITY OF CHICAGO. >> FERNANDO MENDOZA, STANFORD. >> JOYCE HUNTER, NIMHD. >> : THE FIRST ORDER OF BUSINESS IS MINUTES FROM THE SEPTEMBER 2018 COUNCIL. THOSE MINUTES WERE IN YOUR FOLDER, ALSO POSTED ON THE ELECTRONIC COUNCIL BOOK. ARE THERE ANY COMMENTS OR QUESTIONS OR EDITS ABOUT THE MINUTES? HEARING NONE, MAY I HAVE A MOTION TO APPROVE THE MINUTES FROM THE SEPTEMBER 2018 COUNCIL MEETING? >> : I APPROVE. >> : SECOND? OKAY. ALL IN FAVOR? ANY OPPOSED? THE MOTION CARRIES. THE MINUTES FROM SEPTEMBER 2018 ARE APPROVED. ARE THERE ANY GUESTS HERE TODAY? >> : GOOD MORNING, I'M NATASHA WILLIAMS, LEGISLATIVE LIAISON AT NIMHD. TODAY I WOULD LIKE TO INTRODUCE DR. ALEX CARLISLE, FOUNDER AND CEO OF THE NATIONAL ALLIANCE AGAINST DISPARITIES AND PATIENT HEALTH. THIS IS THE NEW LEAD ORGANIZATION FOR THE FRIENDS OF NIMHD. THANK YOU. >> SO GOOD MORNING, EVERYONE. THANK YOU FOR HAVING US HERE. I SEE SOME FAMILIAR FACES. SO I WANTED TO TAKE THE TIME TO FORMALLY INTRODUCE THE ORGANIZATION. WE'RE VERY EXCITED AND PROUD TO BE WORKING WITH THE NIMHD, AND TO BE THE LEAD ORGANIZATION FOR YOUR FRIENDS PROGRAM. I'M JOINED BY SOME OF OUR LEADERSHIP TEAM, SIMMONS, TATE, LAWRENCE, BYNUM. THE ORGANIZATION ITSELF IS A LITTLE OVER A YEAR OLD. NEW. THE CONCEPT AND SOME OF THE WORK THAT'S GONE INTO BUILDING NIDPH HAS GONE IN FOR A DECADE, AND THIS TEAM AND THIS ORGANIZATION IS LED BY PEOPLE WITH VERY, VERY DEEP EXPERIENCE IN ACADEMIC RESEARCH, PATIENT ADVOCACY, AND SOCIAL JUSTICE. SO THAT'S WHAT WE BRING TO YOU HERE TODAY. WE'RE LOOKING VERY MUCH FORWARD TO WORKING WITH YOU TO ADVANCE THIS PROGRAM. THANK YOU VERY MUCH. [APPLAUSE] >> WE'LL START WITH THE DIRECTOR'S REPORT. >> GOOD MORNING, EVERYONE. I'M GOING TO SUMMARIZE SOME OF THE HIGHLIGHTS OF ISSUES OVER THE LAST FOUR MONTHS OR SO AT NIH AND NIMHD. AND POINT SOME OF THE SCIENTIFIC ISSUES OUT. I HAVE TO START WITH REMEMBERING STEVE KATZ. HE PASSED AWAY LAST -- IN DECEMBER. STEVE WAS A LONGTIME DIRECTOR OF THE NATIONAL INSTITUTE OF ARTHRITIS AND MUSCULOSKELETAL AND SKIN DISEASES. HE WAS -- JOINED NIH IN 1970s, AND AS AN INTRAMURAL INVESTIGATOR, DERMATOLOGIST. HE WAS I BELIEVE IN THE NCI INITIALLY WORKING WITH DOUG LOWY, RECENTLY RECOGNIZED WITH A LASKER AWARD FOR HIS WORK ON VACCINE AND TRAINED DOZENS OF IMMUNODERMATOLOGYISTS AROUND THE WORLD. HE WAS BELOVED BY HIS STAFF AND WAS JUST A WONDERFUL COLLEAGUE, A PERSONAL FRIEND. TO ME AND MANY OTHERS. AND JUST SOMEONE WHO WE WILL MISS TREMENDOUSLY FOR HIS ADVICE AND WISDOM. AND DR. ROBERT CARTER WILL SERVE AS ACTING DIRECTOR AS THE SEARCH BEGINS FOR THAT POSITION. SO, ONGOING SEARCHES AT NIH CENTER FOR SCIENTIFIC REVIEW, SHOULD BE WINDING DOWN. I WAS PART OF THAT SEARCH COMMITTEE. WE HAD SOME OUTSTANDING CANDIDATES. THE NATIONAL INSTITUTE ON DEAFNESS AND OTHER COMMUNICATION DISORDERS WHICH ALSO SHOULD BE WINDING DOWN. IT WAS GOING ON AT THE SAME TIME. THE NATIONAL INSTITUTE OF NURSING RESEARCH WHICH STARTED A FEW MONTHS AGO WHEN PAT GRADY RETIRED LAST SUMMER, AND NOW NIAMS WILL BE LAUNCHING A SEARCH FOR A NEW DIRECTOR. CAPTAIN FELICIA COLLINS WAS JUST APPOINTED JUST LAST WEEK AS DEPUTY ASSISTANT SECRETARY FOR MINORITY HEALTH AND DIRECTOR OF THE OFFICE OF MINORITY HEALTH IN THE DEPARTMENT. DR. COLLINS CAME OVER FROM HRSA, HEALTH RESOURCES AND SERVICES ADMINISTRATION, WHERE SHE WAS AN ADVISER IN THE BUREAU OF PRIMARY HEALTH CARE. I TALKED TO HER ON THE PHONE, ALTHOUGH I HAVEN'T MET HER. SHE'S A GRADUATE FROM YALE, AND HARVARD, AND COMPLETED HER RESIDENCY IN PRIMARY CARE PEDIATRICS AT CHILDREN'S HOSPITAL. SHE TAKES PLACE OF DR. MATTHEW LIN WHO MOVED INTO ANOTHER POSITION WITHIN THE DEPARTMENT IN REGARDS TO INDIAN HEALTH -- AMERICAN INDIAN HEALTH ISSUES. AS YOU KNOW, NIMHD WORKS WITH THE OFFICE OF MINORITY HEALTH ACROSS THE DEPARTMENT AND COORDINATED BY THE DIRECTOR OF OMH, SO THIS IS A POSITION THAT WE AT NIMHD RELATE TO, EVEN THOUGH MOST OF THE REST OF NIH DOES NOT INTERACT VERY MUCH WITH THIS GROUP. THE UPDATE ON THE APPROACHES TO PREVENT AND ADDRESS SEXUAL HARASSMENT HAS BEEN A TOPIC OF A LOT OF CONVERSATION AT NIMHD AND NIH. THE CLIMATE SURVEY THAT WAS DEVELOPED TO SORT OF TAKE THE PULSE OF THE SITUATION AT NIH WAS LAUNCHED THIS MONTH AND IS ONGOING RIGHT NOW. IT IS REALLY INTENDED TO CREATE A SENSE OF WHAT THE PREVALENCE OF THE PROBLEM IS, HAS BEEN IN TERMS OF HISTORICAL AND CURRENT. THERE HAS BEEN A LOT OF EFFORT ON THE PART OF LEADERSHIP TO RAISE CONCIOUSNESS ABOUT THIS. WE DEDICATED SIGNIFICANT AMOUNT OF TIME AT OUR LEADERSHIP FORUM IN OCTOBER ON THIS TOPIC. IT HAS BEEN BROUGHT UP AT INSTITUTE DIRECTOR MEETINGS, AT NIMHD OUR LEADERSHIP HAD PRESENTATION BY THE CIVIL GROUP WITHIN NIH, WHICH IS THE ONES WHO HEAR ANY ALLEGATIONS OR COMPLAINTS. TO REITERATE, ALTHOUGH THE EMPHASIS HAS BEEN ON THE TOPIC OF SEXUAL HARASSMENT, WHICH IS, AS WE ALL KNOW, HAS BEEN VERY MUCH PART OF THE CONVERSATION IN SOCIETY OVER THE LAST THREE YEARS, IT INCLUDES ALL FORMS OF HARASSMENT FROM ANY KIND OF INAPPROPRIATE BEHAVIOR BETWEEN PEOPLE TO ANY KIND OF HARASSMENT RELATED TO BELIEFS, APPEARANCE, DISABILITY, RACE, ETHNICITY, LANGUAGE ABILITY, ET CETERA. SO WE'RE VERY MUCH ON BOARD WITH THIS FOR PURPOSES OF NIH. THE NEXT GENERATION INITIATIVE RESEARCH INITIATIVE HAS HAD A LONG DISCUSSION THROUGH THE ADVISORY COMMITTEE TO THE DIRECTOR, A SPECIAL TASK FORCE THAT GENERATED A LONG LIST OF RECOMMENDATIONS. THESE ARE BEING PROCESSED BY NIH LEADERSHIP, AND THE NUMBER OF THEM WILL PROBABLY IMPACT SOME OF THE EXTRAMURAL POLICIES THAT WE USE. THERE HAVE BEEN A LOT OF DIFFERENT RECOMMENDATIONS FROM SHOULD WE LENGTHEN THE PERIOD OF BEYOND 10 YEARS.INVESTIGATOR- THERE'S ALSO BEEN A LOT OF ATTENTION PAID TO THE AT-RISK INVESTIGATOR, SO THIS IS INDIVIDUALS WHO OBTAIN THEIR FIRST R01, AND THEN ARE AT RISK FOR NOT BEING RE-FUNDED BECAUSE OF COMPETITIVENESS OR THE GAPS THAT EXIST IN TERMS OF GETTING PRIOR ACTIVITY OUT, ALL THE ISSUES MOST OF YOU ARE FAMILIAR WITH. AND THEN THERE WAS A LOT OF DISCUSSION ALSO ON INCORPORATING DIVERSITY AND INCLUSION IN THIS, AND HOW YOU COULD MONITOR THE WORKFORCE STABILITY THROUGH METRICS. WE CERTAINLY HAVE NOW THE TOOLS AND DATA TO BE ABLE TO ANALYZE THIS EXTENSIVELY TO SEE WHAT -- HOW PEOPLE DO IN TERMS OF THE LITERALLY THOUSANDS AND THOUSANDS OF APPLICATIONS THAT COME INTO NIH EVERY YEAR, WHO THE INVESTIGATORS ARE, WHAT THE INSTITUTIONS ARE, WHAT THEIR ULTIMATE SUCCESS IS IN TERMS OF CAREER. AND THEN CONTINUE REALLY STRONG EFFORTS ON TRANSPARENCY AND ENGAGEMENT WITH SCIENTISTS ACROSS THE ENTIRE CAREER STAGE. AND THIS IS STILL GOING TO BE A WORK IN PROGRESS, AND MORE TO REPORT ON THIS AS I AM ASSURING YOU AT FUTURE COUNCIL MEETINGS. WE SAID GOOD-BYE IN DECEMBER TO JOAN WASSERMAN, WHO IS -- WAS DIRECTOR OF THE OFFICE OF EXTRAMURAL RESEARCH ADMINISTRATION. SHE BECAME THE DIRECTOR IN DECEMBER OF 2015, ALTHOUGH I SELECTED HER THE PROCESS OF CREATING THIS SEARCH WAS ESTABLISHED BEFORE I GOT HERE. JOAN HAD JOINED NIMHD IN MARCH OF 2014, IF I'M NOT MISTAKEN. SHORTLY BEFORE DR. RUFFIN RETIRED, AS A PROGRAM OFFICER. SHE'S TRAINED AS A NURSE AND HAS A Ph.D. IN PUBLIC HEALTH AND HAD MADE A NUMBER OF IMPORTANT CONTRIBUTIONS TO OUR INSTITUTE. SHE WENT ACROSS THE STREET TO BE THE DIRECTOR OF RESEARCH, SCHOOL OF NURSING AND UNIFORM SERVICES UNIVERSITY OF HEALTH SCIENCES, AND TOM WOLBERG IN THE BACK, TOM, STANDS UP FOR A MINUTE, IS ACTING DIRECTOR. TOM HAS BEEN DIRECTOR OF REVIEW FOR FOUR YEARS NOW AT NIMHD AND HE WILL RUN THE OFFICE AND AS WE INITIATE A SEARCH TO RECRUIT SOMEONE TO REPLACE JOAN. WE'RE HAPPY TO ANNOUNCE A NEW APPOINTMENT FOR DIRECTOR OF OUR CLINICAL HEALTH SERVICES RESEARCH PROGRAM. LARISSA AVILA SANTA FROM NHLBI, PRINCIPAL PROGRAM OFFICER FOR THE HISPANIC COMMUNITY HEALTH STUDY OR STUDY OF LATINOS IN THE EPIDEMIOLOGY BRANCH, POPULATION SCIENCES, CARDIOVASCULAR SCIENCES, A PHYSICIAN FROM PUERTO RICO WHERE SHE TRAINED AT BOTH MEDICAL SCHOOL AND RESIDENCY IN INTERNAL MEDICINE, SHE'S ALSO COMPLETED A FELLOWSHIP IN ENDOCRINOLOGY AT U.T. SOUTHWESTERN, WHERE JOINED THE FACULTY FOR A NUMBER OF YEARS BEFORE BEING RECRUITED TO NIH TO BE THE PROGRAM OFFICER AFTER THE SOL STUDY GOT STARTED. LARISSA WILL START AT NIMHD OFFICIALLY ON MARCH 4. I WANT TO AGAIN THANK DR. JOYCE HUNTER FOR DOING A GREAT JOB AS ACTING DIRECTOR FOR CLINICAL SERVICES RESEARCH OVER THE PAST YEAR. WE'VE HAD ADDITIONAL STAFF COME TO NIMHD. YOU WERE CITED YESTERDAY, SUN MOON, CHIEF OFFICER, MUCH APPRECIATED AND NEEDED AS ANOTHER ADMINISTRATIVE OFFICER IN OUR INSTITUTE THAT IS AN IMPORTANT POSITION IN THE INTRA-- HOW WE FUNCTION INTERN YELL. XINZHI ZHANG MOVED TO TRANSLATIONAL SCIENCES, ACROSS THE PARKING THERE TO DEMOCRACY ONE. AND XINZHI WILL BE MUCH MISSED, AND I THINK WE'LL NEED TO DISCUSS ABOUT HOW WE ADDRESS ISSUES OF DATA SCIENCE FOR THE FUTURE. AND STARSKI CHANG, ADMINISTRATIVE PERSON WHO LEFT TO GO TO NIDDK. THERE ARE A NUMBER OF NEW HIRES IN THE INTRAMURAL PROGRAM, AND I'LL MENTION YOU, IF YOU'RE IN THE ROOM AFTER I FINISH WILL YOU WILL STAND UP. SAIDA CORREIS, POSTBAC FELLOW WORKING WITH ME IN MY LAB, BASED IN NHLBI, CAME FROM CALIFORNIA, RECOMMENDED BY ONE OF OUR FORMER POSTDOCS. LUCY JEN IS POSTBAC FELLOW, DIVISION OF INTRAMURAL WE SEARCH IN NIH. KRISTIN KAMKE, POSTDOC FELLOW WORKING WITH CHARIN ALTUKI. TOLO OMOLE, POSTBAC FELLOW IN DIR AS WELL. I'M NOT SURE IF ANYONE ELSE IS HERE. ASMI PANIGRAHI, MEDICAL STUDENT WORKING WITH ME AND ERIC RODRIGUEZ IN OUR NHLBI LAB, SHE'S PART OF THE MEDICAL RESEARCH -- MEDICAL RESEARCH SCHOLARS PROGRAM, A SPECIAL PROGRAM THAT NIH HAS FOR MEDICAL STUDENTS, PEOPLE APPLY TO, USUALLY IN THE FALL/WINTER, THEY GET INTERVIEWED BY EARLY MARCH, AND THEN SELECTED, AND THEY HAVE A YEAR OF RESIDENTIAL RESEARCH, RESIDENTIAL MEANING THEY LIVE ON CAMPUS, AT NIH. AND WE'VE CREATED I THINK AN OPTION FOR POPULATION SCIENCE COMMUNITY-ORIENTED RESEARCH FOR STUDENTS BETWEEN THE DIR AND NIMHD, MY WORK, AND ALSO OTHER ASSOCIATED FACULTY THAT ARE WORKING IN THIS AREA. AND THEN BONITA SALMERON, POSTBAC FELLOW, DIVISION OF INTRAMURAL RESEARCH. LAST MONTH, I WENT AND MET WITH TERRY SOOLE, REPRESENTATIVE FROM THE 7th DISTRICT IN ALABAMA, INCLUDING UNIVERSITY OF ALABAMA, TO TALK ABOUT HEALTH DISPARITIES AND GRANTS IN HER DISTRICT. SHE'S QUITE AN ENGAGING PERSON. I HAD ALREADY MET AND TALKED TO HER ON A PRIOR VISIT OF THE CONGRESSIONAL BLACK CAUCUS TO CAMPUS, BUT DURING A MEETING WITH HER IN HER OFFICE WAS A WHOLE DIFFERENT EXPERIENCE. MANY OF YOU READ THE DISORDER -- SUBSTANCE USE DISORDER PREVENTION THAT PROMOTES OPIOID RECOVERY AND TREATMENT FOR PATIENTS AND COMMUNITIES ACT. NOT A WHOLE LOT IN THERE RELATED TO NIH, ALTHOUGH THE "HEAL" PROGRAM IS CONTINUING, SO THE EXTRA FUNDING THAT NIH RECEIVED FOR HELPING END ADDICTION LONG-TERM, OR "HEAL," IS BEING ROLLED OUT BEGINNING IN FISCAL 18 AND THROUGH THIS YEAR. DID A FAIR NUMBER OF TRIPS OVER THE PAST THREE, FOUR MONTHS. I MET WITH LEGISLATORS, STATE LEGISLATORS IN WASHINGTON, D.C., IN SEPTEMBER. THAT WAS I THINK A USEFUL MEETING. I ENCOURAGED A LOT OF SORT OF -- ACT LOCALLY, THINK GLOBALLY, MORE POTENTIAL FOR EFFECTIVE CHANGE IN POLICY AT THE STATE LEVEL THAN THERE IS OFTEN AT THE FEDERAL LEVEL. AT LEAST THAT'S THE CURRENT STATUS. AND I THINK IT WAS USEFUL FOR ME TO TALK TO THEM. I WAS IN ATLANTA AT CLARK ATLANTA UNIVERSITY, WHICH HAS AN RCMI GRANT ON PROSTATE CANCER SYMPOSIUM, WENT TO NYU TO TALK ABOUT THE BIENNIAL CONFERENCE, A CENTER OF EXCELLENT GRANTEE SPONSORED THAT CONFERENCE. I WAS IN ROCKVILLE, MET WITH THE HISPANIC SCIENCE NETWORK CONFERENCE, A LONG-TERM GROUP THAT HAS LOOKED TO DEVELOP LATINO SCIENTISTS INTERESTED IN SUBSTANCE USE, BUT THE NETWORK HAS EXPANDED BEYOND THAT. IT WAS HELD IN ROCKVILLE THIS PAST YEAR. AND IT WAS REALLY QUITE EXCITING TO BE IN A GROUP WITH ALL THESE YOUNG EARLY STAGE -- MOSTLY STAGE INVESTIGATORS WITH SOME OTHERS. AGAIN, NIAAA AND NIDA HAVE BEEN SUPPORTIVE OF THIS GROUP. IN OCTOBER ALSO THE INTERNATIONAL ASSOCIATION FOR POPULATION HEALTH SCIENCES HAD THEIR ANNUAL MEETING AT THE NATIONAL ACADEMY OF MEDICINE, OR SCIENCES, AND WE HAD A PANEL IN THE AFTERNOON, ALSO SEVERAL OF OUR GRANTEES FROM SOCIAL EPIGENOMICS MET THAT AFTERNOON AS WELL AND HAD A SPECIAL SESSION. THIS IS SORT OF A NASCENT ORGANIZATION, ABOUT THEIR FOURTH YEAR. SANDRA GALEO WAS PRESIDENT, BRINGS TOGETHER AN EXCITING GROUP OF SCIENTISTS. I WAS BACK AT UCSF DEPARTMENT OF PSYCHIATRY WHERE I GAVE THREE TALKS IN ONE DAY, WHICH WAS NOT MY PLAN. RUTGERS CANCER INSTITUTE IN NEW JERSEY, I WAS AT AAMC. ACTUALLY THEY PROPOSED THAT WE PRESENT A PANEL ON RESEARCH AT NIMHD AND I INVITED TWO SCIENTISTS TO JOIN ME. I DID A BRIEF INTRODUCTION AND THEY PRESENTED THEIR WORK. THIS IS MONA FAWAD FROM UNIVERSITY OF ALABAMA AND STEPHAN FROM UCSF. I VISITED USC FOR THE DEAN'S DISTINGUISHED LECTURE SERIES AT THE KECK SCHOOL OF MEDICINE, WHERE A NUMBER OF EXCITING SCIENCE IS BEING DONE, AND A NUMBER OF COLLEAGUES AND FORMER COLLEAGUES ARE THERE. WE-- YOU ALL HAVE YOUR COPY. AND THOSE OF YOU WHO JUST ARRIVED TODAY SHOULD GET YOUR HARD COPY OF THE AJPH NEW PERSPECTIVES TO ADVANCE MINORITY HEALTH AND HEALTH DISPARITIES, AS OUR SPECIAL ISSUE SUPPLEMENT TO AMERICAN GENERAL PUBLIC HEALTH. THAT SUMMARIZES THE HARD WORK OF THE SCIENCE VISIONING PROCESS THAT STARTED BEFORE I GOT TO NIMHD, CULMINATED WITH THREE DAYS OF WORKSHOPS, AND A TON OF WORK IN PRODUCING THIS VOLUME. LOTS OF SPECIAL WORK BY NANCY BREEN, RENA DAS, TILDA FARHAT, NANCY JONES AND RICHARD PALMER WHO DESERVE A LAND FOR THEIR LEADERSHIP IN THIS, SO THANK YOU. [APPLAUSE] THIRTY RECOMMENDATIONS, AND I THINK A MULTI-YEAR PROCESS, AND THEN ALSO DR. COLLINS HELPED BY HAVING THE EDITORS CHOICE BRIEF INTRODUCTION. WE ALSO CONTINUING OUR NIMHD DIRECTOR SEMINAR SERIES, THREE OF YOU IN THIS ROOM WERE RECENT PRESENTERS, CORBIE-SMITH, EMILY RODRIGUEZ IN OCTOBER, ANDRA VILLEA A COUPLE WEEKS AGO PRESENTED OUR SEMINAR, AND ANOTHER ONE SCHEDULED NEXT MONTH, MONICA PEEK FROM UNIVERSITY OF CHICAGO, AND IN THE FALL WE WILL HAVE DENISE DILLARD FROM ALASKA PRESENTING IN NOVEMBER. WE JUST RECENTLY CONFIRMED THAT. I THINK THIS CONTINUES TO HAVE A PRESENCE OF RESEARCH THAT NIMHD EMBRACES, PRESENTED AT NIH IN A PUBLIC FORUM THAT WILL -- FOR OUR SAKE AS WELL AS THE COMMUNITY'S SAKE. NIMHD HEALTH DISPARITIES RESEARCH INSTITUTE HAS JUST LAUNCHED OPENING UP FOR APPLICATIONS. THIS IS -- THIS WILL BE THE FOURTH TIME THAT WE HOST THIS, BEGINNING -- YES, FOURTH TIME, THE REDONE VERSION. REMEMBER, THIS IS A ONE-WEEK-LONG SORT OF SUMMER INSTITUTE INTENSIVE ENGAGING TRAINING EXPERIENCE, THE IDEA IS TO ATTRACT SENIOR POSTDOCS, ASSISTANT PROFESSORS, WHO ARE POISED AND READY TO WRITE A GRANT. I GUESS THAT'S THE DEFINING CONCLUSION. WITHIN THE NEXT YEAR. OFTEN A K GRANT BUT IT COULD CERTAINLY BE SOMETHING MORE. WE TAKE UP TO 50 OF THE APPLICANTS, WE'VE HAD ON AVERAGE ABOUT 200 OR SO APPLICATIONS EACH CYCLE. STAFF WILL REVIEW THEM. AND MAKE A SELECTION, A VARIETY OF FACTORS. THE WEEK IS INTENDED TO BE NOT A COMPREHENSIVE REVIEW OF THE FIELD, BUT SELECTED TOPICS OF SCIENCE. SOME OF YOU HAVE SPOKEN AT THIS. AND THEN TIME DEDICATED TO A MOCK REVIEW, WHICH TOM WOLBERG ORGANIZES WITH STAFF, AND ALSO WHO HALF DAYS OF TIME WITH PROGRAM. ONE HALF DAY DEDICATED TO OUR PROGRAM STAFF, THE OTHER HALF DAY DEDICATED TO PROGRAM STAFF ACROSS THE AGENCY INTERESTED IN MINORITY HEALTH AND HEALTH DISPARITIES AND HAVE THAT PORTFOLIO IN THEIR INSTITUTE. REMEMBER AT LEAST 80% OF MINORITY HEALTH, HEALTH DISPARITIES RESEARCH AT NIH IS NOT DONE AT NIMHD. SO-- OR NOT FUNDED I SHOULD SAY BY NIMHD. SO WE VERY MUCH ARE INTERESTED IN MAKING SURE THAT PEOPLE ARE ABLE TO CONNECT WITH OTHER INSTITUTES. AND WE DO SOME COLLABORATION WITH AAMC ON THIS IN TERMS OF THE CAREER DEVELOPMENT AND GRANT WRITING SKILLS. SO WE LOOK FORWARD TO THIS. IT'S IN A LOVELY TIME IN BETHESDA, MIDDLE OF AUGUST, WHERE YOU CAN JUST WALK OUT AT NIGHT IN SHORTS AND T-SHIRTS AND BE REALLY PLEASANT, YOU NEVER COULD DO THAT IN SAN FRANCISCO. BUT IT'S KIND OF HOT DURING THE DAY. LET ME SUMMARIZE SOME ASPECTS OF BUDGET FOR THE INSTITUTE. THIS HAS BEEN OUR APPROPRIATIONS NOW FOR THE LAST FOUR YEARS THAT WE'VE BEEN GETTING INCREASES EACH YEAR, REFLECTIVE OF THE OVERALL NIH INCREASE, NOT ANY PARTICULAR FOCUS ON NIMHD. FROM FISCAL 16 WHEN I ARRIVED, A SHADE UNDER $280 MILLION. WE'RE UP TO $314 MILLION THIS YEAR. THE PRESIDENT BUDGET HAS NOT BEEN PUBLISHED YET, IT'S PUBLISHED AFTER THE STATE OF THE UNION WHICH IS TONIGHT, IT WILL PROBABLY BE IN THE NEXT WEEK OR TWO. REMEMBER THE CONGRESSIONAL OFFICES OR COMMITTEES ARE THE ONES THAT PROCESS THIS AND MAKE THESE DECISIONS SO WE SHALL SEE. THIS IS A BREAKDOWN OF OUR BUDGET BY PROPORTIONS, AS I'M TRYING TO CONSIDER THIS. RPG, RESEARCH GRANT APPLICATIONS FUNDED. WE'RE UP TO ABOUT 45%, THIS INCLUDES ALL THE R LINES AND U01s. THE RCMI IS FIXED 20%. THE OTHER CENTERS THAT ARE NOT RCMI AT ABOUT 11%. AND THEN RESEARCH MANAGEMENT AND SUPPORT TO RUN THE PROGRAM, OTHER PROGRAMS AND TRAINING CONTRACTS INCLUDES JACKSON HEART STUDY, THE LOAN REPAYMENT PROGRAM, AND THEN SBIR, STTR IS ALSO A FIXED AMOUNT. INTRAMURAL IS CLOSER TO 1.5%, BUT IT DOES -- LIKELY WILL INCREASE OVER THE NEXT SEVERAL YEARS. THIS IS A SUMMARY OF SOME OF THE FUNDING RESULTS OF OR GRANTS. YOU CAN SEE FOR FISCAL YEAR 2018 RPG AWARDS, THE NUMBER OF R01 APPLICATIONS, THE NUMBER THAT WERE AWARDED, SUCCESS RATE IS ILLUSTRATED HERE AT ABOUT 14.5%, LOWER SUCCESS RATE FOR R21s, SOMETHING THAT IS CONSISTENT ACROSS THE AGENCY. AND THEN EVEN LESS FOR RO3. R15 IS BEING PHASED OUT AND CHANGED, AND WE'LL HAVE A FOLLOW-UP ON THAT. BUT THESE ARE GRANTS THAT ARE INTENDED FOR INSTITUTIONS THAT HAVE LOW RESOURCES. AND THEN THERE WERE ALSO LOAN REPAYMENT AWARDS. WE CONTINUED TO WORK WITH THE INDIAN HEALTH SERVICES ON THE TRIBAL EPIDEMIOLOGY OFFICERS. WE HAVE A JACKSON HEART STUDY CONTRACT. WE'VE TAKEN OVER THE CFARS ADELANE PROGRAM SUPPORT THROUGH EMORY AND CONTINUE TO SUPPORT THE DIFFERENT CENTERS PROGRAMS. OVER THE FIRST -- THESE TRANSITION PERIODS OF WHEN I ARRIVED, WHICH WAS AT THE END OF FISCAL 15 YEAR, WE'VE HAD AN INCREASE IN RESEARCH GRANTS. THAT WAS ONE OF MY INTENDED GOALS, CLEARLY POISED TO DO THAT, GIVEN THAT THE CENTER OF EXCELLENCE PROGRAM WHICH HAD BEEN VERY LARGE AND INCLUDED OVER 50 FUNDED COEs WAS COMING TO AN END OF A CYCLE AS I ARRIVE, ALTHOUGH SOME HAVE BEEN EXTENDED. AS WE RECOMPETED THAT AND FUNDED 12 NEW ONES, ON TOP OF THE OTHER CENTERS, NON-RCMI CENTERS ALREADY FUNDED, WHICH I THINK WAS ANOTHER 10 OR SO, THE REVERSE HAPPENED, WE INCREASED THE NUMBER OF RGFs THAT -- RPGs THAT WERE FUNDED. LOOKING AT THIS, LAST FALL, MAY HAVE BEEN OBVIOUS, DIFFERENT TO SEE IT IN GRAPHIC FORM, AND I THINK NOW WE HAVE TO LOOK FOR MORE STEADY STATE, WHERE WILL WE GO. IN FISCAL 16, OR FISCAL 17 ACTUALLY, WE FUNDED A LOT OF R01 GRANTS, BECAUSE WE STILL DIDN'T HAVE A LOT OF APPLICATIONS. THAT DEFINITELY CHANGED IN FISCAL 18, AND NOW WITH THE AMOUNT OF MONEY WE HAVE WILL VARY TREMENDOUSLY UNLESS WE FIND A WAY TO STABILIZE THAT OR STUDY IT MORE. WE CAN'T ASSUME WE'LL BE GETTING A 2 OR 3% INCREASE EVERY YEAR, REVERSE TREND OF THE CENTER'S FUNDING AS YOU CAN SEE GOING DOWN. WE WILL KEEP THE LEVEL OF CENTERS PROBABLY ABOUT WHERE WE ARE NOW, GIVE OR TAKE A COUPLE, AS OPPOSED TO REEXPANDED OR SHRINKING MORE. AT LEAST FOR THE FORESEEABLE FUTURE. THIS IS A GRAPHIC PRESENTATION OF THE NUMBER OF APPLICATIONS THAT WE HAVE HAD, AND IT IS SOBERING TO SEE THIS, FROM 15 TO 16 THE INCREASE WAS TO ABOUT 30%, FROM 16 TO 17 ANOTHER 50% INCREASE. FROM 17 TO 18 ANOTHER 50% INCREASE. THE ESTIMATES FOR 19 AND 20 ARE FROM THE OFFICE OF EXTRAMURAL RESEARCH IN BUILDING ONE, WHETHER THESE ACTUALLY PLAY OUT OR NOT WE WILL SEE. SOME OF IT IS OUR OWN STIMULATION OF PUTTING OUT PROGRAM ANNOUNCEMENTS AND ASKING PEOPLE TO SEND US GRANTS. THE MESSAGE IS CONSISTENT. AFTER A COUPLE YEARS PEOPLE HEAR THE MESSAGE, AND SO IT TAKES A WHILE FOR INVESTIGATORS TO BEGIN TO THINK, WELL, MAYBE I SHOULD SEND A GRANT TO NIMHD. SO KEEP IN MIND THAT THE NIMHD DID NOT SIGN UP TO THE PARENT R01 UNTIL 2014, SO HERE. PRIOR TO THAT IT WAS ALL THROUGH RFAs FOR AN R01, BUT IT WAS SET ASIDES AS THE INSTITUTE DID FUNCTION PRIMARILY THAT WAY. BUT THE NUMBERS HAVE INCREASED. IN FACT, TRIPLED SINCE -- FROM 15 TO 18. WE'LL SEE WHAT HAPPENS GOING FORWARD. A COUPLE OF HIGHLIGHTS, NIMHD ACTIVITIES, THIS IS A NICE PHOTO FROM THE PRECISION MEDICINE CENTER ANNUAL MEETING IN DECEMBER. I THINK IT WAS A ROBUST PROGRAM. AGAIN, FIVE CENTERS HAVE BEEN FUNDED. I WASN'T ABLE TO BE THERE FOR ALL OF THE PRESENTATIONS, BUT I DID LISTEN TO A GOOD AMOUNT OF IT. AND WE LOOK FORWARD TO SEE HOW THIS PROGRAM DEVELOPS, AND MIKE SAYER, MERRILL SUFIAN AND NASHADI ARE IN THE PHOTO, THEY HAVE BEEN THE PRIMARY -- PRIMARILY INVOLVED IN MANAGING THIS PROGRAM FROM THE NIMHD PERSPECTIVE. WE ALSO HELD A CONFERENCE ON SLEEP HEALTH AND HEALTH OF WOMEN, WITH -- THIS IS IN CONJUNCTION WITH NHLBI. WE HAD A PANEL ON SLEEP DISPARITIES IN WOMEN THAT WE ORGANIZED, INCLUDING A PRESENTATION BY HISPANIC COMMUNITY HEALTH STUDY SOLE INVESTIGATOR, AND CHANDRA JACKSON, NIEHS INTRAMURAL INVESTIGATOR ALSO SUPPORTED BY NIMHD. AND I ALSO -- I RAN THAT PANEL. THERE WAS A LARGE PRESENCE, AS OFTEN IS THE CASE, NIMHD AT THE ANNUAL MEETING OF THE AMERICAN PUBLIC HEALTH ASSOCIATION WHICH WAS IN SAN DIEGO, PARTICULARLY FOCUSED ON THE SCIENCE VISIONING PANEL THAT LED TO THE FINALIZATION OF THE SUPPLEMENT THAT WE DISTRIBUTED, AND YOU CAN SEE THE PHOTO THERE. AND THEN JUST AGAIN TWO WEEKS AGO THERE WAS A MEETING IN BALTIMORE OF THE NIMHD NIEHS ENVIRONMENTAL HEALTH SCIENCES AND EPA CENTERS OF EXCELLENCE ON ENVIRONMENTAL HEALTH DISPARITIES. THIS IS A JOINT PROGRAM THAT WAS FUNDED IN 2015. THEY ARE NOW IN THEIR THIRD YEAR, CO-FUNDED BY ALL THREE. EPA HAS BEEN LESS PRESENT, THEY WEREN'T PRESENT AT ALL, BECAUSE IT WAS DURING THE SHUTDOWN, RIGHT BEFORE THE SHUTDOWN ENDED. AND SO -- BUT IT WAS AN INTERESTING INTERACTION, GOOD SCIENCE, VERY VARIABLE. TWO SOUTHWEST, ONE USC, ONE HOPKINS, ONE HARVARD, THESE ARE THE FIVE. THE TWO IN THE SOUTHWEST ARE BOTH FOCUSED ON AMERICAN INDIANS, AND THE ONE IN USC IS PRIMARILY FOCUSED ON LATINAS, SO ONE AT HOPKINS IS FOCUSED A LOT ON CHRONIC LUNG DISEASE, AND HARVARD ONE I THINK IS PRIMARY FOCUS ON POOR COMMUNITIES. BUT WE WILL SEE HOW THIS PROGRAM AND THIS PARTNERSHIP WITH NIEHS MOVES FORWARD. IN THE DIVISION OF INTRAMURAL RESEARCH IT WAS ALSO AN ACTIVE PRESENCE AT THE AMERICAN PUBLIC HEALTH ASSOCIATION, CHOI, WILLIAMS, ANNAPOLIS, AND JULIA CHEN PRESENTED ON TOBACCO USE, CANCER INCIDENCE AND HEALTH INEQUITIES, ALSO SYMPOSIUM ON CANCER HEALTH DISPARTIES, AN INITIAL ONE A COUPLE YEARS AGO THAT I ATTENDED PART OF. THIS YEAR IT WAS A DAY I COULDN'T POSSIBLY BE THERE. AND DR. ANN ANNAPOLIS AND YOUNG BUN PRESENTED WITH A NUMBER OF TOPICS ON CANCER, HEALTH EQUITY AND A VARIETY OF THE INTERSECTION OF PATHOLOGY AND GENOTYPING OF TISSUES IN MINORITY HEALTH AND HEALTH DISPARITIES. LET ME HIGHLIGHT A FEW SCIENCE ADVANCES, AS I LIKE DO IN THIS REPORT AT COUNCIL. ON THE NATIONA SCENE, OPIOID EPIDEMIC HAS BEEN BIG. THIS CAME OUT LAST FALL, WHAT'S THE PREVALENCE OF HIGH IMPACT CHRONIC PAIN. AS I'VE LISTENED TO ALL THE HORRIBLE THINGS THAT HAVE HAPPENED WITH THE OPIOID OVERUSE EPIDEMIC, MORE THAN 50,000 OVERDOSE DEATHS EVERY YEAR, EXCEEDS TOTAL NUMBER OF AMERICANS WHO DIED IN VIETNAM WAR, AN ANNUAL BASIS DISPROPORTIONATELY AFFECTING POOR PEOPLE AND RURAL AREAS, ALTHOUGH MOST DEATHS ARE IN URBAN AREAS, AS YOU'LL SEE. BUT CHRONIC PAIN, IS THIS THE PATHWAY? NOT THE ONLY ONE BUT LET'S SAY THE PRINCIPAL ONE. THERE IS A SOCIAL CLASS GRADIENT. SO YOU HAVE LESS THAN HIGH SCHOOL EDUCATION, YOU'RE MUCH MORE LIKELY TO HAVE IT THAN IF YOU HAVE A BACHELOR'S DEGREE. CONSISTENT WITH LOTS OF OTHER DATA THAT SAYS EDUCATION IS GOOD FOR YOUR HEALTH. REINFORCES THE IDEA THAT THE MORE WE HAVE FORMAL EDUCATION, THE BETTER OFF OUR POPULATION HEALTH WILL BE. THERE IS NO SIGNIFICANT DIFFERENCE BY RACE ETHNICITY BETWEEN WHITES, LATINOS AND BLACKS. OTHER GROUPS NOT INCLUDED IN THIS REPORT FROM THE CDC. SO THIS IS NOT THE EXPLANATION OF WHY THERE'S DISPROPORTIONATE AFFECTS OF OPIOID USE DISORDER IN SOME GROUPS BY RACE/ ETHNICITY. MEREDITH SHIELDS AND A GROUP AT NCI WORKING TO LINK NATIONAL DEATH INDEX TO AREA VARIABLES, THIS PAPER WAS JUST PUBLISHED THIS MONTH IN LANCET PUBLIC HEALTH, IT LOOKS AT THE DRUG OVERDOSE DEATH BY COUNTY CHARACTERISTICS AND RACE/ETHNICITY. SOCIOECONOMIC CHARACTERISTICS BY COUNTY USING DATA FROM CENSUS ON PERCENT ENEMPLOYMENT, PROPORTION WITH CERTAIN LEVEL OF EDUCATION AND INCOME. AND THEN LOOKED AT RACE/ETHNICITY. THE DATA ALLOWED TO LOOK AT WHITES, BLACKS, LATINOS. MUCH OF THE DEATHS OF LATINOS AND BLACKS IN COUNTIES WHERE THERE ARE VIEW OF THEM WERE SUPPRESSED BECAUSE OF THE CONCERNS FOR CONFIDENTIALITY. SO, YOU HAVE VERY LIMITED NATIONAL DATA ON LATINOS EXCEPT -- OR BLACKS, EXCEPT WHERE PROPORTION OF POPULATION IS SIGNIFICANT. DRUG POISONING MORALITY, THIS IS VERY CLEAR. SO THE COUNTIES WITH LOWER SES, MORTALITY WAS HIGHER. VERY ROBUST GRADIENT OF SOCIOECONOMIC STATUS. EVEN THOUGH THE BUZZ OR CONCERN HAS BEEN BURDEN ON RURAL COMMUNITIES, MAJORITY OF DEATHS ARE IN METROPOLITAN COUNTIES. LON -- LOGICAL BECAUSE MOST PEOPLE LIVE IN POPULATION AREAS. LESS THAN PROPORTIONS, 82% OF AMERICANS LIVE IN METROPOLITAN COMPARED TO RURAL AREAS, AND YOU CAN DIVIDE INTO SEVEN CATEGORIES BUT THIS IS THE MOST COMMONLY USED DIVISION, 76% OF DEATHS OCCUR IN METROPOLITAN AREAS, SO SIMILAR PROPORTIONS. AMONG BLACK MEN AND WOMEN AND LATINO MEN MORTALITY RATES INCREASE IN SOME CATEGORIES WITH COUNTY ATTRIBUTES FOR MID-AGE, 25 TO 49 YEARS OLD, AND REMAINS STABLE IN MOST OTHERS. SO THERE WAS NOT ROBUST SES GRADIENT FOR THE TWO MINORITY GROUPS, THAT IS AN INTERESTING OBSERVATION. I DON'T KNOW WHAT THE IMPLICATIONS ARE, BUT IT IS SOMEWHAT DIFFERENT. THIS IS ALL DRUG OVERDOSE, NOT JUST OPIOID USE OVERDOSE BUT INCLUDES COCAINE, WHICH IS THE NUMBER ONE DRUG OVERDOSE DEATH CAUSE AMONG AFRICAN-AMERICANS. SO IT'S IMPORTANT TO NOTE THAT. THIS IS AN INTERESTING PAPER THAT LOOKED AT SLEEP QUALITY DURING GESTATION, INCREASING GESTATIONAL DIABETES. HEMOGLOBIN A1c GOING UP IN WOMEN WHO WERE PREGNANT VERSUS NON-PREGNANT WOMEN WITH POOR SLEEP QUALITY. AGAIN, I LIKE TO THINK OF SLEEP AS THIS BEHAVIORAL -- IT IS BEHAVIOR, AFTER ALL -- BEHAVIORAL FACTORS WHERE WE SPEND UP TO MAYBE 30% OF OUR LIVES, RIGHT? AND WE REALLY KNOW VERY LITTLE ABOUT HOW IT AFFECTS OUR HEALTH. SCIENTISTS WORK WITH SLEEP, PHYSICIANS FAMILIAR WITH SLEEP DISORDERS, INSOMNIA, SLEEP APNEA, NARCOLEPSY AND OTHER DISEASES CLINICALLY KNOWN FOR A LONG TIME. YOU HAVE THIS POTENTIAL SLEEP IS AN IMPORTANT TIME FOR OUR HEALTH AND WE HAVEN'T HAD GOOD WAYS OF MEASURING UNTIL RECENTLY. DOES IT REALLY LEAD TO ADVERSE CONSEQUENCES LIKE CHRONIC DISEASES? DOES IT DYSREGULATE THE METABOLIC PATHWAYS? DOES THE CAUSE SOME PROBLEMS WITH CELLULAR CONTROL OF MUTATIONS? I DON'T KNOW. NORA VOLKOW TALKS ABOUT SLEEP, WHEN WE WASH OUR BRAINS. SO WE CLEAN IT UP SO IT DOESN'T GET RESIDUAL PROTEINS, MAYBE PREVENT COGNITIVE IMPAIRMENT. BUT I THINK IT'S A CRITICAL FACTOR TO REALLY GET MUCH MORE DEEP INTO STUDYING. I'LL PUT IT UP THERE WITH PHYSICAL ACTIVITY AND NUTRITION, AS NOT ONLY RISK FACTORS BUT ALSO PROTECTIVE FACTORS FOR HEALTH ON A LONG-TERM BASIS. THIS IS IN THINKING ABOUT DEVELOPING WAYS TO LOOK AT COMMUNITY NEEDS AND ASSESSES IN GEOGRAPHIC INFORMATION SYSTEMS. SO HOW WE BLEND OUR INFORMATION ON INDIVIDUALS WITH COMMUNITIES, AND NOW WE HAVE BETTER TOOLS TO BE ABLE TO REALLY LINK THESE KINDS OF DATA. SO THIS IS FROM THE CENSUS, YOU COULD IMPUTE DATA ON INDIVIDUAL AVERAGES IN COUNTY OR EVEN CENSUS TRACT LEVEL AND USE THAT AS VARIABLES. YOU CAN DO ANALYSIS OF CASES BY LOOKING GEOGRAPHICALLY WHERE THEY ARE LOCATED, AND THAT CAN INFORM NOT JUST SCIENTISTS BUT ALSO POLICYMAKERS ABOUT WHERE TO GO WITH THEIR INTERVENTIONS AND I THINK THIS IS ONE OF THE APPROACHES FOR THIS. CHROMOSOME 6, FOUR ALLELES WERE PREDICTED TO RELATE TO WARFARIN RELATED BLEEDING IN AFRICAN-AMERICANS. CONJUNCTION WITH THIS, THERE IS ANOTHER RECENT PAPER, WHICH I DON'T HAVE A SLIDE, THAT SHOWED THAT AFRICAN-AMERICANS WERE LESS LIKELY TO GET THE DIRECT ACTING ORAL ANTICOAGULANTS, EXPIRED TO WHITES. THE COHORT WAS PREDOMINANTLY WHITE BUT DID INCLUDE ENOUGH AFRICAN-AMERICANS TO SAY SOMETHING AND MAY HAVE EXPLANATORY FACTORS AS TO WHY THERE'S LESS GOOD CONTROL. IF THERE'S INCREASED RISK OF BLEEDING, IN SOME OF THE AFRICAN-AMERICANS RELATED TO WARFARIN-RELATED BLEEDING, I THINK THIS TAKES ON HEIGHTENED SIGNIFICANCE. THIS IS ALSO PART OF THE WORK OF THE GROUP IN PITTSBURGH ON LOOKING AT DNA METHYLATION SIGNATURES OF ASTHMA IN PUERTO RICOIAN CHILDREN. PUERTO RICANS HAVE A HIGH RATE OF ASTHMA, THE FOCUS OF RESEARCH TRYING TO LOOK NOT JUST AT CLINICAL AND ENVIRONMENTAL FACTORS BUT BIOLOGICAL FACTORS, OF COURSE INDIVIDUAL FACTORS. WITH THE BIOLOGICAL RELATED TO GENETICS AS WELL AS GENE-ENVIRONMENT INTERACTIONS. THERE'S A GROUP THAT'S DONE THIS, BEGINNING AT UCSF, ALSO BASED IN CHICAGO, PITTSBURGH, NEW YORK, AND IN PUERTO RICO ITSELF. AND THE INCIDENCE RATE IS VERY HIGH, AS WELL AS THE MORTALITY RATE. AND SORT OF THE -- GOING ON NOW FOR NOT QUITE 20 YEARS, I THINK MORE AND MORE LEARNING ABOUT THE COMPLEXITY OF THE INTERACTION, THIS IS NOT SIMPLY A PREDISPOSITION BASED ON GENETICS, OR CLEARLY RELATED ONLY TO THE ENVIRONMENT. AND KEEPING IN MIND WITH THE OBSERVATION THAT PUERTO RICANS ARE LATINOS, AND MEXICANS ALSO LATINOS HAVE A VERY LOW RATE OF ASTHMA, EVEN LOWER THAN WHITES. SO, IT MAKES FOR AN INTERESTING COMPARISON ACROSS GROUPS. THIS CAME OUT OF THE ANNALS OF INTERNAL MEDICINE, I USE IT FOR COMMENT. IT'S A HIGH PROFILE JOURNAL. IF YOU GO TO A DOCTOR, NOT THAT MANY OF YOU DO, WE USED TO -- I USED TO ALWAYS SAY, WELL, WHEN I SAW SOMEONE THEY WOULD SAY WHY SHOULD I WORRY ABOUT HEART DISEASE? AT A CERTAIN AGE, DO YOU A CALCULATION OF WHAT'S YOUR RISK OF DEVELOPING HEART ATTACK OR HAVING A CARDIOVASCULAR EVENT IN THE NEXT TEN YEARS. SO A HIGH RISK, JUST SO PEOPLE ARE ANCHORED IN THIS, THOSE WHO ARE NOT CLINICIANS, IS 1% PER YEAR. SO, TRY TO EXPLAIN THAT TO A LAYPERSON. 1% PER YEAR IS A HIGH RISK THAT WILL LEAD THE CLINICIAN MUCH OF THE TIME TO RECOMMEND THAT YOU TAKE A MEDICATION EVERY DAY FOR THERS ARE -- FOR THE REST OF YOUR LIFE. HOW DO YOU EXPLAIN THAT TO SOMEONE, THEY WILL DO WHAT YOU SAY, MANY OF THEM. MANY WON'T EVER DO WHAT YOU SAY. BUT I THINK IT'S OUR RESPONSIBILITY AS CLINICIANS TO REALLY BE CERTAIN THAT WE WANT TO MEDICALIZE THEIR LIFE BY SAYING YOUR RISK, THERE'S COMPELLING CLINICAL TRIAL EVIDENCE THIS WORKS. OF COURSE, MOST OF THE CLINICAL TRIALS DO NOT INCLUDE MINORITY POPULATIONS. THEY WERE ROBUST AND SHOWED BENEFIT IN PEOPLE WITH ESTABLISHED DISEASE. THE BAR IS MUCH HIGHER FOR PEOPLE WITHOUT ESTABLISHED DISEASE, AND THIS IS WHERE THIS 1% PER YEAR CATEGORY COMES IN. CERTAIN PHYSICIAN GROUPS, PRIMARILY COMPOSED OF CARDIOLOGIST RECOMMEND THIS IS LOWERED TO 7%, INFORMATION FOR SHARED DECISION MAKING IN THE OFFICE WHEN ONE LOOKS AT PREDICTORS. THERE WAS AN EFFORT TO RECALCULATE RISK ON THE BASIS OF FACTORS THAT HAVE NOT BEEN TYPICALLY INCLUDED IN COHORTS LIKE FRAMINGHAM, IT MAY BE THAT, FOR EXAMPLE, IF YOU ACTUALLY TAKE -- HOPEFULLY THE FULL STUDY WILL BE ABLE TO DO THEIR OWN CALCULATOR, ALTHOUGH MAY BE LIMITED TO IMMIGRANTS BUT WE CAN STILL THAT. MESA HAS ANOTHER NHLBI FUNDED COHORT, A SIGNIFICANT NUMBER OF MEXICAN AMERICANS, HAS ITS OWN CALCULATOR FOR LATINOS. IF YOU USE THAT YOU'LL SEE THE RISK OUTCOME IS MUCH LOWER THAN YOU WOULD GET FROM THE AHA RISK CALCULATOR. ALL RELATIVE. IF YOU'RE A MALE, OVER I THINK -- I DON'T KNOW IF IT'S 60 OR 63, YOU AUTOMATICALLY WILL BE OVER 1% PER YEAR BECAUSE, REMEMBER, THESE ARE TAKING POPULATION STATISTICS. THAT'S SOMETHING ELSE TO BE CONSIDERED. CRITICAL AREA TO REALLY LOOK AT IS THE INTERSECTION OF HEALTH AND THE ISSUES AROUND INJUSTICE. AND WHETHER OR NOT THIS IS A FACTOR IN GENERATING INCREASED RISK OF CHRONIC LOW BACK PAIN. THIS IS A PAPER IN THE JOURNAL OF PAIN THAT LOOKED AT ASSOCIATIONS BETWEEN PERCEIVED INJUSTICE AND PAIN, DISABILITY AND DEPRESSION IN DIVERSE COMMUNITYING LEADING TO CHRONIC LOW BACK PAIN WITH HISPANICS, BLACKS AND WHITES. BLACK PARTICIPANTS WERE MORE LIKELY TO REPORT SELFS OF PERCEIVED INJUSTICE RELATED TO THEIR CHRONIC LOW BACK PAIN. AND HAVE ASSOCIATED INCREASED DEPRESSION AND DISABILITY WITH THEIR BACK PAIN. AGAIN, INTERESTING OBSERVATIONS, NOT NECESSARILY TRANSLATED TO HIGHER RISK OF OPIOID USE DISORDER ABUSE. PERHAPS IT'S EXPLANATORY IN BIAS IN NOT PRESCRIBING OPIOIDS TO CERTAIN MINORITY GROUPS ON THE CONCERNS OF MISUSE. EVEN THOUGH THAT HAS NOT BEEN WIDELY SUPPORTED. THE AVAILABILITY OF NATIONAL DIABETES PREVENTION PROGRAM AND U.S. COUNTIES, YOU CAN SEE THE DISSEMINATION ACROSS THE UNITED STATES. THIS IS SORT OF A GREAT CLINICAL TRIAL THAT SHOWED BENEFIT IN PREVENTING PROGRESSION FROM PREDIABETES TO DIABETES. IT'S BEEN WIDELY DISSEMINATED, REIMBURSED NOW BY MEDICARE AND THERE IS A LITTLE BIT OF IDEA THAT YOU HAVE TO DO THE PLAN WITH CERTAIN STRUCTURED PROGRAM OF DIET AND PHYSICAL ACTIVITY, OR CHANGING THE CONTENT OF NUTRITION, YOU KNOW, IF YOU LOOK AT THE DIABETES PREVENTION PROGRAM THE INTERVENTION WAS QUITE INTENSIVE, IT'S BEEN REPRODUCED IN A NUMBER OF SETTINGS WITHOUT THAT LEVEL OF INTENSITY. I THINK THE PRINCIPLE REMAINS THE SAME, THAT YOU CAN CHANGE LIFESTYLE AND PREVENT PROGRESSION OF GLUCOSE INTOLERANCE, IMPAIRED GLUCOSE TOLERANCE, WHICH IN THE LONG RUN WILL ABSOLUTELY BE BENEFICIAL TO THE INDIVIDUAL TO NOT DEVELOP DIABETES. YOU CAN SORT OF STUNT IT OR PREVENT IT. METFORMIN HAS BEEN USED AS WELL AS AN INTERVENTION, AND IT WORKS, PARTICULARLY IN YOUNGER ADULTS, YOUNGER MEANING UNDER 65 IN THIS CASE, IN A SUBANALYSIS OF DPP YOU CAN SEE SIMILAR BENEFIT FROM USING METFORMIN. AND SO THERE IS EVIDENCE TO DO THAT. AGAIN, IF PEOPLE PREFER TO TAKE A PILL THAT WOULD BE ANOTHER APPROACH. THIS IS A STUDY THAT CAME OUT OF OUR INTRAMURAL PROGRAM, ASSOCIATION OF MARITAL STATUS AND CIGARETTE SMOKING VARIES BY RACE, WHEN YOU DESEGREGATE MARITAL STATUS. THIS IS KEL PAN CHOI'S LAB, THE TREND SURVEY, NATIONAL REPRESENTATIVE SAMPLE, FUNDED BY NCI, BUT IT IS AVAILABLE FOR PEOPLE TO ANALYZE IN DISAGGREGATING MARITAL STATUS. BLACKS, COHABITATING, FOLLOWED BY SEPARATED WHITES. ONE SEES INTERESTING OBSERVATION IF YOU'RE MARRIED, IT LOOKS LIKE IT'S GOOD FOR YOU. IT WAS ALWAYS TRADITIONALLY GOOD FOR MEN'S HEALTH, BUT NOT NECESSARILY CLEAR WHAT BEING SEPARATED MEANT, AND THIS GOT INTO MORE NUANCE THAT CO-HABITATTING MIGHT NOT BE AS GOOD. WHEN YOU'RE DIVORCED OR WIDOWS, VERSUS BEING MARRIED OR COHABITATING, AND THAT HAS AN INFLUENCE ON YOUR HEALTH, BOTH IN THIS CASE OF BEHAVIOR, AND OTHERS HAVE LOOKED AT OUTCOMES. THIS IS WORK THAT ANN ANNAPOLIS COMPLETED, BEFORE COMING TO NIMHD, SHE JUST FINISHED THIS PAPER. WILLINGNESS TO PARTICIPATE IN RESEARCH, LOOKING AT SAMPLE OF LATINOS, WHITES AND AFRICAN-AMERICANS, IN LOUISIANA. I THINK THE LINES ARE SEPARATE BUT NOT THAT SEPARATE, INVASIVE STUDIES LESS LIKELY TO INVOLVE WILLINGNESS TO PARTICIPATE IN RESEARCH. NOTICE MOST OF THE LINES ARE STILL -- 30%, 50%, 70%, AND IF WE LOOK AT THE LATINO LINE, IT'S THE HIGHEST, BUT NOT BY MUCH, WITH WHITES BEING SECOND AND AFRICAN-AMERICANS BEING THIRD. BUT MUCH HAS BEEN MADE ABOUT, OH, MINORITIES WON'T PARTICIPATE BECAUSE OF DISTRUST, MINORITIES DON'T WANT TO DO RESEARCH BECAUSE OF THE TUSKEGEE STUDY OR PIMA INDIANS OR PUERTO RICAN STUDIES. YES, THIS IS SOMETHING THAT MANY PEOPLE ARE AWARE OF AND WILL RESPOND APPROPRIATELY AND RESPOND AND RECOGNIZE THESE ARE ISSUES FOR THEM. BUT YOU CAN OVERCOME THESE WITH APPROPRIATE METHODS. AND THERE'S MANY EXAMPLES OF THIS, SO I THINK THE MYTH THAT BARRIERS ARE INSURMOUNTABLE NEEDS TO BE LIMITED. I PULLED THIS FROM A PAPER LAST FALL ABOUT BREAST CANCER MORTALITY HOT SPOTS AMONG LATINAS IN THE U.S. AGAIN, THINKING THAT WE NEED TO USE MORE OF THESE KINDS OF TOOLS AND THINKING ABOUT NOT JUST FROM -- WELL, FROM A DIFFERENT ASPECT, SO WHERE ARE, QUOTE, HOT SPOTS, AND IF YOU LOOK AT THIS, BREAST CANCER IS ABOUT 30% LESS COMMON AMONG LATINOS COMPARED TO WHITES. THERE'S SOME EVIDENCE OF INCREASED EARLY BREAST CANCER AND MORTALITY, TRIPLE-NEGATIVE IN YOUNGER LATINAS UNDER 50, NOT QUITE AT THE LEVEL YOU SEE IN AFRICAN-AMERICANS, BUT THIS IS WELL DESCRIBED. IF YOU LOOK AT THE MAP, WHAT IT POINTS OUT, YOU KNOW, IS THAT THIS WHOLE AREA DOWN HERE, THE BORDER AREA AND HOT SPOTS SCATTERED AROUND DIFFERENT PARTS, NEAR THE BORDER, PERHAPS HIGHER IMMIGRANT, PERHAPS AN ISSUE WITH ACCESS, NOT HAVING EARLY DETECTION, OR DIAGNOSIS SINCE BREAST CANCER IS NOT SOMETHING THAT IF YOU LET GO -- IT'S NOT SOMETHING THAT, OH, YOU CAN COME BACK A YEAR LATER AND NOT HAVE MISSED MUCH. IF YOU MISS A YEAR THE TUMOR HAS PROBABLY DOUBLED AND YOU GO FROM A DIFFERENT STAGE, MAY NOT BE AS MANAGEABLE, AS OPPOSED TO OTHER CANCERS LIKE PROSTATE THAT OFTEN IS MORE INDOLENT OR CLEARLY CERVICAL CANCER WHICH MAY TAKE YEARS TO REALLY DEVELOP INTO AN INVASIVE DISEASE. LET ME FINISH, BRING YOU BACK TO WHAT MY ROLE HERE AS DIRECTOR IS AND WHAT I WANT TO SEE FOR THE INSTITUTE AFTER 3 1/2 YEARS. I THINK I TOLD THE STAFF THIS AT THE END OF 2018, AFTER THREE YEARS AT NIH I REALLY FEEL LIKE THIS INSTITUTE HAS MY MARK ON IT, MY BRAND. I CAN'T LOOK BACK AND SAY, WELL, I DIDN'T DO THIS. I HAVE TO LOOK FORWARD. AND REALLY BUILD ON THE LEGACY OF NIMHD. IT HAS A REMARKABLE RICH HISTORY, YOU KNOW IF IN THE YEAR 2000 PEOPLE THOUGHT THIS WOULD STILL BE -- WE WERE TALKING ABOUT 2020, NIMHD, SKEPTICS WOULD HAVE FELT IT'S NOT GOING TO LAST, YET HERE WE ARE. WE'VE NOT ONLY MADE OUR MARK FROM THE LEGACY AND PROGRAMS THAT HAVE BEEN PART OF THIS INSTITUTE IN THE FIELD, AND HERE IN THIS INSTITUTE, BUT ACROSS THE ENTIRE AGENCY. I DO FEEL COLLABORATION WITH OTHER INSTITUTES IS ROBUST. IT'S THERE. EVEN INSTITUTES I THOUGHT I DON'T HAVE THAT MUCH IN COMMON WITH, WHERE DO I SEE THE OVERLAP OVER HERE? THERE IS TREMENDOUS AMOUNT OF COLLEGIALITY AND MUTUAL SUPPORT, TO LOOK FOR OPPORTUNITY TO FIND OVERLAP. WE ARE REALLY DELIGHTED TO HAVE OUR RESTART OF OUR FRIENDS NETWORK. I'VE KNOWN FOR MANY YEARS THERE'S A LOT OF CONSTITUENTS OUT THERE WHO WOULD BE SUPPORTIVE OF NIMHD, AND YET WE DON'T HAVE ONE PARTICULAR OR TWO OR THREE PARTICULAR THINGS THAT WOULD SAY, ALL RIGHT, THESE PATIENT ADVOCATES ARE GOING -- LAST FRIDAY I WAS WEARING A RED SHIRT IN THE CLINICAL CENTER WITH GARY GIBBONS, AMERICAN HEART ASSOCIATION, WEAR RED THIS MONTH. CANCER SOCIETY SUPPORTS NCI. ALZHEIMER'S ASSOCIATION IS BIG ON NIA, PLUS AARP, ET CETERA. YOU HAVE ALL THESE SORT OF ORGANIZATIONS THAT ARE FOCUSED ON PARTICULAR CONDITIONS THAT GAIN A LOT OF TRACTION IN THE PUBLIC EYE. SOMEHOW DISPARITIES DOESN'T GET THAT TRACTION, I TRUST OUR COLLEAGUES AND FRIENDS WILL HELP. YET IT SPREADS ACROSS THE ENTIRE SPECTRUM. MY BACKGROUND IS GENERAL INTERNIST, CERTAINLY IN THE SOCIETY OF INTERNAL MEDICINE, A SMALL SOCIETY, WE HAVE TWO LEADERS, ONE FORMER AND CURRENT PRESIDENT OF OUR COUNCIL HAS A STRONG MINORITY HEALTH AND HEALTH DISPARITIES FOCUS THAT I SAW GROW OVER THE TIME THAT I WAS -- THAT I'VE BEEN A MEMBER OF THAT SOCIETY. SO LOOKING FOR CULTIVATING THAT SUPPORT IS CRITICAL FOR US. WE REMAIN ABSOLUTELY COMMITTED TO DIVERSITY OF SCIENTISTS. I THINK EVERY OPPORTUNITY I GET I TRY TO REMIND EVERYONE THAT WE ARE FACING A CRISIS. THE SAYING OF 50% OF U.S. CHILDREN TODAY ARE MINORITIES, NOT THE NEXT CENSUS. TODAY. AND THOSE KIDS TEND TO GROW UP. AND SO THE FUTURE IS GOING TO LOOK VERY DIFFERENT THAN WHAT OUR PROFESSIONS LOOK LIKE, WHAT OUR LEADERSHIPS LOOK LIKE ACROSS SOCIETY. SO WE NEED TO ADDRESS THIS URGENTLY. AND THEN ADVANCING THE SCIENCE IS REALLY WHAT NIH IS ABOUT. AND I THINK THE SPECIAL SUPPLEMENT, THE BOOK THAT WE'RE GOING TO PUBLISH THIS YEAR, THE RESEARCH THAT WE'RE FUNDING IS REALLY SETTING A STANDARD OF WHAT EMPIRICAL QUESTIONS CAN LEAD TO. AND WE'RE SCIENTISTS, WE'RE DRIVEN BY DATA, AND WE WANT TO HAVE A CERTAIN GOAL IN MIND ABOUT PROMOTING EQUITY AND DECREASING DISPARITIES, BUT WE HAVE TO DO IT ON THE BASIS OF EVIDENCE. BOTH IN TERMS OF ADDRESSING THE DISPARITIES AND UNDERSTANDING THE MECHANISMS. SO WE KNOW WHERE TO PUSH. ULTIMATELY PROMOTING HEALTH EQUITIES. SO THANK YOU. I THINK WE HAVE TIME, PLENTY OF TIME FOR CONVERSATION, IF PEOPLE HAVE QUESTIONS. THANK YOU VERY MUCH. [APPLAUSE] GREG? >> : YOU MADE AN INTERESTING COMMENT ABOUT SOME OF THE NATIONAL ORGANIZATIONS, CANCER, DIABETES, ET CETERA. BEING SUPPORTIVE OF NIH AND AT THE GENERAL POPULATION LEVEL, BUT MOST OF THOSE AGENCIES DO HAVE I GUESS SUBSETS OR INITIATIVES TARGETING MINORITIES. AND I'M WONDERING HOW WE CAN MAKE THAT CONNECTION WITH THOSE KIND OF AGENCIES. I KNOW THEY TRY A LOT, BUT THEIR FUNDRAISING, I'VE BEEN ON A COUPLE OF PANELS, AMERICAN CANCER SOCIETY, AMERICAN HEART. AND I KNOW THAT A LOT OF THAT UPPER LEVEL, YOU KNOW, BOARD WORK I WAS DOING WAS TO RAISE MONEY, AND RAISING OF THE MONEY WAS HAPPENING IN THE MORE AFFLUENT AREAS AND MOST OF THE PROGRAMS ENDED UP IN THE AFFLUENT AREAS. BUT I'M JUST WONDERING IF WE -- IF THERE MIGHT BE A WAY TO SHIFT THAT PARADIGM AND GET A BETTER CONNECTION WITH MINORITY HEALTH DISPARITIES. >> TALK TO ALEX. I DON'T WANT TO SAY WE HAVEN'T THAT HAD. GROUPS APPROACHED US AND ASKED FOR TIME TO MEET WITH US. I'VE HAD A NUMBER OF INTERACTIONS AND PARTICIPATE IN PROGRAM WAS AAMC, THEY ARE GENERIC. AMERICAN ASSOCIATION OF MEDICAL COLLEGES, BOTH IN PROGRAMS THAT THEY DO. THEY HELP US WITH HEALTH DISPARITIES RESEARCH INSTITUTE, AND THEY LEAD SOME OF THESE EFFORTS ACROSS THE ACADEMIC CENTERS. NEPHROLOGISTS HAVE COME AND TALKED TO US, AND THEY ARE INTERESTED, CHRONIC KIDNEY DISEASE IS A BIG ISSUE FOR MINORITY COMMUNITIES. HEMATOLOGISTS HAVE COME. I COULDN'T PARTICIPATE BUT I KNOW THAT SENIOR STAFF MET WITH CROHN'S COLITIS GROUP. LUPUS ORGANIZATION HAVE ALSO APPROACHED US. IT ISN'T ABSENT, BUT WE COULD COVER THE WHOLE SPECTRUM. ALZHEIMER'S, ONE OF THE ALZHEIMER'S GROUPS HAS ALSO MET WITH US A COUPLE OF TIMES, AND THEY HAVE WANTED TO PUSH THIS ISSUE. WE'VE HAD SOME ENGAGEMENT WITH THEM, LAST YEAR I WENT TO HEALTHY AGING CONFERENCE SPONSORED BY THE DEPARTMENT, THAT THE ASSISTANT SECRETARY WAS THERE, AND MOSTLY COMMUNITY. IT WASN'T THE SCIENTIFIC CONFERENCE, MOSTLY ADVOCATES, SO WE'RE WORKING ON IT. CARMEN AND FERNANDO. >> : INCREMENTAL COMMENTS ON THAT STATEMENT. THERE'S MINORITY HEALTH MONTH BY HHS, SO MAYBE -- I DON'T KNOW IF THIS INSTITUTE ALSO HAS ACTIVITIES TOWARDS THAT OR ENHANCE AWARENESS AND MINORITY HEALTH BUT THAT MIGHT BE A GOOD OPPORTUNITY TO COLLABORATE AND ALSO HAVE VISIBILITY. >> : KELLY, ARE YOU HERE? DO YOU WANT TO SAY SOMETHING? COME TO OUR 5K. >> EXACTLY. I'M KELLY CARRINGTON, COMMUNICATIONS DIRECTOR HERE. AND WE JUST I THINK YESTERDAY, SHELLY GOT AN E-MAIL FROM THE OFFICE OF MINORITY HEALTH, WHO LET US KNOW THE THEME FOR THIS YEAR. SO WE'RE GEARING UP. WE DO THIS EVERY YEAR. WE HAVE SEVERAL ACTIVITIES THAT TAKE PLACE. ONE OF THEM OUR BIGGEST ONE ON THE NIH CAMPUS IS OUR 5K. AND WE BROUGHT OUT ABOUT THREE OR FOUR HUNDRED PEOPLE AROUND THE NIH CAMPUS TO PARTICIPATE. THIS HAS BEEN IMPORTANT BECAUSE EVEN THOUGH WE'RE HERE AT NIH, THERE ARE A LOT OF PEOPLE AT NIH WHO WEREN'T NECESSARILY FAMILIAR WITH NATIONAL MINORITY HEALTH MONTH. IN ADDITION TO THAT, WE HAVE AN ONLINE CAMPAIGN. WE DO TWITTER CHATS. WE'LL BE DOING AN NIH TAKEOVER THIS YEAR, AND HOPEFULLY WE CAN ENGAGE ALL OF YOU IN THAT AS WELL. AND SO WE'RE ALREADY GEARING UP FOR THIS YEAR'S ACTIVITIES AS WELL. SO, YEAH. >> : SO THIS IS AN ACTIVITY WE HAVE BEEN ENGAGED WITH AND THE OTHER OFFICES OF MINORITY HEALTH, THE OTHER DIVISIONS IN THE DEPARTMENT, ALSO ACTIVELY PARTICIPATE. SO IT DOES CREATE SOME TRACTION. I SHOULD MENTION THAT THIS IS BLACK HISTORY MONTH, SO THERE'S AN NIH SPECIAL EXHIBIT AT THE NATIONAL LIBRARY OF MEDICINE ON AFRICAN-AMERICAN SCIENTISTS, SO EACH ALMOST EVERY MONTH THERE'S SOME ACTIVITY AROUND SOME THEME. SO IF YOU'RE SIGNED UP TO OUR E-MAIL NEWS, YOU'LL GET ALL THE PUSHES THAT WE PUT OUT ON THIS AND LINKS RELATED TO IT. SO-- FERNANDO? >> : I KNOW LAST YEAR WE HAD A MEETING ON DIVERSITY WITH AAMC, I DON'T KNOW IF YOU WANT TO MENTION A LITTLE BIT ABOUT THAT. AT THE END OF THE DAY I THINK THIS INSTITUTE HAS A MAJOR ROLE IN INCREASING THE DIVERSITY OF THE WORKFORCE AND BIOMEDICAL, BUT ALSO S.T.E.M., AND I THINK THAT THAT'S ANOTHER POSSIBILITY FOR FUNDING IS THAT MANY FOUNDATIONS AND OTHER PEOPLE IN BUSINESS WANT THIS AREA TO GROW. AND CLEARLY, AS YOU MENTIONED, HALF THE KIDS IN THIS NATION NOW ARE MINORITY. IN CALIFORNIA WE PASSED THAT 20 YEARS AGO. AND AT THE END OF THE DAY THAT'S THE HUMAN CAPITAL THAT WE NEED TO INVEST IN. I'M JUST WONDERING WHEN WE GO FOR HEALTH, SHOULD WE ALSO GO FOR HEALTH WORKFORCE AS ONE AGENDA ITEM TO FUND RAISE. >> : THANK YOU. THE AAMC MEETING WAS IMPORTANT. THE REASON I DIDN'T EMPHASIZE THAT IN THE REPORT TODAY WAS BECAUSE THE MAIN PROPONENT AND LEADER IS ON MATERNITY LEAVE. WHEN COURTNEY RETURNS NEXT MONTH, WE'LL PICK UP WHERE WE LEFT OFF ON THAT. BUT THANK YOU FOR YOUR POINT. I THINK MARSHAL AND THEN EMILY. >> : ALSO YOU MENTIONED ACROSS NIH INSTITUTES THERE'S SOME VARIABILITY IN WHICH SALIENT THE QUESTION, YOU MENTIONED KIDNEY DISEASE WHERE DISPARITY ISSUES ARE SALIENT. WHAT ARE THE FORMAL STRUCTURES YOU HAVE, THE INSTITUTE HAS THEN, TO INTERACT WITH THE OTHER NIH INSTITUTES? FOR EXAMPLE, ON ONE HAND THERE MIGHT BE, YOU KNOW, SPECIFIC EQUITY REPRESENTATIVE FROM EACH INSTITUTE, OR MAY IT BE VERY FREE FORM WHERE IT DOESN'T EXIST AND MAYBE YOU KNOW THAT THERE'S CERTAIN GROUPS WITH THAT TIE. TELL US MORE, LIKE WHAT IS THE STRUCTURE MECHANISMS BY WHICH NIMHD CAN INTERACT WITH DIFFERENT INSTITUTES AND WHAT'S WORKING WELL AND ANY SUGGESTIONS FOR WHAT COULD BE IMPROVED. >> GREAT QUESTION. YOU SHOULD ASK DR. FAUCI THAT. SEE WHAT HE SAYS. I'D BE CURIOUS. IT OCCURS I THINK AT DIFFERENT LEVELS. SO I WILL START WITH, YOU KNOW, THE DIRECTORS. YOU KNOW, WE TALK TO EACH OTHER. WE MEET ON A REGULAR BASIS. WE DO REACH OUT TO EACH OTHER. IF THERE IS A PARTICULAR FUNDING OPPORTUNITY ANNOUNCEMENT THAT WE WOULD LIKE TO SEE INSTITUTES SIGN UP FOR, IT MAKES A DIFFERENCE, SOMETIMES, NOT ALWAYS, FOR ME AS DIRECTOR TO REACH OUT. NOT ALL DIRECTOR, AT LEAST SELECTED ONES THAT I THINK SHOULD BE ON BOARD WITH THIS, BECAUSE OF THE TOPIC. AND I'VE DONE THAT A NUMBER OF TIMES. I THINK THAT'S SORT OF -- HOW DO I GET THERE IS BY BEING PRESENT, BY INTERACTING, BY BEING COLLEGIAL AND COLLABORATIVE. SO AT THAT LEVEL IT OCCURS. AND THE OPPOSITE END IT OCCURS AT ALL LEVELS OF STAFF. SO WHETHER IT BE ALL PROGRAM OFFICERS WHO KNOW WHAT DIFFERENT THINGS ARE GOING ON IN DIFFERENT INSTITUTES, THEY HEAR ABOUT IT AND TALK AND CAN SEE IT IN THE SYSTEM. AND PEOPLE INTERACT AROUND IDEAS. AND EVEN AMONG ADMINISTRATIVE STAFF, OF COURSE, WE'RE A SMALL INSTITUTE SO WE ONLY HAVE X NUMBER OF PEOPLE SO HOW DO I DO THIS AT THIS INSTITUTE OR THAT INSTITUTE, GET SOME COMPARISONS. THE STRATEGIC PLANNING AND REPORTING OFFICES ALSO HAVE PEERS THAT THEY TALK ACROSS, ACROSS THE AGENCY. BUT IT ISN'T AS CHAOTIC OR ANARCHIC OR STRUCTURED AS ONE MIGHT THINK. IT'S A SYSTEM THAT EVOLVED. THINK OF EACH INSTITUTE AS -- I LIKE TO SAY AUTONOMOUS REPUBLIC, LED BY, YOU KNOW, BUILDING ONE. FOR BIG THINGS WE'RE MOVING IN UNISON BUT FOR A LOT OF DETAIL IT'S SORT OF VERY LOCAL. NOT EVERY I.C. HAS MINORITY HEALTH EQUITY PERSON IN CHARGE. MANY DO. THAT BECOMES OUR WINDOW OF PEER CONTACTS. ALL OF THE, YOU KNOW, NCI AND NHLBI AND NIDDK HAVE MAJOR INVESTMENTS IN PROGRAMS RELATED TO MINORITY HEALTH, HEALTH DISPARITIES, AND THEIR DIRECTORS ARE VERY MUCH 100% ON BOARD. NIDA HAS AS WELL. NIAAA HAS AS WELL, NICHD, MENTAL HEALTH. I THINK MOST OF THE INSTITUTE DIRECTORS AND STRUCTURES ARE SET UP TO BE RESPONSIVE AMONGST OR -- NATIONAL INSTITUTE ON AGING AS WELL. OTHERS DON'T OR HAVE SOMEONE WITH DUAL ROLE. THEY MAY ALSO NOT HAVE AS MUCH OF AN ISSUE ON THIS. BUT I THINK THAT THE TIME -- YOU KNOW, WE ARE PART OF THAT CONTINUUM. AND SO BECAUSE OF OUR NATURE, WE INTERACT WITH EVERY SINGLE I.C. IN NIH. THERE ISN'T LIKE -- SOME SAY, WELL, IT'S ASTHMA, NHLBI TOPIC OR NIAID TOPIC, YOU KNOW, OR NIEHS BECAUSE IT'S ENVIRONMENT. YOU KNOW, WE HAVE OVERLAP WITH EVERYONE ESSENTIALLY. A COUPLE MUCH LESS, BUT MOST OF THEM THERE'S SIGNIFICANT OVERLAP. SO WE'RE KIND OF LIKE GLUE ROLL. THE HUMAN GENOME INSTITUTE IS SORT OF LIKE THAT. YOU COULD ARGUE THEY ARE NOT LIMITED TO ONE PARTICULAR GROUP. THEY ARE MORE IN THE INFRASTRUCTURE. NIEHS IS KIND OF LIKE THAT AS WELL. BUT THERE'S MORE LOGIC TO THE MADNESS THAN APPEARS. ACTUALLY I THINK IT'S MORE ORGANIZED AND COLLEGIL THAN ACADEMICS. AT LEAST FROM MY EXPERIENCE, WHERE THERE WERE -- BUT SIMILAR. A LOT IS BASED ON RELATIONSHIPS, AND NOT ON ANY SORT OF PARTICULAR STRUCTURE. SO-- DOES THAT HELP? >> THERE'S A LOT OF PARALLELS. IT'S LIKE IMPLICIT WHEN YOU SAY IT'S GOT TO BE ALL DIFFERENT LEVELS, FOR EXAMPLE IT'S GOT TO BE AT THE SENIOR LEADERSHIP AT NLM IN -- AT NIH, AND EACH INSTITUTE NEEDS TO BE CHAMPIONS AND STRUCTURES THAT ENABLE IT SO THAT IT'S NOT JUST DEPENDENT UPON GOODWILL CAN TRICKLE DOWN. >> : RIGHT. >> : IT GOES BOTH WAYS. AND SO SOUNDS LIKE INSTITUTES ARE DOING GREAT WITH WHAT EXISTS WITH EXISTING RELATIONSHIPS, BUT SOUNDS LIKE AGAIN ANALOGOUS TO LIKE CHANGE AND IMPROVEMENT AT THE LOCAL LEVEL AT AN ORGANIZATION, THERE ARE STRUCTURES THAT WOULD HELP FACILITATE MAKE -- - MAKE THINGS MORE SALIENT AND HIGHER PRIORITY ON THE SCORE CARD OR VISIBILITY FOR NIH AND ACCOUNTABILITY. >> RIGHT. WELL SAID. I AGREE. I THINK THE OTHER POINT I WOULD ADD IS THAT OUR MAIN CURRENCY IN THIS BUSINESS IS SCIENCE. AND HAVING, YOU KNOW, SORT OF RATIONAL HIGH QUALITY SCIENCE, WHAT WE DO, AND PERSUADING OUR COLLEAGUES THAT THERE IS -- THIS IS REAL SCIENCE, WHAT WE'RE DOING. I THINK WE'RE BEYOND THAT IS MY SENSE, ALTHOUGH THERE'S ALWAYS GOING -- MY SCIENCE IS BETTER THAN YOURS, I DON'T CARE IF IT'S BETTER OR NOT. THAT WAS ALWAYS -- WE'RE ALL DOING SCIENCE. AND THEN THAT GETS PEOPLE THINKING IN A DIFFERENT FORMAT THAN WHETHER ONE IS COMING AT IT WITH POLICY OR ADVOCACY PROPOSALS. I THINK YOU COULD PUT ALL OF THOSE THINGS INTO A PACKAGE BUT REALLY IT'S LED BY THE SCIENCE. AND I THINK THAT -- BUT YOU'RE RIGHT. WE CAN'T IMPLEMENT CHANGE IN AN INSTITUTE, IF THERE ISN'T REPRESENTATIVE THERE WHO SAYS, OH, LOOK AT OUR PORTFOLIO, IT SHOWS WE'RE DOING THIS OR NOT DOING THAT, AND THEN THE LEADERS, STARTING WITH THE DIRECTOR BUT NOT JUST THE DIRECTOR SINCE LARGE INSTITUTES HAVE SUCH BIG STRUCTURES SAYING YOU'RE RIGHT, WE NEED TO LOOK MORE INTO THAT AND SORT OF ACKNOWLEDGING THAT THIS IS A LEGITIMATE TOPIC TO DO MORE WORK IN. AND SO I THINK WE'RE -- IT'S A GOOD TIME IN THAT REGARD FOR THIS FIELD. SO-- >> IN FOLLOW-UP TO MARSHAL'S QUESTION, HAVE THE INSTITUTES COME UP WITH ANY KIND OF AGREEMENT ON HEALTH EQUITY OUTCOME MEASURES? YOU KNOW, BECAUSE SOMETIMES WE'RE HELD AT A STANDARD OF SEEING REDUCTIONS IN CHRONIC DISEASE INCIDENCE AND MORTALITY, OUR FIVE YEAR GRANTS ARE NOT CAPABLE OF DOING THAT. ARE THERE ANY OTHER INTERIM MEASURES THAT WE CAN BE THINKING ABOUT CROSS INSTITUTES SO THAT WE CAN COLLABORATIVELY SEE A CHANGE AND SEE SPECIFIC OUTCOMES IN HEALTH EQUITIES? >> WE WRITE ABOUT THAT IN THE SUPPLEMENT SO CAN YOU REFER TO THAT. I THINK EARLY ON, THINKING ABOUT WHAT ARE OUTCOMES THAT WE ALL CARE ABOUT, SO THE FIRST ONE IS PREVALENCE, YOU COULD SAY. AND YOU COULD ARGUE MAYBE THAT'S TOO HIGH OF A GOAL TO DECREASE, HOW CAN YOU DECREASE PREVALENCE WHEN RISK FACTORS AND MECHANISMS ARE THERE, FIVE YEARS IS TOO SHORT. MORTALITY IS THE OTHER. ULTIMATELY THAT'S ONE OF THE BIG THINGS THAT IT'S ABOUT. I'M ENDORSED AND ATTRACTED, I DON'T SAY THAT EVERY I.C. AGREES, BUT I THINK WE'VE BEEN CONSISTENT WITH THIS MESSAGE, IS SOME GLOBAL MEASURE OF POPULATION HEALTH LIKE THE GLOBAL BURDEN OF DISEASE QUALIT TYPE OF MEASURE. A FOURTH CATEGORY IS EVERYTHING AND ANYTHING THAT PATIENTS OR PEOPLE FEEL. THAT COULD BE A SYMPTOM SCORE ON DEPRESSION OR DAILY FUNCTION OR ARTHRITIS PAIN OR, YOU KNOW, AS LONG AS IT'S STANDARDIZED PSYCHOMETRICALLY PROVEN TO TO BE VALUABLE IN TERMS OF MEASURES. SYMPTOM REPORTS, COGNITIVE, MINI MENTAL OR WHATEVER MONTREAL STUDY MEASURE. AND LAST ONE IS SORT OF THE MEDIATING VARIABLES, MOSTLY RELATED TO BEHAVIOR BUT ALSO BIOMARKERS THAT ARE UNEEQUIVOCALLY LINKED TO OUTCOMES. SO YOU DON'T HAVE TO DECREASE LUNG CANCER, YOU CAN DECREASE TOBACCO SMOKING, RIGHT? WE KNOW THAT. WE'VE WORKED IN THAT FOR 40 YEARS. SO BECAUSE IT CAUSES 85, 90% OF LUNG CANCER. IF YOU DECREASE TOBACCO SMOKING YOU'RE DECREASING LUNG CANCER. MAMMOGRAPHY OR OTHER BEHAVIORALS RELATED, I THINK THOSE ARE THE FIVE GLOBAL CATEGORIES. AND THEY ARE NOT SPECIFIC TO MINORITY HEALTH. THESE ARE GENERAL APPLYING TO ALL HEALTH. AND THERE'S HUMAN HEALTH, SO WE'RE WORKING THE HUMAN SIDE OF THINGS. MICE IS ANOTHER STORY. AND CELLS ARE ANOTHER STORY. THAT COULD BE OTHER THINGS THAT MAY BE IN THE FUTURE. IN THE FUTURE THERE MAY BE OTHER FACTORS THAT GET INTRODUCED IN THERE, WHETHER EPIGENETICS OR MICROBIOME OR MONITORING OF BEHAVIOR IN ANOTHER WAY, THAT WILL REACH A LEVEL OF EVIDENCE WHERE WE SAY WE CAN RELY ON THIS AS AN OUTCOME. BUT I WOULDN'T -- IS THERE A CROSS-INSTITUTIONAL AGREEMENT ON THIS? I DON'T KNOW. I'M NOT SURE THERE IS. BILL, DO YOU HAVE ANY THOUGHTS ON THAT? >> : I DON'T THINK THERE'S ACROSS-INSTITUTIONAL AGREEMENT ON ANYTHING. I POINT IS WELL TAKEN, AND THE THING THAT STRUCK ME AS YOU WERE DESCRIBING THAT LIST IS WORKING FROM THE ONES MORE PROXIMAL THAT WE CAN CHANGE A LITTLE SOONER IN THE PROCESS TO THE ONES LATER MORTALITY AND THAT SORT OF THING THAT WILL TAKE A LONGER PERIOD OF TIME TO DO. I GUESS I WAS ALSO STRUCK WHEN YOU WERE DESCRIBING THIS, I THOUGHT ABOUT WHEN I STARTED AT NIH, I STARTED AT NIMH, AND TOM INSEL SAID OUR GOAL, OUR MISSION, IS TO CURE MENTAL ILLNESS. I WENT, YEAH, RIGHT. IT'S AN AWFULLY BOLD AND, YOU KNOW, SOMETHING THAT'S NOT GOING TO HAPPEN CERTAINLY IN MY LIFETIME BUT I THINK YOU HAVE A SIMILAR GOAL HERE, RIGHT? BASICALLY ELIMINATE INEQUITIES AND DISPARITIES, THAT WILL TAKE A LOT OF TIME AND WE HAVE TO THINK ABOUT MORE APPROXIMATE GOALS WORKING TO THE MORE DISTAL ONES. >> I WAS WONDERING ABOUT AGREEMENT VERSUS ULTIMATE GOALS, SOMETIMES WHEN GRANTS ARE EVALUATED THEY WANT TO SEE THE OTHER ENDPOINT, THE INTERIM. ELISEO, ONE OTHER QUESTION WITH REGARD TO PRECISION MEDICINE CENTERS AND "ALL OF US," HOW ARE THEY COLLABORATING AND WHAT ARE SOME KIND OF CURRENT SUCCESSES THAT THEY HAVE HAD? >> IS MIKE HERE? I'LL ASK YOU TO SAY SOMETHING. I DON'T THINK THERE'S ANY EXPLICIT COLLABORATION. REMEMBER, "ALL OF US" IS A SET-ASIDE FUNDING PROGRAM THAT FRANCIS WANTED THAT OBAMA ADMINISTRATION SUPPORTED, AND IT'S OFF AND RUNNING. ALSO GREG IS INVOLVED WITH RECRUITMENT. I BELIEVE 100,000 PEOPLE COMPLETED THE BASELINE AND THERE'S ANOTHER 50,000 OR 60,000 SORT OF STARTED. SO IT'S MOVING. WILLIT GET TO A MILLION? I DON'T KNOW. A MILLION WAS PULLED OUT OF THE AIR, JUST A GOOD NUMBER, SOUNDS GOOD. IT'S LIKE TEN. WE LIKE NUMBERS THAT ARE BIG AND END IN ZERO. AND "ALL OF US" IS DESIGNED TO BE A DATA PLATFORM FOR SCIENTISTS TO USE. AND THEN TO WRITE GRANTS THAT SAY WE WANT TO GO BACK AND DO ANALYSIS OF THIS OR ASSAYS, ALL THESE PEOPLE HAVE DIABETES, WE WANT TO GET THEM AND SEE IF WE CAN DO A TRIAL, THAT'S THE VISION OR THE DREAM OF WHAT "ALL OF US" CAN PROVIDE FOR US. NOW, THIS GIANT COHORT STUDY THAT WE WOULD BE ABLE TO LINK PEOPLE UP THROUGH ELECTRONIC RECORDS. PRECISION MEDICINE CENTERS WERE CONCEIVED BEFORE I GOT TO NIMHD, AS A WAY TO SORT OF HAVE NIMHD BE PART OF THIS, PRECISION MEDICINE WAS JUST STARTING AT THAT TIME AT NIH, THE YEAR-LONG PROCESS OF DISCUSSIONS. SO THESE CENTERS WERE SUBMITTED AND REVIEWED AND FUNDED IN THE FIRST YEAR. THEY AR ALL LED BY -- CO-LED BY MINORITY INVESTIGATORS, THEY ARE DOING DIFFERENT THINGS IN THAT SPACE OF GENOMICS RELATED TO MINORITY HEALTH, HEALTH DISPARITIES. THEY ALL IN AND OF THEMSELVES ARE INTERESTING INTERNALLY, DIFFERENT LEVELS OF SOPHISTICATION BUT GENERALLY ALL MOVING. THERE'S ONE MORE FOCUSED ON CANCER AT MEDICAL UNIVERSITY OF SOUTH CAROLINA. THE VANDERBILT ALLIANCE HAS ONE. ALSO WORKING WITH PEOPLE IN MIAMI, AND I BELIEVE OTHERS IN THE DEEP SOUTH. THERE'S ONE AT STANFORD LED BY MARK CULLEN, AND MALDONADO. THEY ARE DOING -- THEY ARE WORKING WITH NATIVE PEOPLE IN THE DAKOTAS, SOUTH DAKOTA, TO CREATE AN AMERICAN INDIAN BIODEPOSITORY, AS WELL AS WORKING ON SOME STUFF AROUND END OF LIFE I THINK, OR TOM -- THERE'S TOM NEWMAN I THINK HAS BEEN DOING WORK ON OBESITY PREVENTION IN CHILDREN FOR A LONG TIME SO HE'S LOOKING AT -- THEY ARE LOOKING AT THAT IN FOLLOW-UP. THE ONE IN CHICAGO IS DOING ISSUES ON PHARMACOGENOMICS RELATED TO ANTI-COAGULATION, AND MARCELLA'S GROUP AT YALE WITH THE CARIBBEAN CONNECTION, U.S. VIRGIN ISLANDS, PUERTO RICO, ANOTHER ISLAND I THINK. SO NOT A COORDINATED THEME BUT SORT OF WORKING IN THIS WHOLE AREA OF INTERSECTING CLINICAL BIOLOGICAL AND ENVIRONMENTAL FACTORS WITH VARIANCES, SOME MORE DISEASE FOCUSED BUT MORE TOPIC FOCUSED. MIKE, DO YOU WANT TO ADD TO THAT? >> : HI, MIKE SAYER, INTEGRATED BIOLOGICAL AND BEHAVIORAL SCIENCES. THE ONLY THING I WANT TO ADD IS CONSUELA WILKINS, P.I. FOR PRECISION MEDICINE AT VANDERBILT IS INVOLVED, THERE'S INTERSECTION BETWEEN THE TWO. ERIC DISHMAN CAME IN DECEMBER, BUT HE MADE IT CLEAR THAT THEY HAVE THEIR OWN STRATEGY FOR DEVELOPING THIS COHORT, NOT JUST GOING TO TRY TO TAKE OTHER EXISTING COHORTS AND KNIT THEM TOGETHER. THEY ARE STARTING FROM SCRATCH. BUT THE PRECISION MEDICINE CENTERS SEE AN OPPORTUNITY TO DO ANCILLARY STUDIES, YOU KNOW, ONCE THE COHORT IS BIG ENOUGH AND THE DATA IS AVAILABLE. SO, BUT THEY ARE REALLY CONNECTED WELL. >> GREG? >> A COMMENT ON SOME OF THE PRECISION MEDICINE RESEARCH THAT WILL BE DONE IN OUR COMMUNITIES, I THINK THE BIG CHALLENGE FOR US IS GOING TO BE RETURN OF RESULTS AND GAINING ACCESS TO MEDICAL CARE, WHEN THERE ARE CLINICALLY SIGNIFICANT RESULTS RETURNED. I VIEW THAT AS ONE OF THE BIGGEST CHALLENGES RIGHT NOW GOING FORWARD. IT'S EASY TO DO THOSE MICROARRAYS AND FINE PATHOLOGY, BUT RETURN OF RESULTS TO OUR DIVERSE DISADVANTAGED COMMUNITIES, IN MY MIND, IS GOING TO BE THE BIGGEST CHALLENGE FOR THIS WHOLE THING. IT MIGHT BE A GOOD AREA OF RESEARCH FOR MINORITY HEALTH INSTITUTE. >> SPERO? >> OUR CENTER OF EXCELLENCE INTERSECTS THE "ALL OF US" RESEARCH PROGRAM IN SEVERAL WAYS, TRYING TO UNDERSTAND RIGOROUS RCT FRAMEWORK, RELATIVE EFFECTIVENESS OF DIFFERENT MEANS OF RECRUITMENT INTO THESE COHORTS IS ONE OF THE CENTRAL QUESTIONS OF THE DAY, ECHOING SEVERAL THINGS THAT HAVE BEEN SAID EARLIER. AND THE ADDITIONAL THING ABOUT THE ACTIONABLE NATURE OF THE FINDINGS, PARTICULARLY IN THE KINDS OF HEALTHCARE SYSTEMS THAT ARE LARGELY MUCH LESS WELL RESOURCED TO BE ABLE TO ACT ON THOSE KINDS OF FINDINGS, AND THE INTERSECTION BETWEEN THE PERSUASION PROCESS AND COMMUNICATION OF THE POTENTIAL BENEFITS, NOT JUST THE SENSE OF GENERALIZED GOOD BUT ALSO INDIVIDUAL BENEFIT I THINK ARE SOME OF THE BIGGEST CHALLENGES WE FACE. THERE'S SOME REALLY IMPORTANT POINTS OF INTERSECTION AMONG THESE DIFFERENT INITIATIVES AT PRESENT THAT ARE MERGING. >> ALL RIGHT. THERE ARE A COUPLE COUNCIL MEMBERS WHO CAME IN AFTER I STARTED. SANDRA, KARA, DO YOU WANT TO INTRODUCE YOURSELVES? >> : HI, CARA KRULEWITCH FROM DEPARTMENT OF DEFENSE. >> SANDRA GALEEO, BOSTON. >> : AND GREGORY. >> : GREG TELL VEER A, SAN DIEGO STATE UNIVERSITY. >> NO FURTHER COMMENTS OR QUESTIONS -- YES, CARMEN? >> ONE COMMENT I WANT TO ALSO CONGRATULATE EVERYBODY WAS INVOLVED IN THE DEVELOPMENT AND SUPPLEMENT ON PERSPECTIVES ON MINORITY HEALTH AND DISPARITY. I THINK AS A PERSON WAS NOT INVOLVED IN THIS WORK, IT'S FANTASTIC TO READ. IT GIVES THE FRAMEWORK, IT'S ALSO GREAT, AND SO I'M GOING TO USE IT WITH MY STUDENTS, WITH EVERYBODY THAT I KNOW. AGAIN, I WANT TO CONGRATULATE YOU BECAUSE IT REALLY IS WELL COORDINATED, AND VERY USEFUL, AND SO CONGRATULATIONS AGAIN. >> THANK YOU. THAT REALLY HELPS, ESPECIALLY GIVEN ALL THE CHALLENGES AND HARD WORK AND VARIOUS SMALL SETBACKS OVER THE COURSE OF THE LAST COUPLE YEARS, AS WE GOT THIS DONE. AND I ECHO THAT 100%, AND VERY PLEASED WITH RESULTS AND OUTCOME OF THIS EFFORT. ALL RIGHT. SO WE'LL TAKE ABOUT A 20-MINUTE BREAK AND PROMPTLY RESTART AT 10:00 WITH DR. TALAVERA. THANK YOU VERY MUCH. [APPLAUSE] >> WE HAVE TWO EXCITING PRESENTATIONS COMING UP. EVERYONE'S FAMILIAR WITH GREG TALAVERA, WHO IS GOING TO TELL US ABOUT THE FIRST DECADE. THAT'S QUITE IMPRESSIVE. OF RESULTS OF THE HISPANIC COMMUNITY HEALTH STUDY, STUDY OF LATINOS. GREG IS A REMARKABLE SCIENTIST AND INDIVIDUAL, I LIKE TO REFLECT ON THE FIRST TIME I MET HIM. HE WAS WITH JOHN ELDER DOING A SITE VISIT ON OUR HISPANIC SMOKING CESSATION RESEARCH PROJECT IN SAN FRANCISCO. WE HAD PROPOSED TO NCI TO CHANGE OUR AIMS, AND SO OUR PROGRAM OFFICER, TOM GLEN, SAID WE SHOULD DO A FRIENDLY SITE VISIT TO GET THIS VETTED. AND HE SHOWED UP WITH JOHN ELDER, AND IT'S BEEN ALL GREAT EVER SINCE. THANKS TO AMALIE RAMIREZ, WE COLLABORATED ON A PROJECT ON CANCER, THAT AMALIE LED THE CHARGE ON THAT. SINCE 1992, WE WERE COLLABORATORS THROUGH THAT NETWORK, UNTIL I CAME TO NIMHD, IT ENDED THAT SUMMER UNRELATED TO MY MOVE. BUT GREG JUMPED ON THE HISPANIC COMMUNITY HEALTH STUDY AND HAS BEEN ONE OF THE P.I.s, DIRECTOR OF THE SAN DIEGO SITE. IT'S A RICH DATA RESOURCE AND HE WILL TELL YOU ABOUT THE DETAILS. I USED THIS IN TERMS OF ANALYSIS AND COLLABORATING WITH INVESTIGATORS FROM HISPANIC COMMUNITY HEALTH STUDY TO LOOK AT SOME OF THE DATA, AND SO I ASKED HIM TO DO A SUMMARY OF THE HIGHLIGHTS OF THE THINGS HE THOUGHT WERE MOST IMPORTANT. SO GREG? >> THANK YOU, ELISEO. THANKS FOR THE OPPORTUNITY TO SHARE THIS COHORT STUDY WITH YOU. LET'S SEE. WE'RE BACKING UP. SO, YES, THE SOL STUDY NOW JUST COMPLETED LAST YEAR IT'S SECOND EXAMINATION OF THE COHORT, 16,000 INDIVIDUALS FROM FOUR CITIES, DIVIDED 2/3 OLDER, 1/3 YOUNGER, AND FUNDED PRIMARILY BY NHLBI, WITH PRIMARY GOALS OF CARDIOVASCULAR ENDPOINTS. BUT IT'S A VERY RICH DATASET THAT SPANS FROM DENTAL EXAMS, HEARING EXAMS TO TRADITIONAL CARDIOVASCULAR DISEASE. AND TODAY I'M GOING TO SHARE SOME OF THE SCIENCE WITH YOU BUT ALSO SOME OF THE ISSUES AND CHALLENGES THAT THE STUDY FACES GOING FORWARD. AS ELISEO MENTIONED, I AM THE P.I. FOR THE SAN DIEGO SITE. AND I'M ALSO CURRENTLY THE CHAIR OF THE STEERING COMMITTEE, SO VERY ACTIVELY INVOLVED IN THE STUDY. AND ACTUALLY CANNOT GRASP ALL OF THE THINGS THAT ARE GOING ON ALL THE TIME. I'M GOING TO TRY AND GIVE YOU MY PERSPECTIVE. SOME OF THE RESULTS ARE A LITTLE BIASED TOWARDS THE STUDIES AND MANUSCRIPTS I'VE BEEN INVOLVED IN MOST INTIMATELY. SO JUST TO PUT THINGS IN PERSPECTIVE, I LIKE TO SHOW THIS STUDY. SOL IS RIGHT DOWN HERE, IN 2006 WHEN IT FIRST GOT FUNDED, BUT A LOT OF THESE COHORT STUDIES THE MOST PROMINENT OF WHICH IS THE FRAMINGHAM STUDY STARTED WAY BACK IN -- BEFORE I WAS BORN. MOST NOTABLY WE HAVE STRONG HEART STUDY RIGHT HERE. JACKSON HEART STUDY. THIS IS THE HONOLULU STUDY I BELIEVE. FIRST CUT MY TEETH ON COHORT STUDIES AS A CO-INVESTIGATOR ON THE WOMEN'S HEALTH INITIATIVE HELPING THEM TO RECRUIT 800 LATINA WOMEN IN THE SAN DIEGO REGION. I'VE ALWAYS BEEN INTERESTED IN LATINA HEALTH. I'M NOT AN EPIDEMIOLOGIST WHEN THIS RFA CAME OUT, I JUST KNEW FROM ALL MY INTERVENTION WORK IN THE COMMUNITY I WAS WORKING IN THAT WE COULD RECRUIT AND RETAIN A GOOD SAMPLE OF LATINOS LIVING ON THE BORDER, WHICH IS WHAT WE GOT. THAT'S THE PERSPECTIVE. AS I WAS TALKING WITH MANY OF YOU ABOUT I THINK THE ERA OF THE WELL-FUNDED LARGE COHORTS AT NIH MIGHT BE IN THEIR TWILIGHT RIGHT NOW, WITH THE EXCEPTION OF THE "ALL OF US" PROGRAM. THIS MAY NOT BE THE MECHANISM OF THE FUTURE. SO I THINK WE HAVE TO STAY TUNED FOR WHAT'S HAPPENING AND MAYBE LOOK TO BIG DATA OPPORTUNITIES WITHIN LARGE HEALTH PROVIDER ORGANIZATIONS AND HMOs AND THINGS LIKE THAT FOR OUR FUTURE COHORT STUDIES. JUST MY PERSPECTIVE. JUST TO GIVE YOU A LITTLE PERSPECTIVE AND BACKGROUND OF WHERE WE ARE, THIS IS ME IN SAN DIEGO, REPRESENTING THE WEST COAST. DR. DAVIGLAA IS P.I., USED TO BE AT NORTHWESTERN, ROBERT KAPLAN TOOK OVER FOR SYLVIA SMOLER AS P.I. OF THE BRONX, AND NEIL SNYDERMAN. LADISS IS NO LONGER WITH US BUT I'M SURE WE'LL FIND A REPLACEMENT. THERE'S STILL TIME TO CHANGE YOUR MIND. A LITTLE OVERVIEW, WE HAVE A WEBSITE, THOSE OF YOU THAT ARE MENTORING, THE NEXT SET OF SLIDES TO PROMOTE THE STUDY, THE DATA WE HAVE AND ACCESS TO EXPERTISE AND SO FORTH BUT THIS IS OUR MAIN WEBSITE. TO GIVE YOU AN IDEA OF THE DIVERSITY OF DATA THAT EXISTS IN THE SAMPLE, I DECIDED TO SHOW YOU WHAT OUR SCIENTIFIC INTEREST GROUPS ARE. WE HAVE LOTS OF DATA AND ALSO HAVE BANKS, SERUM AND OTHER BIOLOGICAL SPECIMENS. AND WE HAVE A LOT OF PSYCHOSOCIAL SURVEYS, BUT THESE ARE HOW THE SCIENTIFIC INTEREST GROUPS ARE SORTING OUT RIGHT NOW FROM AGING, GENETICS, ANTHROPORMETRY, ORAL, PHYSICAL HEALTH, RESPIRATORY INFORMATION, AND MOST RECENTLY BETWEEN VISIT 1 AND VISIT 2 OF THE STUDY WE DECIDED TO CAPTURE ALL THE INFORMATION ON LIVE BIRTHS OF OUR COHORT. SO THE REPRODUCTIVE AGE WOMEN IN THE COHORT HAVE BEEN PROVIDING INFORMATION ON THEIR BIRTH EVENT, AND WE'RE STARTING TO COLLECT INFORMATION, WE HAVE AN ANCILLARY STUDY. WE ALSO BROUGHT IN SOME OF THE CHILDREN OF THE PARTICIPANTS OF THE STUDY, SO IT'S REALLY BECOMING ALMOST A FAMILY STUDY NOW WITH A LOT OF OPPORTUNITIES. ALTHOUGH THE SAMPLE SIZES AREN'T AS LARGE AS THE PARENT STUDY, AS WE CALL IT, THESE ANCILLARY STUDIES ARE REALLY CONTRIBUTING AND GOING FORWARD THAT'S GOING TO BE THE MECHANISM FOR VISIT THREE. WE HAVE RELATIVELY SMALL AMOUNT OF MONEY TO KEEP THE COHORT INTACT, TO DO ANNUAL FOLLOW-UP AND COLLECT ENDPOINTS, BUT OUR BIG CHALLENGE GOING FORWARD IS GETTING OTHER RESEARCHERS INTERESTED IN THE COHORT, WRITING ANCILLARY STUDIES IN THE FORM OF R01, MAINLY GOING OVER THE CAP FOR IMPORTANT AND LARGE STUDIES, SO THAT'S GOING TO BE OUR SURVIVAL MECHANISM FOR THE NEXT 6 TO 10 YEARS PROBABLY GOING FORWARD. THESE ARE SOME OF THE ANCILLARY STUDIES THAT HAVE BEEN FUNDED ALREADY, THERE ARE 6 TO 10 THAT ARE IN THE PIPELINE, UNDER REVIEW RIGHT NOW, BUT, AGAIN, QUITE DIVERSE WITH GENETICS, ECHO SONOGRAPHY, PAX GENE COLLECTION, ENVIRONMENTAL ASSESSMENT OF HORMONES. AND WE'RE STARTING TO ATTRACT INTEREST IN NATIONAL NATIONAL INSTITUTE OF AGING, EARLY NEURO COGNITIVE IMPAIRMENT AND SUPPLEMENTED WITH BRAIN MRI. WE HAVE SOME LOCAL STUDIES WE'RE INVOLVED IN IN SAN DIEGO WHICH I'LL MENTION BRIEFLY. BUT, AGAIN, MUCH TOO MUCH TO GO OVER. SO ONE OF THE BIG THINGS THAT'S EXCITING ABOUT THIS STUDY, I DON'T THINK THE POTENTIAL HAS BEEN FULLY REALIZED, IS THE FACT THAT WE HAVE GENETIC INFORMATION ON THE SAMPLE. WE HAVE A LOT OF PSYCHOSOCIAL SURVEY DATA, DEMOGRAPHIC DATA, INSURANCE DATA, AND WE'RE BEGINNING TO COLLECT MORE DETAILED ENVIRONMENTAL DATA THROUGH GPS AND SOME OTHER STRATEGIES THAT I'LL MENTION BRIEFLY. BUT HAVING DATA IN ALL OF THOSE DOMAINS, ONE DATASET, PROVIDES FOR THE POSSIBILITIES OF TESTING A LOT OF HYPOTHESES THAT OTHER STUDIES ARE NOT POWERED TO DO OR NOT CAPABLE OF DOING BECAUSE THERE'S A LOT OF COVARIATES MISSING. SO IT'S REALLY QUITE INTERESTING AND EXCITING TO THINK ABOUT THAT. BUT, AGAIN, WE HAVEN'T FULLY PUBLISHED ON A LOT OF THAT STUFF. AN IDEA OF SOME RECENT PUBLICATIONS, SOMEONE WAS LOOKING AT THE IMPORTANCE OF MORTGAGE FORECLOSURE AND HOMEOWNERSHIP IN OUR SAMPLE, LOOKING AT EMPLOYMENT STATUS AND ASSOCIATION WITH SOCIAL, CULTURAL STRESS AND SEVERITY, ALLOSTATIC LOAD AND THINGS LIKE THAT. JUST THE DIVERSE MANUSCRIPTS COMING THROUGH ARE REALLY, REALLY EXCITING. I'M LEARNING A LOT OF THINGS MYSELF. AT THIS POINT WE HAVE A LITTLE OVER 800 MANUSCRIPTS THAT HAVE BEEN APPROVED. THE TOTAL NUMBER IN PRINT RIGHT NOW ARE 214. THIS WAS FOR OUR OSMB REPORT, BUT IF YOU -- IN THE LAST YEAR, THERE WAS ABOUT 47, SO ALMOST AN ARTICLE A WEEK IS BEING PUBLISHED ON THE DATASET THAT WE HAVE. SO THAT'S QUITE A LOT OF WORK ON THE PART OF THE PUBLICATIONS COMMITTEE AND P.I.s AND SO FORTH. BUT WE STILL HAVE ABOUT 600 TO GO, SO STAY TUNED. WE'RE ALSO AS I MENTIONED PROUD OF OUR WORK IN DEVELOPING THE FUTURE WORKFORCE, SCIENTISTS OF THE FUTURE. OVER 90 PUBLISHED PAPERS, NEARLY HALF, PUBLISHED BY EARLY CAREER INVESTIGATORS, AND THERE'S A BIG PUSH FOR EARLY CAREER INVESTIGATORS AND DIVERSE INVESTIGATORS, SO THAT'S REALLY IMPORTANT. WE DO MAKE THE CIRCUIT AROUND AMERICAN HEART ASSOCIATION CONFERENCES, BUT ALSO EPIDEMIOLOGY CONFERENCES, AND SOME OF THE DISEASE-SPECIFIC CONFERENCES. SO JUST TO GIVE YOU QUICKLY A FLAVOR OF THE SAMPLE, THIS IS WHAT IT LOOKS LIKE IN TOTAL, WITH PREDOMINANCE OF MEXICAN HERITAGE INDIVIDUALS. BUT SURPRISINGLY, THERE WAS A LARGE NUMBER OF DOMINICANS WHO WERE SHOWING UP IN THE BRONX, CONTRIBUTING TO THE DIVERSITY OF OUR POPULATION THERE, BUT -- AND THEN WE HAVE CUBAN HERITAGE AND PUERTO PUERTO RICAN HERITAGE. WE'RE TRYING NOT TO LABEL THEM AT PUERTO RICANS AND CUBANS AND MEXICANS BECAUSE 20% IS U.S. BORNE SECOND AND THIRD GENERATION. ONE OF THE THINGS WE'RE TRYING TO DO WITH OUR PUBLICATIONS IS SHIFT THE STEREOTYPE THAT EVERYBODY THAT'S LATINO IS AN IMMIGRANT OR RECENT IMMIGRANT. WE DO HAVE ACTUAL SECOND AND THIRD GENERATION INDIVIDUALS, SO WE HAVE TO THINK ABOUT THE LABELING THAT WE'RE USING, PARTICULARLY IN THESE SOCIAL/POLITICAL TIMES. THIS IS WHAT THE DISTRIBUTION LOOKS LIKE PER SITE. I WON'T GO INTO THE DETAILS BUT YOU CAN SEE THE COLOR VARIATION THERE. YOU CAN REFERENCE SOME OF OUR PUBLICATIONS ON THAT. BUT THEY PRETTY MUCH REFLECT THE GEOGRAPHY THAT IS WELL KNOWN OF HISPANIC BACKGROUND GROUPS. THAT'S ANOTHER THING. WE DON'T CALL THEM SUBGROUPS IN OUR DISCUSSIONS ANYMORE BECAUSE THAT'S SOMEWHAT OF A DEMEANING TERM. THEY ARE SUBPOPULATIONS. I'M TRYING TO BREAK THAT LEXICON AS WELL. GENETIC-WISE, I LOVE LOOKING AT IT ALL THE TIME BECAUSE IT REMINDS ME OF WHAT ARE WE REALLY TALKING ABOUT WHEN WE TALK ABOUT COMPARISONS WITH LATINO GROUPS AND OTHER RACIAL GROUPS. IT'S REALLY KIND OF -- WE NOW KNOW THAT RACE AND ETHNICITY IS A CONSTRUCT. WHEN YOU LOOK AT IT AT THE GENETIC LEVEL IT REMINDS YOU OF THAT. IF YOU LOOK AT THIS, THIS IS THE EUROPEAN CONTRIBUTION TO INDIVIDUALS IN OUR SAMPLE. THE LABELS ARE SELF IDENTIFIED, THEY ARE NOT GENETICALLY IDENTIFIED, BUT THEY HAVE THESE DISTRIBUTIONS. THE QUESTION WE ASKED WHEN WE RECRUITED INDIVIDUALS IS WHICH OF THE FOLLOWING HERITAGE GROUPS DO YOU BELONG TO. AND WE OFFERED THE TERMS CUBAN, DOMINICAN, ET CETERA, ET CETERA. SO THESE ARE SELF IDENTIFIED ETHNIC GROUPS, BUT WHEN YOU TAKE THOSE ETHNIC GROUPS AND DO THIS CONTINENTAL ANCESTRY ON THEM, THIS IS THE DISTRIBUTION THAT YOU GET. AND I'M ALWAYS AMAZED WHEN YOU LOOK AT, FOR INSTANCE, THE MEXICAN HERITAGE GROUP AGAIN IMMIGRANTS, FIRST AND SECOND GENERATION, SOME FOLKS ARE ALMOST ENTIRELY EUROPEAN AND THERE ARE SOME FOLKS THAT ARE ALMOST ENTIRELY OF AMERI-INDIAN BACKGROUND. WHEN WE TALK ABOUT QUOTE/UNQUOTE THE MEXICANS, WHAT ARE WE TALKING ABOUT GENETICALLY? WE'RE GETTING REQUESTS NOW FROM ENTITIES IN IN EUROPE THAT WANT TO COMPARE THEIR WHITE POPULATION WITH OUR QUOTE/UNQUOTE HISPANIC/LATINO POPULATION, NOT KNOWING THAT, YOU KNOW, THERE'S A REALLY HIGH PERCENTAGE OF EUROPEAN GENES THERE. SO I'M NOT A GENETICIST BUT I'M CERTAINLY WONDERING WHY -- HOW WILL THESE ANALYSES BEING PERFORMED AND WHAT ARE THE INTERPRETATIONS FROM THEM I THINK IS MORE IMPORTANT. SO THAT'S WHAT IT LOOKS LIKE. SO ON TO SOME OF THE FINDINGS. CLINICALLY IMPORTANT THINGS, SPIROMETRY REFERENCE EQUATIONS, PRIOR TO THE STUDY THERE WERE SOME REFERENCE EQUATIONS FOR PULMONARY FUNCTION FOR MEXICAN HERITAGE INDIVIDUALS, BUT NOW WE WERE ABLE TO ADD THE DIVERSITY OF OUR SAMPLE TO THOSE EQUATIONS. AND THIS IS IMPORTANT FOR DIAGNOSIS AND TREATMENT OF INDIVIDUALS WITH RESPIRATORY CONDITIONS. A LOT OF WORK IN CARDIOMETABOLIC ASSESSMENTS. ONE OF OUR FIRST MAJOR PUBLICATIONS IN JAMA WAS PREVALENCE OF MAJOR CARDIOVASCULAR RISK FACTOR AND DISEASE AND OUR DIVERSE BACKGROUNDS. WE CALL THEM BACKGROUNDS OR HERITAGE GROUPS, THOSE ARE THE TWO PREFERRED TERMS. AND THIS IS THE PROFILE THAT WE GOT, 71% OF THE WOMEN HAD ONE OR MORE OF THE MAJOR CARDIOVASCULAR RISK FACTORS, 81% OF THE MEN HAD ONE OR MORE OF THE CARDIOVASCULAR RISK FACTORS. SO THESE ARE DEMONSTRATIONS OF THE HIGH BURDEN OF DISEASE OF CARDIOVASCULAR RISK FACTORS IN OUR DIVERSE POPULATION HERE. THIS IS WHAT IT LOOKS LIKE AT THE RISK FACTOR LEVEL, HYPERTENSION, CHOLESTEROLEMIA, ALL THAT YOU CAN SEE THERE. THE RED SQUARES REPRESENT THE HERITAGE GROUP THAT HAD THE HIGHEST PERCENTAGE OR SCORE, AND YOU CAN SEE QUITE A VARIATION FOR LATINO MEN. THIS REPRESENTS LATINO MEN. AND THE VARIATION GOES FROM CENTRAL AMERICAN OBESITY IN PUERTO RICO AND DIABETES AND THE MEXICAN HERITAGE INDIVIDUALS. SOME OF OUR ANALYSES NEED TO BE A LITTLE BIT TEMPERED BECAUSE WHEN YOU DO ANALYSES LIKE THIS, AND YOU HAVE SMALL CELLS RELATED TO GROUPS LIKE QUOTE/UNQUOTE CENTRAL AMERICANS, THAT REPRESENTS ABOUT 10 COUNTRIES. SO WE'RE OFTEN CAUTIONING OUR ABOUT THAT BECAUSE YOU CAN'T GENERALIZE TO A GROUP THAT LARGE, EVEN MORE SO WITH SOUTH AMERICAN. BUT HERE YOU CAN SEE THE DIVERSE REPRESENTATION OF THE HIGHEST GROUPS, AND THEN WHEN WE GO TO WOMEN, IT'S A LITTLE BIT OF A DIFFERENT PATTERN. I'M NOT GOING TO POINT OUT ALL OF THIS, BUT IT GOES TO SHOW YOU THAT, AGAIN, WHAT HAS BEEN SAID AROUND THAT TABLE AND MANY DISCUSSIONS IS THAT FOR HISPANIC LATINOS AND OTHER RACIAL/ETHNIC GROUPS THERE'S QUITE A BIT OF DIVERSITY, THAT NEEDS TO BE RECOGNIZED AND TAKEN INTO CONSIDERATION. THIS IS AN ARTICLE ON PREVALENCE OF DIABETES. THIS IS SOMETHING I THINK THAT WE'VE CONTRIBUTED IMPORTANTLY TO THE LITERATURE. THESE ARE THE RESULTS OF THE PREVALENCE OF DIABETES IN OUR DIFFERENT HERITAGE GROUPS. AND YOU CAN SEE MALES AND FEMALES HERE, AND THE LARGE NUMBERS. SOME OF YOU MAY BE LOOKING AT THESE NUMBERS AND SAYING THEY ARE HIGHER THAN WHAT WE THOUGHT, AND THAT'S CORRECT. I JUST CHECKED THE AMERICAN DIABETES ASSOCIATION AND THESE ARE THE CURRENT ESTIMATES. SO FOR THEM THE HISPANIC PREVALENCE OF DIABETES IS ABOUT 12%, 11% FOR MEN AND WOMEN RESPECTIVELY. IF YOU GO BACK TO THIS, AND THINKING ABOUT THIS, WHY ARE WE GETTING THIS, AND I THINK IT MAY BE DUE TO THE FACT THAT WE USE THREE DIFFERENT MEASURES OF GLYCEMIC CONTROL, FASTING BLOOD SUGAR, A1c, AND 2-HOUR POST GLUCOSE. WHEN YOU USE ALL THOSE THREE MEASURES, AND YOU HAVE EXCELLENT MEDICATION HISTORIES, YOU'RE ABLE TO DERIVE VERY DIFFERENT NUMBER THAN GENERAL SURVEYS TYPICALLY DEMONSTRATE. THIS IS SOME OF THE CONTRIBUTIONS THAT WE'RE MAKING. THIS WAS AN ATTEMPT TO LOOK AT RELATIONSHIP BETWEEN ACCULTURATION AND DIABETES BY LENGTH OF RESIDENCE IN THE UNITED STATES, AND YOU CAN SEE THAT AS PEOPLE LIVE HERE, LATINOS LIVE HERE LONGER IN THE UNITED STATES, THEIR PREVALENCE OF DIABETES GOES UP. AND THIS IS COMPARED TO THE U.S. BORN. SO WE'VE BEEN IN OUR STUDY -- WE HAVE SEVERAL MEASURES OR PROXIES OF ACCULTURATION, ONE IS LANGUAGE, THE OTHER ONE IS LENGTH OF RESIDENCE IN THE UNITED STATES. WE ALSO USED SURVEY, A SHORT ACCULTURATION SCALE FOR HISPANICS, FOCUSING ON MEDIA USE AND SOCIAL NETWORKS. BUT I THINK MOST OF US ARE TENDING TO USE LENGTH OF RESIDENCE IN THE UNITED STATES BECAUSE MECHANISTICALLY FOR CARDIOVASCULAR DISEASE AND MANY OTHER DISEASES IT'S EASIER TO EXPLAIN AND IT HAS A BETTER PUBLIC HEALTH IMPACT, AT LEAST IN MY MIND. BECAUSE IF YOU USE THE SCALE THAT TALKS ABOUT LANGUAGE PREFERENCE AND MEDIA AND SOCIAL -- THE DISCUSSION PART OF IT RESULTS, YOU KNOW, IT'S DIFFICULT TO SAY, YOU KNOW, TO IMPROVE YOUR HEALTH YOU SHOULD SPEAK SPANISH OR TO IMPROVE YOUR HEALTH YOU SHOULD WATCH TELENOVELLAS MORE. I'VE BEEN THINKING ABOUT THIS. WE REALLY NEED A BETTER ACCULTURATION SCALE FOR CARDIOVASCULAR EPIDEMIOLOGY BECAUSE SOME OF THESE OTHER ONES DON'T WORK. AND THEN THE LANGUAGE CORRELATIONS HAVE NOT BEEN STRONG. BUT IT DOES MAKE SENSE BOTH MECHANISTICALLY THAT LENGTH OF RESIDENCE AND LENGTH OF -- BUT WE DON'T KNOW WHAT'S HAPPENING. MECHANISTICALLY WE DON'T KNOW WHAT'S HAPPENING TO PEOPLE DURING THIS TIME PERIOD, SO THAT'S KIND OF INTERESTING. SMOKING, I HAD TO PUT IN SMOKING FOR ELISEO. HE'S BEEN PART OF THE OUR PUBLICATIONS AND DRIVING HIS INPUT HAS BEEN GREAT. WE WELCOME EXPERTISE, BUT THIS IS LOOKING AT SMOKING AMONG THE SAMPLE THAT WE HAD, AND WE DID -- THIS IS ABOUT 16,000 INDIVIDUALS IN THE STUDY AND LOOKED AT THE PREVALENCE OF SMOKING. WITH ELISEO'S INPUT WE DECIDED TO LOOK AT NON-DAILY AND DAILY SMOKERS. I DON'T THINK ANYBODY ON THE TEAM THAT WAS PROPOSING THIS MANUSCRIT WOULD HAVE THOUGHT OF THAT IF WE DIDN'T HAVE OUTSIDE EXPERTISE FROM ELISEO. BUT THIS IS WHAT WE ENDED UP WITH, AND AS YOU CAN SEE HERE THIS IS NON-DAILY CURRENT SMOKERS AND DAILY CURRENT SMOKERS. SO THIS IS A PHENOMENON THAT'S SLIGHTLY DIFFERENT IN THIS POPULATION. MAYBE OTHERS. BUT I DON'T THINK IT'S BEEN EXPLORED. OVER HALF OF THE MEXICAN SMOKERS WERE NOT DAILY SMOKERS. IS THIS SOMETHING CULTURAL, ENVIRONMENTAL? IS IT GENETIC? AND THERE ARE EFFORTS RIGHT NOW TO POSSIBLY TAKE A SAMPLE OF OUR POPULATION OF DAILY AND NONSMOKERS AND LOOK AND SEE IF THERE ARE GENETIC DIFFERENCES THAT AFFECT THEIR SUSCEPTIBILITY TO HABITUAL SMOKING. ELISEO MAY WANT TO COMMENT MORE ON THAT LATER. SO, THESE ARE -- WE'RE NOW -- NOW THAT WE'VE COMPLETED VISIT 2, WE'RE ENTERING A NEW PHASE OF DATA ANALYSIS THAT'S EVEN GOING TO BE MORE DYNAMIC, I THINK, NOW THAT WE HAVE REPEATED MEASURES DATA ON A LOT OF THESE THINGS LIKE THE INCIDENCE OF SMOKING, IS IT GOING UP OR DOWN, INCIDENCE OF DIABETES, IS IT GOING UP OR DOWN WITH TIME, CHRONIC STRESS AND OBESITY AND LOOKING AT SOME OF THE ENVIRONMENTAL FACTORS AND SO FORTH. SO WE'RE REALLY ON THE CUSP I THINK OF SOME MORE SIGNIFICANT FINDINGS, THAT GO BEYOND JUST PREVALENCE AND INTO INCIDENCE AND MORE PREDICTIVE AND EXPLANATORY MODELS. SO HERE'S AN EXAMPLE OF ONE OF THOSE. THIS IS AN ASSOCIATION OF DEPRESSIVE SYMPTOMS WITH THE INCIDENCE OF DIABETES. AND I WON'T GO INTO ALL THE DETAILS BUT THE CONCLUSIONS ARE THAT THE FINDINGS SUGGEST THE ASSOCIATION BETWEEN DEPRESSIVE SYMPTOMS AND TYPE 2 DIABETES AGAIN VARIES BY BACKGROUND. AND WHAT THEY FOUND WAS THAT INDIVIDUALS OF SOUTH AMERICA AND CENTRAL AMERICA BACKGROUND WERE EXPERIENCING SYMPTOMS OF DEPRESSION THAT MAYBE PUT THEM AT INCREASED RISK OF DEVELOPING TYPE 2 DIABETES. THIS IS AN EXAMPLE OF WHAT WE CAN DO NOW THAT WE HAVE REPEATED MEASURES FINALLY IN THE STUDY. WE'RE ALSO -- I'M NOT GOING INTO DETAILS BUT WE'RE CONTRIBUTING OUR DATA, GENETIC DATA, INTO A LOT OF THE COHORTS, CONSORTIUMS LIKE CHARGE AND TOP MED, EUROPEAN COUNTRIES ARE STARTING TO COLLECT THAT, WHICH IS KIND OF INTERESTING. WE'RE ALSO DOING SOME WORK IN THE STUDY OF ENVIRONMENTAL FACTORS AND LIFESTYLE BEHAVIORS AND THINGS LIKE THAT. IN PARTICULAR, AT OUR SITE, WE'RE ACTUALLY TRYING TO GET MICRO LEVEL ENVIRONMENTAL DATA, AND I WILL SHOW YOU SOME OF THAT. THIS STUDY WAS ONLY CONDUCTED IN SAN DIEGO BECAUSE WE'RE DEVELOPING THE METHODS FOR IT RIGHT NOW, BUT IT'S LOOKING AT MICROLEVEL DATA. AND WE ARE USING -- MAPS WAS A SURVEY METHOD DEVELOPED BY JIM SALAS, IT LOOKS AT INDIVIDUALS FROM THEIR HOUSEHOLD AND ROUTES THEY TAKE, SEGMENTS, CROSSINGS, CUL-DE-SACS, THINGS LIKE THAT, WE'RE USING GOOGLE MAPS TO WALK DOWN AN INDIVIDUAL'S WALKWAY AS THEY GO OUT THE FRONT DOOR AND GO TO THE MARKET, WE USE GOOGLE MAPS TO LOOK AT A LOT OF DIFFERENT MICROLEVEL VARIABLES LIKE, YOU KNOW, TRASH AND WALKWAYS AND CONGESTION, GRAFFITI, SO WE CAN GET MICROLEVEL CODING AND TRY TO CORRELATE THAT WITH SOME OF THEIR OUTCOME. THIS IS WHAT OUR RESEARCH ASSISTANTS DO, GOOGLE MAPS, TAKE THE ADDRESS AND WALK DOWN THE PERSON'S AVENUE SEEING HOW THE SIDEWALKS ARE, NUMBER OF EMPTY LOTS AND THINGS LIKE THAT. SO IT'S REALLY ADDING A DEEP DIMENSION TO OUR ABILITY TO LOOK AT ENVIRONMENTAL ASSESSMENTS AND SO FORTH. SOME OF THE ISSUES WE'RE FACING, REPRESENTATIVENESS. WE'RE ONLY IN FOUR URBAN CITIES. WE DON'T COVER MIGRANT HEALTH. AS ELISEO HAS COMPLAINED, WE DON'T HAVE ENOUGH U.S.-BORN LATINOS IN OUR SAMPLE, ALTHOUGH 20% IS PRETTY GOOD. WE'RE RELYING ON COMPARISON GROUPS. WE HAVE TO TRY AND COMPARE OUR RESULTS WITH OTHER STUDIES AND OTHER RACIAL AND ETHNIC GROUPS THAT ARE GOING ON RIGHT NOW. WE'RE PARTICIPATING IN CONSORTIUMS, YESTERDAY I BROUGHT UP THE ISSUE OF TRYING TO PROTECT THE DATA AND PARTICIPANTS IN OUR STUDY FROM POSSIBLE HARM. THE DATA THAT WE HAVE IS NOT TOTALLY DE-IDENTIFIED. THEY ARE IDENTIFIED BY CENSUS TRACT, THEORETICALLY SOMEBODY COULD HACK INTO OUR DATASET AND IDENTIFY A CERTAIN 40-YEAR-OLD FEMALE LIVING IN THE CERTAIN CENSUS TRACT, POSSIBLY IDENTIFY THEM. SO WE'RE VERY CAUTIOUS ABOUT SHARING OUR DATA. AND PROTECTING OUR DATA. EVERYTHING HAS TO BE STORED? THE FMSA ENVIRONMENT. NHLBI AUTHORIZEs INTERVENTION STUDIES,OME ONE SO FAR, A CHALLENGE TO GET THROUGH OSMB AND RESEARCHERS ARE STILL THIS BELIEF THAT COHORT STUDIES SHOULD NOT BE TOUCHED, SHOULD LET NATURAL HISTORY TAKE PLACE. BUT ON THE OTHER HAND, A LOT OF THEM ARE GETTING MODERN INTERVENTIONS AND HEALTH CARE ACCESS AND THINGS LIKE THAT, SO THAT'S CHANGING. SO WE'RE STILL STRUGGLING WITH THAT. THEN AGAIN SOME OF THE SMALL SIZES WHEN YOU USE SUBGROUPS OF OUR POPULATION. LASTLY WE STRUGGLE WITH LEXICON OF TERMS; PARTICULARLY IN THE SOCIAL, POLITICAL ENVIRONMENT THAT EXISTS RIGHT NOW. WE'VE BEEN LOOKING FOR WAYS TO STUDY -- WELL, PRESENT THE DATA THAT ARE NOT, YOU KNOW, VOLATILE AND HOSTILE TOWARD -- INFLAMMATORY IN SOME CIRCUMSTANCES, SO WE'RE EXPLORING TERMS LIKE IMMIGRATION STATUS, FOREIGN BORN, USE OF MORE SPECIFIC TERMS LIKE BORN IN U.S. MAINLAND, BORN IN THE 50 STATES, AND THEN SOMETIMES AUTHORS TRY TO COIN THEIR OWN TERMS, CARIBBEAN LATINOS, BUT THEY REALLY WEREN'T BORN OR LIVED IN THE CARIBBEAN, JUST OF THAT HERITAGE, WE'RE ALWAYS STRUGGLING WITH THAT. THEN OF COURSE WE HAVE THE RECENT -- FAIRLY RECENT PROMOTION OF THE TERM LATIN/X, THAT'S ALWAYS AN ISSUE. BUT WE'RE VERY INTERESTED IN IMMIGRATION STATUS AND DOCUMENT STATUS, AND WE DID COME UP WITH A QUESTION THAT ASKS WHETHER OR NOT YOU'RE A U.S. CITIZEN VERSUS ARE YOU UNDOCUMENTED, AND THEN THERE'S A SERIES OF OTHER QUESTIONS THAT WE GO INTO. AND OUR SECOND VISIT WE TRIED THAT OUT, AND WE'RE LOOKING AT SOME OF THOSE RESULTS. I'M GOING TO SKIP OVER THIS. THIS IS OUR DATA BOOK. WE GAVE -- IN THE EFFORT TO GIVE BACK TO THE COMMUNITY WE GAVE ALL THE PARTICIPANTS AN ENGLISH/SPANISH DATA BOOK WITH BASELINE RESULTS IN LAY TERMS AND SIMPLE GRAPHICS. SO, THAT'S A LITTLE BRIEF OVERVIEW OF WHAT WE'RE DOING SCIENTIFICALLY. OUR CONTRIBUTIONS AND MANUSCRIPTS, THE POTENTIAL THAT EXISTS WITH THIS DATASET, PARTICULARLY AS RELATES TO EARLY CAREER INVESTIGATORS, AND I WILL -- I GUESS WE CAN HAVE A FEW QUESTIONS, ELISEO. [APPLAUSE] I THINK I'M ON TIME. >> YOU'RE FINE. WE HAVE TIME, ABOUT 8 MINUTES FOR QUESTIONS. COULD YOU COME TO THE MIC PLEASE? WE'RE ON WEBCAST. >> THERE'S LARISS'S LAST PICTURE. >> IS THIS A PURPOSESFUL SAMPLE. >> : WHEN WE STARTED PUBLISHING EVERYBODY WAS ASKING THIS. I THINK 70% OF THE LATINO POPULATION IN THE UNITED STATES LIVES IN URBAN CENTERS, SO WE REPRESENT THEM. WE DON'T -- I DON'T THINK WE CAN GENERALIZE TO THE MIGRANT POPULATION. I MEAN, THE FARM WORKER POPULATION. >> OKAY. >> OR MAYBE AFFLUENT SECOND AND THIRD GENERATION LATINOS THAT HAVE DIFFERENT CHARACTERISTICS. >> THANK YOU. >> SO ALONG THOSE LINES, I LIVE IN AN URBANIZED AREA IN NORTH CAROLINA. BUT HAVING GROWN UP IN NEW YORK, MED SCHOOL IN THE BRONX, I KNOW THAT THERE'S SIGNIFICANT DIFFERENCES IN TERMS OF LENGTH OF TIME IN A PARTICULAR URBANIZED AREA, THE SITES THAT -- FIRST OF ALL, GREAT PRESENTATION. I SHOULD HAVE STARTED WITH THAT. BUT I DO WONDER, IT WAS STRIKING TO ME, IN NORTH CAROLINA THE DIFFERENCE IN SOCIAL CONNECTEDNESS AND ISOLATION OF LATINOS IN MY COMMUNITY, COMPARED TO GREG UP IN NEW YORK CITY AND GOING TO MEDICAL SCHOOL IN THE BRONX. >> YES. THAT'S A GOOD POINT. ONE OF THE THINGS WE DID IN SOL, WE HAD STRATIFIED SAMPLING, AND ONE OF THE THINGS WE DID WAS WE RECRUITED FROM ENCLAVES, HIGH DENSITY, AND FROM LOW DENSITY AREAS, AS WELL AS IN SOCIOECONOMIC STATUS. IN SAN DIEGO RECRUITED IN LOW INCOME HOUSING TRACKS OF BORDER REGION BUT ALSO WENT INTO SOME OF THE MORE AFFLUENT SUBURBS AND EVEN MULTI-MILLION DOLLAR HOMES AROUND THE SOUTH BAY AREA. WE THOUGHT ABOUT THAT. WE TRIED TO ADDRESS IT IN THAT WAY. BUT YOU'RE ABSOLUTELY RIGHT. IT'S VERY DIFFERENT, WHAT'S GOING ON. YOU KNOW, SAN DIEGO, THE GROWTH OF LATINO COMMUNITY, IS BY NATIVITY NOW, NOT BY IMMIGRATION. AND SOME PARTS OF COUNTRY LIKE NORTH CAROLINA YOU'RE LIKE 30 YEARS BEHIND CALIFORNIA. SO, YEAH, WE COULDN'T CAPTURE ALL OF THAT UNFORTUNATELY. THAT'S THE NEXT COHORT STUDY. >> GREAT PRESENTATION, GREG. MY QUESTION HAS TO DO WITH THE ROLE OF COLONIALISM, I'VE BEEN FASCINATED WITH PUERTO RICO BECAUSE PHILIPPINES AND PUERTO RICO HAVE IDENTICAL HISTORY AFTER 300 YEARS OF COLONIZATION. THERE'S ALWAYS HIGHER PREVALENCE OF DIABETES IN ASIAN COUNTRIES ONCE THEY MIGRATE, BUT WE FOUND NO DIFFERENCE IN DIABETES PREVALENCE AMONG IMMIGRANTS IN SAN DIEGO, PEOPLE IN THE PHILIPPINES, AND U.S. BORN FILIPINOS IN HAWAII. I WAS WONDERING HOW PUERTO RICANS ARE CONSIDERED HERE, ARE THEY CONSIDERED U.S. BORN SINCE THEY ARE STILL PART OF A U.S. COLONY? AND COULD THE REASON WHY LANGUAGE DIDN'T SEEM TO MAKE A DIFFERENCE IS BECAUSE THEIR MODE OF INSTRUCTION IS ENGLISH, MANY PUERTO RICANS SPEAK ENGLISH IN PUERTO RICO. >> A LOT OF THEM WERE BORN IN NEW YORK, AND BUT DEPENDING ON CERTAINLY ANALYSES, LIKE MARGARETA ALAGRIA MENTIONED BEFORE, THAT PROTECTIVE DID BUFFERING OF GROWING UP IN A SPANISH SPEAKING COUNTRY AND BEING A MAJORITY, I THINK INDIVIDUALS THAT IMMIGRATED FROM PUERTO RICO ARE LIKE THOSE FROM OTHER LATIN-AMERICAN COUNTRIES, SPEAKING SPANISH, NOT THE MINORITY, THEY ARE BUFFERED BY THEIR FAMILIES AND THE ENVIRONMENT AND THEY ARE NOT DISCRIMINATED AS MUCH. SO I THINK IT'S APPROPRIATE IN SOME ANALYSES TO THINK OF THEM AS A LATIN-AMERICAN COUNTRY EVEN THOUGH THEY ARE A TERRITORY OF THE UNITED STATES. GOOD POINT. >> MAHALA FOR YOUR PRESENTATION, IT GOT ME THINKING ABOUT SEVERAL THINGS. ONE, HOW IMPORTANT COHORT STUDIES IS TO UNDERSTANDING DEVELOPMENT OF PROGRESSION OF DISEASE IN POPULATIONS AND IMPORTANCE OF DISAGGREGATING DATA. FOR A LONG TIME PACIFIC ISLANDERS AND HAWAIIANS WERE AGGREGATED WITH ASIANS, WE'RE A DIVERSE GROUP. YOUR FINDINGS SPEAK TO THE IMPORTANCE OF THAT IF WE'RE TO MAKE PROGRESS IN THESE AREAS. I WAS GOING TO ASK AROUND DISCRIMINATION, I DIDN'T SEE PRESENTATION OR ANYTHING ON ETHNIC DISCRIMINATION AND HEALTH OUTCOMES BUT I SEE ON THE WEBSITE A NUMBER OF PUBLICATIONS. IS THERE A PLAN TO EVENTUALLY DO A STUDY LOOKING -- ANALYSES LOOKING AT THE RELATIVE MAGNITUDE OF EFFECTS OF THESE DIFFERENT FACTORS ACROSS THESE GROUPS TO ISOLATE FOR INTERVENTION PURPOSES WHERE WE MIGHT GET THE BIGGEST BANG FOR OUR BUCK? >> WE DO HAVE THEORETICAL MODELS. MY CO-INVESTIGATORS LINDA GALLO LOOKED AT THAT, RISK AND RESILIENCE MODELS THAT INCORPORATE ALL THAT'S THERE. CERTAINLY THE ENVIRONMENT AND PSYCHOSOCIAL DIMENSIONS, CHALLENGE TO BRING IN GENETIC FACTORS. BUT RIGHT NOW IT JUST SEEMS LIKE I DON'T KNOW HOW TO EXPLAIN IT BUT THAT MODEL, THAT COMPLETE MODEL YOU'RE ASKING FOR HAS NOT BEEN ATTEMPTED. IT REMINDS ME WE DO HAVE THEORETICAL MODELS THAT WE WROTE INTO OUR GRANTS AND HAVEN'T FULLY IMPLEMENTED THEM YET. RIGHT NOW, YEAH, IT'S VERY MICROLEVEL TYPE OF ANALYSIS. WE NEED TO DO MORE AND BETTER OF THAT. >> GREG, WHAT A NICE RESOURCE FOR RESEARCHERS. GREAT TO SEE THIS WORK BEING DONE. I'M PROBABLY GOING TO GET IN THE WEEDS BUT THERE ARE A COUPLE POINTS YOU MADE THAT I THOUGHT WERE INTERESTING. ONE IS FOR THE -- IN THE SMOKING WORLD, NON-DAILY RATES ARE WHAT USED TO BE CALLED CHIPPERS, PROCESS OF PEOPLE WHO JUST DON'T SMOKE THAT FREQUENTLY WHICH MAKES NO SENSE WITH WHAT WE KNOW ABOUT NICOTINE DEPENDENCE. HAVE YOU GENETIC DATA. FAST METABOLIZERS OR SLOW METABOLIZERS OF NICOTINE, WHETHER THAT'S SOMETHING THAT COULD BE ADDRESSED. HANG ONTO THAT. THE OTHER ONE THAT INTERESTED ME WAS SPIROMETRY REFERENCE MEASURES AND VARIATION, I NOTICED GEOGRAPHICAL DISPERSION OF LATINO SUBGROUPS, I APOLOGIZE, IT WILL TAKE A WHILE TO BREAK THAT, IS DIFFERENT BY GEOGRAPHICAL REGIONS. YOU ALSO HAVE THE OVERLAY OF SORT OF LENGTH OF RESIDENCE, WHETHER THAT'S HAVING ANY INFLUENCE ON ENVIRONMENTAL EXPOSURES, NET SPIROMETRY DATA. TWO COMPLEX QUESTIONS. >> : LET ME ANSWER THE FIRST QUESTION FIRST. IN FACT, IN COLLABORATION WITH ELISEO, A GROUP OF US ARE TRYING TO CONSTRUCT A MANUSCRIPT -- ANCILLARY STUDY THAT WOULD ACTUALLY LOOK AT THAT RIGHT NOW. SO THAT'S IN THE WORKS. THE SPIROMETRY QUESTION, I COULDN'T TELL YOU. BUT ALL I KNOW IS THAT PRIOR TO THIS THERE WERE NO REFERENCE EQUATIONS FOR THOSE GROUPS, AND I DON'T KNOW WHAT THE IMPACT OF GEOGRAPHIC LOCATION AND URBAN EXPOSURE IS RELATIVE TO THAT. BUT I'LL FOLLOW UP WITH THE EXPERTS. OKAY. THANK YOU. >> THANK YOU, GREG. [APPLAUSE] >> SO TO THE NEXT PRESENTATION, GREAT HONOR AND PLEASURE TO HAVE DR. ANTHONY FAUCI COME TO OUR COUNCIL TO PRESENT. TONY SOME SAY IS A LIVING LEGEND. HE'S A REMARKABLE PHYSICIAN-SCIENTIST THAT I REMEMBER HEARING ABOUT WHEN I WAS A RESIDENT. I THINK IT WAS A PUBLICATION IN NEW ENGLAND JOURNAL THAT GOT OUR ATTENTION AS MEDICAL RESIDENTS. AND WITH THE HIV/AIDS EPIDEMIC HE WAS IN THE VANGUARD OF THE RESPONSE WITH SCIENCE AND EVIDENCE TO ADDRESS THIS CRISIS THAT ENGULFED OUR COUNTRY IN THE 1980s, AND HAVING BEEN A RESIDENT FELLOW AND FACULTY IN ONE OF THE EPICENTERS IN SAN FRANCISCO WE VERY MUCH FOLLOWED THIS. OVER THE LAST 3 1/2 YEARS, DR. FAUCI HAS BEEN A COLLEAGUE, AN ADVISER, A LEADER FOR ALL OF US AND FOR ME IN PARTICULAR AS AN INSTITUTE DIRECTOR AND SO I'M DELIGHTED HE'S COMING TO OUR COUNCIL TO TALK ABOUT ENDING HIV/AIDS PANDEMIC, LET'S FOLLOW THE SCIENCE. TONY? [APPLAUSE] >> THANK YOU VERY MUCH. IT'S A PLEASURE TO BE HERE WITH YOU THIS MORNING TO TALK ABOUT THIS VERY IMPORTANT AND TIMELY TOPIC. IT SEEMS A BIT BOLD TO BE TALKING ABOUT ENDING THE HIV/AIDS PANDEMIC BUT I HOPE I WILL CONVINCE YOU THIS IS SOMETHING FEASIBLE THAT IN MANY RESPECTS WE'RE MORALLY OBLIGATED TO FOLLOW. LET'S TALK ABOUT BACKGROUND FIRST, I'M SURE MOST OF THE PEOPLE IN THIS ROOM KNOW THAT WHEN ONE LOOKS HISTORICALLY AT THE PANDEMICS THAT HAVE AFFLICTED MANKIND, ESSENTIALLY OVER CENTURIES, HIV/AIDS IS AMONG THE VERY SHORT LIST, IF YOU LOOK AT THE NUMBERS HERE, WITH ALMOST 80 MILLION INFECTED, 35 MILLION DIED, 36 MILLION PEOPLE LIVING WITH HIV. WE STILL HAVE 1.8 MILLION NEW INFECTIONS EACH YEAR. IN THE UNITED STATES, ALTHOUGH WE HAVE ESSENTIALLY TRICKLED INTO COMPLACENCY BECAUSE WE'VE BEEN LOOKING AT THIS FOR SO LONG, THE NUMBERS ARE STILL STARK. 1.1MILLION PEOPLE LIVING WITH HIV, 15% OF THEM DON'T KNOW THEY ARE INFECTED, SUBSTANTIAL PROPORTION OF TRANSMISSIONS COME FROM PEOPLE WHO DON'T KNOW THEY ARE INFECTING OTHER PEOPLE. WE HAVE 700,000 PEOPLE WHO HAVE DIED FROM HIV. 38,000 NEW INFECTIONS EACH YEAR, AND CLEARLY THIS IS SOMETHING THAT WE HAVE TO ADDRESS, IS THE EXTRAORDINARY DISPARITY OF INFECTIONS AMONG MEN WHO HAVE SEX WITH MEN, PARTICULARLY AFRICAN-AMERICAN MEN WHO HAVE SEX WITH MEN, PARTICULARLY YOUNG AFRICAN-AMERICAN MEN WHO HAVE SEX WITH MEN. A FEW YEARS AGO I WROTE THIS IN THE NEW ENGLAND JOURNAL OF MEDICINE. I CALLED IT WHAT THE TITLE OF MY TALK IS TODAY, ENDING THE HIV/AIDS PANDEMIC, FOLLOWING THE SCIENCE. THE POINT I WANT TO MAKE, WE HAVE THE TOOLS NOW, TODAY, IN JANUARY -- FEBRUARY OF 2019, TO END THE EPIDEMIC IF WE ACTUALLY IMPLEMENTED THOSE TOOLS. I WANT TO TALK ABOUT THAT OVER THE NEXT FEW MINUTES. SO FROM THE TIME THAT I FIRST GOT INVOLVED WITH AIDS, BEFORE IT HAD A NAME, AND BEFORE WE HAD AN AGENT THAT WE KNEW CAUSED IT, IN THE SUMMER OF 1981, WE KNEW NOTHING ABOUT THIS. OVER THE YEARS, THERE'S BEEN A BREATHTAKING ACCUMULATION OF KNOWLEDGE, AND I COULD SPEND THE ENTIRE ALLOCATED TIME ON EACH OF THE BLUE BOXES BUT IN SAKE OF TIME LET'S JUST FOCUS ON ONE OF THEM THAT HAS BEEN A TRUE GAME CHANGER IN THE AREA OF THE SCIENCE OF HIV MEDICINE, IN THE AREA OF TREATMENT. THIS IS A PICTURE OF ME IN THE NIH CLINICAL CENTER IN THE EARLY 1980'S MAKING ROUNDS ON ONE OF OUR PATIENTS. I SHOW IT BOTH TO REMIND MYSELF THAT I DID HAVE BLACK HAIR ONCE, A LONG TIME AGO, BUT ALSO TO REMIND ME IN A CHILLING WAY THAT BACK THEN, WHEN WE HAD A DISEASE WITH NO NAME AND NO AGENT, THE MEDIAN SURVIVAL OF MY PATIENTS WAS ABOUT A YEAR, WHICH MEANS THAT 50% OF YOUR PATIENTS ARE DEAD IN A YEAR, AND ALMOST ALL OF THEM ARE DEAD IN TWO OR THREE YEARS. WHAT HAPPENS IS THAT THE SCIENCE IN THIS CASE STARTING WITH UNDERSTANDING THE VIRUS AND REPLICATION CYCLE OF THE VIRUS THAT LED US TO APPRECIATE AND PINPOINT VULNERABLE TARGETS WHICH LED TO A BRAND-NEW DISCIPLINE BACK THEN OF TARGETED ANTIRETROVIRAL THERAPY, WHICH SPILLED OVER INTO OTHER FIELDS OF TARGETED THERAPY INCLUDING HCV, SENSELY THE MODEL FROM WHICH HIV WAS COPIED. SO THIS IS THE HISTORY OF WHAT I HAD BEEN DOING SINCE THE ERA OF THERAPY BEGAN BECAUSE I AM AN HIV/AIDS PHYSICIAN, I DID OTHER THINGS AS ELISEO REMEMBERS BACK BEFORE THERE WAS HIV. BUT BACK IN 1987 WHEN WE HAD A SINGLE DRUG, AZT, WE DROPPED THE LEVEL OF VIRUS AS SHOWN IN GREEN SLIGHT TO MODEST WITHOUT ANY DURATION. AND THEN IN 1994 WE HAD TWO DRUGS, WE DROPPED THE LEVEL OF VIRUS AGAIN LOW BUT NOT UNDETECTABLE, BUT AGAIN THE DURABILITY WAS NOT STRONG AS VIRUS REBOUNDED DUE TO MUTATIONS. BY THE TIME WE GOT TO 1996 WITH TRANSFORMING INTRODUCTION OF THE PROTEASE INHIBITORS, THREE COMBINATIONS OF DRUGS, WE DROPPED THE LEVEL OF VIRUS BELOW DETECTABLE AND IT STAYED THERE, ESSENTIALLY DURABLE HIV SUPPRESSION. WE DIDN'T APPRECIATE AT THE TIME WHAT THAT ULTIMATELY WOULD MEAN BUT ONLY YEARS LATER DID WE FULLY APPRECIATE THAT EVERYTHING HAS EVERYTHING TO DO WITH WHAT I'M TELLING YOU ABOUT ENDING THE EPIDEMIC. FAST FORWARD, WE HAVE ABOUT 30 DRUGS WHICH WHEN GIVEN IN COMBINATIONS HAVE TRANSFORMED THE LIVES OF HIV INFECTED INDIVIDUALS. THE DRUGS HERE ON THE RIGHT-HAND SIDE OF THE SLIDE ARE SINGLE PILLS THAT CONTAIN THREE ANTIRETROVIRAL DRUGS, SO INSTEAD OF 28 PILLS A DAY WHICH I HAD TO DO IN THE 1990s, NOW YOU GIVE A PERSON A SINGLE PILL CONTAINING THREE DRUGS AND THEY ARE GOOD TO GO. WHAT HAS THAT RESULTED IN? I SHOW YOU BACK THEN WHEN I SAID MEDIAN SURVIVAL WAS ABOUT A YEAR. RIGHT NOW WITH A 23 OR 25-YEAR-OLD PERSON, NEWLY INFECTED WITH HIV, I START THEM ON A COMBINATION OF THREE DRUGS, I CAN LOOK THEM IN THE EYE AND TELL THEM HONESTLY THAT BY ACTUARY CURVES THEY WILL LIVE ADDITIONAL 50+ YEARS WHICH MEANS IF THEY ARE 25, ADD 50 YEARS, THEY HAVE ALMOST, NOT QUITE, BUT ALMOST A NORMAL LIFE EXPECTANCY. BUT THE STORY EVEN GETS BETTER AS I'LL MENTION IN A MOMENT. SO WITH THAT REGIMEN, WITH PEPFAR, WITH THE GLOBAL FUND, WE NOW HAVE 21.7 MILLION PEOPLE RECEIVING ANTIRETROVIRAL THERAPY WHICH MEANS THAT BETWEEN 2,000 AND 2017 ABOUT 11 MILLION DEATHS HAVE BEEN AVERTED. THAT IS TRULY A TRIUMPH OF BIOMEDICAL RESEARCH APPLIED TO EPIDEMIC OUTBREAK. THE AREAS OF PREVENTION ARE EQUALLY AS STRIKING. THESE ARE A NUMBER OF THE PREVENTION MODALITIES THAT I DON'T HAVE TIME TO GO INTO EACH AND EVERY ONE OF THEM. BUT ONE THAT RELATES TO WHAT I SAID ABOUT TREATMENT IS WHAT WE CALL TREATMENT AS PREVENTION. WHAT DO WE MEAN BY TREATMENT AS PREVENTION? WE DID A STUDY ABOUT 8 YEARS AGO, IN WHICH WE LOOKED AT INDIVIDUALS WHO ARE IN DISCORDANT RELATIONSHIPS, ONE INFECTED, THE OTHER ONE NOT. AND WE DID A STUDY WHERE WE IMMEDIATELY STARTED THERAPY ON THE INFECTED PERSON, OR WAITED UNTIL THE CD4 COUNT DROPPED TO TRIGGER GUIDELINES TO START THERAPY. IN PEOPLE TREATED IMMEDIATELY, THERE WAS 96% REDUCTION IN TRANSMISSIBILITY TO UNINFECTED SEXUAL PARTNERS. FIVE YEARS LATER, WE DID A FOLLOW-UP ONLY MEASURING VIRAL LOAD AND FOUND SOMETHING REALLY THAT WHEN THE VIRAL LOAD WAS UNDETECTABLE, THE INDIVIDUAL DID NOT TRANSMIT TO THEIR SEXUAL PARTNER. SO WE SAID, LET'S REALLY LOOK INTO THIS. IS THIS A REAL PHENOMENON? SO WE DID A NUMBER OF STUDIES, IN HETEROSEXUALS AND GAY MEN. AND WE FOUND SOMETHING THAT WE THOUGHT WAS TOO GOOD TO BE TRUE, WE HAD TO KEEP PROVING IT OVER AND OVER AGAIN. IT WAS TRUE THAT IN THIS STUDY OF PARTNERS IN OPPOSITES ATTRACT, COMBINATION OF 35,000 ACTS OF CONDOMLESS ANAL COURSE IN GAY MEN, ZERO LINKED TRANSMISSION. NOBODY TRANSMITTED TO SEXUAL PARTNERS WHO WAS UNDETECTABLE. SOME WENT OUTSIDE THE STABLE RELATIONSHIP BUT IF YOU STAYED IN THE RELATIONSHIP AND HAD UNDETECTABLE VIRAL LOAD, YOU DIDN'T TRANSMIT. WE DID ANOTHER STUDY AGAIN, UNDETECTABLE VIRAL LOAD, 77,000 CONDOM ONSEXUAL ACTS OF ANAL INTERCOURSE, NO LINKED TRANSMISSION, EXTRAORDINARY FOR ANY OF YOU INVOLVED IN CLINICAL STUDIES, NO LINKED TRANSMISSIONS IN THAT MANY MEANS THIS IS A VERY EFFECTIVE WAY TO PREVENT INFECTION. YOU HAVE A TWO-FER. YOU SAVE THE LIFE OF THE PERSON WHO YOU ARE TREATED AND MAKE IT VIRTUALLY IMPOSSIBLE FOR THAT PERSON TO TRANSMIT THE INFECTION WHICH PROMPTED ME TO WRITE AN ARTICLE A COUPLE WEEKS AGO IN WHICH I SAID, MANY PEOPLE HAVE BEEN SAYING THAT UNDETECTABLE EQUALS UNTRANSMITTABLE. IF YOU HAVE AN UNDETECTABLE VIRAL LOAD, WILL YOU NOT TRANSMIT THE INFECTION TO A SEXUAL PARTNER. IF YOU THINK ABOUT THAT FOR A MOMENT, PEOPLE ARE NOW DOING THAT. IN SAN FRANCISCO THE RAPID PROGRAM TOO, BAD YOU'RE NOT -- I'M GLAD YOU'RE HERE ELISEO, THEY ARE DOING AMAZING THINGS, IDENTIFY AND PUT THEM ON THERAPY. NEW YORK IS LINKING PEOPLE TO CARE, PUTTING THEM ON THERAPY AND AGAIN SEARING A CLEAR-CUT DECREASE IN TRANSMISSIBILITY. WHAT THIS MEANS THEORETICALLY, JUST THINK ABOUT IT, WE LIVE IN A REAL WORLD, NOT A THEORETICAL WORLD. IF WE WOULD GO INTO A THEORETICAL WORLD, IF YOU COULD IDENTIFY EVERYBODY WHO IS INFECTED WITH HIV, AND PUT THEM ON THERAPY, YOU WOULD STOP THE EPIDEMIC TOMORROW. THIS BECOMES AN IMPLEMENTATION ISSUE WHICH WE'LL GET INTO IN A MOMENT. FOR UNINFECTED INDIVIDUALS THERE'S PRE-EXPOSURE PROPHYLAXIS, A SINGLE PILL, IF YOU GIVE IT ONCE A DAY TO INDIVIDUAL AT HIGH RISK, YOU WILL DIMINISH BY 95% THE LIKELIHOOD THAT THEY WILL ACQUIRE HIV INFECTION, IF THEY ARE IN A RISK POPULATION. STUDIES AGAIN WERE DONE IN NORTHERN CALIFORNIA, PERMANENTE SYSTEM, 5,000 YEARS OF PrEP, NO HIV INVECTION, U.S. PREVENTIVE SERVICES TASK FORCE MADE PRE-EXPOSURE PROPHYLAXIS FOR HIGH RISK INDIVIDUALS A GRADE A RECOMMENDATION. THE REASON THAT'S IMPORTANT IS THAT NOW INSURANCE COMPANIES WILL BE PAYING FOR THAT. THAT'S ABSOLUTELY CRITICAL. NOW, I'VE GIVEN YOU GREAT NEWS ABOUT THE SCIENCE. NOW WE HAVE A PROBLEM OF IMPLEMENTATION. BECAUSE SCIENCE MAGAZINE SAID THE EPIDEMIC IS FAR FROM OVER, AND WE HAVE WHAT I'VE BEEN REFERRING TO OVER THE YEARS AS IMPLEMENTATION GAP IN ADDRESSING THE HIV/AIDS PANDEMIC. I SAID WITH A GOOD DEAL OF OPTIMISM THAT WE HAVE 21 MILLION PEOPLE WHO ARE RECEIVING ANTIRETROVIRAL THERAPY. BUT THAT MEANS WE HAVE 15.2 MILLION PEOPLE WHO ARE NOT RECEIVING ANTIRETROVIRAL THERAPY. IN THE UNITED STATES THERE'S SOMETHING CALLED A CARE CONTINUUM. IN OTHER WORDS, IF YOU GO FROM THE PEOPLE WHO ARE INFECTED, HOW MANY KNOW THEY ARE INFECTED, HOW MANY ARE ON THERAPY, HOW MANY HAVE A SUPPRESSED VIRAL LOAD? THE RIGHT ANSWER SHOULD BE SOMEWHERE BETWEEN 95% AND 100%. WE'RE AT 51% IN THIS COUNTRY. WORLDWIDE, IT'S EVEN WORSE. THE OTHER THING IS WE'RE NOT UTILIZING THE TOOLS. THERE ARE 1.1 MILLION PEOPLE IN THIS COUNTRY AT RISK THE CDC WOULD SAY THEY COULD BENEFIT FROM PrEP. HOWEVER, ONLY ABOUT 200,000 OF THOSE INDIVIDUALS ARE ACTUALLY RECEIVING PrEP. WE HAVE A BIG IMPLEMENTATION GAP. AND, AGAIN, EXPOSURE TO PrEP, THE ACCESSIBILITY TO PrEP, IS, AGAIN, WITH ALL THINGS A GREAT DISPARITY. THERE'S A SUBSTANTIAL GAP IN THAT AFRICAN-AMERICAN INDIVIDUALS, HISPANIC-LATINO INDIVIDUALS HAVE MUCH LESS OF A LIKELIHOOD OF BEING ON PRE-EXPOSURE PROPHYLAXIS. IT HAS TO DO WITH EVERYTHING YOU ALL KNOW WITH REGARD TO THE ACCESSIBILITY OF CARE. IF YOU LOOK AT THIS LINE HERE, WHICH IS THE UNAIDS TARGET FOR 2020, WE SHOULD BE WHERE THE GREEN LINE IS GOING DOWN. BUT RIGHT NOW WE'RE STILL ON THE DOTTED RED LINE WHICH MEANS IF WE REALLY WANT TO GET THE TARGET TO ENDING THIS AS A PANDEMIC IT'S GOING TO GO WAY OUT IN DECADES UNLESS WE INCREASE THE IMPLEMENTATION. SO HOW DO WE DO THAT? WE DO THAT NOW BY LOOKING AT IT IN A DIFFERENT WAY. WE USED TO SAY FOR VARIETY OF REASONS THAT HIV WAS AN EQUAL OPPORTUNITY DISEASE. IT IS NOT AN EQUAL OPPORTUNITY DISEASE. THERE ARE INCIDENTS, HOT SPOTS, WE NEED TO FOCUS ON. SUCH AS GEOGRAPHIC HOT SPOTS. I'M SURE IT'S GOING TO SHOCK YOU TO KNOW THAT WHEN YOU LOOK WORLDWIDE, BUT THEN WE'LL GET BACK TO THE UNITED STATES, THE DARK AREAS OF THIS HEAT MAP ARE THE AREAS THAT ARE THE MOST HIV INFECTION. IF YOU GO TO SOUTH AFRICA, IN THE AREA OF NATAL, NEAR DURBIN, YOU SEE HERE THE DARK RUST COLOR, WHERE THE INCIDENCE IS EXTREMELY HIGH. IT DEPENDS ON HOW FAR YOU ARE FROM THE EPICENTER. SO IF YOU LOOK AT THE RED, IF YOU HAPPEN TO LIVE 6 KILOMETERS AWAY, THE RISK OF HIV INFECTION DROPS DRAMATICALLY. IF YOU LIVE 14 KILOMETERS AWAY, IT DROPS EVEN MORE DRAMATICALLY. SO GEOGRAPHICALLY IT'S CLUSTERED SO YOU KNOW WHERE YOU HAVE TO PUT YOUR RESOURCES. THAT'S WHAT WE MEAN BY GEOGRAPHIC HOT SPOTS. THE SAME THING WITH KENYA. RIGHT AROUND THE LAKE REGION IS WHERE ALL THE INFECTIONS ARE. BUT WE IN THE UNITED STATES ARE NO DIFFERENT. SO ALL THESE BOXES ARE COUNTIES IN THE UNITED STATES. THE INCIDENCE OF HIV INFECTION, WE HAVE 3,000 COUNTIES IN THE UNITED STATES. ACTUALLY 3,007. 50% OF THE INFECTIONS ARE IN 48 COUNTIES, WASHINGTON, D.C. AND PUERTO RICO. 50% ARE IN 48 OUT OF 3,000 COUNTIES IN THE UNITED STATES. AND 52% OF ALL THE NEW INFECTIONS ARE IN THE SOUTHERN STATES PARTICULARLY THE SOUTHERN RURAL REGIONS. NOW, WHAT WE ARE DOING AND YOU'LL PROBABLY HEAR MORE ABOUT THIS OVER THE NEXT FEW DAYS, IS SUPPLEMENTING OUR CENTERS FOR AIDS RESEARCH PARTICULARLY IN THE SOUTH, IN ALABAMA, NORTH CAROLINA, IN GEORGIA, IN WASHINGTON, D.C., AND IN TENNESSEE TO TRY AND PARTNER WITH COMMUNITIES TO REACH OUT THE WAY THEY ARE DOING IN SAN FRANCISCO, TO BEING NOT PASSIVE BUT ACTIVE IN GETTING OUT TO THE INDIVIDUALS. NOW THERE ARE DEMOGRAPHIC HOT SPOTS THAT ARE EVEN MORE STRIKING THAN GEOGRAPHIC HOT SPOTS. TAKE A LOOK AT SOUTH AFRICA. SOUTH AFRICA IS A TRAGEDY. IF YOU LOOK IN NATAL AND GO INTO AN ANTENATAL CLINIC, WOMEN WHO ARE PREGNANT COMING FOR ANTENATAL VISIT, LOOK AT INCIDENCE OF PREVALENCE OF INFECTION WOMEN 25 TO 29 YEARS OLD. 57% OF THE WOMEN WHO COME INTO AN ANTENATAL CLINIC AT THAT AGE ARE HIV INFECTED. THAT IS -- HORRIBLE IS AN UNDERSTATEMENT TO SAY THE LEAST OF WHAT THAT IS. AGAIN, IF YOU LOOK IN THE UNITED STATES, THIS IS INTERESTING, 43% OF THE NEW INFECTIONS ARE AMONG AFRICAN-AMERICANS, DESPITE THE FACT THAT AFRICAN-AMERICANS COMPRISE ONLY ABOUT 12% OF THE POPULATION. SO HERE IF YOU GO DOWN THE LINE, 12% OF OUR POPULATION IS AFRICAN-AMERICAN, 44% NEW DIAGNOSES ARE AMONG AFRICAN-AMERICAN. 60% AMONG MEN WHO HAVE SEX WITH MEN, MOST ARE AFRICAN-AMERICAN, AND 75% ARE INDIVIDUALS WHO ARE UNDER AGE 35. SO, IF YOU ARE A YOUNG AFRICAN-AMERICAN MAN WHO HAS SEX WITH MEN, YOU ARE AT A VERY, VERY HIGH RISK OF GETTING HIV INFECTED. THAT'S WHAT'S CALLED A DEMOGRAPHIC HOT SPOT THAT WE NEED TO ADDRESS. OKAY. NOW, WHAT ABOUT THE SCIENTIFIC CHALLENGES THAT ARE STILL LEFT? THERE'S ABOUT A VACCINE -- A VACCINE WILL BE A SHOW STOPPER BUT I BELIEVE WE CAN END THE EPIDEMIC WITHOUT A VACCINE BUT I CANNOT TALK ABOUT THE SCIENCE WITHOUT AT LEAST MENTIONING A LITTLE BIT ABOUT VACCINES. SO, THE CLASSIC APPROACH IS TO EMPIRICALLY TEST THE VACCINE THE WAY YOU WOULD DO IN A NORMAL WAY THAT WE DO WITH ANY OTHER DISEASE. WE DID THAT AND CAME UP WITH A VACCINE CANDIDATE THAT WAS TESTED IN THAILAND THAT SHOWED 31% EFFICACY, IT'S NOT READY FOR PRIME TIME BUT GIVES US A SIGNAL ABOUT WHAT CORRELATE OF IMMUNITY AND HOW YOU FOLLOW THAT UP IS YOU TRY AND INCREASE STRENGTH, BREADTH AND DURABILITY BY MULTIPLE VECTORS, BOOSTING ADJUVANTS, THAT'S WHAT WE'RE DOING IN TWO MAJOR TRIALS IN SOUTHERN AFRICA. ONE IN MEN AND WOMEN IN SOUTH AFRICA, AND ONE JUST IN WOMEN IN SUB-SAHARAN AFRICA. BY THE END OF 2020, BEGINNING OF 2021 WE SHOULD KNOW WHAT THE RESULTS ARE. THERE'S SOMETHING A LITTLE BIT MORE SOPHISTICATED FROM A SCIENTIFIC STANDPOINT, THAT IS TO ASSUME CORRELATE OF IMMUNITY, IF YOU ASSUME NEUTRALIZING ANTIBODY IS WHAT YOU NEED TO PROTECT AGAINST HIV INFECTION, THE REASONABLE ASSUMPTION, BECAUSE NEUTRLIZING ANTIBODIES ARE KIND OF THE GOLD STANDARDS OF PROTECTION AGAINST ANY VIRAL DISEASES, THIS IS A STRUCTURAL REPRESENTATION OF THE HIV ENVELOPE, AND ALL OF THOSE LETTERS HERE ARE MONOCLONAL ANTIBODIES THAT HAVE BEEN DIRECTED AGAINST WHAT WE CALL NEUTRALIZING EPITOPES, AND IN FACT IF YOU LOOK AT THOSE SUCH AS STRANGE NAMES LIKE THE SUBUNIT INTERFACE, FUSION PEPTIDE, ALL OF THOSE ARE EPITOPES THAT MONOCLONAL ANTIBODIES FROM HIV INFECTED INDIVIDUALS HAVE BOUND TO, SO THE CHALLENGE IS TO BE ABLE TO TAKE THOSE EPITOPES, TURN THEM INTO IMMUNOGENS, AND DEVELOP A VACCINE. THERE ARE A LOT OF STUDIED EMANATING OUT OF THE NIH VACCINE RESEARCH CENTER, APPROACHES GOING ON AROUND THE COUNTRY. NOW, WHAT ARE WE ASKING OF A VACCINE? HOW GOOD IS GOOD ENOUGH? PERSONALLY, AND PROFESSIONALLY, I DON'T THINK WE'RE GOING TO GET A MEASLES-LIKE VACCINE, 97% EFFECTIVE. KNOWING HIV THAT'S NOT GOING TO HAPPEN. WE KNOW THAT WE CAN GET 31% BECAUSE WE'VE ALREADY DONE IT. SO, WHAT IS ONE THAT WOULD BE ACCEPTABLE TO IMPLEMENT? I BELIEVE ABOUT 50 TO 60% EFFECTIVE VACCINE, IF YOU COMBINE IT, IF YOU COMBINE IT WITH NON-VACCINE WAYS OF PREVENTING HIV INFECTION, THAT YOU COULD HAVE A MAJOR IMPACT ON ENDING THE EPIDEMIC. AS A MATTER OF FACT, ALLISON GALVANI AT YALE HAS DONE A MODELING STUDY THAT I ASKED HER TO DO, AND SHE FIGURES THAT A VACCINE THAT HAS A 50% EFFICACY COULD BE HIGHLY IMPACTFUL IN ENDING THE EPIDEMIC. SO, GETTING BACK TO WHAT I SAID AS THE TITLE OF MY TALK, ENDING THE EPIDEMIC, FOLLOW THE SCIENCE, THE POINT I WANT TO LEAVE YOU WITH, WE RIGHT NOW IN FEBRUARY OF 2019 ALREADY HAVE THE TOOLS THAT IF APPLIED AGGRESSIVELY IN A FOCUSED WAY FROM A DEMOGRAPHIC AND GEOGRAPHIC STANDPOINT, THAT GLOBALLY WE SHOULD BE ABLE TO END THE EPIDEMIC AS WE KNOW IT. I THINK IN THE UNITED STATES, GIVEN THE RESOURCES WE HAVE, THAT WE ACTUALLY HAVE A MORAL OBLIGATION TO DO THAT. I MEAN, TO SAY THAT WE HAVE THESE TOOLS, WE KNOW WHAT THE TARGET POPULATION IS, WE KNOW WHERE THEY ARE, AND WE KNOW WHO THEY ARE. IF WE DON'T DO THAT, I THINK THAT YEARS FROM NOW, HISTORY IS GOING TO JUDGE US REALLY HARSHLY, THAT WE WERE A COUNTRY THAT HAD ENORMOUS SCIENTIFIC ADVANCES BUT WE DID NOT PASS THE BATON TO IMPLEMENT THAT. THAT'S THE REASON WHY I SAY, I SAY WITH CONFIDENCE, THAT ENDING THE HIV EPIDEMIC PARTICULARLY IN THIS COUNTRY IS A FEASIBLE GOAL. THANK YOU. [APPLAUSE] >> QUESTIONS? >> YEAH, SURE. >> OPEN FOR QUESTIONS. SANDRA? >> THANK YOU. THAT WAS GREAT. SEEMS LIKE THE PRESIDENT IS GOING TO ADDRESS THIS IN THE STATE OF THE UNION. >> : I WONDER HOW HE THOUGHT OF THAT. >> WHAT NEW RESEARCH IS NEEDED? >> I CAN'T TALK ABOUT THAT NOW. TURN YOUR TELEVISION ON TONIGHT, YOU'LL-- YEAH. >> MARSHAL CHEN, UNIVERSITY OF CHICAGO. YOU TALK ABOUT IMPLEMENTATION, SCIENTIFIC ADVANCES, I WANT TO SUGGEST ADDING THE WORD SCIENCE WITH IMPLEMENTATION, SCIENTIFIC QUESTIONS ABOUT IMPLEMENTATION. BUILDING UPON TWO THEMES, HOT SPOTTING, CONTEXTUAL HOT SPOTTING AND DEMOGRAPHICS IN TERMS OF SPECIFIC FEATURES, IT'S INTENTIONALITY OF THE APPROACH, LIKE INEQUITY, BEING INTENTIONAL WITH THE EQUITY APPROACH AS OPPOSED TO GENERIC ONE-SIZE-FITS-ALL APPROACH. THE EXAMPLE OF DEMOGRAPHICS AND HOT SPOTTING, IN CHICAGO WE HAVE A PROJECT LOOKING AT LGBTQ PEOPLE OF COLOR, DIFFERENT ISSUES, SIMILARITIES, DIFFERENCES BETWEEN LGBTQ COMMUNITY OR PRIMARILY PEOPLE OF COLOR, SO THAT HAS TO BE WITHIN THE CONTEXT OF SPECIFIC NEIGHBORHOODS, SPECIFIC COMMUNITIES. A WHOLE SCIENCE OR SCIENCE THAT NEEDS TO BE EXPLORED FURTHER ABOUT HOW DO YOU POTENTIALLY DO THAT IMPLEMENTATION. HOW DO YOU OVERCOME ISSUES OF MISTRUST, FOR EXAMPLE, OR ESTABLISH LIKE THE TIES IN THE COMMUNITY TO DO THIS TYPE OF WORK. SO I'M CURIOUS LIKE DO YOU CONSIDER LIKE THE SCIENCE AS PART OF THE IMPLEMENTATION? >> OKAY. YOU MAKE A VERY GOOD POINT. IN FACT, THE ROLE THAT NIH WILL HAVE, BECAUSE WE'RE A FUNDAMENTALLY A RESEARCH INSTITUTION, AS YOU KNOW, ANY ROLE WE HAVE THAT YOU'LL HEAR MORE ABOUT IN THIS ATTEMPT TO SO-CALLED END THE EPIDEMIC IN THE UNITED STATES WILL BE IMPLEMENTATION SCIENCE. THAT'S WHAT IT WILL BE. BECAUSE WE WOULD HAVE TO EVALUATE AND THEN CHANGE HOW WE APPROACH THINGS ON A REALTIME BASIS. JUST THE REASONS YOU SAY, PARTICULARLY IN THE SOUTH, YOU KNOW, WHAT'S THE BEST WAY TO ACCESS PEOPLE IN BATH HOUSES, VERSUS GAY BARS, VERSUS SEXUALLY TRANSMITTED DISEASE CLINICS, WHO SHOULD GET PrEP, HOW SHOULD YOU OFFER AND TALK TO THEM, YOU'RE CORRECT. WE'VE ALREADY DEVELOPED DRUGS, DEVELOPED PREVENTION. OUR ROLE IN THIS KIND OF EFFORT WOULD BE MUCH MORE IMPLEMENTATION SCIENCE. >> HOW WILL YOU DEAL WITH THE ACCESS ISSUE? BECAUSE WE STILL HAVE A LARGE POPULATION THAT'S UNINSURED, AND NOT -- THEY WON'T HAVE ACCESS TO THE MEDICATION. >> THAT'S A GOOD QUESTION. I THINK THAT HAS TO BE WORKED OUT. THAT'S BEING DISCUSSED RIGHT NOW. THERE ARE A COUPLE TYPES OF ACCESS. THERE'S ACCESS TO CARE AND ACCESS TO MEDICATIONS THAT YOU'RE NOT INSURED FOR. I THINK WHAT WE'RE GOING TO HAVE TO DO IS DEVELOP A HELP FORCE OUT THERE, PARTICULARLY IN THE COMMUNITIES AND GET PEOPLE INTO CARE, THAT'S THE REASON WHY, YOU KNOW, THE WHOLE QUESTION OF INSURANCE AVAILABILITY IS CRITICAL TO ANY OF THIS. YOU CAN'T SEPARATE THE TWO. YOU TALK ABOUT THE AFFORDABLE CARE ACT AND YOU TALK ABOUT IT, THEY ARE THE SAME THING. YOU CAN'T DO ONE WITHOUT THE OTHER. >> ONE OTHER COMMENT ON THE QUESTION, PART OF THE ANSWER IS FQHCs, THEY DO HAVE HIV CLINICS, THEY DO HAVE ACCESS TO DISCOUNTED PHARMACY, SO IT'S BEING MADE AVAILABLE IN THOSE SITES FOR SURE RIGHT NOW. >> THE WHOLE ISSUE OF IMPLEMENTATION SIGH AS SOON AS NOT NEW. IN CANCER IF WE APPLY WE COULD REDUCE BY 50%, A NUMBER OF ISSUES, AS MARSHAL ARTICULATED. >> ONE THINGS THAT MAKES THIS DIFFERENT THAN CANCER, IT CAN BE DEALT WITH AN AMBULATORY CARE SETTING AND NOT NOT TERTIARY. A QUESTION ABOUT PrEP, HAS THERE BEEN STUDIES TO DETERMINE WHAT'S THE PERCENTAGE OF MEDICATION ADHERENCE TO ACHIEVE EFFECTIVENESS? WHEN DOES IT START TO DIMINISH? >> YEAH, SO THE MOST EFFECTIVE WAY IS SINGLE PILL A DAY EVERY DAY. IF YOU TRY AND TAKE IT AROUND THE TIME WHEN YOU ARE EXPOSED, LIKE DAY BEFORE, YOU KNOW, WHO KNOWS THE DAY BEFORE IF YOU'RE GOING TO GET EXPOSED OR NOT, BUT AT LEAST A COUPLE DAYS AFTER, IT REALLY DROPS SIGNIFICANTLY. SO THE ONE THAT'S THE MOST IS THE TAKING IT EVERY DAY, NO MATTER WHAT. AND THEN THE OTHER THING WE HAVE TROUBLE WITH, WHICH WE DID A BUNCH OF STUDIES, IT TOOK A WHILE TO PROVE IT, IS THAT WE WERE UNAWARE OF THE LACK OF ADHERENCE AMONG CERTAIN GROUPS. SO WHEN THE RESULTS WENT DOWN TO 60% EFFICACY, AND 65 AND 55%, OH MY GOODNESS. THEN WE WERE THE BAD GUYS AND DID DRUG LEVELS ON THEM. IF YOU ELIMINATED EVERY ONE WHO DIDN'T HAVE A DRUG LEVEL, IT WENT UP TO 97%. >> I WANTED TO -- I'LL MENTION MAYBE HAVE A COUPLE REALITIES INTRODUCED INTO THE CONVERSATION. KNOWING MULTIPLE GUYS WITH HIV, MULTIPLE GUYS ON PrEP, THE KNOWLEDGE ABOUT PrEP IS WIDESPREAD AND WELL KNOWN. GETTING ACCESS IS A HUGE BARRIER. BEING ABLE TO GET ACCESS AND CONFRONTING A PHYSICIAN WHO KNOWS ANYTHING ABOUT IT, DOESN'T KNOW WHY YOU WOULD NEED IT -- OR DENTIST KNOWING WHY YOU WERE PRESCRIBED IT IS ADDITIONAL BARRIER. SO THAT GETS TO THE KIND OF LIKE PREVIOUS HAND WAVING OF, OH, WE KNOW HOW THE ACCESS PROBLEM IS RELATED TO HEALTH DISPARITIES, HOW ARE THOSE GOING TO BE ADDRESSED? THAT'S THE FIRST THING. THE SECOND THING IS STIGMA IN NON-WHITES, IT STILL EXISTS, PARTIALLY RECOMMENDS THE DISTRIBUTIONS OR DISPARITIES YOU SEE IN HIV PREVALENCE THAT STILL IS HIGH AMONG LATINO AND AFRICAN-AMERICANS, AND HOW IS THAT GOING TO BE ADDRESSED, AND THE REALITIES OF INDIVIDUALS GETTING PrEP LET ALONE OTHER MEDICATIONS. >> : OKAY. YOU MAKE VERY GOOD POINTS. YOU'RE ABSOLUTELY RIGHT. THE PEOPLE WHO NEED PrEP KNOW ABOUT PrEP. THE PHYSICIANS AND THE COMMUNITY, THEY DID A SURVEY IN AN AREA WHERE PEOPLE WOULD BENEFIT FROM PrEP AND LESS THAN 1/3 OF PHYSICIANS KNEW WHAT YOU WERE TALKING ABOUT WHEN YOU MENTIONED PrEP, YOU'RE ABSOLUTELY CORRECT. THAT'S THE PROBLEM I DON'T HAVE THE ANSWER FOR RIGHT NOW BUT THAT'S CERTAINLY A PROBLEM THAT WE NEED TO ADDRESS. ACCESS TO PEOPLE, STIGMA IS STILL PREVAILING AS THE BIGGEST OBSTACLE TO EVERYTHING THAT WE'RE TRYING TO DO. STIGMA IS PREVALENT AND DIFFICULT TO OVERCOME IN THE BEST POSSIBLE WORLD. WHEN YOU'RE DEALING WITH A SOUTHERN RURAL POPULATION OF AN AFRICAN-AMERICAN MAN WHO HAS SEX WITH MEN, STIGMA IS A SHOW STOPPER FOR THEM. THAT'S FOR SURE. >> YEAH, THANKS FOR THE GREAT PRESENTATION, AS CO-DIRECTORY OF A CFAR I'M HAPPY TO HEAR ABOUT THE GOAL OF ENHANCING WE HAVE EVIDENCE ABOUT WORKING IN D.C. TO IMPROVE AND INTEGRATE RESEARCH AND POTENTIAL. TREMENDOUS POTENTIAL. AS IMPLEMENTATION SCIENTIST I'M THINKING HOW TO INFUSE IMPLEMENTATION SCIENCE INTO THE INITIATIVE. IT'S COME UP A FEW TIMES ALREADY. HOW WE MIGHT THINK ABOUT WHAT MIGHT BE DONE AT EACH CFAR COULD CREATE LOCAL KNOWLEDGE BUT IF WE LOOK AT STRATEGIES THAT WE COULD COMPARE ACROSS JURISDICTION, WE COULD TAKE WHAT WOULD BE LOCAL KNOWLEDGE AND CREATE GENERALIZABLE KNOWLEDGE THAT COULD GENERALIZE TO OTHER PLACES AS WELL. I'M WONDERING AS THIS INITIATIVE IS BEING ROLLED OUT IS THERE A THOUGHT HOW TO INFUSION IMPLEMENTATION SCIENCE ACROSS INITIATIVES AND CFAR SO THERE'S A COORDINATED EFFORT. >> : YES, YOU JUST ARTICULATED OUR STRATEGIC PLAN, THANK YOU VERY MUCH. RIGHT. NO, ALL YOUR POINTS ARE VERY WELL TAKEN. THAT IS THE CORE OF WHAT WE'RE DOING, IMPLEMENTATION SCIENCE. >> THANK YOU FOR THE NICE PRESENTATION. I WANT TO ADD TO WHAT ERIC JUST SAID. I COME FROM GHANA, AND COMING FROM A DEVELOPING COUNTRY, DISCRIMINATION AND STIGMATIZATION IS A BIG ISSUE. HEALTH CARE WORKERS ARE NOT SUPPORTIVE WHEN YOU GO TO THE CLINIC. SO WE WILL BE ABLE TO ELIMINATE HIV IN THE U.S. AND OTHER DEVELOPING COUNTRIES BUT WHAT HAPPENS TO THOSE DEVELOPING COUNTRIES LIKE SOUTH AFRICA AREA, GHANA, AREAS OF KENYA. SECONDLY COMING BACK TO THE U.S., COMING FROM TENNESSEE, THE SOUTHERN PART OF THE U.S. IS CONSIDERED THE BIBLE BELT. WE CAN'T EVEN GET PARENTS TO VACCINATE THEIR KIDS WITH HPV. IN TERMS OF IMPLEMENTATION WE NEED TO DO WORK IN THE COMMUNITIES IN TERMS OF EDUCATION. SO WHAT IS YOUR TAKE ON THIS IN ORDER TO ADDRESS THE DISPARITY WITH PrEP AND VACCINES IN GENERAL. THANK YOU. >> WE'VE DISCUSSED THAT IN SOME QUESTIONS ALREADY. THAT IS REALLY THE MAIN CHALLENGE IS TO GET INTO THE COMMUNITY AND ESSENTIALLY EMPLOY COMMUNITY WORKERS AS WE ALWAYS SAY, YOU DON'T NEED A WHITE GUY IN A SUIT LIKE ME GOING INTO A FUNDAMENTALLY AFRICAN-AMERICAN COMMUNITY OF MEN WHO HAVE SEX WITH MEN TELLING THEM WHAT THEY NEED TO DO TO GET INTO A PROGRAM. YOU NEED TO GET COMMUNITY PEOPLE MOBILIZED. THAT'S REALLY WHAT WE'RE GOING TO BE DOING. THE SAME WAYS THEY HAVE DONE IN SAN FRANCISCO. THE SAN FRANCISCO MODEL IS A TERRIFIC MODEL, INTERESTING COMMUNITY PEOPLE OUTREACH, AND DESTIGMATIZE WHEN YOU DO THAT. SO IT'S NOT EASY. I'M SAYING IT LIKE, OKAY, CAN YOU DO IT. IT'S NOT EASY AT ALL. THE SITUATIONS IN SOUTHERN AFRICA ARE A DIFFERENT STORY BUT WE HAVE A PLAN FOR THAT TOO AS YOU PROBABLY KNOW IN CERTAIN AREAS WHERE PEPFAR AND GLOBAL FUND AND OTHERS. >> THANKS FOR THE TALK. I THINK IN PARALLEL TO THE RESEARCH SUCCESSES THERE'S ALSO AVAILABILITY OF FUNDING THROUGH THE ACT SO COMMUNITIES AND PEOPLE HAD ACCESS TO CARE AND TREATMENT. AND ONE ELEMENT WE MIGHT NEED TO AT ONE POINT INCLUDE INTO THIS IMPLEMENTATION SCIENCE IS THE FACT THE GRANT WRITE FUNDING HAS TO DO OR IT'S BASED ON AIDS INCIDENTS AND NOT HIV INCIDENTS, SO AREAS WITH HIGH HIV MIGHT NOT NECESSARILY HAVE HIGH AIDS. THE OTHER POINT AS BE ON OB/GYN I WANT TO MAKE SURE PEOPLE UNDERSTAND THAT WE TALK ABOUT RAPID ENGAGEMENT AND CARE AS SOMETHING NEW, BUT WE BE ON HAVE BEEN DOING THIS IN 30 YEARS WHEN WE SEE A PREGNANT WOMAN WITH HIV WE IMMEDIATELY START MEDICATION, IT'S SOMETHING WE'VE BEEN DOING FOR THREE DECADES. >> YES, A VERY GOOD MODEL BECAUSE THEY HAVE TO COME AND SEE YOU IF THEY ARE GOING TO DELIVER. YOU GOT A CAPTIVE POPULATION. >> SO, THANKS AGAIN FOR THE PRESENTATION. IT WAS REALLY WONDERFUL AND INSPIRING. I WILL TELL YOU IN RURAL NORTH CAROLINA YOU WOULD BE WELCOME ANYTIME IF YOU WANT TO COME. BUT REALLY WANTED TO UNDERSCORE THIS INTERSECTION OF IMPLEMENTATION SCIENCE AND COMMUNITY ENGAGEMENT, AND HOW IT CAN SHIFT WHILE WE HAVE THESE TOOLS, HOW IT CAN SHIFT THE IMPLEMENTATION WHEN YOU ACTUALLY ENGAGE AND TALK WITH INDIVIDUALS ON THE GROUND. RATHER THAN -- I WOULD ASK YOU RATHER THAN SIMPLY SHIFTING THE IDEA OF EMPLOYING FOLKS ON THE GROUND WILL YOU ENGAGING WITH WHAT THE RIGHT APPROACH WOULD BE. WHEN THE LITTLE BIT OF HIV PREVENTION WORK THAT I DID IN RURAL NORTH CAROLINA, MY COLLABORATORS TOLD US WE HAD TO GO TO A MUCH YOUNGER AGE TO THINK ABOUT HIV PREVENTION, CHILDREN AGES 10-14 AND ENGAGE FAMILIES IN THE CONVERSATION. THAT WAS NOT -- I'M NOT AN HIV RESEARCHER NECESSARILY BUT THIS IS WHAT MY COMMUNITY WANTED TO FOCUS ON. THE ISSUES AROUND STIGMA I THINK ARE THERE, PALPABLE, AS YOU POINT OUT, ONE OF THE MAJOR HURDLES WE HAVE TO OVERCOME THERE AS WELL. >> ALL GOOD POINTS. >> : SPERO? >> : SPERO MANSON, UNIVERSITY OF COLORADO. SHIFTING FROM IMPLEMENTATION, 15% OF THOSE CURRENTLY INFECTED ARE UNDETECTED. >> RIGHT. >> APART FROM UNIVERSAL SCREENING WHAT ARE YOUR INITIAL THOUGHTS ABOUT HOW TO IDENTIFY THOSE INDIVIDUALS AND MOVE THEM INTO THIS IMPLEMENTATION STRING? >> THAT REQUIRES ACTIVE PROBING OUT INTO COMMUNITIES BECAUSE THOSE PEOPLE WHO ARE INFECTED AND DON'T KNOW IT ARE PEOPLE WHO ARE INACCESSIBLE TO EVERYTHING. THEY ARE HOMELESS PEOPLE, THERE ARE PEOPLE WHO ARE INJECTION DRUG USERS, COMMERCIAL SEX WORKERS AND PEOPLE WHO HAVE SO MANY OTHER PROBLEMS HIV IS THE LEAST THING THEY ARE WORRIED ABOUT. IT'S A TOUGH GROUP TO ACCESS, IT REALLY IS. >> THANK YOU, TONY. YOU'VE INSPIRED A LOT OF QUESTIONS AND LAID OUT ON ONE HAND AN OPTIMISTIC FUTURE POTENTIALLY, AND ON THE OTHER HAND A TRACK RECORD OF SCIENCE ADDRESSNG THIS MAJOR PUBLIC HEALTH CRISES HAVING BEEN THROUGH IT ALL THIS YEARS, CLEARLY SOMETHING -- SUSTAINABILITY IS A CRITICAL COMPONENT. I THINK THE CHALLENGE OF THE GRAPHIC THAT YOU SHOWED IS WHAT I'LL COME BACK TO YOU AT SOME POINT ABOUT, 65% OF NEW INFECTIONS ARE LATINO AND AFRICAN-AMERICAN MEN, PARTICULARLY AFRICAN-AMERICANS IN RURAL SOUTH AND MOSTLY MEN WHO HAVE SEX WITH MEN, I THINK THERE IS A ROAD MAP TO WHAT TO DO. >> EXACTLY. >> EVEN GOING BACK 30 YEARS, IT'S UNCANNY HOW MUCH PARALLEL THERE IS WITH TUBERCULOSIS EPIDEMIC AND HIV, MULTIPLE DRUG THERAPY, CONTACT TRACING, TREAT ACTIVE CASES TO DO PREVENTION. THERE'S A LOT OF PARALLEL. SO I WANT TO THANK YOU AGAIN FOR TAKING THE TIME TO COME HERE TO OUR COUNCIL. >> THE TIME HAS COME TO RECOGNIZE OUR RETIRING COUNCIL MEMBERS. WE HAVE FOUR PRESENT TODAY. AND WE HAVE A SMALL TOKEN OF OUR APPRECIATION. DR. MARIA HAPPY, A MEMBER OF THE COUNCIL SINCE BEFORE I STARTED, HAPPY IS FROM UCSD AND HAS JUST BEEN A TREMENDOUS CONTRIBUTOR IN THESE FOUR YEARS, I DON'T KNOW HOW MANY COUNCIL MEETINGS HAVE NOW PRESIDED OVER, I'VE LOST COUNT. THIS MUST BE THE -- AT LEAST THE TENTH THAT I'VE HAD. IT'S OUR 50th I GUESS MEETING AS A COUNCIL TODAY. HAPPY, WILL YOU COME AND RECEIVE? [APPLAUSE] >> BRIEFLY, IT'S BEEN SUCH A MEANINGFUL HONOR TO BE PART OF THE NIMHD COMMUNITY, NOT JUST TO ARTICULATE THE PERSPECTIVE AND CONCERNS OF THE COMMUNITIES I'VE WORKED WITH BUT FOR THE OPPORTUNITIES TO LEARN FROM AND WITH YOU. I WOULD -- IT'S BEEN SUCH A VALUABLE OPPORTUNITY WORKING WITH THE SCIENTIFIC VISIONING PROCESS, TEACHING IN THE SUMMER INSTITUTE, GIVING TALKS WITH OUR OTHER COUNCIL MEMBERS, AND I HOPE THAT WHEN YOU VISIT SAN DIEGO, YOU LOOK ME UP, I'LL TAKE YOU TO THE BEST FISH TACO PLACES. >> WE WILL MAIL THE PLAQUE TO YOU, BUT THE BLUE ENVELOPE CONTAINS YOUR LETTER SIGNED BY THE SECRETARY. I THINK THAT WILL FIT IN YOUR PURSE. >> YOU CAN ALSO TAKE IT WITH YOU IF YOU WANT TO LUG IT WITH YOU ON THE PLANE. NEXT I WANT TO ASK SANDRA GALEO TO GET HIS PLAQUE. GETTING TO KNOW SANDRO HAS A BENEFIT TO ME. HE'S A LUMINARY, SCIENTIST WITH A BROAD VIEW OF HEALTH AND PUBLIC HEALTH, I'VE APPRECIATED HIS MANY INSIGHTS OVER THE THERE'S 3 1/2 YEARS AND THANK YOU FOR YOUR SERVICE ON THE NIMHD COUNCIL. SANDRO. [APPLAUSE] >> THANK YOU, IT'S A PRIVILEGE TO SERVE. I WAS TELLING ELISEO EARLIER, OUR TERMS COINCIDED WITH ELISEO'S LEADERSHIP, I CAME ON A LITTLE BIT BEFORE, LOVELY TODAY TO SEE THE PROGRESS THAT HAS HAPPENED IN THE PAST FOUR YEARS. I FEEL LIKE THE INSTITUTE IS IN A DIFFERENT PLACE THAN FOUR YEARS AGO, GREAT TO SEE, ELISEO WITH JOYCE AT HIS SIDE POISED FOR THE RIGHT NEXT STEPS. SO THANK YOU. [APPLAUSE] >> NEXT I WANT TO CALL ON LINDA GREENE, OUR FAVORITE ATTORNEY ON COUNCIL. WHO HAS ALWAYS MADE GREAT OBSERVATIONS, INSIGHTS, KEPT US CONNECTED OUTSIDE OF THE NIH SCIENTIST WORLD. BUT THANK YOU VERY MUCH FOR ALL OF YOUR TIME AND EFFORT ON THE COUNCIL. >> THANK YOU. [APPLAUSE] >> I'LL BE VERY BRIEF BECAUSE I WANT TO REPRESENT MY LAWYER COMMUNITY WELL. THIS HAS BEEN AN INCREDIBLE HONOR, THE TALENT AROUND THE TABLE, THE GREAT OPPORTUNITY TO KNOW DR. EVAN MADDOX AND NOW ELISEO, AMAZING. MY GRANDFATHER WOULD BE PROUD. HE WENT TO MEHARRY IN THE '20s, A SURGEON AND PATHOLOGIST, MOVED TO NEW ORLEANS, ESTABLISHED THE SECOND HOSPITAL FOR BLACKS IN NEW ORLEANS IN THE 1940s, AND WAS VERY ACTIVE IN THE NMA AND WAS A LEADER IN THE NAACP IN NEW ORLEANS AND RICHMOND, HE FOCUSED ON, AMONG MANY THINGS, BUT UPON DISPARITIES AND ACCESS TO MEDICAL CARE AND SO HE IS SMILING ON ME NOW AND GIVING ME HIS SMILE OF APPROVAL. SO THANK YOU FOR THE OPPORTUNITY TO VINDICATE HIS MEMORY. DR. PAUL TIMOTHY ROBINSON IS HIS NAME. [APPLAUSE] >> THAN YOU FOR THAT HISTORICAL. AND FINALLY, LAST BUT NOT LEAST, BRIAN RIVERS HAS BEEN ON COUNCIL FOR FOUR YEARS, BRIAN HAS BEEN THE SECOND REPRESENTATIVE FROM MOREHOUSE SCHOOL OF MEDICINE ON COUNCIL, A CONSISTENT FORCE IN BEHAVIORAL SCIENCE, ISSUES AROUND CANCER, AND MUCH APPRECIATED MANY OF YOUR INSIGHTS AND CONTRIBUTIONS TO OUR WORK. SO BRIAN. [APPLAUSE] >> LAST BUT NOT LEAST. I DO COUNT IT AN HONOR AND PRIVILEGE TO HAVE SERVED IN THIS CAPACITY AS WELL. I GUESS I'M THE HISTORIAN OF THE GROUP. I GOT APPOINTED IN 2013, RIGHT BEFORE DR. RUFFIN RETIRED. AND SO I WAS -- I'VE BEEN PART OF THE TRANSITION WITH DR. YVONNE MADDOX AND DR. LARRY TABAK, AND NOW SEEING EVOLUTION UNDER LEADERSHIP OF DR. ELISEO, TREMENDOUS TO SAY THE LEAST. VERY EXCITING, EVEN IN GRAD SCHOOL I FOLLOWED THIS, THIS CENTER, WHEN IT WAS JUST AN OFFICE. TO SEE EVOLUTION FROM OFFICE TO CENTER, NOW TO INSTITUTE, AND TO HAVE BEEN PART OF THAT, IT'S VERY MEANINGFUL. I WANT TO COMMEND THE STAFF, I WANT TO COMMEND THE LEADERSHIP OF NIMHD, I WISH YOU WELL GOING FORWARD AND KNOW I'M ALWAYS A RESOURCE YOU CAN ALWAYS CALL ON TOWARD, YOU KNOW, THE HIGH VISION THAT YOU HAVE SET ALREADY. I WANT TO CONGRATULATE EVERYONE, BITTERSWEET, I ENJOYED MYSELF. BUT FEBRUARY, MAY AND SEPTEMBER WILL BE DIFFERENT NOW. I'LL EXPECT MYSELF TO BE COMING HERE BUT I'LL HAVE TO ADJUST ACCORDINGLY. BEST WISHES ON EVERYTHING. THE INSTITUTE IS IN TREMENDOUS HANDS, BEST WISHES TO THE COUNCIL AS WELL. A LOT OF YOU GUYS WILL CONTINUE THE NOBLE WORK WE'VE BEEN CALLED TO. AGAIN, THANK YOU. [APPLAUSE] >> WELL, WE'LL REMIND EVERYONE YOU'RE STILL GOING TO BE PART OF THE FAMILY. SO WE'LL STILL CALL ON YOU AND WE HOPE THAT YOU'LL BE THERE FOR US WHEN WE ASK YOU TO DO SOMETHING OF SOME SORT. SO DON'T DISAPPEAR. >> I WON'T. >> I WANT TO ADD THAT OUR SLIDES WILL BE AVAILABLE, I THINK THAT WE ROUTINELY POST MY REPORT SLIDES ON THE WEBSITE, AND DR. FAUCI IS FINE WITH HAVING HIS SLIDES POSTED AS WELL. KELLY, YOU'LL HELP US MAKE SURE THAT WE TAKE CARE OF THAT. SO I THINK WE NOW HAVE TIME FOR PICKING UP YOUR LUNCH, RIGHT? DO YOU NEED TO SAY ANYTHING? NO? AN EXTRA FIVE MINUTES, BACK BY NOON, DAVID WILSON WILL BE COMING TO PRESENT ON TRIBAL HEALTH RESEARCH OFFICE. THANK YOU. >> I WANT TO INTRODUCE DAVID WILSON. DAVE IS DIRECTOR OF THE OFFICE OF TRIBAL HEALTH RESEARCH. I HAD THE PRIVILEGE OF INTERVIEWING HIM WHEN HE WAS APPLYING FOR THIS POSITION AFTER HE WAS SELECTED AS A FINALIST, AND WAS THAT TWO YEARS AGO, DAVE? OKAY. TIME FLIES, YEAH. HE IS TERRIFIC ENERGY TO THE TRIBAL HEALTH RESEARCH OFFICE, ESTABLISHED NOT LONG AFTER I STARTED AS DIRECTOR OF NIMHD, AT THAT TIME THINGS WERE COMING AT ME RIGHT AND LEFT, I WASN'T SURE WHAT ALL WAS GOING ON BUT THIS CAME OUT OF DR. TABAK'S OFFICE, WE'RE GOING TO DO THIS, THAT, AND THIS. THIS TRIBAL HEALTH RESEARCH OFFICE WAS GOING TO HAPPEN. NIMHD WAS VERY MUCH INVOLVED SINCE WE'VE BEEN AT NIH ALWAYS LINKED TO ISSUES AROUND TRIBAL HEALTH, ALTHOUGH IT'S NOT UNIQUELY OUR TERRITORY, IT INVOLVES ALL THE NIH INSTITUTES. AND DAVE I THINK WAS A TERRIFIC CHOICE IN THAT HE HAS A STRONG SCIENCE BACKGROUND, HAD ALREADY BEEN IN GOVERNMENT FOR SEVERAL YEARS, A LOT OF ENERGY, A BROAD SPECTRUM OF INTEREST, AND HE IS 100% NAVAJO, AS HE TOLD ME WHEN I FIRST MET HIM. SO PLEASE WELCOME DR. DAVID WILSON TO GIVE US AN UPDATE ON THE TRIBAL HEALTH RESEARCH OFFICE. [APPLAUSE] >> ALL RIGHT. WELL, THANK YOU ALL. IT'S A PLEASURE TO BE HERE. I TERMED THIS PRESENTATION AS AN INTRODUCTION AND UPDATE. FOR FOLKS LIKE DR. ARANETA WHO HAS ALREADY SEEN THE INTRODUCTION, IT'S AN INSTRUCTION AND UPDATE. I WANT TO TALK ABOUT WHY THE OFFICE EXISTS AND WHY AMERICAN INDIANS ARE UNIQUE IN TERMS OF THE POPULATION. YOU SEE HERE THE MAP IN 1492 THAT ALL OF THE NORTH AMERICA WAS TRIBAL LANDS. THROUGHOUT THE YEARS AS COLONISTS BEGAN TO SETTLE AND MOVE WEST, YOU CAN SEE THE PURPLE COLORS ARE SLOWLY DIMINISHING, AND THESE ARE REPRESENTATIVE OF THE TRIBAL LANDS. IN 1990, THAT'S CONSISTENT WITH WHAT THEY LOOK LIKE TODAY. THERE'S QUITE A DIFFERENCE BETWEEN AMOUNT OF TRIBAL LANDS IN 1492 AND TODAY. DURING THAT TRANSITION, SINCE THE FORMATION OF THE UNION, THE'S ALWAYS RECOGNIZED TRIBAL NATIONS AS SOVEREIGN NATIONS, AS A RESULT OF LAND TRANSFERS THAT OCCURRED DURING THIS COLONIZATION, PART OF THAT TRANSITION WAS THE FEDERAL PROGRAMS AND SERVICES THAT BENEFIT AMERICAN INDIANS AND ALASKA NATIVES, UNDER THE CONCEPT OF GOVERNMENT TO GOVERNMENT RELATIONSHIP, THAT'S REALLY IMPORTANT. MANY PEOPLE NOTED THIS AND RECOGNIZED THIS AS FEDERAL TRUST RESPONSIBILITY. ALSO AMERICAN INDIANS ARE PROVIDED HEALTH CARE AND EDUCATION AS OUTLINED IN THE TREATIES AROUND THIS. THIS WAS REALLY IMPORTANT BECAUSE A LOT OF TIMES WHEN WE TALK ABOUT PROGRAMS AND INITIATIVES THAT AMERICAN INDIANS ARE CLASSIFIED UNDER THE RACE AND ETHNICITY CATEGORY WHEN THERE'S ALSO A UNIQUE SPECIAL FEDERAL STATUS OR SPECIAL STATUS, POLITICAL STATUS WE'RE ASSOCIATED WITH. SO CURRENTLY THERE ARE 573 FEDERALLY RECOGNIZED TRIBES IN THE U.S., IMPORTANT BECAUSE EACH OF THESE TRIBES HAS A UNIQUE HISTORY, CULTURE, DIFFERENT LANGUAGES, GOVERNMENT STRUCTURES ARE UNIQUE. WE'RE THE ONLY POPULATION TO HAVE DUAL CITIZENSHIP IN THE U.S., AND THE GOVERNMENT STRUCTURES HAVE BEEN REALLY IMPORTANT FOR US TO UNDERSTAND, ESPECIALLY IN TERMS OF RESEARCH, AND WE HAD SOME REALLY UNIQUE EXAMPLES AND MODELS I'LL TALK ABOUT LATER IN MY PRESENTATION. SO I WANTED TO GIVE YOU A QUICK LAYOUT, I KNOW EVERYBODY HERE IS PROBABLY FAMILIAR WITH THIS BUT WHY I SHOW THIS SLIDE, IT'S IMPORTANT TO SHOW ALL THE DIFFERENT COLLABORATORS WE HAVE ACROSS THE AGENCY. THIS IS A MAP OF THE HEALTH AND HUMAN SERVICES AGENCY, YOU CAN SEE THE VARIOUS OPERATING DIVISIONS, INDIAN HEALTH SERVICE, CENTERS FOR MEDICARE AND MEDICAID, CMS, CDC, SAMHSA, ALL PARTNERS FOR OUR OFFICE, TRIBAL HEALTH RESEARCH OFFICE. AND WE'VE FORMED A LOT OF PARTNERS, I'LL TALK ABOUT SOME OF THOSE A LITTLE BIT LATER AS WELL. SO COMING INTO THIS, YOU CAN SEE THESE ARE THE -- THIS IS THE LAYOUT OF THE NIH, 27 INSTITUTES AND CENTERS. WHEN WE FIRST CAME INTO EXISTENCE WE WERE TRYING TO TALK ABOUT FUNCTION OF THE OFFICE. THIS IS A BUSY SLIDE. HOW CAN WE DISPLAY THIS A LITTLE CLEANER AND A LITTLE NICER? SO HERE WE CAME UP WITH THIS VERY NICE DIAGRAM HERE THAT SHOWS VERY WELL I THINK WHAT OUR OFFICE DOES AND WHAT WE ARE HERE TO DO. YOU CAN SEE THE MIDDLE OF THE DREAM CATCHER AND INSTITUTES AND CENTERS SURROUNDING IT. WE COORDINATE ACROSS THE AGENCY. SOME THINGS WE FOCUS ON, CAREERS AND RESEARCH PROGRAMS, POLICIES, COMMUNITIES, WHICH IS A BIG PART OF THE WORK WE DO, AND ALSO HEALTH RESEARCH. SO THE OFFICE WAS CREATED IN 2015. I WAS APPOINTED IN 17. I'VE BEEN IN THE POSITION FOR TWO YEARS. WE HAVE MADE TREMENDOUS STRIDES. I WILL TALK A LOT ABOUT THOSE. THE POSITION OF THE OFFICE IS VERY WELL DESCRIPTIVE OF OUR FUNCTION AS WELL. DIVISION OF PROGRAM COORDINATION PLANNING AND STRATEGIC INITIATIVES. THAT IS EVERYTHING THAT WE DO WITHIN THE OFFICE. THINKING ABOUT HOW TO COORDINATE ACTIVITIES, CREATING NEW IDEAS THAT HAVE NEVER BEEN DONE BEFORE, TO ADDRESS THE -- HELP ADDRESS AND CLOSE HEALTH DISPARITIES GAP THAT EXISTS WITHIN TRIBAL COMMUNITIES. SO, THERE'S TWO MAIN WAYS THAT WE COMPLETE OUR CARRY OUT THE FUNCTIONS OF THE WORK, ONE THROUGH THE THRCC. THIS IS A GROUP THAT'S MADE UP OF INDIVIDUALS THAT WERE APPOINTED BY EACH OF THE INSTITUTES AND CENTERS, AND WE MEET MONTHLY AND TALK ABOUT DIFFERENT INITIATIVES, DIFFERENT PROGRAMMATIC IDEAS, AND HOW THESE ARE THE DIFFERENT INSTITUTES AND CENTERS CAN CONTRIBUTE TO THE MISSION OF THE TRIBAL HEALTH RESEARCH OFFICE. SO THIS IS ONE OF THE KEY WAYS, YOU CAN SEE WHERE IS DOTTY? SHE'S A MEMBER OF OUR COMMITTEE. ALSO JOYCE, RIGHT THERE IN FRONT. THE SECOND WAY THAT WE GET OUR WORK DONE IS THROUGH THE NIH TRIBAL -- >> WE TURNED THE TABLES ON THEM AND MET A NICE POOL OF STUDENTS GETTING READY TO GRADUATE AND WANTED TO GO BACK TO THEIR COMMUNITIES AND SERVE AND HAVE BIOMEDICAL RESEARCH OPPORTUNITIES. WHAT WERE THERE AVAILABLE? IT WAS GOOD CONVERSATION, TRIBAL LEADERS SAID WE NEED TO THINK ABOUT THIS MORE CLOSELY, ABOUT HOW WE CAN CREATE OPPORTUNITIES FOR THESE KIDS SO THEY CAN COME BACK TO THE COMMUNITIES AS PROFESSIONALS. DURING THE EARLY DAYS, UP TO NOW, WE'VE BEEN ABLE TO FOCUS ON TWO FOUNDATIONAL DOCUMENTS FOR THE OFFICE. NUMBER ONE, THE FIRST AMERICAN INDIAN/ALASKA NATIVE PORTFOLIO ANALYSIS, A SNAPSHOT OF THE INVESTMENT IN TRIBAL HEALTH RESEARCH, AN IMPORTANT DOCUMENT BECAUSE WE DIDN'T KNOW HOW THE AGENCY WAS POSITIONING THE INVESTMENT AND HOW IT WAS SERVING COMMUNITIES. WE WERE ABLE TO WORK THIS OUT AND PUBLISH THIS LAST YEAR, AND I'LL SHOW A LITTLE BIT ABOUT THAT. AND THEN ALSO SECONDLY, WE'RE VERY CLOSE TO RELEASING THE FIRST TRANS-NIH STRATEGIC PLAN FOR TRIBAL HEALTH RESEARCH. MY BOSS, DR. JIM ANDERSON, LIKES TO SAY WITHOUT A STRATEGIC PLAN ANYWHERE YOU GO WILL GET YOU TO WHERE YOU WANT TO BE, THAT'S KIND OF DEPICTIVE OF THAT MAP. ANY DIRECTION WE GO WILL GET US WHERE WE WANT TO BE, THAT'S NOT HOW WE WANT TO WORK IN THE TRIBAL HEALTH RESEARCH OFFICE. THE RESEARCH PORTFOLIO, THE PORTFOLIO ANALYSIS HERE IS LOCATED ON OUR WEBSITE. YOU CAN SEE THIS, THE COVER, WHAT WE'VE TRIED TO DO, AGAIN, WAS CAPTURE WHERE THE MONEY IS BEING PLACED, WHERE THE INVESTMENT IS, IS IT BEING USEFUL. THE FIRST ROUND FOR FY 15, WE'RE NOW FY17, WE'LL DO THIS BIANNUALLY, MANY GRANTS ARE MULTI-YEAR GRANTS. WHAT WE WANT TO DO, THE FIRST ONE TO GET THE STAKE IN THE GROUND, GET THE INITIAL STAKE IN THE GROUND AND BEGIN ASSESSING HOW WE CAN IMPROVE FROM THERE MOVING FORWARD. SO WE'RE RIGHT NOW KNEE DEEP IN FY17, LOOKING FORWARD TO CLARIFYING AND GETTING INTO MORE OF THE DETAILS AROUND HOW THE RESEARCH IS FUNDED. SOME OF THE THINGS THAT WERE IMPORTANT TO US WERE UNCOVERING SOME SUBGRANTS, THE AWARDS UNDER LARGER PARENT GRANTS THAT WEREN'T CLEARLY IDENTIFIABLE IN THE FIRST ROUND OF SEARCHING SO WE CAN GET A BETTER IDEA WHAT THE INVESTMENT IS. THIS SERVES A KEY DOCUMENT OR KEY RESOURCE FOR TRIBAL COMMUNITIES, TO BEGIN TO UNDERSTAND IF RESEARCH IS HAPPENING IN THEIR SPECIFIC AREAS AROUND SPECIFIC DISCIPLINES THAT ARE IMPORTANT TO THEM, AND IF NOT, WHY NOT. AND HOW CAN THEY EXPLORE ADDITIONAL OPPORTUNITIES IN THESE AREAS. I MENTIONED THE STRATEGIC PLAN, AND HERE ARE -- I WANTED TO BRING OUT THE FOUR STRATEGIC GOALS YOU'LL BE SEEING SOON, ONCE THE PUBLIC DOCUMENT IS RELEASED. ENHANCING COMMUNICATION AND COORDINATION, BUILDING RESEARCH CAPACITY FOR TRIBAL COLLEGES AND UNIVERSITY AND TRIBAL ORGANIZATIONS AS WELL. EXPANDING RESEARCH IN MANY FORMS. AND I THINK SOMETHING THAT APPLIES TO ALL GOES AND PRINCIPLES IS ENHANCING COMMUNITY ENGAGEMENT, KEY IN ALL THE WORK WE DO WITHIN THIS COMMUNITY. SO EVERYTHING THAT I'LL TALK ABOUT FROM HERE MOVING FORWARD IS THINGS TO ADDRESS THE STRATEGIC PLAN. THE FIRST THING WE DID, YOU CAN RECOGNIZE THE GENTLEMAN FRONT AND CENTER THERE, WE'VE HAD THE VERY FIRST TRIOPERATING DIVISION CONSULTATION WITH TRIBAL NATIONS, THIS HAPPENED IN MINNESOTA LAST YEAR. THIS WAS A PARTNERSHIP BETWEEN THE NIH, SAMHSA AND INDIAN HEALTH SERVICE, FIRST OF ITS KIND, EFFECTIVE ON MANY LEVELS. WE RECENTLY AT THE REQUEST OF OUR TRIBAL ADVISORY COMMITTEE RELEASED AND IT'S ON THE STREET NOW AN RFI TO CONCLUDE THIS EVENT TO GET ADDITIONAL INFORMATION ABOUT THE MEETING ABOUT THE CHALLENGES THAT COMMUNITIES ARE FACING IN ADDRESSING THE OPIOID EPIDEMIC. TO DATE WE'VE RECEIVED A LOT OF REALLY GOOD FEEDBACK, BECAUSE WE WERE ABLE TO RELEASE THE SUMMARY OF THE EVENT AND THE CONTRIBUTIONS THAT TRIBAL LEADERS MADE IN MINNESOTA DURING THIS EVENT. WE HAD DR. NORA VOLKOW AND WE HAD ALSO ELISEO THERE TO REPRESENT TWO ICs, THE FIRST TIME WE HAD TWO INSTITUTE DIRECTORS DIRECTLY ENGAGED IN CONSULTATION WITH TRIBAL LEADERS. WE GOT A LOT OF GOOD FEEDBACK FROM HHS THAT RECEIVED FEEDBACK HOW THE IMPACT WAS PERCEIVED, TRIBAL LEADERS THOUGHT IT WAS GREAT, IT WAS CLEAR, CONCISE, ALLOWED ENOUGH OPPORTUNITY FOR TRIBAL LEADERS TO PROVIDE INPUT ON THEIR ISSUES AND CHALLENGES. SO THIS WAS GREAT. THIS IS GOING TO SERVE AS A MODEL MOVING FORWARD FOR OTHER OPERATING DIVISIONS WITHIN HHS. THIS WAS A GREAT OPPORTUNITY FOR US, ALSO TO CLARIFY OUR ROLE IN WHAT THE NIH DOES THAT WE'RE ABOUT RESEARCH. A LOT OF COMMUNITIES GET CONFUSED THAT THE NIH PROVIDES HEALTHCARE SERVICES, WE'RE NOT IHS. SO IT WAS REALLY GOOD FOR US TO -- WE PROVIDE THE RESEARCH TO IMPROVE THE DELIVERY OF HEALTH CARE. SO IT WAS A TERRIFIC COMMUNITY AND I REALLY APPRECIATE THE SUPPORT FROM NIMHD AND NIDA. ANOTHER THING WE'RE DOING THAT'S EXTREMELY IMPORTANT IS COMMUNITY ENGAGEMENT. YOU CAN SEE WE TRAVELED TO THE NAVAJO NATION, THE CENTER PICTURE THERE, THERE'S DR. JULIANNA BLOOM, NOW OUR ASSISTANT DIRECTOR FOR TRIBAL HEALTH RESEARCH OFFICE, AND CURRENT DIRECTOR OF THE ECHO PROGRAM, DR. MATT GILMAN. WE MET WITH NAVAJO NATION AND THEIR LEADERSHIP TO TALK ABOUT DATA SHARING PROGRAM, OR POLICY. AND THE REASON BEING IS THE NAVAJO NATION, A LOT OF TRIBAL COMMUNITIES HAVE TRUST ISSUES AROUND UNETHICAL USE OF DATA. AND THE MAIN REASON BEHIND THAT IS INCREASING OR PERPETUATING STEREOTYPES. THEY WANTED TO KNOW IF THEY WERE TO PARTICIPATE IN THIS VERY LARGE PROGRAM WHICH IS VERY MUCH NEEDED IN THIS COMMUNITY BECAUSE THE ENVIRONMENTAL INFLUENCES ON CHILD HEALTH OUTCOMES PROGRAM WILL SPECIFICALLY STUDY THE LONG-TERM EFFECTS ON CHILDREN AROUND THE OPEN URANIUM MINE PITS ON THE NAVAJO RESERVATION, AN IMPORTANT STUDY THEY NEED AND WANT TO PARTICIPATE IN BUT HAVE CONCERNS AROUND HOW THE DATA IS GOING TO BE HELD, SECURED AND MANAGED. WE WERE THERE TO HAVE THESE CONVERSATIONS WITH THEM, AND THAT'S AN ONGOING PROCESS, BUT I THINK IT'S GOING TO SERVE AS A UNIQUE TEMPLATE FOR OTHER TRIBAL COMMUNITIES, EVEN OTHER MINORITY COMMUNITIES THAT HAVE TRUST ISSUES AROUND RESEARCH, HOW THEY CAN PARTICIPATE BUT MAKE SURE THAT ALL OF THEIR CONCERNS ARE ADDRESSED. WE HAVE A REALLY GOOD SCHEMATIC THAT OUTLINES THE ENTIRE PROGRAM OF BEFORE AND AFTER WHERE YOU CAN SEE ALL THE DIFFERENT POINTS OF INTERSECTION WHERE THE TRIBE WANTS TO HAVE SOME SAY HOW THE DATA IS MANAGED, APPROVED. IT WAS A GOOD EXPERIENCE. ALSO ON THE FAR RIGHT HERE WE TRAVELED TO ALASKA OOCYTE VISIT TO VISIT A HEALING CAMP, WITH THE SECRETARY'S TRIBAL ADVISORY COMMITTEE. AND THE DIRECTOR OF SAMHSA IS RIGHT THERE IN THE MIDDLE PETTING THE DOG, DR. ELEANOR MCCANN KATZ, SHE WAS INTERESTED IN HEARING ABOUT TRADITIONAL PRACTICES, A GREAT OPPORTUNITY FOR AGENCIES TO HEAR ABOUT THE FOUNDATION FOR HEALING AND HOW THAT PLAYS A ROLE WITHIN THE COMMUNITIES. ON THE FAR LEFT YOU CAN SEE WE'RE NOT ALWAYS SUCCESSFUL WHEN WE GO TO THE COMMUNITIES. THIS WAS A TRIP EARLY LAST YEAR TO SOUTH DAKOTA, WE HAD -- THAT'S LIKE 20 INCHES OF SNOW. WE DIDN'T GET FAR. WE GOT TO KEEP CONTINUING TO TRY TO GET INTO THE COMMUNITIES. ONE THING GOOD ABOUT THIS, I WAS SNOWED IN, BUT I WAS WITHIN WALKING DISTANCE OF A BASKETBALL TOURNAMENT. I WENT TO THE TOURNAMENT, LO AND BEHOLD THERE WERE EIGHT TRIBAL LEADERS I WAS ABLE TO HAVE CONVERSATIONS WITH. IT WAS MORE EFFECTIVE THAN ACTUALLY GOING TO THE IRB MEETING WE WERE SUPPOSED TO GO TO. SOME MORE COMMUNITY ENGAGEMENT IS THAT YOU CAN SEE HERE ON THE FAR RIGHT WE BEGIN TO ALSO MEND RELATIONSHIPS AND BUILD MORE TRUST AND THE FAR RIGHT IS WHEN I HAD THE OPPORTUNITY TO TRAVEL TO ARIZONA AND MEET WITH THE HAVASU COUNCILWOMAN ON THE FAR RIGHT, A MEMBER OR STUDY PARTICIPANT IN THE HAVASU ISSUE, SHE WAS ABLE TO GO BACK TO ARIZONA STATE AND HAVE CONVERSATIONS AROUND THIS. WE TALKED ABOUT THE PRIORITIES OF OUR TRIBAL HEALTH RESEARCH OFFICE, AND THE ROLE AND NIH'S COMMITMENT TO THIS. SO SHE WAS VERY HAPPY TO HEAR ABOUT ALL THIS. THEY WERE INTERESTED IN RESEARCH, AND THE THING WE CAN DO IS TO BE MORE TRANSPARENT AND INCREASE OUR COMMUNICATION AROUND RESEARCH. AND I THINK THAT WILL LEAD TO MORE PARTICIPATION OF TRIBAL COMMUNITIES IN HEALTH RESEARCH. BELOW IS THE GOVERNOR OF THE GILA RIVER COMMUNITY, I WANTED TO VOICE OUR APPRECIATION FOR THAT COMMUNITY'S ENGAGEMENT IN THE STUDY. AND THEN AGAIN HERE WE WERE MEETING WITH THE PRESIDENT OF THE NAVAJO NATION IN THE MIDDLE TO HEAR ABOUT RESEARCH CHALLENGES OR PRIORITIES WITHIN THAT COMMUNITY. AND IT WAS GREAT. IT WAS A TWO-HOUR MEETING. WITHIN THAT MEETING COULD HAVE IDENTIFIED FIVE TO TEN THINGS EACH I.C. COULD BE ADDRESSING. THE CHALLENGES ARE NOT SMALL. CHALLENGES TO BE ADDRESSED AT OUR AGENCY LEVEL. WE'VE BEEN MEETING WITH THE ALASKA DELEGATION, IT'S IMPORTANT TO HEAR ABOUT THESE. I'LL REAFFIRM THIS DOWN THE LINE BUT HEARING ABOUT THE DIFFERENT PERSPECTIVES AND CHALLENGES WITH EACH OF THE COMMUNITIES IS VERY UNIQUE. WITHIN THE TRIBAL HEALTH RESEARCH OFFICE, GOING INTO YEAR TWO, OUR FIRST YEAR WAS FOCUSED ON MAKING SURE EVERYBODY IN THE COMMUNITY KNEW WE WERE OPEN FOR BUSINESS. YEAR TWO WAS ABOUT UNIFYING THE SUMMER INTERNSHIP PROGRAM AT THE AGENCY. WE WANTED TO FOCUS ON PROFESSIONAL DEVELOPMENT AND MAKE -- AND INCREASE THE AWARENESS ABOUT THE OPPORTUNITIES THAT EXIST AT THE AGENCY FOR THESE STUDENTS TO TRAIN IN BIOMEDICAL RESEARCH. A LOT OF THEM ARE KIND OF INTERESTED BUT NOT QUITE INTERESTED BECAUSE THEY DON'T KNOW WHAT'S OUT THERE. OUR GOAL WAS TO MAKE SURE WE INCREASED THAT DISSEMINATION OF INFORMATION. A LOT OF STUDENT ENGAGEMENT. ON THE FLIP SLIDE, IT'S ENGAGING THE SCIENTIFIC COMMUNITIES. MAKING SURE THAT THEY UNDERSTAND HOW WE'VE BEEN APPROACHING TRIBAL COMMUNITIES AND SOME BEST PRACTICES THAT WE'VE LEARNED IN THE DEVELOPMENT OF THE OFFICE THAT HAVE BEEN EFFECTIVE FOR US. A LOT OF THESE, YOU CAN SEE A LOT OF THE PEOPLE, THIS WAS AT THE SUPERFUND MEETING IN CALIFORNIA LAST FALL. AND THIS WAS SPONSORED BY NIEHS, INTERESTED IN WORKING WITH TRIBAL COMMUNITIES BUT UNSURE HOW TO DO THAT. WE TALKED ABOUT SOME OF THESE BEST PRACTICES AND THEY WERE EXCITED, A LOT OF FOLLOW-UP. A LOT OF YOUNG INVESTIGATORS GET STYMEDIED BY THE PROCESS. THEY MAY BE A YEAR BEHIND, ONCE APPROVED, IN THEIR GRANT MEASURES AND OUTCOMES. IT'S REALLY IMPORTANT TO UNDERSTAND GOING INTO THIS WHAT THE TIMELINES ARE. ANOTHER PART OF ENGAGING SCIENTIFIC COMMUNITY INTERNALLY AT THE NIH IS WE WERE ABLE TO INVITE DR. JOHN GONE FROM HARVARD, IT'S STILL ON THE WEBSITE IF YOU WANT TO LOOK IT UP, VIDEOCAST, DISCUSSING INTERFACE BETWEEN TRADITIONAL MEDICINE AND WESTERN MEDICINE. IT WAS A REALLY NICE -- A VERY DETAILED DESCRIPTION OF TRADITIONAL CEREMONIES. SO DETAILED THAT I THOUGHT IT WAS UNIQUE BECAUSE A LOT OF TIMES THE DETAILS OF THOSE CEREMONIES ARE SACRED AND SECRET BUT I WENT INTO DETAIL BECAUSE HE WANTED PEOPLE TO REALIZE THIS FORM OF HEALING IS CUSTOMIZED. IT'S VERY PRECISION ORIENTED IN ITS WAY, IT'S CUSTOMIZED TO A SPECIFIC INDIVIDUAL AND THEIR SPECIFIC HEALTH NEEDS. SO IT'S REALLY A GREAT CONVERSATION, AND WE WERE EXCITED TO HAVE HIM COME TO THE CAMPUS. SO SOME OF THE OTHER THINGS WE WERE DOING IS REALLY TRYING TO MAKE THE ENORMOUS AMOUNT OF INFORMATION THE NIH HOLDS ACCESSIBLE TO TRIBAL COMMUNITIES. WE DEVELOPED THIS INTERACTIVE MAP. IF YOU GO TO THE WEBSITE, TRIBAL HEALTH RESEARCH OFFICE WEBSITE AND MOUSE OVER THE SITES, YOU'LL SEE, CLICK ON IT, THE HIGHLIGHTS OF THE RESEARCH HAPPENING IN THAT AREA DURING THAT SPECIFIC YEAR WILL POPULATE DOWN BELOW. AND IF YOU'RE MORE ADEPT AT NAVIGATING THE REPORTER WEBSITE, WHICH ALL OF YOU HERE ARE, THERE'S A LINK HERE IN THE BLUE WHERE YOU CAN CLICK ON THAT AND IT WOULD PULL UP EVERYTHING THAT HAPPENED WITHIN THIS AREA DURING THIS YEAR. IT'S BEEN GREAT BECAUSE WE'VE BEEN ABLE TO GET SCIENCE FELLOWS, NATIVE, VISITING FOR A COUPLE YEARS, TO HELP US POPULATE THIS. THIS WAS INITIALLY DONE, THIS SET OF DATA FROM 14, 15, WAS DONE BY ONE OF OUR INTERNS THAT WE HAD FROM THE YAKIMA NATION, A BUSINESS MAJOR, INTERESTED IN SCIENCE POLICY. SHE CAME IN AND DID A TERRIFIC JOB BECAUSE SHE WANTED TO LEARN MORE ABOUT HOW GRANTS AND HOW HEALTH CARE WERE INTERCONNECTED. IT WAS A GREAT OPPORTUNITY FOR HER. SHE DID A FANTASTIC JOB. WE'VE SEEN NOTHING BUT TREMENDOUS SPIKE IN INTEREST IN THIS SPECIFIC AREA. OTHER THINGS WE'RE DOING TO INFORM THE COMMUNITIES ARE THROUGH PUBLICATIONS. THE WORK THAT WE'VE DONE IN THE NAVAJO NATION, PARTNERED WITH NHGRI IN FALL OF 2017 AND HELD A GENETICS WORKSHOP AT UNIVERSITY OF NEW MEXICO CANCER CENTER, THAT BEGAN CONVERSATIONS ABOUT THE NATION REVISITING THE GENETIC RESEARCH MORATORIUM IN PLACE SINCE 2002. BECAUSE THEY UNDERSTAND AND THEY HAVE BEEN SEEING A RISE IN INCIDENCE IN CANCER ACROSS THE NATION ABOUT RESEARCH AND ITS IMPORTANT ROLE IN ADDRESSING THIS. SO NATURE THOUGHT THIS WAS IMPORTANT AND IT WAS EXCITED THEY WERE INTERESTED IN THIS ARTICLE, THEY WROTE A PIECE ON IT THAT TALKED ABOUT THE NATION RECONSIDERING. SO CURRENTLY THEY HAVE A SUBCOMMITTEE THAT'S FORMED, THEY HAVE ALREADY WRITTEN A DRAFT, AND THEY ARE MOVING FORWARD. WE'LL BE PROVIDING TECHNICAL ASSISTANCE WHEN ASKED ABOUT IT. WE WERE HAPPY TO BRING THAT CONCEPT BACK UP TO THE SURFACE AGAIN, HAVING ROBUST CONVERSATIONS ABOUT IT. ADDITIONALLY TALKING ABOUT THINGS IMPORTANT TO THE COMMUNITIES, ABOUT INDIVIDUAL PROTECTIONS, THE BELMONT REPORT, WE TALKED ABOUT COMMUNITY ASPECT OF BELMONT REPORT THAT WAS NOT IDENTIFIED IN THERE. AND RECENTLY JUST WITHIN A COUPLE WEEKS HAD ANOTHER PUBLICATION COME OUT, IT'S ABOUT THE DIRECT TO CONSUMER TESTING KITS. THIS IS INSTRUCTING IDENTITIES THROUGH IMPLICATIONS OF ANCESTRY, WANTING TO MAKE SURE PEOPLE -- COMMUNITIES ARE AWARE OF, THAT IT'S A LOT MORE TO BE CONSIDERED A MEMBER OF A TRIBAL COMMUNITY THAN A DNA TEST KIT. SO YOU CAN READ IT. IT'S ONLINE. ONE OF THE THINGS I WANTED TO END WITH, DOING REALLY GOOD ON TIME, I'M WORKING ON THAT, IS THE SOCIAL VALUE THING, THAT WE DO A LOT OF SITE VISITS, A LOT OF COMMUNITY ENGAGEMENT BECAUSE YOU SEE THIS WORD CLOUD, A LOT OF WORDS ARE VERY IMPORTANT TO TRIBAL COMMUNITIES AND THEY ALL EXIST IN THE TRIBAL COMMUNITIES BUT PRIORITY RANKING MAY BE DIFFERENT. IT'S IMPORTANT FOR RESEARCHERS TO GO INTO THE COMMUNITIES AND ASK YOUR PRIORITIES AS OPPOSED TO DICTATING TO THE COMMUNITIES WE THINK YOU NEED TO FOCUS ON SUBSTANCE ABUSE OR MENTAL HEALTH ISSUES, THAT MAY NOT BE THEIR PRIORITY AND YOU MAY FACE RESISTANCE, SO IT'S MUCH EASIER AND MORE EFFECTIVE TO COMMUNICATE WITH THE COMMUNITIES, FIND OUT THEIR PRIORITIES AND BEGIN GOING DOWN THE AVENUES. WITH THAT I WANT TO INTRODUCE THE THRO TEAM, THEY WERE AT ANOTHER MEETING BUT DR. JULIANA BLOOM, AND DR. JAY RUBIEZA, AND TED KEENE, OUR OTHER HEALTH SCIENCE POLICY ANALYST. WE'RE HAPPY THE OFFICE IS CONTINUING TO GROW, WE'RE GETTING MORE REQUESTS TO DO A LOT OF INNOVATIVE THINGS. SOME THINGS WE HAVE ON THE HORIZON, THIS YEAR WE'RE GOING TO BE PARTICIPATING WITH THE "ALL OF US" RESEARCH PROGRAM HOLDING THEIR FORMAL CONSULTATION AND HOW THEY ARE RECRUITING AND ENROLLING TRIBAL COMMUNITIES, PARTICIPANTS FOR THE STUDY. ALSO WE'RE GOING TO BE HOLDING A TRIBAL CONSULTATION ON INTELLECTUAL PROPERTY, SO WHAT ARE THE ISSUES AND THINGS THAT COMMUNITIES SHOULD BE AWARE OF WHEN THEY THINK ABOUT ENGAGING IN THESE PARTNERSHIPS AROUND RESEARCH? AND ALSO WE'RE THINKING ABOUT HOLDING OUR SECOND MEETING WITH NIMH AND SUICIDE PREVENTION HUB MEETING IN FAIRBANKS, ALASKA, LATER THIS YEAR. WE'RE DOING INTERESTING THINGS AND WE'RE EXCITED WE HAVE THE OPPORTUNITY TO SHARE WITH YOU SOME OF OUR TRAVELS. THIS IS OUR TRIP DOWN THE TANAMOW RIVER IN THE FALL OF LAST YEAR, 30 MILES DOWN THE RIVER TO THE HEALING CAMP I SHOWED EARLIER. WITH THAT, I'LL STOP, RIGHT ON TIME AND ASK FOR ANY QUESTIONS. THANK YOU. [APPLAUSE] >> THANK YOU, DAVID. IF YOU HAVE QUESTIONS, PLEASE IDENTIFY YOURSELF. >> GISELLE CORBIE-SMITH, THANK YOU FOR THE PRESENTATION. I LIVE IN A STATE THAT HAS MANY TRIBAL COMMUNITIES THAT ARE STATE RECOGNIZED BUT NOT FEDERALLY RECOGNIZED. AND SO, I GUESS I WONDERED IN YOUR STRATEGIC PLAN, I HAVE ABOUT THREE QUESTIONS. DO YOU WANT TO HEAR THEM ALL OR -- >> SURE. WE HAVE 15 MINUTES. >> YOU WERE CLEAR IN THE INTRODUCTION. HOW ARE STATE RECOGNIZED COMMUNITIES INTEGRATED, WHAT KIND OF OUTREACH DO YOU HAVE PLANNED FOR THEM? >> : YEAH. >> WANT ME TO GO ON WITH THE OTHERS? >> : SURE. >> YOU MENTIONED TRIBAL COLLEGES AND UNIVERSITIES. IN OUR STATE WE HAVE UNC PEMBROKE THAT IS MINORITY SERVING INSTITUTION, PREDOMINANTLY STUDENTS FROM TRIBAL COMMUNITIES, HOW THAT MIGHT FIT INTO YOUR STRATEGIC PLAN IN TERMS OF OUTREACH, CAREER DEVELOPMENT, ET CETERA. AND FINALLY YOU MENTIONED AND YOU'VE DONE AND ILLUSTRATED BEAUTIFULLY IMPORTANCE OF DEMONSTRATING TRUSTWORTHINESS OF INVESTIGATORS. I WILL INTENTIONALLY FLIP THE PARADIGM OF TALKING ABOUT DISTRUST VERSUS US AS INVESTIGATORS DEMONSTRATING OUR TRUSTWORTHINESS BY GOING OUT, MEETING WITH PEOPLE, UNDERSTANDING WHAT THEIR CONCERNS ARE, BUT I WOULD ALSO SUGGEST THAT THERE'S A CIRCLE TO THAT, IRONICALLY, THAT ALLOWS US, ONCE WE IDENTIFY THOSE CONCERNS, HOW ARE THOSE CONCERNS INTEGRATED INTO THE PRIORITIES OF THE OFFICE, WHAT'S THE DISSEMINATION OF THOSE RESULTS BACK TO COMMUNITIES, HAVE YOU THOUGHT ABOUT HOW YOU CLOSE THAT CIRCLE. >> I'LL START WITH THE LAST ONE, CONSULTATION PROCESS, A FORMAL ENGAGEMENT, GOVERNMENT TO GOVERNMENT RELATIONSHIPS, EACH OF THE HEADS OF GOVERNMENTS HAVE THE OPPORTUNITY TO CONVERSE BACK AND FORTH. HOW WE DO THIS, WE CAPTURE WHAT TRIBAL LEADERS -- WHAT THEIR RECOMMENDATIONS AND SUGGESTIONS ARE, POSTING THOSE ON OUR WEBSITE AND WRITING REPORTS, WRITING SUMMATIONS HOW WE'RE ADDRESSING EACH OF THOSE. IT'S A REALLY GREAT QUESTION. AND THIS IS SOMETHING WE'RE CURRENTLY DRAFTING AN NIH TRIBAL CONSULTATION PROTOCOL, VERY USED FOR ALL THE OPERATING DIVISIONS. WE'RE HOPING THE "ALL OF US" PROGRAM WILL BE THE FIRST TO PILOT THIS. IT'S A FORMAL PROCESS AND IT'S A TIME LINE TO MAKE SURE IN THAT ALL THE CRITICAL ELEMENTS ARE MET BECAUSE A LOT OF THINGS WE HEAR ABOUT WE DIDN'T HAVE AWARENESS OR ADVANCED NOTICE, DIDN'T HAVE OPPORTUNITY FOR PEOPLE NOT ON SIGN TO ENGAGE, WITH VALUABLE INPUT TO PROVIDE. WE'RE PROVIDING DIFFERENT MECHANISMS AND METHODS TO MAKE SURE WE HAVE THE MOST PARTICIPATION AND MOST VOICES WHEN WE HAVE THESE CONSULTATIONS. AND IN TERMS OF THE NORTH CAROLINA, MORE OF THE EAST COAST, SO WE -- BECAUSE I'M NAVAJO, SOUTHWEST AND FAMILIAR WITH THAT COAST OR AREA IN CALIFORNIA, IN THE FIRST YEAR WE'VE BEEN ABLE TO HAVE A LOT OF ENGAGEMENT THERE. WE'VE BEEN A LOT IN ALASKA AND NOW BEGINNING TO MOVE EAST. AND WE'VE ALSO -- WE WENT TO NIEHS, CAROLINA, AN ACADEMIC WAS ABLE TO SERVE ON THE PANEL. THAT'S OUR KEY FOCUS FOR US, TO MAKE SURE WE HAVE UNIFORM COVERAGE ACROSS THE COUNTRY. THE TALENT IS EVERYWHERE. WE NEED TO IDENTIFY IT. IN TERMS OF THE STATE, RECOGNIZED TRIBES, OUR GOAL IS TO MAKE SURE WHOEVER HAS VALUABLE INPUT, FOR THE CONSULTATIONS, THE ONLY LIMITATION IS THE GOVERNMENT-TO-GOVERNMENT STATUS, SO THEY CAN'T SIT AT THE TABLE WHEN WE HAVE POLICY DISCUSSIONS OR PROGRAMMATIC DISCUSSIONS BUT CAN PROVIDE INPUT ANY WAY THEY WANT TO, AND HOW THEY CAN DO THAT IS TO GO THROUGH ONE OF THE SEATED DELEGATES, THROUGH THE COMMITTEE AND PROVIDE RECOMMENDATIONS OR THAT INPUT AND WE CAN ADDRESS IT IN THAT WAY AS WELL. SO THERE ARE DIFFERENT MECHANISMS AND WE ARE APPROACHING OUR -- WE ARE ADDRESSING ISSUES THAT ARE BROUGHT UP BY STATE-RECOGNIZED TRIBES, IT'S -- ALSO APPLIED TO FEDERALLY RECOGNIZED TRIBES. >> DAVID, THANK YOU VERY MUCH. SPERO MANSON, UNIVERSITY OF COLORADO. UNTIL THE OFFICE WAS ESTABLISHED AND YOU YOUR STAFF OCCUPIED IT SEVERAL YEARS AGO, IT WAS ONE INSTITUTE OR DIVISION OR PROGRAM WITHIN AN INSTITUTE. WE ALL KNOW, YOU'VE SEE AND KNOW ONE INSTITUTE, YOU SEE AND KNOW ONE INSTITUTE. LEGAL COUNSEL AROUND DATA SHARING, GOVERNMENT ARRANGEMENT RANGED FROM ABSOLUTE IGNORANCE THROUGH REALLY SUBSTANTIAL UNDERSTANDING. IT WAS VERY DIFFICULT FOR THOSE OF US IN THE SCIENTIFIC FIELD AS WELL AS OUR CONSTITUENTS TO NAVIGATE THE INSTITUTE SO WITH THE ESTABLISHMENT OF THIS OFFICE IT REALLY HAS SERVED AS A MAJOR POINT OF CONTACT. I WANT TO CREDIT NOT ONLY DAVE'S WORK AND THAT OF HIS STAFF BUT ALSO NIMHD AND WITH ELISEO'S LEADERSHIP, THE RELATIONSHIP BETWEEN NIMHD AND DAVE'S OFFICE IS EXEMPLARY. WE HOLD THAT AS A MODEL FOR THE OTHER INSTITUTES, THE DEGREE OF COLLABORATION, BOTH AT THE LEVEL OF VISIONING AS WELL AS IMPLEMENTATION OF THAT VISION IS REALLY SUBSTANTIAL. AND THIS IS NOT JUST ABOUT MATTERS OF SOCIAL JUSTICE AND ADVOCATING FOR HEALTH EQUITY. ONE OF THE THING DAVE AND COLLEAGUES BROUGHT TO THE CONVERSATION AS WE CONSTANTLY HEAR ABOUT FROM NIMHD IS REAL COMMITMENT TO THE SCIENCE AND THE ABILITY TO TRANSLATE THE IMPORTANCE OF THE SCIENCE INTO MATTERS OF EQUITY AND JUSTICE. AND DEMONSTRATING THE INTIMATE RELATIONSHIP IN THAT EXCHANGE. AND I THINK IT'S REALLY MOVED THE DISCOURSE FORWARD IN OUR RESPECTIVE COMMUNITIES. AND THE RECEPTIVITY THAT'S COMING ABOUT. I WANTED TO THANK DAVE AND ELISEO BROADLY FOR THIS COMMITMENT. >> THANK YOU. >> : FERNANDO MENDOZA, STANFORD. IN MY REGION, THERE'S A NATIVE AMERICAN HEALTH CENTER, AND THE URBAN AREAS.ERICAN PEOPLE IN AS YOU LOOK AT THIS, THAT'S GOING TO BE ONE OF THE CHALLENGES, HOW TO REACH OUT TO THAT GROUP. MOREOVER, THE OTHER QUESTION I WOULD LIKE TO GET SOME INFO ON IS WITH REGARD TO FQHCs, HOW DO THEY LINK TO HELP YOUR CAUSE. >> WE WANT TO MAKE SURE -- WE WORK THROUGH THE INDIAN HEALTH SERVICE. THAT'S OUR PRIMARY PARTNER IN TERMS OF THE CLINICAL CARE AND ENGAGING THAT COMMUNITY. THROUGH THE FQHCs WE'VE BEEN WORKING WITH THE "ALL OF US" RESEARCH PROGRAM, AND ESTABLISHING THEIR PROTOCOL FOR ENGAGING TRIBAL COMMUNITIES IN THE RESPECTFUL WAY SO WE'RE HOPING THAT WILL TRANSLATE INTO BROAD SPECTRUM PRACTICES AT EACH OF THE DIFFERENT SITES. SO I HOPE THAT ANSWERS YOUR QUESTION. WE HAVEN'T REALLY GOTTEN INTO DEPTH ABOUT STANDARDIZING THAT ENGAGEMENT YET. >> I'M IGNORANT ABOUT GOVERNMENT T GOVERNMENT POLICIES AND ISSUES WILL SOVEREIGNTY BUT SEE RELEVANCE TO NATIVE HAWAIIANS, SOCIAL JUSTICE ISSUES, AND I WAS WONDERING IF THERE IS ANY PLAN TO CREATE A SIMILAR OFFICE WITHIN DPCPSI FOR NATIVE HAWAIIANS AND PERHAPS OTHER POPULATIONS, AMERICAN SAMOANS. >> A GREAT QUESTION. THIS IS SOMETHING THAT WE HAVE BEEN DISCUSSING FOR QUITE A WHILE. AND THIS IS ACTUALLY ON THE RADAR FOR ELISEO AND I TO HAVE CONVERSATIONS WITH OTHER I.C. DIRECTORS ABOUT HOW THIS VERY IMPORTANT NEED IS GOING TO BE MET. SO IT IS NOT SOMETHING THAT WE'RE NOT PAYING ATTENTION TO. >> I RECALL MEETING YOU TWO YEARS AGO, I ASKED THE SAME QUESTION REGARDING NATIVE HAWAIIANS AND PACIFIC ISLANDERS, THE OTHER INDIGENOUS POPULATION THAT DON'T HAVE THE TRIBAL RECOGNITION AT AMERICAN INDIANS AND ALASKA NATIVES BUT WE HAVE NATIVE HAWAIIAN HEALTH AUTHORIZATION ACT. I DON'T KNOW IF THERE'S AN OPPORTUNITY TO ENHANCE OPPORTUNITIES FOR HEALTH RESEARCH FOR NATIVE HAWAIIANS OR LEVERAGE THAT, SIMILAR TO THE -- YOU FOLKS HAVE A PARTICULAR POLITICAL STATUS. WE DON'T. PERHAPS THROUGH THAT KIND OF FEDERAL ACT MAYBE THERE'S AN OPPORTUNITY TO LEVERAGE THAT FOR SOMETHING. I DON'T I DON'T KNOW. >> OUR TEAM WILL BE IN HAWAII FOR THE NARCH P.I. MEETING DURING HALLOWEEN, IF YOU'RE AROUND, IF YOU'RE THERE. >> I'LL BE AROUND. >> FANTASTIC. THANKS. >> ANN ANNAPOLIS, INTRAMURAL, NIMHD. I HAD A QUICK QUESTION ABOUT THE -- I'M INTRIGUED BY THE TRIBAL CONSULTATION PROCESS WITH PRECISION MEDICINE, WITH THE "ALL OF US" MOVEMENT, HOW YOU WILL EVALUATE THAT EFFORT AND WHAT OUTCOMES, WHAT METRICS, WHAT DO YOU EXPECT, WHAT ARE THE OBJECTIVES OF THAT EFFORT? >> : SO, THE OBJECTIVES ARE TO HOLD IT IN A STANDARD UNIFIED WAY THAT TRIBAL NATIONS FROM ANYWHERE ACROSS THE COUNTRY WILL KNOW IF YOU SAY THAT THE "ALL OF US" PROGRAM IS IN STEP THREE OF THE CONSULTATION PROCESS, THEY WILL KNOW EXACTLY WHERE THEY ARE AT AND WHAT'S HAPPENING NEXT. THE OUTCOMES ARE BROAD AND UNIQUE TO EACH CONSULTATION PROCESS. WHAT WE WANT TO DO IS JUST PROVIDE THE OPPORTUNITY FOR TRIBAL NATIONS TO HAVE THAT OPPORTUNITY TO PROVIDE INPUT AND THEN IT'S UP TO THE PROGRAM SINCE WE RUN THE THRO THEN WHOEVER IS MANAGING, ERIC DISHMAN AND HIS TEAM WILL ADDRESS THE COMMENTS OR RECOMMENDATIONS THAT COME OUT OF THE CONSULTATION >> GOOD AFTERNOON, EVERYONE. I AM GOING TO TAKE A FEW MINUTES TO TALK ABOUT THE TRIENNIAL REPORT. THIS DOCUMENT WAS POSTED ON THE ELECTRONIC COUNCIL BOOK, AND IT WAS IN YOUR PACKETS TODAY. SO, JUST SOME BASIC FOUNDATION. NIH IS REQUIRED BY LAW TO INCLUDE WOMEN AND MINORITIES IN ALL CLINICAL RESEARCH STUDIES. AND IF IT IS AN NIH PHASE 3 CLINICAL TRIAL MUST VOID VALID ANALYSIS WITH SEX, GENDER, RACE AND ETHNICITY. AND THIS ALSO REQUIRES THAT THE RESULTS BE POSTED IN clinicaltrials.gov. AND THIS IS THE DEFINITION OF THE CLINICAL RESEARCH USED BY NIH, INCLUDE PATIENTS ORIENTED RESEARCH, EPIDEMIOLOGICAL AND BEHAVIOR STUDIES, OUTCOMES, RESEARCH AND HEALTH SERVICES RESEARCH. IT DOES NOT INCLUDE THOSE STUDIES THAT WOULD FALL UNDER EXEMPTION 4, WHICH AS MANY OF YOU KNOW ARE ANY STUDIES OR RESEARCH THAT IS DONE ON EXISTING DATA. SO ANY DOCUMENTS, RECORDS, PATHOLOGY SPECIMENS, ANYTHING THAT IS PUBLICLY AVAILABLE OR DE-IDENTIFIED WHEN IT COMES TO SAMPLES AND SPECIMENS. THE TRIENNIAL REPORT WAS FORMERLY KNOWN AS THE BIENNIAL REPORT, PRESENTED TO COUNCIL BIANNUALLY. WITH THE 21ST CENTURY CURES IT'S NOW TRIENNIALLY, AND MUST BE PART OF THE NIH DIRECTOR'S REPORT. AND SO THE CURRENT PLAN BASED ON THE REQUIREMENT FROM THE 21ST CENTURY CURES IS THE REPORT FOR 2019 WILL INCLUDE DATA FROM 2016, 2017, AND 2018. THIS IS AGGREGATE DATA. AGAIN, THE REPORT IS TO BE COMPLETED IN 2019. SO, THE IMPLEMENTATION OF THE POLICY INVOLVES A PARTNERSHIP BETWEEN RESEARCHERS, THE NIH STAFF, AND ALL OF THE MILLIONS OF INDIVIDUALS THAT AGREE TO PARTICIPATE IN CLINICAL RESEARCH. BRIEFLY, SOME OF THE NIH RESPONSIBILITIES INCLUDE TRAINING OF STAFF, PROVIDING TRAINING MATERIALS FOR STAFF, FOR RESEARCHERS, AND FOR REVIEWERS, THAT SERVE ON THE PEER REVIEW PANELS. THE APPLICANT'S RESPONSIBILITY IS TO HAVE INCLUSION PLAN IN THEIR APPLICATION AND TO PROVIDE ENROLLMENT TABLES. AND, AGAIN, IF IT'S AN NIH PHASE 3 CLINICAL TRIAL THERE MUST BE A PLAN FOR VALID ANALYSIS. AND THEY MUST PROVIDE YEARLY UPDATES ON HOW THEY ARE DOING. AND I'M GOING TO GO THROUGH THESE QUICKLY BECAUSE I KNOW YOU GUYS KNOW ALL OF THIS, BUT I JUST WANT TO LET YOU KNOW WHAT THE PARTNERSHIP INVOLVES. THE REVIEWER'S RESPONSIBILITY, THAT'S A BIG ONE. THEY HAVE TO EVALUATE THAT PLAN. AND TO SEE IF IT REALLY IS IN COMPLIANCE. AND THEN THEY HAVE TO RATE THE PLAN. THE PLAN IS RATED EITHER ACCEPTABLE, IF IT MEETS THE COMPLIANCE ISSUE OR UNACCEPTABLE. AND IF IT IS UNACCEPTABLE, THAT IS A BAR TO AWARD. AND SO THE RATING MUST BE FACTORED INTO THE OVERALL SCORE, BUT EVEN IF THIS SCORE IS IN WHAT WE'VE CONSIDERED THE, YOU KNOW, GREATEST POSSIBILITY OF BEING FUNDED, IF THAT BAR IS NOT REMOVED, THEN THERE CAN BE NO FUNDING UNTIL THERE'S SOME RESOLUTION OF WHATEVER THOSE ISSUES WERE IDENTIFIED BY THE REVIEWERS AS CAUSING THIS APPLICATION TO HAVE AN UNACCEPTABLE RATING. SO THIS IS WHERE PROGRAM STAFF WORKS VERY CLOSELY WITH INVESTIGATORS TO TRY AND ADDRESS WHAT THOSE ISSUES ARE, HOW TO GET THEM CLEARED UP AND LIFT THE BAR WORKING DIRECTLY WITH INVESTIGATORS AND WITH THE O D'S OFFICE TO GET THAT INFORMATION CLEARED. BEFORE THAT, ONE OF THE THINGS THAT PROGRAM OFFICERS DO ROUTINELY WHEN IT'S APPROPRIATE TO MAKE SURE THAT THE INCLUSION INFORMATION IS IN ALL FOAs. WHEN THE APPLICATIONS HAVE GONE THROUGH PEER REVIEW AND THEY ARE ON OUR LIST TO DISCUSS FOR FUNDING THEY TAKE A SECOND LOOK TO MAKE SURE THAT THE INCLUSION INFORMATION IS IN THE APPLICATION AND ONCE WE HAVE AGREED THAT THESE APPLICATIONS ARE THE ONES THAT WILL BE FUNDED, PROGRAM STAFF WILL MONITOR THE PROGRESS WHEN IT COMES TO THE RECRUITMENT AND ENROLLMENT OF INDIVIDUALS. I ALREADY MENTIONED THEY WORK WITH THE INVESTIGATORS TO REMOVE THE UNACCEPTABLE RATING. AND GRANTS MANAGEMENT HAS A ROLE IN THIS TOO BECAUSE GRANTS MANAGEMENT HAS TO ENSURE APPROPRIATE TERMS OF CONDITION ARE ON THE NOTICE OF GRANT AWARD, AND THEN THEY ALSO HAVE TO MAKE SURE THAT THE OFFICIAL FILES ARE DOCUMENTED, EVERYTHING THAT IS DONE HAS TO BE REPORTED AND RECORDED. AND NOW I WANT TO TELL YOU ABOUT THE DATA THAT YOU SAW IN THE REPORT THAT WAS IN YOUR -- THAT WAS SENT TO YOU. THIS IS AGGREGATE DATA, OKAY? AND, AGAIN, IT'S GOING TO COVER 2016, 2017, 2018, AND SO THE TOTAL NUMBER OF RECORDS THAT WERE PULLED TO LOOK AT THIS, THESE ARE RECORDS THAT WERE IDENTIFIED AS BEING CLINICAL RESEARCH. SO AS YOU CAN SEE FOR 2016 THERE WERE 364, 2017 THERE WERE 378, 2018, 551. NOW, FROM THESE RECORDS THEY IDENTIFIED THE ONES WHO ACTUALLY DIDN'T HAVE ANY ENROLLMENT. THERE COULD BE ONE OF THE MOST COMMON REASONS OF THAT IS THEY HADN'T STARTED ENROLLMENT YET. SO THAT'S WHY THERE WAS NO INDICATION, NO ENROLLMENT TABLE. THE NEXT THING THEY DO IS TO LOOK AT U.S. SITES VERSUS NON-U.S. SITES, AS YOU CAN SEE FOR ALL OF THE YEARS WE ONLY HAVE ONE STUDY THAT WAS IDENTIFIED AS CLINICAL RESEARCH, THAT WAS A FOREIGN SITE, OR NON-U.S. SITE. THE NEXT THING THAT IS DONE IS TO REMOVE FEMALE-ONLY STUDIES AND REMOVE MALE-ONLY STUDIES. AND BY THE WAY, I DIDN'T THINK I MENTIONED IT BUT THIS DATA IS MONITORED AND TRACKED THROUGH THE OFFICE OF EXTRAMURAL RESEARCH AND O.D. THE FINAL TALLY OF NUMBER OF RECORDS IS IN THE FAR RIGHT-HAND COLUMN. YEAH, OR LEFT? IS 232, 220, 209, THE FIRST CATEGORY OF DATA THAT WE'RE GOING TO LOOK AT IS THE NIMH M.D. ENROLLMENT BY SEX AND GENDER. YOU HAVE THE -- YOU HAD -- IN YOUR REPORT, YOU HAD ONE BIG TABLE THAT HAD A LOT OF INFORMATION IN IT, SO I'M TRYING TO DECIPHER SOME FOR YOU. I'M STARTING WITH SEX AND GENDER, AGAIN YOU'RE LOOKING AT TOTAL ENROLLMENT, IT SHOWS TOTAL NUMBER OF FEMALES. AND WHAT WE WANT TO FOCUS ON IS IF YOU LOOK FROM 2016, 2017, 2018, YOU CAN SEE THAT NIMHD IS PRETTY MUCH AT THE 50% LEVEL ACROSS ALL YEARS WHEN IT COMES TO THE ENROLLMENT OF FEMALES IN OUR PROJECTS THAT ARE LABELED AS CLINICAL RESEARCH. THIS IS CONSISTENT. AND I'LL TALK ABOUT UPS AND DOWNS, DIPS AND RISES IN THE DATA WHEN I GET TO THE BIGGER PICTURE. BUT AS YOU CAN SEE WHEN IT COMES TO THE INCLUSION OF WOMEN IN CLINICAL RESEARCH, NIMHD HAS BEEN CONSISTENT IN HAVING 50% OR CLOSE TO 50% ACROSS THE THREE YEARS IN WHICH WE'RE REQUIRED TO REPORT ON. AND NOW I'M GOING TO -- THIS IS ANOTHER WAY OF LOOKING AT THE DATA, IT HAS THE ACTUAL NUMBERS IN THE BAR GRAPH. SO IT'S A COMPLEMENT OF THE SAME DATA THAT YOU SAW IN THE LAST SLIDE. THEN I'M GOING TO MOVE TO MINORITY ENROLLMENT. POLICY REQUIRES INCLUSION OF WOMEN AND MINORITIES IN ALL CLINICAL RESEARCH. AGAIN, WE'RE LOOKING AT TOTAL NUMBER OF ENROLLEES AT THE FIRST COLUMN. THEN THE MINORITY ENROLLMENTS AND PERCENTAGES. AND YOU CAN SEE AS WE MOVE FROM 2016, 2017, TO 2018, THE ENROLLMENT OF MINORITIES IN THE PROJECTS THAT WE HAVE SUPPORTED AS CLINICAL RESEARCH HAS BEEN VERY GOOD, OVER 50%. 64.7%, 67.1% IN 2017, AND 66.6% IN 2018. AND JUST AS A QUICK UNOFFICIAL REFERENCE, THIS IS THE DATA FROM NIH, AGAIN THIS IS AGGREGATE DATA, IT INCLUDES ALL OF THE NIH INSTITUTES AND CENTERS, SO WE ARE INCLUDED IN THAT. AS YOU CAN SEE WHEN IT COMES TO CLINICAL RESEARCH, THE 2016, THE PERCENTAGE OF MINORITIES FOR ALL OF NIH STUDIES IS 36.4, 017 IS 28.3, 2018 IT'S 29.3. SOME STUDIED MIGHT HAVE BEEN ENDING, SOME LARGE STUDIES MIGHT HAVE HAD MINORITIES, MIGHT HAVE BEEN SUNSETTING OR CLOSING. AND THEN AGAIN YOU HAVE RECRUITMENT OF NEW SUBJECTS. SO JUST TO KEEP YOUR FOCUS AGAIN ON THE NIMHD DATA, WE'RE DOING VERY WELL WITH REGARDS TO COMPLYING WITH THE POLICY FOR INCLUSION OF WOMEN AND MINORITIES IN CLINICAL RESEARCH. AND NOW I'LL MOVE TO RACE. THIS IS THE BOTTOM TABLE, ONE OF THE TABLES THAT IS IN YOUR REPORT. AND THIS IS JUST A NICE WAY OF LOOKING AT THE DIFFERENT CATEGORIES OF RACES THAT WERE INVOLVED IN THE STUDY. FROM THE WAY THAT -- SO WE'RE FOCUSING ON WHITES, NATIVE HAWAIIAN, PACIFIC ISLANDERS, BLACK, AFRICAN-AMERICANS, ASIAN, AMERICAN INDIANS/ALASKA NATIVES. THERE'S THOSE THAT WERE MORE THAN ONE RACE, AND UNKNOWN, NOT REPORTED. SO, IF YOU LOOK AT THE DATA AND WE JUST TAKE AFRICAN-AMERICANS AS WE GO FROM 2016 TO 2017 TO 2018, WE'RE PRETTY STEADY IN TERMS OF INCLUDE OF AFRICAN-AMERICANS. AGAIN, IF YOU WANT TO FOCUS ON WHITES, WE GO FROM 35.4 IN 2016, TO 39.1 IN 2017, TO 38.8 IN 2018. WHEN YOU SEE FLUCTUATIONS, WHERE THERE MAY BE A DROP IN A PARTICULAR RACE OR BACK IN THE CASE WITH WOMEN, KEEP IN MIND THAT WE TRANSITIONED FROM OUR LARGE CENTERS, CENTERS OF EXCELLENCE, RESEARCH CENTERS, TO R01s. AND SO DURING THAT TIME PERIOD, SOME OF THOSE LARGE POPULATIONS THAT MIGHT HAVE HAD WOMEN OR PARTICULAR RACE, YOU KNOW, AND MINORITIES IN THEM, THERE MAY BE A DROP. AT THE SAME TIME, WE TRANSITIONED FROM THOSE CENTERS TO R01s, SO DURING 2017 THOSE STUDIES WERE PROBABLY ENROLLING SUBJECTS AT THAT TIME. AND SO WHEN YOU SEE THE NUMBERS GO UP AGAIN IN 2018, IT'S BECAUSE NOW YOU'RE COUNTING THOSE INDIVIDUALS THAT WERE BEING RECRUITED AT THE END OF 2016 AND INTO 2017. AND THIS IS JUST ANOTHER WAY OF LOOKING AT THE DATA, THIS IS THE SAME DATA YOU SAW IN THE LAST SLIDE. IT'S JUST PIECHARTS SEEM TO BE EASIER TO DIGEST SOMETIMES. BUT IT'S THE SAME DATA IN TERMS OF THE PERCENTAGES. SO THOSE -- YOU CAN SEE HOW THEY VARY ACROSS THE THREE YEARS THAT WE'RE REQUIRED FOR REPORTING. AND THEN THE LAST SLIDE IS ON ETHNICITY. FOCUSING ON NOT HISPANIC AND HISPANIC/LATINO, UNKNOWN, NOT REPORTED. AS YOU LOOK AT DATA AS WE GO FROM 2016 TO 2018, THE PERCENTAGE OF NOT HISPANIC GOES FROM 81, 82.5, TO 81.2, PRETTY STEADY. THE PERCENTAGE OF HISPANIC/LATINO FROM 13.8 TO 16.1, TO 16.8. AND THEN WE HAVE PROPORTION OF INDIVIDUALS THAT WERE UNKNOWN. AND THAT'S JUST THE ACTUAL NUMBERS OF ENROLLEES, BUT AS YOU CAN SEE WE HAVE COMPLIED WITH THE INCLUSION POLICY, WITH REGARDS TO ENROLLING WOMEN AND MINORITIES. AND ALL OF THE RESEARCH THAT WE FUND THAT IS CONSIDERED CLINICAL RESEARCH. SO, AT THIS POINT I'LL STOP AND IF YOU HAVE ANY QUESTIONS I'LL BE HAPPY TO ANSWER THEM. YES. DR. GREENE. >> I'M NOT SURE HOW TO FORMULATE THIS PROPERLY. BUT I TAKE THE OVERALL GOAL IS TO HAVE MORE INCLUSION OF MINORITIES AND ETHNICITIES IN RESEACH, BUT HOW DO YOU ASSESS WHETHER THE NUMBERS ARE -- HOW DO YOU ASSESS WHETHER THE NUMBERS ARE APPROPRIATE IN RELATION TO INCIDENCE OF PARTICULAR DISEASES IN A POPULATION. I'M TRYING TO FIGURE OUT HOW YOU GO FROM THE GROSS NUMBERS, MAYBE AN INCREASE, TO WHETHER IN FACT THE PARTICULAR POPULATIONS HAVE HIGHER BUT INCIDENCES AND THEN THEREFORE THE FACT THAT THEY ARE REPRESENTED IS ONLY ONE LEVEL OF INQUIRY. THE QUESTION IS WHETHER THEY ARE APPROPRIATELY REPRESENTED, AND I KNOW AROUND THE TABLE PEOPLE COULD PUT THAT QUESTION A LITTLE BIT DIFFERENTLY BASED ON THEIR EXPERTISE. >> EXCELLENT QUESTION THE WAY YOU POSED IT. >> I'VE LEARNED A LOT, THANK YOU. >> FOR THIS DATA, THIS IS NOT -- YOU KNOW, IT'S NOT TYING IT TO A PARTICULAR DISEASE OR CONDITION. THIS REPORT IS REALLY FOCUSED ON INCLUSION OF WOMEN, INTO OUR CLINICAL RESEARCH, INCLUSION OF MINORITIES INTO OUR CLINICAL RESEARCH. NOW, TO GET AT YOUR QUESTION, WHERE THAT IS DONE, THAT STARTS IN WITH THE APPLICANT AND THEN IN THE REVIEW PROCESS BECAUSE THE -- THERE ARE PARTS OF THIS POLICY THAT ALSO FOCUS ON HAVE YOU INCLUDED THE PERCENTAGE OF INDIVIDUALS, WOMEN OR MINORITIES, THAT IS APPROPRIATE FOR THAT DISEASE OR CONDITION. THAT IS A CRITERIA FOR EVALUATION. AND THAT IS DONE. NOT FOR THIS REPORT BUT THAT IS DONE. AND THEN TO HELP WITH THAT THERE ARE RCDC REPORTING CATEGORIES, AND I DON'T REMEMBER WHAT RCDC STANDS FOR, DR. STINSON, IF YOU WANT TO IDENTIFY WHAT THAT IS. OH, HE DOESN'T WANT TO. OKAY. WELL, OKAY. REALLY, THOSE ARE THE CATEGORIES. SO WHETHER IT WOULD BE HEART DISEASE OR MENTAL HEALTH OR DIABETES OR OBESITY, AND THAT IS IDENTIFIED. AND THAT'S VERY IMPORTANT, BECAUSE EVEN WITH THE POLICY YOU DON'T JUST PUT NUMBERS IN JUST BECAUSE -- JUST FOR THE SAKE OF NUMBERS. IT SHOULD BE RELEVANT TO THE DISEASE OR THE CONDITION THAT IS BEING STUDIED. FOR THIS REPORT IT'S JUST TO SHOW WE HAVE COMPLIED. THIS IS AGGREGATE DATA. THE NIH DATA, THE BIG REPORT THAT WILL BE -- WHETHER ALL OF THE I.C.s ARE SIMULATED INTO THE DIRECTOR'S O AGAIN THAT'S AGGREGATE DATA. >> AT THE LEVEL OF THE REVIEW OF A PARTICULAR GRANT PROPOSAL, THEN WHAT IS THE MECHANISM FOR ENSURING THAT THE REVIEW HAS APPROPRIATELY EVALUATED THAT PERCENTAGE OF INCLUSION. >> RIGHT. THAT'S A GOOD QUESTION TOO. SO DURING THE REVIEW PROCESS, FIRST AGAIN, IT ALWAYS STARTS WITH THE INVESTIGATOR, YOU KNOW, FOR WHATEVER STUDY HE IS PROPOSING TO PUT IN THE RIGHT PERCENTAGES, BUT AT THAT REVIEW MEETING YOU HAVE EXPERTS THAT ARE SITTING THERE WHO ARE SUPPOSED TO BE EXPERTS IN THE FIELD FOR WHATEVER THE DISEASE OR CONDITION IS BEING, YOU KNOW, PROPOSED IN THE APPLICATIONS, THE PEER REVIEW PEOPLE SPENT A LOT OF TIME MAKING SURE THEY HAVE THE RIGHT LEVELS OF EXPERTISE. AND SO THEY ARE EVALUATING SCIENTIFIC MERIT OF THAT APPLICATION AND SCIENTIFIC MERIT AND SIGNIFICANCE OF THE PROJECT THAT IS BEING PROPOSED. AND SO IF YOU HAVE A STUDY ON A CONDITION IN WHICH WE KNOW THERE'S A SIGNIFICANT NUMBER OF MINORITIES IN IT, WHETHER IT BE ONE PARTICULAR MINORITY GROUP OR ANOTHER, THAT'S NOT INCLUDED IN YOUR STUDY, THE FIRST THING THE PEER REVIEWERS ARE GOING TO DO, REMEMBER I WAS SHOWING WHAT PEER REVIEW, THEY WILL SAY THAT PLAN IS UNACCEPTABLE. OR IF THERE'S NO PLAN AT ALL, THAT'S ANOTHER UNACCEPTABLE RATING FOR THAT APPLICATION. >> CAN I ADD ANOTHER COMMENT TO WHAT DR. GREENE WAS SAYING? ONE OF THE THINGS THAT NIH HAS REALLY REEMPHASIZED WITH THE PROGRAM OFFICIALS IN THE INSTITUTE IS THAT THE ISSUES AROUND INCLUSION ARE CRITICALLY IMPORTANT BEYOND WHAT HAPPENS AT THE REVIEW STAGE, AS DR. HUNTER MENTIONED, SO THAT THE PROGRAM OFFICIALS NEED TO BE LOOKING CRITICALLY AT THE ENROLLMENT DURING THE LIFE OF THE GRANT ITSELF. AND TO BE WILLING TO TAKE STEPS UP TO THE POINT OF ENDING A STUDY IF THEY ARE NOT ENROLLING PARTICIPANTS AS HAD BEEN, YOU KNOW, DECLARED IN THE APPLICATION ITSELF BECAUSE WHEN RETROSPECTIVE LOOK WAS TAKEN THAT, YOU KNOW, A LOT OF APPLICANTS KNOW WHAT WE HAVE AN INTEREST IN OR WHAT THE TARGET ENROLLMENT REALLY SHOULD BE BASED ON CONSIDERATIONS YOU MENTIONED BUT AT THE END OF THE STUDY GO BACK AND LOOK AT THE ACTUAL ENROLLMENT THAT HAS OCCURRED A LOT OF TIMES THE NUMBERS ARE LOW AND DIVERSITY OF PARTICIPATIONS DO NOT MATCH WHAT YOU'RE SAYING. SO THAT'S SOMETHING THAT THE OFFICE OF EXTRAMURAL RESEARCH HAS EMPHASIZED AT ALL THE INSTITUTES TO TAKE A VERY, VERY CRITICAL APPROACH TO HOW THE GRANTEES ARE ENROLLING PEOPLE IN A MUCH MORE REALTIME BASIS. THAT'S WHY SOME OF THE TOOLS THAT THEY HAVE GIVEN WITH THE NEW ENROLLMENT SYSTEM, WHERE WE CAN SEE A MORE REALTIME GLIMPSE OF WHAT ENROLLMENT IS INSTEAD OF JUST LOOKING AT THE END OF A PROGRESS REPORT, KIND OF A YEAR BEHIND. >> I HAVE AN OBSERVATION AND QUESTION. SO I NOTICED FOR AMERICAN INDIANS/ALASKA NATIVES, THERE WAS A SIGNIFICANT DROP OVER THE YEARS IN THEIR ENROLLMENT. NATIVE HAWAIIANS, PACIFIC ISLANDS STAYED SAME, OTHER STAYED SAME OR IMPROVED. DOES THAT REFLECT THE MOVE AWAY FROM CENTERS TO MORE R01s WHICH CENTERS WERE ADDRESSING AMERICAN INDIAN/ALASKA NATIVES OR ARE WE SEEING YES. >> THE FIRST PART IS YES, IT'S A SHIFT FROM THE RESEARCH CENTERS TO R01s, AND ALSO THE SUNSETTING OF -- OR ENDING OF A COUPLE OF TRANSCOLLABORATIVE CENTERS THAT WE HAD. AND ONE OF WHICH WAS ON SOCIAL DETERMINANTS OF HEALTH WITH A LARGE AMERICAN NATIVE POPULATION IN IT. NOW AS WE MOVE TOWARDS THE R01s, NOW WE HAVEN'T -- WE'RE STILL DOING CENTERS, BUT EVERYTHING HAS A CYCLE. BUT SO WITH THE R01s, THEY WERE STARTING TO ENROLL, AND THOSE STUDIES WILL HAVE -- YOU KNOW, HAVE AMERICAN INDIANS IN THEM AS WELL. SO THAT'S WHY YOU SEE THE NUMBERS ACTUALLY KIND OF STAYED -- WELL, THEY WENT UP. OKAY, I'M NOT LOOKING AT THIS GOOD. YEAH. THEY WENT DOWN, THE PERSONAL WENT DOWN. SO THAT'S MORE RELATED TO SUNSETTING OF SOME OF THOSE PROJECTS. >> SO, LUCIA BROUGHT UM -- UP HALF OF THE UNITED STATES KIDS ARE MINORITIES, TO ME TO THINK ABOUT MEASURING THESE ASSESSMENTS OF PARTICIPATION BASED ON POPULATION THAT THEY ARE LOOKING AT, SO FOR KIDS RIGHT NOW THE MARK OUGHT TO BE 50%, BECAUSE THAT IDEALLY IS WHAT THE UNIVERSE OF OUR KIDS LOOKS LIKE. IF IT'S 30%, THAT MEANS THEY ARE MISSING AN OPPORTUNITY THERE. SO AS THE POPULATION CHANGES OVER TIME, NEXT 20 YEARS, 50% MINORITIES, THESE NUMBERS NEED TO KIND OF BALANCE THEMSELVES OUT AS THE POPULATION CHANGES. SO SOMEHOW THAT NEEDS TO GET INTO RESEARCHERS' PERSPECTIVES. >> YES. >>> THANK YOU FOR THE PRESENTATION. I THINK A THREE-YEAR LOOK IS A BETTER WAY FOR US TO THINK ABOUT THESE TRAJECTORIES BECAUSE JUST TWO POINTS IN TIME CAN BE MISLEADING. I HAVE TWO QUESTIONS SOMEWHAT UNRELATED. THE FIRST IS TO ADDRESS LINDA'S QUESTION AROUND PARITY, AND WHAT IS THE MOST APPROPRIATE MEASURE OF PARITY. AND I ACTUALLY THINK IT'S AN EMPIRICAL QUESTION THAT NEEDS TO BE TESTED TO LOOK AT IS IT PARITY BY SORT OF THE DEMOGRAPHICS OF OUR NATION, PARITY BY THE INCIDENCE OR PREVALENCE OF DISEASE, OR PARITY IN TERMS OF OUTCOMES. AND WHILE MY HOPE IS THAT STUDY SECTIONS ARE LOOKING AT THE QUESTIONS OF PARITY, AS WE THINK ABOUT THE STUDIES BEING FUNDED, MY EXPERIENCE IS THAT THERE ARE VERY FEW STUDIES THAT ARE NOT MOVING FORWARD, WHEN WE DON'T SEE THE APPROPRIATE PARITY. PART OF IT HAS TO DO WITH THE WAY WE -- WHICH IF ANY OF THESE MEASURES THAT WE USE IN TERMS OF THINKING ABOUT PARITY, IF WE'RE THINKING ABOUT, SAY, DIABETES AND WE'RE JUST LOOKING AT THE DEMOGRAPHICS OF OUR NATION, WE'RE MISSING A HUGE OPPORTUNITY LOSS THERE. THE OTHER IS WE'VE HAD OVER -- IN THE CLOSED SESSION YESTERDAY AND OVER THE COURSE OF TODAY SOME REALLY FABULOUS PRESENTATIONS ABOUT THE DIVERSITY AND THE WAYS IN WHICH WE NEED TO BE THINKING ABOUT THE POPULATIONS THAT ARE INCLUDED IN THESE TABLES. THAT ARE NOT REFLECTED. AND I REALIZE ALL OF THESE CATEGORIES ARE DRIVEN BY OUR OFFICE OF MANAGEMENT AND BUDGET, SO I DO RECOGNIZE THAT, I DO THINK THERE'S ALSO AN OPPORTUNITY. FOR EXAMPLE, THE DICHOTOMY AND WAY WE THINKING ABOUT GENDER IN OUR TABLES I THINK WE'RE WELL BEYOND THAT, RECOGNIZING AND IN FACT HAVING STUDIES THAT ARE ACTUALLY LOOKING AT NON-BINARY WAYS OF THINKING ABOUT GENDER. I DON'T KNOW HOW THAT'S CAPTURED IN THESE STUDIES, IN THESE TABLES. WHEN WE THINK ABOUT THE DIVERSITY OF THE SOL PROJECT, IT'S JUST NOT CAPTURED HERE. SO I WANTED YOUR REFLECTIONS ON SORT OF WHAT THIS MEANS FOR US AS THE INSTITUTE AND ACROSS THE NIH, AS WE'RE MOVING FORWARD, HOW WE'RE GOING TO CATCH UP AND ADDRESS HEALTH INEQUALITIES IF WE'RE NOT CAPTURING, JUST THE BASIC INFORMATION. >> SO THAT'S A GOOD QUESTION. THANK YOU. THIS BASIC INFORMATION COVERS THE SYSTEM THAT WAS IN PLACE IN 2016, 2017, AND 2018. WELL, YEAH, 2018. WHAT'S IMPORTANT AND WHAT CAN'T BE SEEN HERE OR YOU WOULD KNOW IS THAT THE ENROLLMENT TABLES HAVE CHANGED. THEY HAVE BEEN EXPANDED IN TERMS OF THE CATEGORIES THAT ARE NOW REQUIRED TO BE REPORTED. SO THE 2019, 20 AND 21 DATA WILL HAVE MORE CATEGORIES. THE OTHER IMPORTANT THING THE INCLUSION ACROSS THE LIFESPAN POLICY IS IN PLACE. THAT WILL BE REFLECTED IN THE DATA THAT IS TO COME IN THE NEXT REPORTING PERIOD. SO IT'S GOING TO LOOK A LOT DIFFERENT. IT'S STILL GOING TO BE REPORTING ON INCLUSION OF WOMEN AND MINORITIES, BUT THE DATA YOU'RE TALKING ABOUT, IT IS BEING RECORDED. THERE ARE NEW TABLES, A NEW SYSTEM FOR THIS INFORMATION. AND THAT WAS PART OF THE TRAINING, THE MOST RECENT TRAINING THAT STAFF RECEIVED, REVIEWERS RECEIVED, AND SO THAT IS GOING TO BE -- IT'S NOT HERE. IT'S NOT REFLECTED HERE. BUT THAT INFORMATION IS CHANGING IN TERMS OF THE CATEGORIES THAT ARE BEING REPORTED ON WITH REGARD TO SEX AND GENDER, WITH REGARD TO RACE AND ETHNICITY. NATHAN, DID YOU WANT TO ADD ANYTHING ELSE? ALL RIGHT. YES. >> THANK YOU FOR COMPILING AND PRESENTING AND EXPLAINING TO US. ONE THING THAT I HOPE TO LOOK FORWARD IN THE NEXT PRESENTATIONS, THE NEXT COMPILATION OF DATA, WOULD BE MAYBE AN OVERREPRESENTATION OF MINORITIES, SPECIFICALLY LET'S USE THE EXAMPLE OF HISPANICS, THEY ARE 17% OF THE POPULATION AND WE HAVE EXACTLY 17% OF HISPANICS IN THIS TABLE. SO THIS IS INSTITUTE OF MINORITY HEALTH AND DISPARITIES SO I WOULD THINK WITH THE NEW RFAs, NEW INITIATIVES FOR SPECIFIC STUDIES THAT ADDRESS MINORITY HEALTH WE MIGHT -- I EXPECT AN OVERREPRESENTATION OF MINORITIES IN THESE TABLES, IN OUR INSTITUTES. >> THANK YOU VERY MUCH. YES. >> ANOTHER WAY TO LOOK AT THIS DISPARITY AND INCLUSION IS ONCE I WAS TOLD WHEN I WAS APPLYING FOR A GRANT, I CAN'T REMEMBER WHAT IT WAS ABOUT, I ASKED HOW MANY DO I NEED TO HAVE. THE ANSWER I GOT ONCE, I THOUGHT IT WAS VALID, YOU SHOULD HAVE INCLUSION, ADEQUATE FOR THAT GROUP, TO ANSWER THE PRIMARY QUESTION, PRIMARY HYPOTHESIS OF THE STUDY. I THINK IF WE PROMOTE THAT, THEN THE THINGS WILL FALL INTO PLACE. I'LL GO OVER THIS CONCEPT, NANCY JONES WORKED WITH ME ON THIS. AND JUST A REMINDER ABOUT HOW THIS PARTICULAR CONCEPT AND I THINK IT APPLIES TO THEIRS AS WELL, THAT THESE CONCEPTS ARE REALLY BROAD IDEAS, THEY DON'T NECESSARILY JUST REFLECT WHAT WILL BECOME A SINGLE FOA BUT MAY REFLECT MULTIPLE INITIATIVES THAT STEM FROM THIS. HAVING SAID THAT, OBJECTIVE OF THIS INITIATIVE TO SUPPORT PROJECTS TO ADVANCE MEASUREMENT AND ASSESSMENT OF COMPLEX CONSTRUCTS RELEVANT TO MINORITY HEALTH. AND HEALTH DISPARITIES. SO HOPEFULLY THIS IS FAMILIAR TO YOU, THIS IS OUR NIMHD RESEARCH FRAMEWORK, IT HAS NEW COLORS, YOU MAY BE USED TO SEEING -- THIS IS AVAILABLE NOW ON OUR WEBSITE. AS WE MOVE FORWARD PROMOTING THIS FRAMEWORK, TO ENCOURAGE RESEARCH THAT TAKES A MULTI-DOMAIN, MULTI-LEVEL APPROACH, THERE'S CLEARLY LOTS OF STUFF HERE REGARDING DETERMINANTS OF HEALTH THAT REQUIRE ADEQUATE MEASUREMENT OF THESE CONSTRUCTS. IF WE DON'T HAVE ADEQUATE MEASUREMENT, WE'RE NOT GOING TO MAKE A LOT OF PROGRESS IN MOVING -- GENERATING KNOWLEDGE CONSISTENT WITH THIS FRAMEWORK. SO, IF YOU LOOK AT THE LITERATURE ON MEASUREMENT IN HEALTH DISPARITIES RESEARCH, I MEAN LITERALLY IF YOU GOOGLE MEASUREMENT IN HEALTH DISPARITIES RESEARCH BECAUSE THAT'S WHAT I DID, WHAT YOU'LL FIND IS A LOT OF DISCUSSION ABOUT THE MOST APPROPRIATE WAY TO DETERMINE THE PRESENCE AND MAGNITUDE OF DISPARITIES, HOW YOU DEFINE A DISPARITY, COMPARISON GROUP, WHAT INDICATORS YOU USE. THERE'S A LOT IN THE LITERATURE ABOUT HOW TO MEASURE SOCIAL DETERMINANTS OF HEALTH IN THE ELECTRONIC HEALTH RECORD. LESS ATTENTION IN THE MEASUREMENT FOCUS RESEARCH HAS BEEN GIVEN TO HOW TO MEASURE COMPLEX MULTI-FACETED SOCIAL DETERMINANTS OF HEALTH THAT REFLECT INTERPLAY OF CULTURAL FACTORS, ENVIRONMENT AND INDIVIDUAL PERCEPTIONS THAT CREATE A LIVED EXPERIENCE FOR INDIVIDUALS AND POPULATIONS. OF COURSE, RESEARCH IS INCLUDING THESE KINDS OF CONSTRUCTS, NOT TO SAY NO ONE IS DOING RESEARCH ON THESE THINGS BUT THERE'S LESS MEASUREMENT-FOCUSED RESEARCH FOCUSED ON PERFORMANCE, UTILITY AND ACCEPTABILITY OF MEASURES, WHICH MAY BE MOST APPROPRIATE TO ANSWER WHICH TYPES OF RESEARCH QUESTIONS, AND HOW TO USE MEASURES AT DIFFERENT LEVELS OF INFLUENCE, A LA RESEARCH FRAMEWORK IN CONJUNCTION WITH ONE ANOTHER. WE THINK A SPECIFIC MEASUREMENT IS NEEDED. WE DO GET A SMATTERING OF MEASUREMENT FOCUSED APPLICATIONS COMING THROUGH OUR REGULAR CHANNELS, BUT OFTEN MEASUREMENT-RELATED APPLICATIONS AS OPPOSED TO OUTCOME, HEALTH OUTCOME RELATED APPLICATION MAY NOT DO SO WELL IN STUDY SECTION BECAUSE REVIEWERS WHO ARE NOT MEASUREMENT NERDS MAY BE UNDERWHELMED BY MEASUREMENT STUDIES, MAY THINK THEY ARE BORING, EXPENSIVE, WHAT'S THE END PRODUCT, SO IT'S GOOD TO HAVE SPECIFIC PEER REVIEW RELATED TO MEASUREMENT TO HAVE THAT EXPERTISE AND TO HAVE SPECIFIC REVIEW CRITERIA, TO APPROPRIATELY -- PEOPLE TO HAVE APPRECIATION FOR THESE PROJECTS. NOW, THERE ARE SOME EXISTING FOAs ON MEASUREMENT. ONE BY OBSSR I THINK, RIGHT? ON METHODOLOGY AND MEASUREMENT IN THE BEHAVIORAL AND SOCIAL SCIENCES AND A COUPLE OTHERS REALLY SPECIFIC ABOUT MEASUREMENT IN MORE NARROW FIELDS. IF YOU LOOK AT THE APPLICATIONS THAT ARE SUBMITTED TO THESE FOAs, THEY ARE VERY TECHNOLOGY DRIVEN, SO THEY ARE ABOUT HOW TO OBTAIN AND ANALYZE BIG DATA, HOW TO COLLECT BIOMETRIC DATA THROUGH FIT BITS AND SMARTPHONES THAT MEASURE SLEEP AND HOW TO LINK DIFFERENT KINDS OF DATA SOURCES. SO VERY TECHNOLOGY AND ANALYTIC DRIVEN, WHERE THIS CONCEPT IS FOCUSED ON HOW TO BEST CAPTURE THE LIVED EXPERIENCE OF INDIVIDUALS AND POPULATIONS. THAT'S NOT SOMETHING THAT AT LEAST SPONTANEOUSLY THAT I'VE SEEN COMING INTO THESE ANNOUNCEMENTS. SO FOR THIS INITIATIVE OBJECTIVE TO PRODUCE KNOWLEDGE THAT CAN INFORM THE FIELD ABOUT WHAT KINDS OF MEASUREMENT APPROACHES OF COMPLEX CONSTRUCTS MAY BE MOST SUITABLE FOR DIFFERENT HEALTH DISPARITIES RELATED RESEARCH QUESTIONS, POPULATION SETTINGS OR CONTEXT. IT'S NOT ABOUT WHAT'S THE BEST MEASURE. WHAT'S THE SINGLE BEST MEASURE FOR PARTICULAR THING, BUT WHAT KINDS OF MEASURES MAY BE MOST APPROPRIATE FOR WHAT KINDS OF THINGS AND WHAT KINDS OF STUDIES. IN THIS ERA OF BIG DATA THE PHILOSOPHY IS OFTEN IF YOU CAN GET DATA, IF YOU CAN ACCESS DATA, OBTAIN DATA, JUST GET EVERYTHING YOU CAN AND FIGURE OUT HOW TO ANALYZE IT LATER. WHEN YOU ARE COLLECTING DATA DIRECTLY FROM PEOPLE ASKING THEM FOR THEIR EXPERIENCES, THOUGHTS, FEELINGS, PERCEPTIONS, THAT MAY NOT BE THE MOST APPROPRIATE STRATEGY. SO, OF PARTICULAR INTEREST IS HOW COMPREHENSIVE GRANULAR APPROACHES ASSESSING EVERY OCCURRENCE OF A PARTICULAR KIND OF EVENT OR EVERY SINGLE EXPERIENCE, FOR EXAMPLE, COMPARED TO MORE HOLISTIC APPROACHES, AND THAT WILL WELCOME MORE CLEAR AS I GO THROUGH EXAMPLES, WITH RESPECT TO WHAT KINDS OF INFORMATION THESE DIFFERENT APPROACHES PROVIDE, USABILITY OF THE DATA, WHAT IT TAKES TO ACTUALLY ANALYZE THE DATA. AND HOW ACCEPTABLE AND RELEVANT THEY ARE TO RESPONDENTS, SO DO THEY CAPTURE THE RESPONDENT EXPERIENCE OVERLY BURDEN SOME OR INTRUSIVE. SO THE KINDS OF PROJECTS WE WOULD WANT TO SEE BECAUSE THE FOCUS IS ON THE LIVED EXPERIENCE WE WOULD CERTAINLY LIKE TO SEE MULTI-LEVEL DATA FROM A VARIETY OF SOURCES, BUT THERE IS AN EMPHASIS ON SELF REPORT MEASURES OR SELF REPORT DATA TO BE INCLUDED IN PROJECTS IN SOME WAY. AND SOME COMPLEX CONSTRUCTS OF SPECIFIC INTEREST INCLUDE BUT NOT LIMITED TO THE FOLLOWING, I WANT TO EMPHASIZE NOT LIMITED TO, WE WANT TO BE VERY OPEN TO THERE'S A LOT OF COMPLEX CONSTRUCTS OUT THERE AND WE WOULDN'T WANT TO LIMIT THIS INITIATIVE TO THESE FOUR. AND I ALSO WANT TO EMPHASIZE THAT THIS IS TO DO MEASUREMENT-RELATED RESEARCH. THIS INITIATIVE IS NOT TO SAY ARE THESE FOUR THINGS RELATED TO HEALTH DISPARITIES. NO, IT'S REALLY ON THE MEASUREMENT OF THESE CONSTRUCTS. INTERSECTIONALITY, MULTIPLE MARGINALIZED IDENTITIES, MAY BE STRAIGHTFORWARD IDENTIFYING DEMOGRAPHICALLY IF PEOPLE HAVE INTERSECTIONAL STATUS BUT WHAT IS THE LIVED EXPERIENCE OF INTERSECTIONALITY AND HOW IT RELATED TO SELF IDENTITY, AFFILIATION, MEMBERSHIP OF PARTICULAR COMMUNITIES, AS WELL AS EXPERIENCE OF STIGMA DISCRIMINATION RELATED TO STATUSES. THERE'S LESS WORK ON HOW BEST TO MEASURE THAT. SO FOR EXAMPLE JESSE, IN THE NEWS LATELY FOR APPARENTLY BEING THE VICTIM OF AN INTERSECTIONAL HATE CRIME, ATTACKED BY WHO MEN WHO USED HOMOPHOBIC AND RACIAL SLURS, IS THAT EXPERIENCE OF THAT INTERSECTIONAL EVENT THAT HE EXPERIENCED, DOES THAT IMPACT HIS HEALTH AND WELL BEING DIFFERENTLY THAN IF HE EXPERIENCED SOMETHING THAT WAS MORE UNIDIMENSIONAL IN NATURE. THESE KINDS OF -- WE DON'T KNOW THESE -- WE WON'T BE ABLE TO ANSWER QUESTIONS LIKE THAT UNLESS WE HAVE WAYS TO ACTUALLY CAPTURE THIS INTERSECTIONAL EXPERIENCE. ANOTHER EXAMPLE IS COMPOSITE AND CUMULATIVE EXPOSURE TO ADVERSITY, A LOT OF EXISTING MEASURES OF ADVERSE EVENTS OR TRAUMA, RACISM AND DISCRIMINATION, ASK HAVE YOU EVER EXPERIENCED THIS, AND THAT LOSES CONTEXTUAL DATA ABOUT HOW OFTEN IT OCCURS, THE SEVERITY OF IT, WHEN IT OCCURRED IN THE PERSON'S LIFE, DID IT OCCUR DURING PARTICULAR DEVELOPMENTAL PERIODS OR LIFE STAGES. WHAT WAS THE CONTEXT OF THE EXPOSURE? WHAT WAS THE MIDDLE MEANING OF THE EXPOSURE AND CONSEQUENCES OR RESPONSE TO THE EXPOSURE? SO THERE'S A LOT OF NUANCED INFORMATION RELATED TO THIS. IT'S POSSIBLE BUT I THINK THE RESPONDENT EXPERIENCE IS CRITICAL IN THIS AREA. ON THE ONE HAND, DOING COMPREHENSIVE APPROACHES OF THESE EXPOSURES MAY REALLY GIVE VOICE TO PEOPLE'S EXPERIENCE AND DO JUSTICE TO THEIR EXPERIENCE, PARTICULARLY FOR PEOPLE WHO HAVE EXTENSIVE EXPOSURES TO TRAUMA AND ADVERSITY, THAT KIND OF COMPREHENSIVE ASSESSMENT MAY AT BEST BE TIME CONSUMING, AT WORST RETRAUMATIZING, SOCIAL SUPPORT AND NETWORK THERE'S A GROWTH OF MEASURES OF BOTH CONSTRUCTS, AND THIS EXPECTATION THAT YOU HAVE TO SORT OF COLLECT ALL THIS DATA FOR EVERY RESEARCH QUESTION THAT YOU NEED TO FULLY ACCOUNT FOR EVERY SINGLE PERSON IN AN INDIVIDUAL'S SOCIAL SUPPORT NETWORK, AND THEIR CHARACTERISTICS, WHAT THEY HAD FOR BREAKFAST, MAYBE SATISFACTION IS WHAT'S RELEVANT. SO WHAT KINDS OF RESEARCH QUESTIONS MAY BE MOST -- WHAT MEASURES MAY BE MOST AMENABLE AND NECESSARY AND USEFUL FOR WHAT KINDS OF RESEARCH QUESTIONS, AND THEN THE RESPONDENT SORT OF EXPERIENCE AND BURDEN PLAYS OUT HERE AS WELL. AND THEN THE FOURTH EXAMPLE IS THE RELATIONSHIP BETWEEN INDIVIDUAL EXPERIENCES AND NEIGHBORHOOD OR COMMUNITY LEVEL FACTORS, SO PARTICULARLY WITH THE GROWTH OF EXAMINING GEOSPATIAL FACTORS WE SEE A LOT MORE KIND OF NEIGHBORHOOD LEVEL DISADVANTAGE OR FACTORS BEING RELATED TO INDIVIDUAL HEALTH BUT WHAT IS REALLY THE RELATIONSHIP OF THESE HIGH LEVEL FACTORS AND, SAY, MY EXPERIENCE AS AN INDIVIDUAL. SO IF I -- IF WE KNOW THAT LIVING IN A ZIP CODE WITH HIGH POVERTY IS BAD FOR MY HEALTH, WHY IT'S BAD BECAUSE I'M LIVING IN POVERTY, LIVING AROUND PEOPLE WHO ARE POOR IS BAD FOR MY HEALTH, IS IT BECAUSE THERE ARE FEWER RESOURCES IN MY NEIGHBORHOOD? SO THERE MAY BE SITUATIONS WHERE HIGHER LEVEL FACTORS CAN BE USED AS A PROXY TO ASSUME INDIVIDUAL LEVEL FACTORS, SOME CASES MAYBE NOT SO MUCH. SO IT'S IMPORTANT, MORE WORK IS NEEDED TO UNDERSTAND THOSE RELATIONSHIPS. THERE'S ALSO THE NEED TO KNOW WHETHER THERE'S KIND OF DIFFERENTIAL INFORMATION THAT YOU GET FROM OBJECTIVE MEASURES OF STRUCTURAL VARIABLES, SAY STRUCTURAL -- SAY THE INCIDENCE OF HATE CRIMES IN A PARTICULAR NEIGHBORHOOD, HOW IS THE RELATIONSHIP BETWEEN THOSE KIND OF OBJECTIVE NUMBERS AND MY EXPERIENCE EVER HOW PREVALENT HATE CRIMES ARE IN MY NEIGHBORHOOD, DO THEY ADD -- ARE THEY ADDITIVE, CAN YOU USE ONE OR THE OTHER, DO YOU GAIN ANYTHING BY USING BOTH, SO SOMETHING TO EXPLORE AS WELL. SO, THE KINDS OF STUDIES THAT I THINK WE WOULD BE LOOKING FOR AGAIN THESE ARE EXAMPLES, NOT EXHAUSTIVE, BUT LOOKING AT HOW DIFFERENT MEASURES OPERATE AND THE FINDINGS THEY PRODUCE, DIFFERENT MEASURES OF THE SAME CONSTRUCT ACROSS EXISTING STUDIES OR DATASETS, SO SECONDARY DATA ANALYSIS, LOOKING& AT HOW EXISTING MEASURES OF THE SAME CONSTRUCT WORK WITHIN A SINGLE PROJECT, SO ADMINISTERED TO THE SAME PEOPLE, MIXED METHODS APPROACHES, WHERE PARTICIPANTS COMPLETE THE QUANTITATIVE MEASURES AND THEN THEIR PERSPECTIVES ARE OBTAINED THROUGH FOCUS GROUPS OR COGNITIVE INTERVIEWS. MEASUREMENT EQUIVALENCE ACROSS DISPARITY POPULATIONS AND EXAMINATION OF ETHICAL ISSUES RELATED TO DIFFERENT MEASUREMENT STRATEGIES. SO THAT IS THE CONCEPT. I'M HAPPY TO ANSWER ANY QUESTIONS. >> FIRST THE REVIEWERS. THE FIRST REVIEWER IS MARSHALL CHIN. >> CAN PEOPLE HEAR ME OKAY? >> YES. >> WE'RE GOOD? >> YES. >> OKAY. GREAT. SO, I LOVED THE GENERAL CONCEPT THAT I THINK WHEN PEOPLE READ, A LOT OF PEOPLE SAY, WE NEED THIS. THERE'S A LOT OF CONSTRUCTS IN HEALTH DISPARITIES AND MINORITY HEALTH THAT PEOPLE AGREE ARE IMPORTANT, THE EXAMPLES THAT JENNIFER AND NANCY ISSUED ARE GOOD EXAMPLES. IT'S POINTED OUT WE HAVE LIMITED ABILITY TO MEASURE MANY CONSTRUCTS, LIMITED KNOWLEDGE HOW TO OPERATIONALIZE AND USE THEM. THERE'S GOING TO BE A LOT OF ENTHUSIASM FROM THE FIELD OF THE NEED FOR THIS TYPE OF WORK. I THINK ONE OF THE CONCERNS IS THAT I THINK THIS IS A VERY TOUGH AREA, IT CAN BE ONE OF THESE SITUATIONS WHERE WE HAVE RFAs THAT UNLESS THEY ARE CAREFULLY WORDED AND COMMUNICATED WON'T GET A LOT OF RESPONSE BECAUSE THESE ARE HARD STUDIES, AND PERCEPTIONALLY AND ANALYTICALLY TO GET YOUR HEAD AROUND THESE QUESTIONS, IT NEEDS TO BE AS CLEAR AS POSSIBLE, AND A VARIETY OF FLESHED OUT EXAMPLES TO MAKE IT AS CLEAR AS POSSIBLE WHAT THE TYPES OF QUESTIONS ARE THAT NIH IS INTERESTED IN. EXAMPLES, LOOK AT THE FIRST PAGE, DESCRIPTION OF INITIATIVE, ONE CAN READ THAT PARAGRAPH, YEAH, MAKES A LOT OF SENSE. YOU THINK ABOUT OPERATIONALIZING IT, IT GETS HARDER. SECOND PAGE, FOUR EXAMPLES, THEY VARY IN TERMS OF HOW CLEAR THEY ARE AND THE DEGREE THESE ARE GOES TO HELP PEOPLE UNDERSTAND THE RANGES OF POSSIBILITIES AND TYPE OF QUESTION VERSUS EITHER NOT CLARIFYING OR DIFFERENT WAYS, FOR EXAMPLE THE ONE THAT WAS THE CLEAREST WAS THE SECOND ONE ON ADVERSE EVENTS, THAT WAS CLEARLY DESCRIBED. INTERSECTIONALITY, THE KEY POINT THERE IS AS WE TALKED ABOUT THE NUMBER OF EXAMPLES, YOU MIGHT HAVE SIMPLE CASE TWO DIFFERENT IDENTITIES, AND IT'S NOT GOING TO BE NECESSARILY ADDITIVE IN A SIMPLE WAY OF RACE, ETHNICITY AND LGBTQ STATUS. THE EXAMPLE WAS GIVEN IN TERMS OF IN THE NEWS, INTERACTING IN WAYS THAT WILL BE HARD TO PREDICT AND OFTEN INDIVIDUALIZED, AND SO COMPLEXITIES COME ACROSS IN THE DESCRIPTION. FOR EXAMPLE, I THINK IN ALL THE EXAMPLES NEED TO BE VERY CLEAR THINKING ON THE -- THE RFAs AND INVESTIGATOR'S RESPONSE, WHAT IS THE UNDERSTANDING AND THE GOAL, THEN ARE THEY GOING TO OPERATIONALIZE AND THEN ANALYZE QUANTITATIVE OR QUALITATIVE OR BOTH THE RESEARCH QUESTION. ONE THING THAT WAS NOT CLEAR TO ME, THE FOUR EXAMPLES, CONCEPTUAL PART WHERE ALMOST ASSUMED, PEOPLE COULD HAVE DIFFERENT UNDERSTANDINGS OF HOW THINGS MAY PLAY OUT, WILL THEY HAVE CONTRADICTORY ASSUMPTIONS TO SOME OF THE EXAMPLES GIVEN, WITH THE FOUR POINTS. ONE EXAMPLE IF SOMEONE HAD A DIFFERENT CONCEPTUAL MODEL, INTERSECTIONAL EXAMPLES, ADDITIVE THINKING AS OPPOSED TO THIS NEED FOR CONTEXT AND IT'S NOT GOING TO BE STRAIGHT REGRESSION MODEL WITH SIMPLE INTERACTION TERM, THE THIRD ONE, SOCIAL SUPPORT, ANOTHER EXAMPLE WHERE THERE'S IMMENSE SOCIOLOGY AND SOCIAL SCIENCE LITERATURE ON SOCIAL SUPPORT AND NETWORKS, AND I TALKED TO JENNIFER ABOUT THIS AND NANCY TODAY, AND THEY CLARIFIED. THEY DON'T EXPECT PEOPLE TO DUPLICATE LITERATURE. THEY HAD QUESTIONS THAT BECAME MORE SPECIFIC, STILL HAD TROUBLE IN TERMS OF UNDERSTANDING WHAT THEY ARE GETTING AT IS NOVEL IN TERMS OF ANALYTICAL RESEARCH QUESTION BUT THE GENERAL POINT IS IT NEEDS TO BE CLARIFIED WHAT'S THE INTENTION, HOW DOES IT DIFFER FROM EXISTING KNOWLEDGE, WHAT SPECIFICALLY ARE WE INTERESTED IN, AND AGAIN I UNDERSTAND THIS IS JUST EXAMPLES BUT EACH NEEDS TO BE FLESHED OUT IN MORE DETAIL TO GIVE THE READER A BETTER SENSE OF WHAT THE A VARIETY OF MIXED METHOD STATISTICAL MODELS, BEING ABLE TO DIFFERENTIATE HIGHER LEVEL EFFECTS, AND SO HOW IS THIS DIFFERING FROM THAT. NANCY AND I HAD A CONVERSATION EARLIER TODAY IT MATE BE GOOD TO SEPARATE THAT BULLET A FIFTH ONE, INSPIRED BY DR. FAUCI'S TALK. WHEN WE WERE BRAINSTORMING THINKING THE WAY DR. FAUCI GAVE THE EXAMPLE OF GEOGRAPHIC DISTANCE, THE SOCIAL ENVIRONMENT, HISTORY, VALUES, THE CULTURE OF THE PLACE, POLITICS OF THE PLACE, SO IT'S ANOTHER EXAMPLE IF IT WAS FLESHED OUT WOULD GIVE PARTICULAR EXAMPLES OF RICHNESS AND TYPE OF QUESTIONS THAT WE'RE LOOKING FOR IN TERMS OF EXPLORING THESE DIVERSE CONCEPTS. I THINK OVERALL THE MAIN POINT IS I LOVE THE IDEA. LOVE THE CONCEPT. I THINK IT NEEDS TO BE DONE. I THINK COMBINATION OF THE WORDING, FLESHING OUT THE EXAMPLES IN MORE DETAIL, WE CAN DO BETTER IN TERMS OF GIVING THE PERSPECTIVE APPLICANTS AN IDEA OF WHAT WE'RE INTENDING IN A WAY TO HOPEFULLY INSPIRE THEM AS OPPOSED TO HAVING THEM FEEL BEFUDDLED BECAUSE IT'S A DIFFICULT RESEARCH QUESTION. THANKS. >> JENNIFER, DID YOU WANT TO ADDRESS ANY OF THAT? IF NOT I'LL GO TO SOMEONE ELSE. >> NO, THANK YOU. >> YEAH, THANK YOU. I WOULD LIKE TO COMMEND DR. ALVIDREZ AND JONES, A WELL WRITTEN CONCEPT, VERY HIGH PRIORITY AREA AND GOOD EXAMPLE OF WHAT WOULD BENEFIT FROM AN RFA BECAUSE I THINK THIS KIND OF WORK PROBABLY WOULDN'T REVIEW WELL IN STANDING COMMITTEE FOR THE REASONS YOU ARTICULATED SO I THINK IT'S A GOOD USE OF RFA APPROACH. I ALSO THINK THAT ONE OF THE BENEFITS THAT MAYBE WE HAVEN'T DISCUSSED YET IN THIS WORK IS THAT IF THESE STUDIES -- IF STUDIES FUNDED UNDER A MECHANISM LIKE THIS WERE SUCCESSFUL WOULD LEAD TO MORE MEASUREMENT IN A VARIETY OF STUDIES INCLUDING STUDIES THAT MAYBE DON'T HAVE A MINORITY HEALTH OR HEALTH DISPARITIES FOCUS AND WHERE INVESTIGATORS MAY FEEL LIKE IT'S TOO COMPLICATED, TOO COMPLEX, I NEED 50-ITEM MEASURE, ET CETERA, SO THE MEASUREMENT ISN'T OCCURRING SO I THINK THAT IS A HUGE CONTRIBUTION TO MINORITY HEALTH AND HEALTH DISPARITIES RESEARCH. I THOUGHT THAT WAS GREAT. I WAS REFLECTING IN CONTEXT OF THINKING ABOUT MEASUREMENT OF SEXUAL AND GENDER MINORITY STATUS, IN PARTICULAR, AN AREA OF INTEREST OF MINE, AND THE AREA WHERE WE NEED A LOT OF METHODS RESEARCH, SO FOR EXAMPLE SEXUAL MINORITY STATUS IS A MULTI-DIMENSIONAL CONSTRUCT INCLUDING IDENTITY, BEHAVIOR, ATTRACTION, NEW LABELS EMERGING ALL THE TIME. AND SOME OF THESE ASPECTS OF THE MULTI-DIMENSIONAL CONSTRUCT ARE MORE VISIBLE, OTHERS MORE INTERNAL. I THINK THAT IS A PARALLEL WITH OTHER MINORITY STATUSES OR CAN BE. I THINK ONE OF THE THINGS I WAS WONDERING IF WE WOULD WANT TO CALL OUT NEED FOR MEASUREMENT OF MINORITY IDENTITIES WHICH IS SUBSUMED UNDER THE PIECE ABOUT INTERACTIONALITY BUT MAYBE NOT ENTIRELY, SO THINKING ABOUT WAYS TO MEASURE IDENTITIES STABLE OVER TIME, ACROSS GENERATIONS, DIFFERENT CULTURAL AND SOCIAL CONSTRUCTS ACROSS AGE AND DEVELOPMENTAL CHANGE, HIT UNDER INTERSECTIONALITY BUT PERHAPS COULD BE MORE EXPLICIT. THE FOCUS ON ON GRANULAR VERSUS MACRO, PERSPECTIVES AND OBJECTIVE MEASURES WHICH DOES BELONG IN QUOTES AS YOU PUT IT IN THE CONCEPT, THAT MIGHT BE OF HIGHER LEVEL, NEIGHBORHOOD CHARACTERISTICS VERSUS PERCEIVED NEIGHBORHOOD CHARACTERISTICS, AND IN THE AREA OF SOCIAL NETWORK RESEARCH, FOR EXAMPLE, THERE ARE EMERGING COMPLEX MEASUREMENT APPROACHES, COMPLEX ANALYTIC APPROACHES FOR ANALYZING SOCIAL NETWORK DATA, BUT AS YOU MENTIONED I DON'T THINK WE KNOW IF THEY OFFER INCREMENTAL VALIDITY. THE ONE SUGGESTION, ANOTHER SUGGESTION THAT I WOULD HAVE AS WELL TO THINK ABOUT PERHAPS EXPLICITLY CALLING OUT APPLICATIONS TO CONSIDER INNOVATIVE APPROACHES FOR DISSEMINATING FINDINGS, THAT'S AN ISSUE IN MEASUREMENT, SOMETIMES MEASURES ARE CREATED AND COPYRIGHTED OR BURIED IN A TABLE IN A PAPER HARD TO FIND, OR THE ITEMS ARE INCLUDED BUT NOT THE INSTRUCTIONS FOR ADMINISTRATION, AND SO IF WE WANT TO MOVE THIS FIELD FORWARD I WOULD HOPE THAT THE WORK THAT WOULD BE DONE WOULD BE PRODUCED IN A WAY THAT'S ACCESSIBLE TO OTHER SCIENTISTS. YOU AND I DISCUSSED, FOR EXAMPLE IN OUR WORK WITH MEASURING SEXUAL GENDER MINORITY CONSTRUCTS IN SPANISH, DISSEMINATING THAT WORK. I THINK IT WOULD BE GREAT TO SEE APPLICANTS BE REWARDED FOR DESCRIBING INNOVATIVE APPROACHES THEY MIGHT USE TO DISSEMINATE SOME OF THEIR FINDINGS. THANK YOU FOR WHAT I THOUGHT WAS A STRONG CONCEPT. >> THANK YOU VERY MUCH. I'LL OPEN THE FLOOR TO ALL THE COUNCIL MEMBERS. DR. TALAVERA HAS BEEN WAITING. >> ONE MINOR BUT VERY IMPORTANT SUGGESTION IS UNDER THE SUGGESTION FOR INVARIANTS, I WOULD THROW INTO THIS OR AN FOA LANGUAGE INVARIANCE, IT'S REALLY IMPORTANT, IN SOL WE HAD A SOCIAL SUPPORT TOOL THAT REALLY DIDN'T PERFORM WELL IN SPANISH AND WE JUST PULLED IT OUT OF THE DATA SET TOTALLY BECAUSE IT WAS GOING TO GENERATE A LOT OF INAPPROPRIATE RESULTS IN MANUSCRIPT, SO I THINK MORE OF THAT, ESPECIALLY IN OUR BIG STUDIES WHERE THEY HAVE THAT CAPACITY WOULD BE REALLY GOOD. >> ONE MORE QUESTION. >> YES, SO THIS IS THE MOST AMAZING CLASSROOM EVER. ONE OF MY THOUGHTS WAS THAT THERE MUST BE A CONNECTION BETWEEN THIS VOLUME, JUST PRODUCED UPCOMING DISPARTIES BOOK THAT ELISEO SIGNALED, AND THE CONTENT OF THIS CONCEPT, I KNOW IT'S THERE, BUT I WONDER IF THERE'S ROOM FOR A MUCH MORE DEFINITE LINKAGE. THE SECOND POINT HAS TO DO WITH METHODOLOGY, IT MAY BE ASSUMED BUT AS YOU DEAL WITH THE MULTIVARIATE ANALYSIS YOU'RE TALKING ABOUT THE COMPUTATIONAL CAPACITY AND MATHEMATICAL MODELS AND WHETHER IT'S SOMEHOW POSSIBLE TO MAKE SURE THAT THAT HIGHER LEVEL OF MATHEMATICAL ANALYSIS AND MODELING SOMEHOW IS INVITED, AND THEN ALL THE WAY TO THE OTHER END THE GRANULAR AND INDIVIDUAL NATURE OF SOME OF THE EXPERIENCES SEEM TO MAYBE CALL OUT FOR ETHNOGRAPHIC APPROACHES AS WELL, SO I'M JUST THROWING THAT OUT THERE. AND I LOVE THE INTERSECTIONALITY ASPECT. IT'S CRUCIAL TO THIS CONCEPT THAT THERE ARE MULTIVARIATE FACTORS AFFECTING HEALTH. AND, YOU KNOW, THERE'S BEEN A LOT OF RESEARCH GROWING OUT OF THE LEGAL PROFESSION ON INTERSECTIONALITY, MEDICINE AND DISCRIMINATION, YOU'RE PROBABLY FAMILIAR WITH THAT WORK, BUT I'D LOVE TO SHARE WITH YOU SOME THINGS I'VE WRITTEN THAT HAVE TRIED TO BRING THAT WORK TOGETHER. AND IT'S HAVING QUITE AN INFLUENCE IN THE LEGAL FIELD. ACTUALLY, EVEN THOUGH THIS CONCEPT ACTUALLY INITIALLY EMERGED FROM THE SGM MEASUREMENT WORKSHOP, THE SEX AND GENDER MINORITY RESEARCH OFFICE OF NIH PUT ON, AS INTERSECTIONALITY AROSE AS A THEME. BUT I THINK IN RELATION TO THE CONNECTION WITH THE VISIONING ARTICLES I THINK THERE'S -- IT'S CONSISTENT, PARTICULARLY WITH SOME OF THE WORK IN THE ETIOLOGY SECTION, REGARDING KIND OF LIFE THINGS OVER TIME, CAPTURING THE EXPERIENCE OF RACISM AND DISCRIMINATION, KIND OF IN A HISTORICAL CONTEXT, AND SO I THINK THERE'S -- IT'S CONSISTENT WITH THE WORK IN THE VISIONING, BUT IT DIDN'T EMERGE AS A ONE-TO-ONE MAPPING AS A CONCEPT BUT I THINK IT'S SYNERGISTIC WITH IT. >> ONE LAST QUESTION AND THEN WE HAVE TO MOVE ON. >> THE LAST QUESTION. JUST ONE THOUGHT, ONE OF THE CHALLENGES IS FINDING MEASURES. I LIKE THE IDEA YOU'RE LOOKING AT MEASURES TO CAPTURE CONTEXT IN WHICH BEHAVIORS WILL OCCUR. BUT I'M WORRIED IF WE DON'T HAVE LANGUAGE IN THEIR THAT SPECIFICALLY STATES MEASURES THAT LOOK AT DIFFERENT DIMENSIONS OF BEHAVIORS BECAUSE MOST, BDI, CSD, ONLY MEASURE ONE DIMENSION OF BEHAVIOR. >> GOOD AFTERNOON. THE OBJECTIVE OF THIS CONCEPT IS TO ADVANCE SCIENCE OF MINORITY HEALTH AND HEALTH DISPARITIES BY SUPPORTING RESEARCH ON FAMILY HEALTH, FAMILY WELL BEING AND FAMILY RESILIENCE. FOR THIS CONCEPT, THIS IS A WORKING DEFINITION OF FAMILY, I'M GOING TO PROVIDE ONE OF FAMILY RESILIENCE. FAMILIES ARE DEFINED BROADLY IN THIS CONCEPT, TO BE TWO OR MORE INDIVIDUALS OF ANY GENDER WHO SHARE ENDURING INTIMATE SOCIAL RELATIONSHIPS THAT MAY BE CHARACTERIZED IN BLOOD OR LEGAL TIES, SHARED RESIDENCE, ECONOMIC COOPERATION WITHIN OR ACROSS BORDERS, SHARED RESPONSIBILITIES AN SENSE OF MUTUAL OR COLLECTIVE OBLIGATION. NUCLEAR, EXTENDED, BLENDED, ADOPTED, CHOSEN AND FOSTER. MEMBERS MAY INCLUDE LEGALLY RECOGNIZED CONNECTIONS THROUGH ANCESTRY, MARRIAGE, ADOPTION, LEGAL GUARDIANSHIP OR LESS FORMAL BUT EQUIVALENTLY CLOSE RELATIONSHIPS, DOMESTIC PARTNERSHIPS, STEP RELATIVITIES OR EFFECTIVE KIN. THE FAMILY PROCESSES THAT FOSTER POSITIVE ADAPTATIONS, FAMILY HEALTH, FAMILY WELL BEING, FOR THE FAMILY UNIT AND ALL OF ITS MEMBERS INCLUDING THOSE THAT MAY BE PART OF A NETWORK. I MENTION THAT IT'S ABOUT ADVERSITY, LIFE CHALLENGES, THESE ARE JUST SOME OF THE LIFE CHALLENGES, AND ADVERSITIES THAT ARE PART OF THIS INITIATIVE, AT LEAST IN OUR CONCEPTUALIZATION, POVERTY HAS A TREMENDOUS BURDEN ON HEALTH DISPARITY POPULATIONS, AS WELL AS OTHER ISSUES, I'M NOT GOING THROUGH EACH BUT IMMIGRATION, ACCULTURATIONS. I WANT TO TAKE YOU BACK TO OUR RESEARCH FRAMEWORK. HERE, JUST EMPHASIZING MAJORITY OF OUR WORK. THE PURPOSE OF THE INITIATIVE IS TO MOVE US TO SUPPORT MORE FAMILY LEVEL RESEARCH. NOW, I DON'T HAVE DOWN THERE ON THE HEALTH CARE SYSTEM, IT DOESN'T EXTEND DOWN THERE, BUT THAT'S IMPLIED BECAUSE WITHIN THE HEALTH CARE SYSTEM EVEN THOUGH THE PREDOMINANT MODEL MAY BE INDIVIDUALS GOING TO THE DOCTOR AND ESTABLISHING A CLINICIAN-PATIENT RELATIONSHIP, IN MANY CULTURES, IT IS MORE FAMILIES GOING TO THE DOCTOR. MIGHT BE A YOUNG CHILD, WORKING WITH THEIR MOTHER, GOING WITH THEIR PARENT. MAYBE TO HELP TRANSLATE. IT REFERS THE INTERPERSONAL LEVEL OF INFLUENCE. WITH THAT, AS A FOUNDATION, HERE WE'VE LOOKED AT TRYING TO UNDERSTAND AND CHARACTERIZE WHAT MAY BE MISSING CENTERING AROUND INDIVIDUALS. SELDOM DOES IT FOCUS ON THE HEALTH AND WELL BEING OF OTHER FAMILY MEMBERS WHO MAY BE IMPACTED BY THE PARTICULAR FAMILY MEMBER'S DISEASE. RETURNING BACK TO THE FRAMEWORK, OF THE 90 R01, 18% HAD INTERPERSONAL FAMILY LEVEL OUTCOMES. ONLY 2 OF THE 18 OF THE TOTAL. SO CLEARLY JUST LOOKING AT IT FROM THE PERSPECTIVE OF THE RESEARCH FRAMEWORK AND R01s PART OF THAT STUDY, THERE'S A NEED FOR THIS KIND OF RESEARCH. 2010 SYSTEMATIC REVIEW, THERE WERE OVER 100 MEASURES OF FAMILY FUNCTIONING WERE REPORTED, YOU CAN SEE WHAT SOME OF THOSE ARE. FAMILIES FROM RACIAL AND ETHNIC AND HEALTH DISPARITIES POPULATIONS ARE DISPROPORTIONALLY EXPOSED TO ADVERSE SOCIAL, ECONOMIC AND ENVIRONMENTAL STRESSORS AND THESE MAY THREATEN DIRECTLY OR INDIRECTLY THE HEALTH OF THE ENTIRE FAMILY UNIT OR ITS MEMBERS. THESE STRESSES AND RELATED STRESSES INCLUDE THOSE THAT I SHOWED IN THAT TABLE, BUT MAY ALSO BE FOR RACIAL/ETHNIC MINORITIES, OCCUPATIONAL EDUCATION, ECONOMIC, DISCRIMINATION, IMMIGRATION RELATED, MARITAL, ACCULTURATION GAP, SO FORTH. WHEN WE DID A REVIEW OF THE NIH FUNDED GRANTS, RESILIENCE AND FUNCTION, IDENTIFIED SOME GAPS. THERE'S A GAP IN TERMS OF THE IMPACT OF STRESSORS MAINLY AT THE INDIVIDUAL LEVEL AS I'VE MENTIONED RATHER THAN AT THE FAMILY LEVEL. SO HOW ARE THESE STRESSORS IMPACTING THE FAMILY? THERE'S A LACK OF RESEARCH IN MULTIPLE FAMILIES MEMBERS, OFTENTIMES RESEARCH MAY FOCUS ON ONE, MAY FOCUS ON A MOTHER AND CHILD DYAD, BUT WON'T NECESSARILY EXTEND TO OTHER FAMILY MEMBERS, OR ACROSS GENERATIONS. AND THERE WERE, AGAIN, A LACK OF FAMILY LEVEL INTERVENTIONS BEYOND THE PARENT-CHILD DYAD. SO BASED ON THIS INFORMATION, AND OTHER LITERATURE, WE INCLUDED A NEED FOR MORE RESEARCH AS A FAMILY LEVEL. MORE FAMILY LEVEL INTERVENTIONS, MORE NUANCED UNDERSTANDING OF FAMILY LEVEL HEALTH, RISK AND RESILIENCE. AND KNOWLEDGE OF HOW FAMILY HEALTH MAY BE AFFECTED BY ADVERSE EXPERIENCES. THIS INITIATIVE WILL SUPPORT OR WE PROPOSE THAT IT WOULD BE DESIGNED TO SUPPORT MULTI-DISCIPLINARY FAMILY LEVEL RESEARCH TO EXAMINE HOW RACIAL/ETHNIC MINORITY AND HEALTH DISPARITY FAMILIES PROMOTE, SUSTAIN OR ENHANCE HEALTH IN RESPONSE TO EXPOSURES TO ADVERSITY RESULTING FROM VARIOUS FACTORS. JENNIFER MENTIONED MEASUREMENTS REFLECTING THE LIFT EXPERIENCE. WE'RE PROPOSING IN TERMS OF LIVED EXPERIENCE OF FAMILIES AS LOT ABOUT THE RESPONSE OF INDIVIDUALS TO RACISM AND ITS IMPACT ON HEALTH, BUT WE DON'T KNOW SO MUCH ABOUT THE COLLECTIVE, HOW OUR FAMILIES AND TYPICALLY FAMILIES HAVE THIS EXPOSURE, NOT JUST AT THE INDIVIDUAL LEVEL, BUT AT A MORE FAMILY LEVEL. ALSO TO SUPPORT RESEARCH TO UNDERSTAND CLARITY, AND TO CLARIFY THE DYNAMIC MECHANISMS AND PROCESSES THAT OPERATE AT THE FAMILY SYSTEMS LEVEL, IN RESPONSE TO THESE VARIOUS ADVERSITIES. AND MORE IMPORTANTLY, THE IMPACT OF THIS ON FAMILY WELL BEING, FAMILY HEALTH, AND FAMILY RESILIENCE. IT IS THAT ASSOCIATION BETWEEN THE EXPOSURES AND THE IMPACT ON HEALTH OR THE HEALTH OUTCOMES. THIS WILL ALSO, WE SUSPECT, PROVIDE AN OPPORTUNITY TO DEVELOP NEW METHODS TO IDENTIFY MEASURE FAMILY LEVEL FACTORS, MEASURING FAMILY LEVEL, TAKING MEASUREMENT AT THE FAMILY LEVEL ARE CHALLENGING. AND SO THIS WOULD PROVIDE AN OPPORTUNITY TO DO THAT. WE SUPPORT RESEARCH ADVANCING UNDERSTANDING OF THE MECHANISMS AND PATHWAYS BY WHICH ADVERSITIES AND THEIR INTERACTIONS AFFECT RISK AND PROTECTIVE FACTOR CHANGES ON FAMILY HEALTH AND WELL BEING. ONE OF THE THINGS IS HOW DO WE ASSESS AND START TO UNEARTH THE STRENGTHS THAT EXIST WITHIN OUR FAMILIES WHEN EXPOSED TO THESE DIVERSITIES -- OR ADVERSITIES. ALSO, THIS INITIATIVE WILL FOCUS ON PROMOTING FAMILY LEVEL INTERVENTIONS FOR PREVENTING OR MITIGATING IMPACT OF THESE STRESSES ON FAMILY HEALTH AND FAMILY WELL BEING. FAMILY LEVEL RESEARCH STUDIES ARE THE FACTORS PROMOTING OR THREATENING THE HEALTH OF RACIAL/ETHNIC MINORITY FAMILY UNITS INCLUDING ROLE OF POLICY, COMMUNITY SERVICE ORGANIZATIONS, AND HEALTH SERVICES ARE OF INTEREST. THIS WILL ALLOW US TO GET AT WHAT EXISTS OUTSIDE OF THE FAMILY, THAT MAY PROVIDE RESILIENCE. AS OUR FAMILY DERIVED AND FAMILY LEVEL INTERVENTIONS FOR PREVENTION ARE MITIGATING IMPACT OF THESE ON FAMILY HEALTH AND INCREASING WELL BEING, RESEARCH PROJECTS EXPLORING RELATIONSHIP BETWEEN FAMILY CHARACTERISTICS, COMPOSITION, STRENGTHS, RESOURCES, SOCIAL AND DEVELOPMENTAL CONTEXT, AND NATURE OF THE ADVERSE CONDITIONS AND FAMILY HEALTH ARE ALSO OF INTEREST IN HOW THEY MAY OPERATE OVER TIME. ALSO EXAMINATION OF FAMILY STRESSORS, MARITAL CONFLICT, CONTEXT OF OTHER FAMILY STRESSORS, CHRONIC DISEASE, FOR EXAMPLE, RESILIENCE STRATEGIES IMPLEMENTED BY FAMILIES AND FAMILY HEALTH AND WELL BEING OUTCOMES. THIS IS, AGAIN, CONTINUAL DESCRIPTION OF THE INITIATIVE. EXAMINING FAMILY STRESSES OVER TIME, ACROSS GENERATIONS, UNDERSTANDING THE IMPACT OF STABILITY OR CHANGING NATURE OF FAMILY STRESSES OVER TIME ON FAMILY HEALTH, FOR EXAMPLE RECURRING CYCLES OF FAMILY SEPARATION, AND REUNIFICATION. EXAMINATION OF FAMILY RESILIENCE, IMPACT OF PARENTAL INCARCERATION ON CHILDREN, SUICIDE, SUBSTANCE ABUSE, VIOLENT BEHAVIOR, COPING, AND FUNCTIONING ON FAMILY WELL BEING. THE FOCUS OF THE IMPACT OF ANTICIPATED STRESSORS, VERY LITTLE RESEARCH SEEMS TO FOCUS ON ANTICIPATION OF STRESSORS NAMELY JOB LOSS, DEPORTATION, ET CETERA, ON FAMILY HEALTH, HEALTH OF FAMILY MEMBERS, AND WHAT ARE THE COPING MECHANISMS IN DIFFERENT IMMIGRANT COMMUNITIES AND FAMILIES. STUDIES DEVELOPING INTERVENTIONS FOCUS ON ENHANCING RESILIENCY FACTORS WITHIN A FAMILY SETTING, TO REDUCE RISK MUCH CHRONIC DISEASE, DISEASE, AND INCLUSION OF FAMILY MEMBERS AND KIN IN ASSESSMENT OF FAMILY DYNAMICS AND FUNCTION TION TO ADDRESS HEALTH DISPARITIES. PURPOSE TO SUPPORT HEALTH AND FAMILY RESILIENCE. >> THANK YOU, DR. TABER. DR. ARANETA? >> THIS IS COMPREHENSIVE BUT I SEE THE POSSIBILITY OF TURNING THIS INTO FOUR FOAS BECAUSE IT'S BROAD AND FLUIDITY OF EXPOSURE AND OUTCOME WHERE FAMILY RESILIENCE OR WELL BEING OR COHESIVENESS COULD BE EXPOSURE, OUTCOME OR MEDIATOR. I WOULD -- HAVING SAID THAT I THINK IT MIGHT BE USEFUL TO PROVIDE SPECIFIC EXAMPLES SUCH AS THE PAPER THAT DR. MENDOZA CO-AUTHORED PREVIOUSLY, DO CHILDREN OF DACA MOTHERS HAVE LESS MENTAL HEALTH OUTCOME COMPARED TO CHILDREN OF NON-DACA MOTHERS, OR INTERVENTIONS SUCH AS DOES PROVIDING PARENTING EDUCATION REDUCE LOSING CUSTODY TO CHILD PROTECTIVE SERVICES OR DOES -- AND THIS IS SOMETHING WE DID IN OUR PEDIATRIC HIV CLINIC, DOES PROVIDING PARENTING EDUCATION REDUCE HIV VIRAL LOAD IN THE MOM. SO I THINK MORE SPECIFIC EXAMPLES MIGHT BE HELPFUL IN GUIDING THE APPLICANTS AS WELL AS REVIEWERS INTO WHAT NIMHD WOULD LIKE TO SEE. I THINK IT WOULD BE VALUABLE TO INCLUDE SUGGESTIONS -- TOPICS WHERE THERE ARE MODIFIABLE OPPORTUNITIES. IT MIGHT NOT BE POSSIBLE TO CHANGE THE FAMILY STRUCTURE BUT IT MIGHT BE POSSIBLE TO PROVIDE INTERVENTIONS THAT CHANGE THE FAMILY DYNAMICS. AND JUST TO FURTHER BROADEN THE COMPREHENSIVE WRITE-UP, I WANTED TO -- THAT YOU CONSIDER SOME OTHER POSSIBLE STRESSORS AND THAT IS TIME, SO YOUR ARTICLE WITH GILBERT WAS SO FAR MY FAVORITE ARTICLE IN THE SUPPLEMENT. >> THANK YOU. >> AND TIME AND RACISM AS AN IMPORTANT STRESSOR, I THINK IT'S IMPORTANT TO LOOK AT STRESSORS, THAT STRESSORS DIFFER BY AGE AND FAMILY SIZE, AGE OF THE CHILDREN, STRESSORS OF RAISING A TODDLER IS DIFFERENT FROM TEENAGERS, DIFFERENT MEASURES OF STRESS INCLUDING SYMPTOMS AMONG BABIES, VERSUS BIOCHEMICAL ASCERTAINMENT, SEPARATION LIKE DEPORTATION BUT SEPARATION ALSO OF THE KIDS, EITHER WHO ARE IN JUVENILE HALL OR CHILD PROTECTIVE SERVICES, AMONG IMMIGRANT FAMILIES CONFLICTS IN CHILD REARING BETWEEN GRANDPARENTS VERSUS PARENTS. THE ISSUES OF TRADITIONAL CULTURES VERSUS ACCULTURATING TO A NEW ENVIRONMENT. PIETY, IMPORTANT IN SOME CULTURES, RESPONSIBILITY OF CARING FOR YOUNGER SIBLINGS, DIFFERENCES IN DISCIPLINE, HARSH VERSUS PERMISSIVE, AND ROLE REVERSALS AS YOU ALLUDED TO WITH CHILDREN SERVING AS INTERPRETERS FOR THEIR PARENTS, OR CULTURAL NEGOTIATORS, AND FUNCTIONING AS A PSEUDOPARENT. BUT I WOULD LIKE, IF WE WERE TO PRIORITIZE FOAs, IT WOULD BE I THINK PRACTICAL TO LOOK AT WHAT ARE THE MODIFIABLE RISK FACTORS, OTHERWISE WE MIGHT END UP WITH DESCRIPTIVE STUDIES, WHAT KIND OF INTERVENTIONS, CREATIVE INTERVENTIONS, COULD BE IMPLEMENTED THAT WOULD ENHANCE WELL BEING, RESILIENCE, AND FAMILY COHESIVENESS. >> THANK YOU. >> THANK YOU VERY MUCH. DR. MENDOZA. >> THIS IS VERY COMPREHENSIVE, AS SUCH SPEAKS TO THE CHALLENGE YOU'RE FACED WITH TRYING TO DO THIS. HAPPY THE IDEAL THING WOULD BE ABLE TO DO ALL THIS BUT I THINK AS A PRIOR ONE, WE WERE DISCUSSING ABOUT MEASURES, I THINK IT'S USEFUL TO HAVE A CONCEPTUAL MODEL TO PUT OUT THERE TO SAY HERE'S WHERE WE ARE, HERE'S A PART OF THE MODEL THAT WE REALLY WANT TO LOOK AT. IT MAY BE WHAT ARE THE SOCIAL NETWORKS OF FAMILIES, BECAUSE I THINK THERE'S LOTS OF THINGS YOU COULD LOOK AT. AND THE OTHER ASPECT THAT CAME OUT FOR ME IN THIS PRESENTATION AND PAPER WAS WHAT'S THE COMPARISON GROUP. WHEN WE TALK ABOUT DISPARITIES, WHO ARE WE GOING TO COMPARE AS THE GOLD STANDARD? IS IT WHITE MIDDLE CLASS FAMILIES? TWO-PARENT FAMILIES? NUCLEAR FAMILIES? WHAT IS THAT COMPARISON? I THINK AS WE START TO LOOK AT DISPARITIES, IT'S GOING TO BE A BIG DEAL ABOUT WHAT ARE WE TALKING ABOUT, WHAT'S THE DIFFERENCE. I THINK THE OTHER THING THAT WAS BROUGHT OUT IS THE TIME FRAME. CLEARLY TO ME WHEN YOU THINK ABOUT FAMILIES, YOU'RE TALKING ABOUT SOCIAL INTERACTIONS OVER TIME. AND I THINK THE QUESTION WILL BE WHAT'S THE LENGTH OF TIME OF OBSERVATION, THAT ONE COULD LOOK AT RATHER THAN CROSS-SECTIONAL. IF YOU TRY TO SEE WHAT CAN BE MODIFIED, YOU'LL WANT TO SEE WHAT'S THE TIME FRAME OF THAT MODIFICATION. WHAT ARE THE TIMEFRAMES OF SOMETHING HAPPENING BEHAVIOR A AFFECTING OUTCOME C, RIGHT? AND THAT WOULD BE SOMETHING TO THINK ABOUT AS WELL. OUR DISCUSSION WAS ON SOCIAL DETERMINANTS. I THINK IT'S IMPORTANT FOR US TO PUT OUT THERE THESE ARE SOCIAL DETERMINANTS, WE'RE TRYING TO LOOK AT. I KNOW YOU CAN TALK ABOUT FAMILIES, BUT TO ME, THAT'S THE ECOLOGY FOR ME, AS A PEDIATRICIAN, HOW KIDS GROW UP, RIGHT? IT IS THAT, THAT MAKES THEM WHO THEY ARE, OVER TIME, BECAUSE THAT'S THE CONSTANT ASPECT OF THEIR LIFE. SO, IT'S IMPORTANT TO PUT THAT ALSO IN THE FRAMEWORK THAT INTERSECTS POVERTY, ENVIRONMENT, ET CETERA. ACCESS TO RESOURCES, THERE'S ISSUES ABOUT OFFICIALS, HEALTH SERVICES, ORGANIZATION, COMMUNITY ORGANIZATIONS, BUT A LOT OF OUR COMMUNITIES HAVE INFORMAL, RIGHT? CHURCHES, ALL KINDS OF SOCIAL GROUPS. AND I SAY THAT IN THE CONTEXT THAT MOST OF OUR LARGE CITIES HAVE 100 LANGUAGES SPOKEN, THAT MEANS THERE ARE AT LEAST 100 CULTURES THAT WE'RE GOING TO BE DEALING WITH. HOW DO WE START TO UNDERSTAND WHAT IS THE SOCIAL NETWORK OF THOSE COMMUNITIES VERSUS TRADITIONAL COMMUNITIES? I THINK WE TALKED ABOUT LOOKING AT BEING IMPLEMENTS. THE OTHER THING FOR ME WAS HOW DO FAMILIES RELATE TO SOCIAL INSTITUTIONS? AND THAT COULD BE POLICE, SCHOOLS, YOU KNOW, VOTING, ET CETERA. I THINK AT THE END OF THE DAY THERE'S A LOT OF SENSE OF NOT BEING EMPOWERED BY FAMILIES. IF YOU LOOK AT OUR COMMUNITIES, THERE'S A SENSE, WELL, I JUST GET BY AND LIVE. I LET THOSE GUYS DO WHATEVER THEY WANT, RIGHT? AND YET THEY ARE ALL AMERICANS. THEY ALL DESERVE TO GET SOCIAL INSTITUTIONS TO AFFECT THEIR LIVES IN A WAY THAT'S POSITIVE. AND IT WOULD BE INTERESTING TO SEE AS A FAMILY HOW DOES THAT GET MIXED IN. BECAUSE THAT'S WHERE THEY GET RESOURCES. AND THAT'S WHERE THAT COULD BE VERY HELPFUL. THE LAST, GETTING BACK TO THE LIFE COURSE ISSUE, I THINK TO ME THE INTERGENERATIONAL ASPECT OF FAMILY ARE KEY, AS WE SEE THERE ARE GENERATIONS THAT GO BACK MORE THAN JUST ONE GENERATION, RIGHT? THAT FAMILY HISTORY COMES TO AFFECT HOW PEOPLE INTERACT, HOW PEOPLE FEEL, RACISM COMES THROUGH THAT. IMMIGRATION ISSUES, I'M CONCERNED FOR KIDS, ARE GOING TO AFFECT THEM FOR THE NEXT COUPLE OF GENERATIONS BECAUSE THERE'S SUCH HATRED ABOUT IMMIGRANTS NOW. I THINK THAT THAT, TO ME, ARE THINGS WE NEED TO LOOK AT, SOCIAL STRUCTURE OVER THE LIFE COURSE AND HOW DOES THAT AFFECT THE INTERGENERATIONAL ASPECTS OF HEALTH. >> THANK YOU VERY MUCH. THE FLOOR IS NOW OPEN. COMMENTS FROM OTHERS? BRIAN. >> THREE QUICK COMMENTS. ONE IS I WOULD LOVE TO SEE UNDER THE STRESSORS AND RELATED STRESSORS EXAMPLES, CHILDREN OR PARENTS COMING OUT AS SEXUAL GENDER MINORITY BECAUSE I THINK BOTH COULD BE RELEVANT, HAVEN'T BEEN WELL STUDIED, YOU NEED TO CONSOLIDATE, COULD POTENTIALLY COMBINE LACK OF ACCESS TO WATER AND FOOD INSTEAD OF TWO DIFFERENT EXAMPLES. I WAS READING, WONDERING ABOUT WHETHER THIS IS ABOUT INTERVENTIONS OR MECHANISMS OR BOTH, BECAUSE THERE'S -- THE PARAGRAPH ABOUT DESCRIPTIONS OF INITIATIVES MAKES THE CASE WITHOUT BETTER UNDERSTANDING OF MEASUREMENT AND MECHANISMS THAT INTERVENTIONS WILL BE INAPPROPRIATELY DESIGNED, IRRELEVANT, UNACCEPTABLE, MAKES THE CASE WE NEED TO TO DO MECHANISTIC WORK, MAKING THAT EXPLICIT WOULD HELP AND HELPFUL TO MAKE CLEAR IF OUTCOMES ARE HEALTH ISSUES OR OUTCOMES ARE FAMILY HEALTH AND WELL BEING, MAYBE BEING SUPER CLEAR ABOUT THAT, IF YOU'RE OPEN TO BOTH OR NOT, BECAUSE IF I WAS THINKING ABOUT APPLYING I MEET THINK IS IT OKAY IF THE OUTCOME IS DEPRESSION, OR IS THE PRIMARY FOCUS AND OUTCOME THAT'S FAMILY HEALTH, FAMILY WELL BEING, SO JUST MAKE THAT EXPLICIT WHETHER BOTH ARE OKAY OR IF YOU'RE REALLY LOOKING FOR THE PRIMARY OUTCOMES TO BE FAMILY HEALTH AND WELL BEING. A COUPLE SUGGESTIONS. >> THANK YOU. >> I HAVE JUST A COUPLE ALSO BECAUSE WE ACTUALLY ARE IN THE SAME CATEGORY. THE-- I REALLY APPRECIATE THE FOCUS ON STRENGTH. AND ASSETS WITHIN FAMILIES. I THINK WHEN I INITIALLY READ THE CONCEPT I WAS CONCERNED IT WAS PRIMARILY FOCUSED ON SORT OF LOSS AND INEQUALITY AND STRESSORS. AND SO I THINK THAT BALANCE NEEDS TO MAYBE COME OUT A LITTLE BIT MORE, WHEN THE RFA OR WHATEVER FUNDING OPPORTUNITY COMES OUT. I WOULD ASK YOU TO THINK ABOUT MULTI-COMORBIDITIES IN FAMILIES, AND PARTICULARLY AS WE'RE THINKING ABOUT DISPARITY POPULATIONS, A THREAD RAISED IN A BUNCH OF THE COMMENTS SO FAR. BUT THAT, TO ME, GIVES OPPORTUNITY, I THINK REALLY HIGHLIGHTS THIS BALANCE OF STRENGTHS THAT MIGHT BE CULTIVATED OVER TIME AS A FAMILY HAS DEALT WITH HYPERTENSION, DIABETES, ET CETERA. AS WELL AS STRESSORS, THE STRESSOR OF THE DISEASE. I'M A LITTLE CONCERNED ABOUT HAVING ANY SUGGESTION THAT THERE'S A GOLD STANDARD WHAT A FAMILY SHOULD BE AND WHAT APPROPRIATE COMPARISON WOULD BE, I WOULD BE VERY CAUTIOUS ABOUT INSINUATING THAT IT MIGHT DIFFER FROM EARLIER COMMENTS, AND THEN THIS ISSUE OF A GENERATIONAL -- THE GENERATIONAL IMPACT, I THINK REALLY BEARS OUT, BEARS SORT OF ELEVATING EVEN MORE IN THE DESCRIPTION, SO GOING BACK TO SORT OF ENVIRONMENTAL CONTEXT, SOCIAL AND PHYSICAL ENVIRONMENT, AND PRE-CONCEPTION, ALL THE WAY THROUGH CONCEPTS OF HISTORICAL TRAUMA, I THINK IS ANOTHER OPPORTUNITY TO REALLY HAVE A MORE COMPREHENSIVE VIEW OF WHAT IT MEANS TO BE IN A FAMILY. >> OKAY. THANK YOU. >> I WOULD AGREE WITH MY COLLEAGUE. >> CAN I GET YOU TO VOTE BEFORE YOU GO? >> : IT WASN'T THE SENSE OF HAVING A GOLD STANDARD. WHAT ARE WE GOING TO COMPARE THIS TO WHEN WE LOOK AT DISPARITY. CLEARLY WE'RE TALKING THE SAME LANGUAGE. >> THANK YOU. >> THANK YOU ALL VERY MUCH. I APPRECIATE THAT. MAY I HAVE A MOTION TO RECOMMEND THIS CONCEPT TO MOVE FORWARD? MAY I HAVE A SECOND? ALL IN FAVOR? ANY OPPOSED? THANK YOU VERY MUCH. THE MOTION CARRIES. THIS CONCEPT WILL MOVE FORWARD. THANK YOU VERY MUCH. >> THANK YOU. >> THANK YOU, DEREK AND JENNIFER, FOR THE CLEAR PRESENTATION. IS THERE ANYONE WHO WOULD LIKE TO MAKE ANY PUBLIC COMMENTS FROM THE ROOM? HEARING NONE, I WANT TO BRING THE 50th MEETING -- SHOULD HAVE MADE MORE OF THE LANDMARK, ALTHOUGH AT MY AGE IT SEEMS YOUNG, RIGHT? 50th MEETINGS OF THE NATIONAL ADVISORY COUNCIL ON HEALTH AND HEALTH DISPARITIES NOW OFFICIALLY ADJOURNED, AND WE'LL SEE YOU ALL IN MAY. THANK YOU VERY MUCH.