>> WE'RE ON WEBCAST SO IF WE CAN START WITH INTRODUCTIONS. >> BRYAN RIVERS AT MOREHOUSE SCHOOL OF MEDICINE. >> I'M AN OB GYN. >> ASSISTANT DEAN OF DIVERSITY AND COMMUNITY PARTNERSHIPS AND PROFESSOR UC SAN DIEGO. >> I'M PROFESSOR OF SCHOOL OF MEDICINE AT UNC CHAPEL HILL. >> FERNANDO MENDOZA FROM STANFO STANFORD UNIVERSITY. >> I'M THE CHIEF OF SCIENTIFIC REVIEW AND SITTING HERE IN THE ROLE OF ACTING DIRECTOR OF THE OFFICE OF EXTRAMURAL RESEARCH ADMINISTRATION. >> I'M JOYCE HUNTER THE SENIOR ADVISER TO THE DIRECTOR AND DESIGNATED FEDERAL OFFICIAL OR THE ADVISORY COUNCIL. >> I'M ELISEO PEREZ-STABLE DIRECTOR OF THE NATIONAL INSTITUTE OF MINORITY HEALTH AND CHAIR OF THIS NATIONAL ADVISORY COMMITTEE. >> DIRECTOR OF DIVISION OF SCIENTIFIC PROGRAMS NIMHD. >> DISTINGUISHED PROFESSOR OF PUBLIC HEALTH AND PSYCHIATRY UNIVERSITY OF COLORADO. >> I'M PROFESSOR AND CHAIR OF THE DEPARTMENT OF POPULATION HEALTH SCIENCES AT UT HEALTH SAN ANTONIO. >> AT FROM NORTHWESTERN UNIVERSITY AND CO-DIRECTOR OF THE CENTER FOR AIDS RESEARCH. >> PROFESSOR SAN DIEGO STATE UNIVERSITY SCHOOL OF PUBLIC HEALTH AND DIRECTOR OF THE SOUTH >> JUDITH LONG CO-DIRECTOR OF THE V.A. CENTER FOR HEALTH EQUITY RESEARCH AND PROMOTION AND CHIEF OF GENERAL INTERNAL MEDICINE AT THE UNIVERSITY OF PENNSYLVANIA. >> DIRECTOR OF THE OFFICE OF BEHAVIORAL SOCIAL SCIENCES RESEARCH HERE AT THE NIN. -- NIH. >> ARE THERE ANY MEMBERS ON THE PHONE THIS MORNING? DR. REED, ARE YOU ON THE PHONE? AT TIS TIME I'LL START WITH THE REVIEW OF THE MINUTES FROM THE FEBRUARY MEETING. THE MINUTES WERE IN YOUR FOLDER. THEY WERE ALSO POSTED ON THE ELECTRONIC COUNCIL BOOK. AND I'D LIKE TO ASK AT THIS TIME IF THERE ANY CONCERNS OR CORRECTIONS. HEARING NONE MAY I HAVE A MENTION TO A -- MOTION TO APPROVE THE MINUTES FROM THE MEETING. SECOND? ALL IN FAVOR. ANY OPPOSED? THE MOTION CARRIES. THANK YOU VERY MUCH. I'D LIKE TO REMIND YOU OF THE FUTURE MEETING DATES. I'D LIKE TO REMIND YOU WITHIN A CALENDAR YEAR YOU'RE ONLY ALLOWED TO MISS ONE MEET. AND WE THANK YOU FOR YOUR SERVICE. I'LL NOW TURN THE MEETING BACK TO PEREZ-STABLE. >> GOOD MORNING, EVERYONE. I'M GOING GIVE THE OFFICIAL DIRECTOR'S REPORT THIS MORNING AND THERE SHOULD BE HOPEFULLY TIME FOR CONVERSATION AFTERWARDS BEFORE WE TAKE A BREAK AND LISTEN AND HEAR FROM OUR PRESENTERS. I'LL START BY SUMMARIZING SOME OF THE HIGHLIGHTS BY NIH IN THE LAST THREE MONTHS. FIRST, WE HAVE A NEW DIRECTOR OF THE CENTER FOR SCIENTIFIC REVIEW. NONI HAD BEEN ACTING DIRECTOR SINCE THE RETIREMENT LAST SPRING. I WAS ON THE SEARCH COMMITTEE. I THINK SHE'S AN OUTSTANDING APPLICANT AND I THINK WE HAVE ALREADY MET WITH HER A COUPLE TIMES TO DISCUSS STRATEGIES AND HOW TO MANAGE THE MINORITY HEALTH DISPARITIES APPLICATIONS. I LOOK FORWARD TO WORKING WITH HER. HER BACKGROUND IS IN BASIC SCIENCE AND Ph.D. IN ANALYTICAL CHEMISTRY AND WE WELCOME HER TO THE TABLE OF DIRECTORS. WE ALSO SAW A TRANSITION OF NED SHARPLESS WHO HAD BEEN DIRECTOR OF THE NATIONAL CANCER INSTITUTE OVER A YEAR. HE WAS TAPPED BY THE ADMINISTRATION TO BECOME ACTING COMMISSIONER OF THE FOOD AND DRUG ADMINISTRATION WHEN SCOTT GOTTLIEB DECIDED TO STEP AWAY FOR APPARENTLY PERSONAL FAMILY REASONS AND THE COMMUTE TO CONNECTICUT EVERY WEEK WAS GETTING TO HIS YOUNG KIDS. NED CAME TO NIH FROM THE UNIVERSITY OF NORTH CAROLINA WHERE HE WAS A DIRECTOR AND WAS THE 15th DIRECTOR OF THE NCI NOT QUITE A YEAR AND A HALF. HE DID AN OUTSTANDING JOB AND I HAD A VERY GOOD CONNECTION AND COMMUNICATION WITH HIM AS NCI DIRECTOR AND THINK HE WILL DO A GREAT JOB AT THE FDA WHERE DR. GOTTLIEB HAD DONE AN OUTSTANDING JOB. DOUG LOWY IS ACTING DIRECTOR SECOND ROUND AND SINCE BOTH ARE PRESIDENTIAL APPOINTMENTS, IT'S UNLIKELY EITHER ONE WILL BE PERMANENTLY NAMED BEFORE THE RESULTS OF THE 2020 ELECTION. YOU NEVER KNOW. THE FDA IS SENATE CONFIRMED. THE NCI IS NOT. SO WE CAN SEE SOME MOVEMENT THERE. FRANCIS COLLINS JUST A COUPLE WEEKS AGO ANNOUNCE THE APPOINTMENT OF DEBORAH TUCCI AS THE NEW DIRECTOR OF THE NATIONAL INSTITUTE ON DEAFNESS AND OTHER COMMUNICATION DISORDERS. JIM BEATTY HAD BEEN THE DIRECTOR A LONG TIME PRIOR TO THIS. DEBORAH IS A HEAD AND NECK SURGEON OR E.N.T. AS WE USED TO CALL THEM. SHE'LL OVERSEE THE BUDGET OF $459 MILLION AND LEAD THE PROGRAM'S RESEARCH AND TRAINING PROGRAM FOCUSSED ON HEARING, BALANCE, TASTE, SPEECH AND LANG LANGUAGE. HER BACKGROUND IS IN BASIC AND CLINICAL DIRECTOR AND IS THE DIRECTOR OF THE DUKE UNIVERSITY MEDE CAL HEARING CENTER AND HER RESEARCH FOCUSSED ON COCHLEAR IMPLANT AND ADDRESSING HEARING DISORDERS. WE LOOK FORWARD TO HER HAVING JOINED THE DIRECTOR'S TABLE IN SEPTEMBER RIGHT AFTER LABORER DAY IS THE PLAN. ON JUNE 20th, NIMHD HAS BEEN THE MAIN DRIVER OF THIS PATHWAYS TO PREVENTION WORKSHOP SHE NIH IS PUTTING ON AT THE OFFICE OF DISEASE PREVENTION. RICK BURSON TOOK OVER THE PROGRAM LEAD AND IT WILL BE BROADCAST. I LOOK FORWARD TO THE CONTENT. IT WAS DRIVEN BY A NUMBER OF RECOMMENDATIONS BASED ON GENERAL FINDINGS. THE EXAMPLES MOST READILY COME TO MIND ARE THINGS LIKE MAMMOGRAPHY SCREENING OR PROSTATE CANCER SCREENING THAT DO NOT HAVE ANY INCLUSION POPULATIONS IN THE CLINICAL TRIALS HAD SHOWN EFFICACY OR NOT SHOWN EFFICACY IN THE CASE OF PROSTATE CANCER AND WE MAKE RECOMMENDATIONS BASED ON THE DATA WHEN THEIR POPULATION GROUPS WITH TWO TO THREE TIMES THE DISEASE RATES ARE CLEARLY SHOWN MORE AGGRESSIVE DISEASE AND THIS IS PART OF WHAT'S DRIVING THIS MEETING. SO I LOOK FORWARD TO SEEING WHAT THE CONVERSATION AND THE PRESENTATION WILL BE LIKE. DR. LARRY TABAK ANNOUNCED A RECENT AND WE'LL HAVE NOR -- MORE AGREEMENT AND A RECENT DATA SHARING WITH THE NAVAJO NATION AND THIS HAS BEEN IN THE WORKS AND DEVELOPMENT WELL OVER A YEAR. RICK WILSON WAS THE MAIN NAVAJO NATION AND WILL CONTINUE TO BE PART OF THE ECHO PROGRAM. AND IT DOES NOT COVER GENETIC DATA OR SHARING OF BIOSPECIMENS WHICH IS THE MOST CHALLENGING OR SENSITIVE PART OF THIS. WE'D BE INTERESTED IN HEARING COMMENTS OR RESPONSES FROM YOU ALL ON THIS. SIMILAR TO THIS THERE ARE OTHER CHALLENGES RELATED TO WORK THE TRIBES ON ISSUES AROUND THE "ALL OF US" COHORT WHICH CONTINUE TO CREATE A PROBLEM FOR THIS DATA SHARING ASPECT PARTICULARLY AROUND THE RECENT DATA TOOL RELEASED. AND I THINK IT'S THE FRUIT OF THE WORK WE'VE BEEN DOING IN THIS RESEARCH. WE HAVE AN UPUPDATES IN OUR OWN INSTITUTE. DAGAR HAS BEEN APPOINTED IN A PERMANENT POSITION AS THE HEALTH SCIENCE ADMINISTRATOR IN CLINICAL RESEARCH AND WAS AN AAA FELLOW WITH US ABOUT NOT QUITE A YEAR AND A HALF OR SO. AND WE'RE DELIGHTED TO HAVE HER JOIN THE GROUP LED BY DR. LORISSA SANTOS AND WE HAD AN PRESENTATION FOR 50 YEARS OF SERVICE AND THERE WAS A SPECIAL CEREMONY AT THE HUMPHREY BUILD SOG WE'RE HAPPY FOR VINCE AND HIS CONTRIBUTIONS. AND OUR PUBLIC LIAISON TRANSITIONED OUT OF NIMHD AND JULIETTE PLAYS THE HARP IN THEAND OUR PUBL IC LIAISON TRANSITIONED OUT OF NIMHD AND JULIETTE PLAYS THE HARP IN THE TALENT SHOW AND KIMBERLY AND I SANG AS OUR CONTRIBUTION. WE DIDN'T WIN BUT WE DID WELL ESPECIALLY WHEN I LOOK AT THE SPECTRUM OF WHAT WAS PRESENTED. IT WAS A LOT OF FUN. JULIA PLAYED BEAUTIFULLY. THE INTRAMURAL PROGRAM HAS HIRED NEW TRAINEES AS YOU CAN SEE HERE. I DON'T KNOW IF CHARMAINE CHAN IS HERE OR COLLINS PERRAMIN. IF YOU'RE HEAR STAND UP, PLEASE. AND KHALID PRINCE. AND COLON'S GOING TO WORK WITH ANNA AND CHARMAINE IS WORKING WITH CALVIN. WE ARE DELIGHTED TO HAVE THEM AS PART OF OUR INSTITUTE. THERE WAS A CONGRESSIONAL HEARING WITH NIH LEADERSHIP FRANCIS COLLINS GOES TO EVERY YEAR AND THE SENATE APPROPRIATIONS ON LABOR THE HOUSE HEARING WAS NOTEWORTHY BECAUSE OF THE NUMBER OF QUESTION THE HOUSE MEMBERS HAD ABOUT HEALTH DISPARITIES AND DR. COLLINS REFERRED TO WELL, NEXT TIME HE'LL HAVE ME THERE TO ANSWER THEM. THERE WERE OTHER QUESTIONS YOU CAN SEE THAT WERE DIRECTORS FROM NCI AND NICHD, NIAID, HEART, LUNG AND BLOOD WERE PRESENT BUT NOT ALL THE DIRECTORS ARE INVITED AND FRANCIS DECIDES WHO COMES DEPENDS ON THE KIND OF QUESTIONS THE MEMBERS HAVE SENT HIS WAY. SIMILARLY FOR THE SENATE APPROPRIATIONS NINE DAYS LATER THERE WERE THE LARGE INSTITUTE AND DK AND DR. HOTIS FROM AGING AND NORA VOLKOW FROM NIAID. THE INTEREST CONTINUES TO BE HIGHLY POSITIVE. THERE'S A LOT OF INTEREST IN NIH AND A LOT OF SUPPORT FOR NIH IN GENERAL AND OUR CONGRESSIONAL SUPPORT SEEMS TO BE STRONGER THAN EVER. I GREAT CREDIT GOES TO NOT JUST DR. COLLINS' LEADERSHIP BUT THE UNDERSTANDING OF SCIENCE NOT TO RELIEVING YOU IN SUFFERING BUT AS A CONTRIBUTOR TO THE ECONOMY OF THE COUNTRY. THERE'S A NUMBER OF OTHER CONGRESSIONAL ACTIVITIES I WAS INVOLVED WITH. THE CHILDREN'S INN CONGRESSIONAL RECEPTION AND A NUMBER OF MEMBERS WERE THERE INCLUDING TOM COLE WHO'S BEEN A CHAMPION BY NIH AND A REPRESENTATIVE OF OKLAHOMA. I MET WITH A REPRESENTATIVE FROM LOUISIANA AND IS AN ENTEROLOGIST AND HAS EXPRESSED ISSUES RELATED TO NIH AND ITS FUNDING. IT WAS VERY INFORMATIVE MEETING. HE BASICALLY LISTENED TO ME MOST THE TIME. TOM LAVIST A FRIEND, A FORMER FACULTY AT HOPKINS, PREVIOUSLY FUNDED BY NIM HD AND MOVED TO GEORGE WASHINGTON TO BE A CHAIR AND MOVED ON TO BE DEAN AT TULANE. AND I THINK THE MEETING WAS INTENDED TO MAKE A CONNECTION BETWEEN NIMHD AND TOM THOUGH IT WAS PROBABLY NOT NECESSARY BUT IT GAVE ME AN OPPORTUNITY TO TALK TO SENATOR KASSIDY WITH TOM AND PEOPLE FROM TULANE AND IT WAS A POSITIVE DISCUSSION ON A NUMBER OF ISSUES. ON MARCH 14, I PRESENTED TO THE CONGRESSIONAL HISPANIC CAUCUS ONE OF THE CALIFORNIA MEMBERS WAS PRESENT AND SHE SAID A FEW WORDS AND THE TOPIC WAS INCLUSION OF DIVERSE PARTICIPANTS PRIMARILY LATINOS SINCE THIS WAS A HISPANIC CAUCUS INSTITUTE. WE TALKED ABOUT A NUMBER OF TOPICS AND THERE WERE REPRESENTATIVES FROM INDUSTRY TALKING ABOUT FDA APPROVAL FOR DRUGS AND IT WAS A GOOD CONVERSATION AND WELL ATTENDED. APRIL 15 WE HAD A CONGRESSIONAL BRIEFING ON HEALTH DISPARITIES SPONSORED BY SOME FRIENDS AND I'LL HAVE SOME WORDS SAID ABOUT OUR FRIENDS NETWORK HOSTED BY OUR LOCAL REPRESENTATIVE FROM MARYLAND. I'VE BEEN A NUMBER OF PLACES THE LAST FEW MONTHS LOCALLY AND NATIONALLY. THE INNER SOCIETY TI COORDINATING COMMISSIONER FOR GENOMICS WAS A PRESENTATION PRESENTED BY NHGRI FOCUSSED ON NON-CLINICIANS WHO ARE NOT PHYSICIANS WORKING IN GENETICS. I VISIT THE MEDICAL COLLEGE OF WISCONSIN AND GAVE MEDICAL GRAND ROUNDS AND GAVE A SEMINAR TO THEIR HEALTH SERVICES RESEARCH GROUP. THE SOCIETY FOR NICOTINE AND TOBACCO WAS IN SAN FRANCISCO AND GAVE AN ADDRESS ON PUBLIC HEALTH THEME THAT WAS A GOOD THING FOR ME. I FELT IT WAS A GOOD TOPIC TO EMBRACE AND THERE WAS A SOCIETY MEETING OUR OWN CALVIN CHOI WAS HONOR AND PRECEDED ME ON THE TALK AND GAVE HIS OWN LECTURE. IT WAYS FULL HYMNHOOD -- NIMHD LECTURE. AND THERE WAS AN ANNUAL CANCER SYMPOSIUM IN CLEVELAND MARCH 1. IT WAS A GOOD VISIT AS WELL MUCH THE CENTERS I VISITED IN THE PAST FOUR YEARS PLUS IT'S THE ONLY ONE WHERE THE DIRECTOR WAS THERE AND HE SPOKE AND PRESENTED HIS OWN RESEARCH AND ASKED ME A QUESTION AFTER MY TALK AND A VERY ENGAGED LEADER SO I WAS VERY IMPRESSED BY THAT AND THE OTHER LEADERS I DIDN'T KNOW WHO THEY ARE. THAT WAS A GOOD EXCHANGE. I WAS IN HUNTINGTON, WEST VIRGINIA I THINK IN MARCH. I VISITED THEIR MEDICAL CENTER AND HUNTINGTON, FOR THOSE WHO DON'T KNOW WHERE IT IS, IT'S ABOUT A SIX-HOUR DRIVE FROM HERE. I DIDN'T GO THROUGH AIRPLANES. IT'S ON THE BORDER WITH OHIO-KENTUCKY IN THE LOWER PART OF THE STATE. CLOSE TO WHAT SOME CONSIDER IS AN EPICENTER TO THE OPIOID USE DISORDER EPIDEMIC. IT WAS A GOOD VISIT. HOST IS A COLUMBIAN SURGEON I MET THROUGH THE NATIONAL HISPANIC MEDICAL ASSOCIATION. I MOSTLY INTERACTED WITH BASIC SCIENTISTS THEY HAD LITTLE IN THE KIND OF RESEARCH WE FUND. IT WAS A GOOD VISIT AS I LEARN. I SPOKE TO THE LIEU PASS RESEARCH -- LUPUS RESEARCH ALLIANCE IN MARCH HERE IN D.C. I WENT TO BALTIMORE FOR THE SOCIETY FOR RESEARCH OF CHILD DEVELOPMENT WHICH IS MORE SOCIAL SCIENCE MEETINGS AND I SPOKE TO THE PEDIATRIC ACADEMIC SOCIETIES IN BOSTON -- BALTIMORE IN APRIL WITH A PANEL THAT FOCUSSED ON RACISM. REPAIRING THAT WAS A GOOD EXERCISE FOR ME AND A KNOW FERNANDO WAS THERE AND IT WAS WELL ATTENDED. I SPOKE TO THE NATIONAL SCIENCE EDUCATION PROJECTS FOCUSSED ON A VARIETY OF PROGRAMS THAT ARE FUNDED OF WHICH INCLUDED SOME PEOPLE I KNEW FOCUSSED PRIMARILY ON THE PIPELINE DEVELOPMENT THE NATIONAL INSTITUTE OF GENERAL MEDICAL SCIENCES PROGRAM. AND I WAS IN XAVIER UNIVERSITY IB NEW ORLEANS FOR THEIR ANNUAL HEALTH DISPARITIES CONFERENCE. XAVIER IS ONE OF OUR FUNDED -- RECENTLY FUNDED RCMI AWARDS AND HAD AN RCMI FOR A LONG TIME. I THINK IT WAS A GOOD VISIT IN MANY WAYS. AND FINALLY, JUST LAST WEEK I GAVE A COMMENCEMENT ADDRESS TO THE GEORGE MASON UNIVERSITY COLLEGE OF HEALTH AND HUMAN SERVICE WHERE'S THE DEAN IS A FORMER NIH, NICHD SENIOR INVESTIGATOR WHO'S BEEN THERE IT'S ALWAYS EXCITING ESPECIALLY HAVING MY OWN SON GRADUATING ON THURSDAY. WE PUBLISHED THIS MEDICAL CARE SUPPLEMENT. I THINK RIGHT NOW IT'S ONLY OUT ELECTRONICALLY. IT HAS A NUMBER OF PEER-REVIEWED RESEARCH PAPERS AND AN EFFORT LAUNCH REGINA JAMES AND FOLLOWED A WORKSHOP SOME MAY HAVE BEEN AT ON HEALTH DISPARITIES. THE SUM RIFF THE WORKSHOP -- SUMMARY OF THE WORKSHOP IS INCLUDED AND SOME WE WROTE WITH OTHERS. WE ENCOURAGE YOU TO TAKE A LOOK. IT WILL BE AVAILABLE ONLINE. WE CONTINUED OUR SUCCESSFUL COLLABORATION WITH NIDDK WITH THE FELLOWSHIP PROGRAM. WE PROVIDE FUNDING FOR A VISITING ONE-YEAR FELLOWSHIP OF A PHYSICIANS FROM UGANDA. WE HAVE THE THIRD UGANDAN FELLOW AND IAN SUMNER WHICH IS THE MAIN SUPPORTER WITH THE FELLOWS PRESENTED HER WORK ON DIABETES THIS MONTH AND DEVELOPED A COST-EFFECTIVE MODEL TO DIAGNOSE DIABETES AND DEVELOPED AN ALGORITHM TO SEE WHAT WOULD BE THE MOST SPECIFIC SENSITIVE MEASURE TO USE AND HAS DONE HER OWN PRIMARY WORK AND IN TURNING TO RWANDA LATER THIS JUNE TO CONTINUE HER WORK AS A PHYSICIAN. MARSHAL CHEN WHO WAS ON THE PHONE YESTERDAY AND HOPEFULY WILL JOIN US WROTE A FASCINATING BLOG ON ADDRESSING NEEDS TO ADDRESS SOCIAL HEALTH DISPARITIES AND CALLED TO ACTION ASIAN AMERICANS TO TAKE ON A HERITAGE MONTH. WE ALSO HAD A WONDERFUL NATIONAL MINORITY HEALTH MONTH LONG BEFORE ALL THE DETAILS WERE WORKED OUT. WE HAD SCHEDULED THE 5K EVENT FOR NIMHD ON APRIL 24. I THINK IT GOT PUT ON MY CALENDAR EIGHT OR NINE MONTHS BEFORE TO MAKE SURE IT WAS OKAY. I HADN'T SEEN A NEW ONE FOR 2021 YET BUT I'M SURE THAT'S COMING. AND THEN WE PARTNER WITH THE OFFICE OF MINORITY HEALTH. FELICIA COLLINS THE NEWLY APPOINTED DIRECTOR OF THE OFFICE MINORITY HEALTH IN JANUARY SAID SHE WOULD COME AND DO THE RUN/WALK WITH US AND WE HAD A FAIR AMOUNT OF PRESENCE OF SOCIAL MEDIA AND THEN WERE SURPRISED TO SEE THE SURGEON GENERAL A FEW DAYS BEFORE SAID I'M GOING TO JOIN YOU AND COME THOUGH HE WAS GETTING PULLED IN THE DIRECTION OF THE OPIOID SUMMIT. THIS IS BEFORE WE STARTED. AFTER THE INTRODUCTORY REMARKS. I SPOKE, FELICIA SPOKE AND DR. ADAMS ACTUALLY, WHO'S AN ANESTHESIOLOGIST AND A PASSIONATE SURGEON GENERAL AND WAS CALLED TO BUILDING 1 TO MEET WITH DR. TABAK AND WE GOT DR. TABAK TO COME OUT. HE DID NOT RUN OR WALK BUT DID COME OUT AND SUPPORTED US HE SAID I WANT TO GET CLOSER AND DID A CALL OUT TO DR. COLLINS AND DID A TWITTER VIDEO WHERE HE HAD PEOPLE RESPOND TO HIS ACTIVE HEALTHY LIFE OR SOMETHING. I DON'T KNOW WHAT IT WAS AND TWEETED AT DR. COLLINS WHO SAW IT AND RESPONDED TO IT. AND AS MENTIONED AT THE DIRECTOR'S MEETING WHEN HE SAID HE HAD GOTTEN THE TWEET FROM JEROME. I THINK IT WAS A POSITIVE DEVELOPMENT FOR US IN GENERAL. MAYBE NEXT YEAR WE'LL GET FRANCIS COLLINS TO GET OUT AND RUN WITH US AS WELL. LET'S TALK ABOUT THE BUDGET. THIS IS BASED ON FISCAL 2020. WE HOPE THIS WILL NOT BE THE OUTCOME OF THE LEGISLATIVE BUDGET AND SEE A SIMILAR BUDGET IF NOT AN INCREASE. WE'RE HOPEFUL BOTH THE HOUSE AND SENATE WILL CONTINUE TO BE SUPPORTIVE OF NIH BUT WE'LL KEEP OUR EYE ON THE LEGISLATIVE PROCESS SINCE A LOT WILL HAPPEN BEFORE THESE GET IMPLEMENTED. HOPEFULLY BY OCTOBER 1 WE'LL GO INTO A CONTINUED RESOLUTION IF IT'S NOT RESOLVED PRIOR IT THAT. THIS IS AN ILLUSTRATION THAT WAS PUT TOGETHER FOR US REGARDING HOW EFFICIENT ARE WE AT GETTING AWARDS OUT. PROBABLY MOSTLY A REFLECTION OF MY LEARNING HOW TO DO THIS AS A DIRECTOR MAKING FUNDING DECISIONS. THERE WERE SOME ISSUES IN THE PAST WITHOUT CERTAINTY OF A BUDGET WHEN WE WERE IN CONTINUING RESOLUTION. IT WAS UNKNOWN HOW WE'D SPEND IT AND AS WE WERE TRANSITIONING PROGRAMS THAT WERE UP UNTIL THEN CONSUMING MUCH OF OUR BUDGET AND WE WERE ALSO NOT GETTING ENOUGH COMPETITI COMPETITIVE RESEARCH AND WE'RE GETTING LOTS OF RO1 APPLICATIONS WELL REVIEWED AND WE'RE HAVING TO MAKE TOUGH DECISIONS ABOUT WHAT TO FUND BUT WE ARE GETTING AWARDS OUT IN A MORE EFFICIENT PACE AND HOPEFULLY WHEN IT COMES TO AUGUST, WE'RE NOT SCRAMBLING TO FIGURE OUT WHAT ELSE TO FUND OR TO GET ALL THE BUREAUCRACY WORKING WITH A SHORT TURNAROUND. THIS IS OUR GROWTH. YOU CAN SEE PRIMARILY IN RESEARCH GRANTS THE RCMI IS PROJECTED GROWTH BASED ON WHAT IS ALLOCATED BY CONGRESS. R&D CONTRACTS I THINK REFLECTS OUR COMMITMENT TO THE NHLBI COHORT. THERE'S FUNDING FOR THE JACKSON HEART STUDY, WHICH HAS FOR MANY YEARS FROM THE BEGINNING. AND WE STARTED FUNDING THE HISPANIC COMMUNITY HEALTH STUDY OF LATINOS THIS FISCAL YEAR. WE LOOK FORWARD TO BOTH OF THOSE STUDIES GENERATING CRITICAL DATA FOR USE BY ALL OF THE SCIENTIFIC COMMUNITY AND PARTICULARLY NIMHD INVESTIGATORS WHO WOULD LIKE TO USE IT AND I WORKED WITH THE DATA AS NOT PART OF THE TEAM OF THE INVESTIGATORS AND I THINK IT'S A GREAT DATA SET TO WORK WITH A VARIETY OF PEOPLE BOTH WITH TRAINEES AND COLLABORATORS ACROSS THE COUNTRY. A COUPLE OF HIGHLIGHTS FROM SOME OF OUR PROGRAMS. THIS IS THE BIOETHICS SCHOLARS. THIS IS NOW THE THIRD YEAR THEY'VE COME TO NIMHD. THE PERSON IN THE MIDDLE IS FROM FORDHAM AND THE FOUR SCHOLARS SPENT THE BETTER PART OF A DAY WITH US AND PRESENT THEIR WORK AND HAD INTERACTIONS WITH US AND GET EXPOSURE TO NIH ACTIVITIES. WE DID A SIMILAR THING WITH THE CRECD SCHOLARS. THESE ARE R25s THAT ARE FUNDED. TWO OF THE THREE LINKED TO THE RCMI PROGRAMS FOCUSSING ON THE DEVELOPMENT OF PIPE LIN WITH POST-DOCTORAL JUNIOR FACULTY MOSTLY MINORITY RESEARCHERS. THEY PRESENT THEIR WORK AND GET FEEDBACK AND I THINK OTHERS ARE INVOLVED WITH THE ORGANIZATION AND PLANNING. ONE OF MY COLLEAGUES SAW THE NIMHD DESCRIPTION OF THIS AND SENT ME A NOTE SAYING YOU SHOULD INVITE THE SCHOLARS AND I'M NOT SURE WE CAN ACCOMMODATE 15 OR 20 PEOPLE BUT IT'S AN IDEA WE SHOULD ENTERTAIN FOR THESE KINDS OF PROGRAMS. THEY'RE FUNDED BY NIH OR IN PART BUT THE SCHOLARS WOULD BE A GREAT ONE TO TRY TO FIND SOME COMMON GROUND WITH IN THE FUTURE. WOMEN'S HISTORY MONTH. ANNA DID A MOVING CONVERSATION OFFICE OF NIH EQUITY AND INCLUSION. I ENCOURAGE YOU TO LISTEN TO IT. SHE TALKED ABOUT HER PERSONAL JOURNEY, HER CAREER AND OFFERING ADVICE TO YOUNG WOMEN. WE WILL GET A LOT OF LEVERAGE OUT OF THE FACT THAT ANNA IS THE FIRST LATINA SCIENTIFIC DIRECTOR. THERE AREN'T TOO MANY WOMEN SCIENTIFIC DIRECTORS, THERE ARE SOME. AND IN JUST LESS THAN TWO YEARS ON CAMPUS HAS MADE A BIG IMPACT ON AMBIANCE AND LEADERSHIP ROLE AND HAVING A VOICE AT THAT TABLE OF THE INTRAMURAL PROGRAM. IT'S NOT AS MUCH AS IN THE LIMELIGHT AS THE EXTRAMURAL BUT AN IMPORTANT CONTRIBUTOR ON CAMPUS. CALVIN WAS HONORED WITH THE INVESTIGATOR AWARD. THAT'S WHAT HE ACTUALLY PROCEEDED MY TALK. CALVIN, ARE YOU HERE? HE'S RECOGNIZED AND HOPING HIS PROFESSIONAL FOR ACHIEVING TENURE AT NIMHD WILL HAVE A POSITIVE OVERCOME OVER THE COURSE OF THE NEXT ONE TO TWO YEARS. IN THE DIVISION OF INTRAMURAL RESEARCH AND I MENTIONED DR. CHOI'S PRESENTATION ON THE SOCIETY FOR NICOTINE AND TOBACCO AND A NUMBER OF HIS TRAINEES WERE THERE PRESENTING POSTERS. SIMILARLY AT THE SOCIETY FOR BEHAVIORAL MEDICINE WHERE WE HAD A PRESENTATION WITH POSTERS. THIS ONE WAS HELD IN WASHINGTON . THE AMERICAN ASSOCIATION OF CANCER RESEARCH ANNUAL MEETING THERE WAS A PRESENTATION OF THE GENOTYPING WORK I MENTIONED YESTERDAY. LET ME GO ON TO DISCUSS SOME OF THE SCIENTIFIC ADVANCES PRESENTED TO ME BY STAFF. ONE FOUR-MONTH PERIOD THERE'LL BE FOUR PAPERS AND OTHER TIMES IT CAN BE INTERESTING BUT NOT SO GREAT. I THINK THEY'RE ALL PRETTY EXCITING. THIS WAS A PAPER ON THE FOLLOW-UP ON COLORECTAL SCREENING AND MANY DOCTORS WILL NOT TAKE MEDICAID BECAUSE OF REIMBURSEMENT AND YOU SEE THE MEDICAID POPULATION IS NOT UP TO THE SAME LEVEL. I WOULD ARGUE AFTER THE CHEMICAL TEST IS A HIGH BAR. IF YOU GOT IT IN SIX MONTHS OR A YEAR YOU'RE PROBABLY STILL OKAY SINCE POLYPS IT TAKE SIX YEARS TO GO FROM A POLYP TO ONE THAT CANCEROUS. IT'S A LARGE STUDY AND IT'S PRE-MEDICARE. SO MEDICAID COMPARED TO COMMERCIAL INSURANCE OR OTHER INSURANCE. IT'S NOT MEDICARE. WE'RE SFOEFD SPEND A THIRD OF OUR LIVES SLEEPING. I'M NOT SURE ANYONE IN THIS ROOM DOES BUT MAYBE WE SHOULD, RIGHT?PEND A THI RD OF OUR LIVES SLEEPING. I'M NOT SURE ANYONE IN THIS ROOM DOES BUT MAYBE WE SHOULD, RIGHT? IT'S A WASH YOUR BRAIN TIME ACCORDING TO DR. VOLKOW. AND AN ESSENTIAL PART OF WHAT WE DO LIKE EATING AND PHYSICAL ACTIVITY AND YET WE'VE KIND OF IGNORED IT FOR THE LARGER PART OF OUR SCIENTIFIC PERSPECTIVES. SLEEP DISORDERS HAVE BEEN PRESENTED BUT I'M PRESENTING THE IDEA WE'RE PUSHING ON THIS IS SLEEP AS A RISK FACTOR. THE FACT YOU GET ADEQUATE SLEEP MEANS YOU'LL GET LESS CHANCE OF DIABETES OR IMMUNOGENIC PATHWAYS BUT THESE ARE THE KINDS OF QUESTIONS THAT NEED TO BE PRESENTED. THERE WAS ASSOCIATION OF DISCRIMINATION WITH DISRUPTIVE OR DYSFUNCTIONAL SLEEP AND HIGHER SLEEPINESS IN ADOLESCENCE. PEOPLE THINK OF SLEEPS IN DIFFERENT TIMES OF THE LIFE COURSE. EARLY IN LIFE, OF COURSE, EVERYONE KNOWS ABOUT BABIES AND SLEEP AND HOW MUCH THEY SLEEP AND HOW IMPORTANT IT IS AND HOW DISRUPTIVE IT CAN BE FOR THE ADULTS PRIMARILY. THE ADOLESCENT IS ANOTHER CRITICAL PERIOD. YOUTH ARE BEGINNING TO HAVE A SOCIAL ACTIVITY, THEY STAY UP LATE AND FORCED TO GET UP EARLY TO GO TO SCHOOL AND HOW MUCH DOES THAT EFFECT THEM AND THE OLD SAYING WAS WELL, AS YOU GET OLDER YOU DON'T NEED AS MUCH AS SLEEP AND FACULTY WOULD SAY I OME -- ONLY FOUR HOURS OF SLEEP AND I'M DOING GREAT AND WE KNOW HOW NOT GOOD THAT IS AND I ENCOURAGE EVERYONE TO LOOK AT THIS AS A CONSTRUCT THAT NEEDS MORE ATTENTION. AND DATA ON SEXUAL GENDER MINORITY RISKS ARE CRITICAL. THE NATIONAL HEALTH INTERVIEW SURVEY PUBLISHED RATES ON SMOKING ON SEXUAL, GENDER MINORITY YOUTH AND THEY TEND TO BE HIGHER THAN ANY OTHER RACE ETHNIC GROUPS LOOKING AT THOSE AS MUTUALLY EXCLUSIVE CATEGORIES. THIS WAS A SMOKING BEHAVIOR AMONG YOUNG ADULTS THAT HAVE HIGHER SMOKING PREVALENCE. IT'S A SMALL STUDY IN TERMS OF SAMPLE SIZE. IT ALLOWS YOU TO LOOK AT THE DETAILS. LESBIAN WOMEN SMOKE AT AN OLDER AGE AND TRANSGENDER SMOKE THE MOST COMPARED TO SIS -- CISGENDER AND OTHER GROUPS AND THERE'S A LOT OF IMPORTANT DEVELOPMENTS AND I'LL COME BACK TO OTHER PAPERS IN A FEW MINUTES. I LIKE THIS PAPER BECAUSE IT KIND OF REINFORCES MY BIAS. THAT'S WHAT RESEARCH IS SUPPOSED TO DO. WHEN IT DOESN'T YOU CHANGE YOUR PERSPECTIVES OR TRY TO FIND A FLOW. THIS IS AN ANALYSIS IN THE ANNALS OF INTERNAL MEDICINE. AND I'VE ALWAYS BEEN A BELIEVER THAT TAKING SUPPLEMENTS IS A WASTE OF MONEY UNLESS HAVE YOU A DEFICIENCY AND I ENCOURAGE PEOPLE TO SPEND MONEY ON GOOD FOOD, HEALTHY FOOD OPPOSED TO VITAMINS. IT FIRST HIT ME MANY YEARS AGO WHEN A CLOSE FRIEND JUST PULLED OUT THIS 20 PILLS THEY WERE TAKING EVERY DAY. I WONDERED ABOUT THAT. SO YOU CAN'T MAKE AN ASYMPTOMATIC PERSON FEEL BETTER AND IT'S A MULTI-BILLION INDUSTRY AND MAKES YOU WONDER WHAT WE'RE DOING WITH OUR HEALTH. AND EXCESS INTAKE OF CALCIUM WAS ASSOCIATED WITH THE INCREASE RISK OF CANCER AND SEEMED TO BE RELATED TO SPLUMEUPPLEMENTS NOT EXCESS CALCIUM IN THE DIET. THIS IS AN INNOVATIVE WAY TO APPROACH STRUCTURAL CHANGES OR POLICY AND HOW'S IT AFFECT HEALTH. THE EARNED INCOME TAX CREDIT FOR MANY OF US IS NOT SOMETHING WE REALLY KNOW THAT MUCH ABOUT OR EVER USE BUT IT IS A FORM OF INCOME REDISTRIBUTION AND CASH TRANSFERS AND IF YOU'RE BELOW A POVERTY LEVEL SOMETHING LIKE $12,000 A YEAR FOR AN INDIVIDUAL, YOU ARE ELIGIBLE FOR EARNED INCOME TAX CREDIT. YOU ACTUALLY GET MONEY FROM THE FEDERAL GOVERNMENT OPPOSED TO PAYING FEDERAL TAXES. I LEARNED THIS MANY YEARS AGO FROM AN EMPLOYEE, A PART-TIME EMPLOYEE WE HAD IN OUR HOME TO HELP WITH DOMESTIC WORK WHEN OUR KIDS WERE YOUNG AND MY TAX PERSON SAID, WELL, YOU'RE AN EMPLOYER. YOU CAN BENEFIT FROM THIS AND IT'S THE DIRECT WAY OF SUPPORTING SOMEONE WHO OTHERWISE LIVES IN POVERTY. INCLUDING THIS FINDING IMPROVEMENT IN PRENATAL AND BIRTH OUTCOMES IN THE WASHINGTON, D.C. AREA FROM THIS STU STUDY IN SOCIAL SCIENCE AND POPULATION HEALTH IS AN IMPORTANT TRACT -- CONTRIBUTION AND MORE RESEARCH IS NEEDED. THIS IS CLINICAL RESEARCH ON THE TYPES OF BREAST CANCER RESEARCH IN PUERTO RICO AND FINDING RATES OF CANCER AND BREAST CANCER DIAGNOSED AT AN EARLIER AGE AND LOTS OF MISSING DATA LIMITING THE GENERALIZATION AND THIS IS A PRODUCT OF THE RCMI IN PUERTO RICO WHICH I THINK WAS THE KIND OF DATA WE NEED TO GENERATE MORE OF BECAUSE IN THE AVERAGE KIND OF STUDY LIKE THIS IS DOES NOT INCLUDE DIVERSE SAMPLES WHETHER IT'S LATINOS OR ASIANS OR AFRICAN AMERICANS OR PACIFIC ISLANDERS. ASTHMA AND COPD. THIS IS A SOCIOECONOMIC PERSPECTIVE THOUGH THERE ARE ENOUGH LATINOS IN OREGON TO LOOK AT THEM SEPARATELY. AND THE NON-HISPANIC WHITES INSURED AS A PREFERENCE POINT INSURANCE FOR LATINOS HELP AMELIORATE THE RATIOS AND YOU SEE LOWER DIAGNOSIS OF COPD. ASK YOURSELF A QUESTION, WHAT IS THE BENEFIT OF DIAGNOSING A CHRONIC DISEASE EARLIER? IF YOU DIAGNOSE SOMEONE EARLY YOU AVOID SOMEONE LOSING MUSCLE MASS IN THEIR HEART IN THE CASE OF ASTHMA AND COPD YOU HELP THEM QUIT SMOKING IF THEY'RE SMOKING. THAT'S THE BIGGEST FACTOR TO HELP WITH THIS LUNG DISEASE AND IT'S SYMPTOM DRIVEN. IF THE PATIENT ISN'T SICK YOU'RE NOT DOING ANYONE FAVORS BY AN EAR EARLY DIAGNOSIS AND YOU HAVE UNNECESSARY VISITS AND HOSPITALIZATIONS WHICH BECOME A SOCIETAL ISSUE BECAUSE OF COST AND MORBIDITY FOR THE INDIVIDUAL PATIENTS. THIS IS AN OBSERVATIONAL STUDY OF PATIENTS WITH CANCER SURVIVORS AND HAVING INSURANCE COVERAGE AND A REGULAR DOCTOR OR CLINICIAN AND CHILDREN WHO SURVIVE CANCER AND TRANSITION FROM PEDIATRICIANS OR MAYBE THEY STAY WITH A FAMILY FISSION FISSIFISSION -- PHYSICIAN OR GO TO AN INTERNIST NEED FOLLOW-UP AND SURVEILLANCE. THIS IS INDIRECT EVIDENCE ABOUT INSURANCE AND A REGULAR PROVIDER BEING IMPORTANT. THIS IS THE SAME DATA WHERE NATURAL LANGUAGE PROCESSING WAS USED AT THE UNIVERSITY OF SOUTH CAROLINA TO TRY TO IDENTIFY SOCIALLY ISOLATED PATIENTS. IT'S A PERVASIVE ARGUMENT. WHO DO YOU LIVE WITH, WHAT'S YOUR HOME SITUATION LIKE BUT THERE IS NO AUTOMATIC REGISTRATION OF THESE RISK FACTORS. WE KNOW SOCIAL ISOLATION'S A RISK FOR A VARIETY OF IMPORTANT OUTCOMES AND MENIALLY AND TROUBLE WITH FALLS OR FOOD OR COMPLETING YOUR INSTRUMENTAL ACTIVITIES OF DAILY LIVING AND IF YOU HAVE CHRONIC THESE IT'S INCREASED RISK OF HEALTH OUTCOME AND CARDIOVASCULAR DISEASE AND OTHERS AS WELL. AND BEING ABLE TO IDENTIFY THIS FROM THE NARRATIVE OF THE MEDICAL RECORDS OR WHAT CLINICIANS WRITE SAY CHALLENGE. WE USED THIS STUDY TO TRY TO DO THAT WITH SOME SUCCESS. SELF-SILENCING AND HIV PREVENTION AMONG LA TINA IMMIGRANT FARM WORKERS LITTLE KNOWN AND THE SELF-EFFICACY FOR HIV PREVENTION AND EGALITARIAN ATTITUDES WERE ASSOCIATED. SELF-SILENCING BEHAVIORS WERE NEGATIVELY ASSOCIATED WITH THESE BEHAVIORS AND EGALITARIAN WERE POSITIVELY RELATED TO THESE BEHAVIORS AND HELP US UNDERSTAND WHAT LEADS TO HIV TRANSMISSION NOW A PRIORITY AREA FOR NIH AND THE COUNTRY TO TRY TO ELIMINATE OR DRASTICALLY REDUCE. AND THIS PAPER FROM MOREHOUSE LOOKED AT THE RATES OF ALZHEIMER'S DEMENTIA AND RELATED DEMENTIAS IN THE U.S. POPULATION USING CLAIMS DATA FOR MEDICARE FEE-FOR-SERVICE BENEFICIARIES. THERE'S NOT A LOT OF PUBLISHED ON THIS TOPIC. THIS IS NOT STRUCTURED CRITERIA DIAGNOSIS. THIS IS SOME DOCTOR LIKE I USED TO BE THAT CHECKS AND SAYS ICD9, DEMENTIA. THEN USE CLAIMS AND THE NUMBERS AND COULD BE OVER DIAGNOSIS AND UNDER DIAGNOSIS. WE'RE BETTER AT SCREENING AND USING TOOLS FOR THAT WITH MENTAL EXAMINE AND OTHER SCREENING MEASURES BUT A FORMAL DIAGNOSTIC CRITERIA IS NOT AS RIGOROUS RIDGE CLAIMS DATA. UNLIKE OTHER CHRONIC DISEASES YOU CAN DO WITH A TEST, ALZHEIMER'S-RELATED DEMENTIAS ARE NOT DIAGNOSABLE WITH A SIMPLE TASK. AN MRI WILL NOT GIVE YOU THE DIAGNOSIS NOR WILL A DRUG TEST. ONE IS WOMEN ARE AT GREATER RISK FOR DEMENTIA. THIS IS NOW CLEAR IN EVERY SINGLE STUDY THAT'S BEEN LOOKED AT. AND UNDERSTANDING WHY -- I DON'T KNOW WHY THAT IS BUT IT'S NOT JUST BECAUSE WOMEN LIVE LONGER. OR HAVE MORE EXPOSURE OR AFRICAN AMERICANS HAVE A HIGHER PREVALENCE OF DEMENTIA. THAT'S BEEN PRETTY CONSISTENT IN THE LARGE STUDIES LOOKED AT THIS. WITH LATINO OR HISPANICS IT'S BEEN CONTRADICTORY IN THE CALIFORNIA STUDIES MEXICAN AMERICANS HAVE A SIMILAR OR LOWER RATE OF DEMENTIA BUT IN THE STUDIES DONE IN THE EAST THERE'S HIGHER RATES AND FEW STUDIES HAVE HAD SUFFICIENT AMERICAN INDIANS IN THIS ANALYSIS THEY ARE MIXED. IN THE KAISER DATA I HAD AND HELP COLLABORATE WITH OUR SCHOLARS AT UCSF PACIFIC ISLANDERS WERE NOT HIGHER THAN THE AVERAGE GROUPS IN TERMS OF PREVALENCE OF DIAGNOSIS. IMPORTANT WORK. KEEP IN MIND, I DIDN'T MENTION THIS EARLIER THAT THE CENTER FOR MEDICAID AND MEDICARE SERVICES AND NIH HAVE ONGOING DISCUSSIONS ABOUT COLLABORATION ONE OF THE AREAS LIKELY TO GROW IS DATA SHARING AND THERE'S A MECHANISM WHEREBY IF HAVE YOU AN NIH STUDY HAVE YOU ACCESS TO MEDICARE DATA WITHOUT HAVING TO USE MONEY TO PAY MEDICARE TO GET DATA. KEEP IN MIND MEDICARE CLAIMS DATA ARE LIMITED AND MESSY AND THE REAL VALUE OF MEDICARE AND MEDICAID ARE LINKING THEM TO OTHER DATA. AND ONE OF THE GREAT EXAMPLES IS THE MEDICARE DATA CREATE NCI WHICH IS A USEFUL DATA SET TO ANALYZE FOR A VARIETY OF OUTCOMES. I THINK THIS IS DATA SHARING FUTURE. WE'LL SEE MORE IN THIS SPACE AND I BRING THIS OUT TO HAVE YOU THINK ABOUT IT. PROTECTIVE FACTORS OF BEHAVIORAL OUTCOMES AMONG HIGH-RISK AFRICAN AMERICAN YOUTH. A STUDY WE HELP FUND AND THIS RELATED TO FINDING THINGS THAT ARE GOOD AND TO PREVENT PROBLEMS IN THE FUTURE. THE TEST OF THE PROTECTIVE EFFECT LIKE RELIGION AND COLLECTIVE EFFICACY ON STRESS AND BEHAVIOR ON AFRICAN AMERICAN YOUTH WITH THINKING ABOUT ISSUES AROUND DRUG USE AND THE HIGH-POVERTY NEIGHBORHOODS AND WHAT THEY FOUND WAS PERHAPS NOT TOO SURPRISING BUT REINFORCING ADOLESCENT RELIGIOCITY WAS HELPFUL AND I THINK KEEPING A CHECK ON THINGS THAT ARE ALWAYS WORTHWHILE. AND RURAL RESIDENTS AND POVERTY. THINK YESTERDAY THERE WAS A STUDY MENTIONED FROM YESTERDAY AND WE'VE KNOWN COPD IS HIGHER IN RURAL AMERICAN RATHER THAN S SUBURBANICITY. AND THERE WAS AN ASSOCIATION WITH HOUSEHOLD WEALTH AND NEVER-SMOKERS IT WAS LESS ASSOCIATED WITH AND ASSUMPTION IS THERE'S SOMETHING ENVIRONMENT PROVOKING THIS IN TERMS OF POLLUTION. ALMOST THINK COUNTERINTUITIVE. WE USED TO THINK URBAN ENVIRONMENTS WERE MORE CONTAMINATED WIN AIR POLLUTION AND IT'S NOW -- WITH AIR POLLUTION AND IT'S VARIED SOME DEPENDS ON THE FUEL USED FOR HEATING IN INDOOR EXPOSURE AS WELL AS HOW POLLUTANTS GET TRAPPED AND PARTICULATE MATTERS GET TRAPPED IN CERTAIN PARTS OF THE ENVIRONMENT AND VALLEYS IN PARTICULAR AROUND MOUNTAINS. COPD, AS YOU MAY KNOW IS ABOUT 80% IS CAUSED BY TOBACCO SMOKE AS WE SEE A LOWERING OF TOBACCO SMOKE. THE OTHER CONTRIBUTORS ARE GOING TO BECOME MORE RELEVANT. THERE'S A CLEAR AGING EFFECT. WOMEN SEEM TO BE MORE VULNERABLE TO THIS AS YOU AGE. I'M REFERRING TO LATE 70s, EARLY 80s, YOU BEGIN TO SEE THIS COPD-LIKE ILLNESS OR CLINICAL ENTITY UNRELATED TO EVER HAVING SMOKED TOBACCO OR BEING EXPOSED TO IT AND IN RACE ETHNIC EVALUATION IN CHRONIC PULMONARY DISEASE'S CLEAR AFRICAN AMERICANS AND LATINOS HAVE LOWER RATES AFTER YOU ADJUST FOR TOBACCO EXPOSURE. AGAIN, NOT FULLY UNDERSTOOD BUT THE DATA THAT'S BEEN PUBLISHED THAT LOOKED AT THIS. A COUPLE STUDIES FROM CALVIN CHOI'S LAB. THIS IS ONE THAT WAS DONE BY A FULLBRITE SCHOLAR LOOKING AT THE TOBACCO USE SUPPLEMENT AND U.S. BLACKS AND IMMIGRANT BLACKS AND NOT MANY HAVE LOOKED AT THIS AND A COUPLE CROSS-SECTIONAL DATA AND EUROPEAN BLACKS SPOKE 17% GIVEN A COUPLE POINTS AND WEST INDIES BORN BLACKS 14%. THE AFRICAN DATA IS VERY LOW. SUB-SAHARAN AFRICAN DON'T SMOKE CIGARETTES THOUGH ZIMBABWE IS ONE OF THE LEADING WORLD PRODUCERS OF TOBACCO. I DON'T KNOW IF ANYONE HAS AN EXPLANATION FOR IS. I DON'T KNOW WHAT THE FACTORS INVOLVED HERE ARE. SIMILARLY FORECLOSURE YOU LOOK AT CURRENT SMOKES, THE METRIC OF FIRST-CIGARETTE WITHIN 30 MINUTES OF WAKING IS LOWER FOR AFRICAN AND WEST INDIAN IMMIGRANT AND USING MENTHOL CIGARETTE AMONG THOSE WHO SMOKE IS LOWER BUT HIGHER FOR THE WEST INDIES BLACKS THAN THE AVERAGE AMERICAN SMOKE. AND THIS IS LOOKING AT MARKETING THAT LATINOS AND BLACKS WERE MORE SUSCEPTIBLE TO MARKETING AND ANNAPOLIS PUBLISHED THIS WORK WITH A PILOT STUDY LOOKING AT PRE AND POST INTERVENTION OUTCOMES WITH ALL SPANISH-SPEAKING STRESSED OUT AND THE STRESS OF IMMIGRATION DID MODIFY BUT DEPRESSIVE SYMPTOMS HAD A MARKED DECREASE AFTER THE INTERVENTION. THIS WAS ONE OF OUR INVESTIGATIONS IN SAN FRANCISCO. LET ME FINISH WITH SOME NATIONAL DATA TRENDS. THE YOUTH CIGARETTE, TOBACCO SURVEY GRADES 9 TO 12. COMBUSTIBLE CIGARETTES, 14% FOR WHITES AND 13% FOR BLACKS AND 13% FOR LATINOS. SO NOT DIFFERENT. COMPLETELY LEVEL. NOT TRUE FOR ADULTS. WE SEE DIFFERENCES IN ALL. KEEP IN MIND WHEN WE ASK YOUTH ABOUT SMOKE WEG -- SMOKING WE SAY THE LAST 30 DAYS. SOME SAY THE AGE OF INITIATION IS HOLD OLDER AND USUALLY BEEN BEFORE 13 AND THERE'S DATA THE MINORITIES ARE MORE LIKELY TO BECOME REGULAR SMOKES AT AN OLDER AGE. . THE RATE OF SMOKING YOUTH HAS DROPPED SIGNIFICANTLY. WHEN YOU ASK ADOLESCENTS IN THE LAST 30 DAYS HAVE YOU SMOKED AND THE PROPORTION WHO SAY YES HAS GONE DOWN STEADILY. THE PROPORTION WHO EVER TRIED A CIGARETTE SAYING HAVE YOU SMOKED EVEN A PUFF HAS ALSO GONE DOWN. IT USED TO BE 70%, 75% WOULD TRY AND NOW IT'S WELL UNDER 50%. IT'S IN THE 30s. BUT THE PROPORTION WHO IS SUSCEPTIBLE HASN'T BUDGED BUT INCREASED BASED ON DATA WE'RE NOT BUDGETING THE COMPONENT AND IT'S STILL ATTRACTIVE TO KIDS WHO HAVE NEVER SMOKED. NOW WE HAVE THE COLLECT TRONICS AND THE LOW PRESSURE HAVE THE ELECTRONICS AND VAPING THERE'S NO DATA THE AMOUNT OF TOXIC PRODUCTS YOU PUT IN YOUR LUNGS WITH COMBUSTION IS GREATER AND WE DON'T KNOW AS MUCH ABOUT ELECTRONICS NOTICE THE RATES OF WHITES GRADES NINE THROUGH TWELVE AND A QUARTER OF THE YOUNG OF WHITE YOUTH ARE USING ELECTRONIC CIGARETTES. THIS IS WHAT GOT SCOTT GOTTLIEB EXCITED OR WORRIED ABOUT THE EPIDEMIC AND LEADING DOWN THE PATH OF REGULATION. AFRICAN AMERICAN KIDS ARE LESS LIKELY TO USE ELECTRONICS AND LATINOS IS IN BETWEEN. THIS OTHER RACE GROUP SAY MIX. YOU CAN SPECULATE WHAT THAT MEANS. AS IT SOMETHING WHERE WE KNOW WHAT TO DO TO ADDRESS THIS AND WE'RE NOT DOING ENOUGH. ANOTHER IMPORTANT HOT COPPIC IN THE LAST FEW MONTHS HAS BEEN THE ISSUE AROUND MATERNAL MORBIDITY. SOME WAS HIGHLIGHTED BY A HIGHLY PUBLICIZED EVENT WITH SERENA WILLIAMS A COUPLE YEARS AGO AND SO THE CONSISTENT EVIDENCE THAT AFRICAN AMERICAN WOMEN HAVE INCREASED NOT JUST MORBIDITY BUT MORTALITY AND SEVERE AND UNDERSTANDING WHY THAT IS. ONE OF OUR STAFF WAS HIGHLIGHTED AND LOOKED AT STRUCTURAL FACTORS LOOKING AT THE QUALITY OF HOSPITALS WOMEN WERE GOING TO AND THERE ARE POTENTIAL BIOLOGICAL FACTORS THAT HAVEN'T BEEN WORKED OUT IN TERMS OF INCREASED RISK OF DEVELOPING VENUS THROMBOEMBOLISM AND THERE WAS A PRESENTATION ON THE INCREASED GENETIC RISK OF THROMBOLISM AND MOST THE TIME IT'S RELATED TO CARDIOVASCULAR EVENTS AND NOT TO PERI-PARTUM EVENTS. MEDICARE IS INTERESTED IN THIS AND CMS IS INTERESTED IN THIS BUT WE HAD MEDICAID ENGAGE AND WITH NICHD AND NHLBI WE'LL SEE WHAT WE CAN LEARN AND THERE WAS A PAPER EARLIER THIS YEAR FROM A COHORT STUDY. THERE WERE TALKS THAT IF YOU WERE A CIGARETTE SMOKER VARIED BY THE AMOUNT YOU SMOKED IN TERMS OF CIGARETTES AND RACE ETHNICITY IN AFRICAN AMERICAN AND PACIFIC ISLANDERS THE STUDY IS IN CALIFORNIA AND HAWAI'I AND THEY HAVE A SUBSTANTIAL NUMBER AT HIGHER RISK OF DEVELOPING LUNG CANCER WHILE LATINOS IN THAT CASE AND THEY MODEL RISK BY MODELING 50 YEARS OF 50 CIGARETTES PER DAY. 25-PACK A YEAR EQUIVALENT AND NATIVE HA WINES -- HAWAIIANS HAD THE HIGHEST RISK. WHITE HALF AND JAPANESE SIMILARLY AND LATINOS LOWER. THEY COULDN'T EXPLAIN IT IN THEIR ADJUSTED MODELS. BY ANY OTHER THINGS MEASURED INCLUDE SUBSAMPLE WITH INCOME TEEN EQUIVALENT. -- NICOTINE EQUIVALENT. THEY BELIEVE THE REASON WE SEE THESE DIFFERENCES IN JAPANESE AMERICANS IS OTHER CAUSES. THIS IS A GROUP FROM USC AND WORKED WITH NCI'S PROGRAM AND WE CO-FUNDED A PROSTATE CANCER STUDY TO LOOK AT PROSTATE CANCER ON A NATIONAL BASIS AND THIS IS THE SAME GROUP THAT LOOKS AT PUBLISHED GENETICS. MY VOICE IS RUNNING OUT SO I'LL STOP FOR QUESTION. I THINK WE HAVE 20 MINUTES. THANK YOU FOR YOUR ATTENTION. I WANT TO ADD TO THE CONVERSATION. CALIFORNIA JUST APPOINTED ITS FIRST SURGEON GENERAL IT'S AN INTERESTING PROCESS. SHE CAME TO GIVE GRAND ROUNDS AT OUR INSTITUTION. THEY'RE ON THE VERGE OF DEVELOPING STATEWIDE SCREENING FOR ADVERSE CHILDHOOD EVENTS. I WONDER WHAT YOUR THOUGHTS ARE AND THERE'S INFORMATION WE CAN GET BY SCREENING IN EARNEST. AND WHEN YOU SCREEN FOR THINGS YOU CAN'T DO MUCH ABOUT IT SO IT'S GOING BRING INTERESTING DISCUSSIONS ON THE ISSUE OF PREVENTION. >> SO WHO IS THE NEW SURGEON GENERAL. NA NADINE BURKE. >> I KNOW THAT NAME. >> SHE WAS A RESIDENT AT STANFORD AND PEDIATRICS AND WENT ON. >> THAT'S GREAT. I THINK SOME THINGS SHOULD MOVE FORWARD ON A STATE LEVEL. THIS SAY GREAT SAMPLE. CALIFORNIA IS A LITTLE BIT OUT THERE AND LARGE. IT HAS A HUGE OPPORTUNITY TO MAKE A BIG IMPACT. MORE IMPORTANT IS LINKING IT AND MEASURES IT ONCE -- YOU SAY WHAT DO YOU DO ABOUT IT? IF YOU'RE ABLE TO THEN HAVE A REGISTRY OR A DATABASE AND A POPULATION DATABASE LINKED TO THE BIRTH CERTIFICATE DATABASE IS ROBUST. THAT WOULD BECOME VERY HELPFUL IN LOOK AND MOVING FORWARD. WE DON'T NEED CAUSAL PATHWAY DATA FOR KNOWING TO DO SOMETHING ABOUT ADVERSE CHILDHOOD EVENTS. WE OUGHT TO DO INTERVENTIONS AND PEOPLE ARE TRYING WHETHER IT'S INTER/PERSONAL VIOLENCE IN THE HOME OR FOOD INSECURITY. WE KNOW TOO MUCH TO SAY, WE'RE GOING JUST WATCH AND SEE WHAT HAPPENS. BECAUSE WE HAVEN'T BEEN ABLE STO DO LONG-TERM PERSPECTIVE FOLLOW-UP IS WHERE IT'S HELPFUL. ESPECIALLY THE RICH DIVERSITY THAT EXISTS IN CALIFORNIA. SPERO. >> GOING BACK TO YOUR QUESTION, THERE'S BEEN WONDERFUL EVIDENCE TO POTENTIAL EFFICACY AND THE DETECTION AND MANAGEMENT AND TRIAGE OF THINGS LIKE ALCOHOL USE AND DEPENDENCE AND ETCETERA. AND FROM MY WORK IN ALASKA WHICH RESONATES DEEPLY AMONG ALASKAN NATIVE COMMUNITIES IS THE EXPERT IS NOW FUNDED IN THE STATE OF ALASKA THROUGH REVISED CBT CODES IN MEDICAID. THE PROBLEM IS IF THERE'S NOT A SPECIFIC KIND OF TREATMENT THAT IS DIAGNOSTICALLY FORMED WE HAVE A BARRIER WITH THE IMPLEMENTATION WITH REFERENCE TO A SPECIFIC CONDITION. I EXPECT THAT'S A SIMILAR CHALLENGE IN OTHER STATES. >> THERE'S BEEN ADVANCEMENT FOR THE CENTERS FOR AIDS RESEARCH PROGRAM WHICH NIMHD PARTICIPATES IN AND THERE'S A PLAN TO END HIV TRANSMISSION IN THE UNITED STATES. WE KNOW THAT LATINO, YOUNG AND BUY SEXUAL MEN ARE ONE OF THE ONLY GROUPS SEEING AN INCREASE IN THE RATE OF DIAGNOSIS. WE KNOW THERE'S LARGE RACIAL DISPARITIES ALREADY. AND THAT'LL PLAY A ROLE IN THE SCIENCE AND THEY'RE WORKING WITH HEALTH DEPARTMENTS AND COMMUNITY ORGANIZATIONS TO REALLY END THE EM -- EPIDEMICS WHERE WE SEE THE HIGHEST RATES AND THIS IS IN LINE WITH THE NIMHD MISSION WITH COMMUNITY ENGAGEMENT AND ADDRESSING DISPARITIES BECAUSE WE KNOW WE WON'T END THE EPIDEMIC IN THE UNITED STATES IF WE DON'T PAY ATTENTION TO THESE DISPARITIES. I WANTED TO PUT THAT ON YOUR RADAR TO SAY A LOT OF EXCITING THINGS WILL HAPPEN IN THE NEAR FUTURE TO HAVE PEOPLE BE AWARE OF. STRAND THERE'S OUTREACH AND ACTIVITIES. THERE WAS PROPOSED FUNDING BUT WE'RE AWARE OF THIS CRITICAL ISSUE AND TO ME IT'S A MUCH MORE IMPORTANT ISSUE THAN MANY THINGS GET MORE NOTICED AND IT'S A MATTER OF HOW DO WE FUND THINGS THAT RESEARCH WISE WE'RE FOCUSSED ON. MINORITY NSM WHO ARE THE MAIN SOURCE OF NEW INFECTIONS AND THE HOT SPOTS IDENTIFIED INCLUDE COUPLE STATES IN PROSECUTOR IT'S IN OUR AREA OF INTEREST. AND WE EXPECT TO PROMOTE THIS. JOYCE. ANY OTHER COMMENTS OR QUESTIONS? >> THANK YOU FOR YOUR PRESENTATION. WHAT CAN WE TO TO BEGIN -- WHAT CAN WE DO TO LOOK AT PACIFIC ISLANDERS. >> WHY DON'T WE WRITE A BLOG AND START PUSHING IT AND START A COMMENTARY. THE FUNDAMENTAL PROBLEM, I'VE DISCOVERED AFTER MANY QUESTIONS, WAS THAT DEATH CERTIFICATES ARE CODED THIS WAY. SO ALL THE MORTALITY ANALYSIS ARE FLAWED IN THAT WAY. AND WHAT I'VE GOTTEN MY COLLEAGUES TO AT LEAST DO IS STOP CALLING IT ASIAN/P.I. WE'RE REPORTING ASIAN MORTALITY AND YOU CAN PUT AN ASTERISK TO SAY PACIFIC ISLANDERS ARE INCLUDE BUT WE DON'T HAVE THE POW POWER. WHENEVER DATA HAS BEEN DISAGGREGATED WITH KAISER STUDY OR THE MULTIETHNIC COHORT STUDY OR OTHER SUCH STUDIES IT'S CLEAR THE PACIFIC ISLANDERS PROFILE IS ON AVERAGE MUCH WORSE THAN ASIANS AND PRIMARILY WE MEAN EAST ASIANS NOT SOUTH ASIANS COMPARATIVELY AND THERE HAVEN'T BEEN ENOUGH SOUTH ASIANS IN THE U.S. TO HAVE AN IMPACT ON THE OVERALL RATES BUT AS THAT EVOLVES AND CHANGES, WE'LL ALSO GET MORE -- WHEN YOU GET NOISE AND DATA WHAT IT DOES IS GUIDES US TOWARDS THE NUL AND YOU LEARN LESS. THERE'S GOING TO BE DIFFERENCES THERE YOU WON'T SEE THEM. IT'S A CRITICAL POINT. I'VE BEEN MAKING THAT EVERY TIME I DO ANY TALK. THEY SHOW THE CATEGORIES. I MAKE A POINT WE SHOULD ALSO ACTIVELY ABANDON THE TERM CAUCASIAN IN REFERRING TO WHITES. BECAUSE CAUCASIAN IS AN ANTIQUATED TERMINOLOGY OF ANTHROPOLOGISTS WHEN THEY BELIEVED HUMANS ORIGINATED IN THE CAUCUSES SO IF YOU KNOW THAT YOU STOP USING IT RIGHT AWAY BECAUSE IT'S WRONG. WE HAVE COMPELLING EVIDENCE HUMANS SPECIES AS WE KNOW IT ORIGINAT ORIGINATED IN [INDISCERNIBLE] BUT IT'S AN IMPORTANT THING WE NEED TO CONTINUE TO ADDRESS. >> AND I THINK THE STUDY HAS INFORMED DISPARITIES WITHIN LATINO POPULATIONS. THERE IS A SIMILAR NATIONAL STUDY WITH DISAGGREGATED ASIAN PACIFIC ISLANDER GROUPS I THINK THAT'S WHEN WE'LL GET TO APPRECIATE THAT KIND OF INFORMATION EVEN WITH PACIFIC ISLANDERS THERE'S DISPARITIES WHERE POPULATIONS TEND TO BE HEALTHIER. >> THOSE NOT FOLLOWING THE "ALL OF US" RESEARCH DATA THE DATA WILL BE PUBLICLY AVAILABLE SOON IF NOT ALREADY AND THEY PROBABLY HAVE THE MOST DIVERSE SAMPLE IN THE UNITED STATES IN TERMS OF A COHORT. I THINK SOME OF THE QUESTIONS CAN BE LOOKED AT OR BEGUN TO BE LOOK AT IN THAT SAMPLE SINCE THEY ARE ACTIVELY LOOKING AT RACIAL/GENDER POPULATIONS. THEY HAVE A DATA TOOL OUT THOUGH YOU CAN'T HAVE IT DISAGGREGATE BECAUSE THEY HAVEN'T FIGURED OUT TO DO WITH THE AMERICAN INDIANS WHO WERE RECRUITED INTO THE SAMPLE. IT'S VERY BASIC INFORMATION. ABOUT HALF THEIR SAMPLE IS FROM MINORITY RACE ETHNIC GROUP. FERNANDO. >> SO YOUR DATA FOR SMOKING AND DIFFERENT PREVALENCE OF SMOKING, REAFFIRMS THE ISSUE OF IMMIGRANT PARADOX OF BEHAVIORS AND THINGS THAT HAPPENED. I THINK THAT'S KEY FOR US BECAUSE AT THE END OF THE DAY IF WE CAN UNDERSTAND WHY PEOPLE DON'T DO THAT AND WHAT POSITIVE REINFORCEMENT WE CAN HAVE, THAT WOULD BE VERY POSITIVE. THE FACT THAT SMOKE KILLS MORE PEOPLE THAN MOST OTHER KINDS OF EXPOSURES AND WE HAVE A GROUP THAT'S NOT DOING THAT, WHY, RIGHT? AND AS WE LOOK, FOR EXAMPLE, AMONG KIDS, ONE OF FOUR CHILDREN LIVES INANE -- IN AN IMMIGRANT FAMILY AND INSTEAD OF BREAKING THEM UP IN CATEGORIES IT'S ALSO IMPORTANT TO UNDERSTAND THEIR LEGACY AND THEIR LEGACY OF IMMIGRATION AND THE CULTURAL VALUES. >> THANK YOU. AS WE LOOK AT RACE AND ETHNICITY IT'S GOING TO BECOME A BLENDED COMMUNITY AND HOW CAN WE LEARN MORE ABOUT ANCESTRY WHETHER IT'S "ALL OF US," GIVING US THAT INFORMATION AND WHAT CAN WE DO GOING FORWARD TO BE AHEAD OF THE GAME TO SHOW US THE DIVERSITY OF OUR POPULATIONS AND TRY TO GATHER THE DATA AND SEE WHAT KIND OF CHRONIC ILLNESSES AND WE'VE KNOWN WHEN WE TRY TO DISAGGREGATE LATINOS WE'RE ONE OF THE FIRST TO BE ABLE TO LOOK AT THE DIFFERENCES BECAUSE SOCIOECONOMIC STARTS SOCIOECONOMIC STATUS AND ALL THOSE THINGS CONTRIBUTE TO THE DIVERSITY OF OUR POPULATION. AS A GROUP WE NEED TO THINK ABOUT IS IT A SWAB OR WHAT ARE WE GOING TO NEED AND START BUILDING THAT INTO OUR STUDIES TO BE ABLE TO DO THOSE ANALYSES. >> I COULDN'T AGREE WITH ALL THESE COMMENTS MORE BUT I'LL ADD AN ADDITIONAL PERSPECTIVE. NIMHD WE SAID OUR FOCUS IS TWO PILLARS, RACE ETHNICITY, MINORITY HEALTH AND SOCIOECONOMIC STATUS. WE DON'T SEE THESE AS INDEPENDENT VARIANCES. THEY OVERLAP. SOMETIMES THEY ACCOUNT FOR THINGS INDEPENDENT OF ONE ANOTHER. SO SOMETIMES IT'S SOCIAL CLASS OR ACCESS IT PREDICTS MORTALITY AND OUTCOMES AND RACE ETHNICITY CARRIES WITH IT THINGS THAT INCLUDE HISTORICAL LEGACY AND STRUCTURE AND SOCIAL DETERMINATES THAT ACCOUNT FOR OUTCOMES IN VARIANCE. DISAGGREGATION IS GOOD. WE NEED MORE DATA. IF AMERICAN INDIANS WERE GOING TO DISAGGREGATE, YOU'D HAVE 500 DIFFERENT SAMPLES AND THEN WHAT WOULD WE SAY? I THINK THE IDEA OF TOO MUCH DISAGGREGATION CAN REALLY BE HARMFUL UNLESS YOU BRING IT BACK TOGETHER AND SAY, WHAT ARE WE SAYING ABOUT OUR POPULATION. WE DON'T DISAGGREGATE AFRICAN AMERICANS THAT MUCH BUT IF YOU'RE BLACK AND BORN IN MISSISSIPPI IT'S THE SAME AS BEING FROM OAKLAND? AGE THE TOOLS WE GET FROM GERM LINE MUTATIONS OR METABOLIC PATHWAYS OR SLEEP PATTERNS OR THINGS WE COULD MEASURE WITH A QUANTITATIVE BIO BEHAVIORAL METRIC I THINK WILL BE ADDED TO THE UNDERSTANDING OF PATHWAYS TO SEE WHAT THE OUTCOMES ARE. WELL, LAST WORD. >> I WANT TO ADD TO YOUR POINT ABOUT THE ASSOCIATION BETWEE S.E.S. AND ETHNICITY AND RACE. I THINK IT'S A MARK FORESOMETHING ELSE GOING ON AND WE NEED TO DO SOMETHING ELSE TO FIGURE THAT OUT TO BETTER UNDERSTAND THE ROLE OF ETHNICITY AND RACE ON HEALTH DISPARITIES ASIDE FROM SIMPLE S.E.S. AND OTHER FACTORS. AND I THINK IT MATTERS IN THE EXPERIENCE OF DIFFERENT GROUPS IN THE U.S. >> I'LL PUT YOU ON ONE OF OUR PAGES ON THE WEBSITE. THIS IS WHAT OUR COUNCIL MEMBER SAYS. IT'S OUR MISSION. LET ME CALL ON DR. CARLYLE TO SAY A FEW WORDS ABOUT OUR FRIENDS NETWORK BEFORE WE TAKE A BREAK. >> I WANT TO COMMEND ELISEO ON DOING A WONDERFUL JOB OF MAKING US AWARE OF SOME OF THE VERY INTERESTING STUDIES THAT ARE GOING ON IN THE FIELD OF HEALTH DISPARITIES RESEARCH. IT'S NO SECRET THAT AS WE'RE EMBARKING ON THIS TRANSFORMATION IN HEALTH CARE THAT TIMES ARE MORE CRITICAL IN HAVING A MARKED IMPROVEMENT IN OUTCOMES AND THE SUSTAINABILITY OF OUR HEALTH CARE SYSTEM. THE IMPORTANT DISCOVERY RESEARCH IN SCIENCE TAKING PLACE IS CRITICAL AND THERE'S A MISSING COMPONENT TO THAT AND ACROSS THE STAKEHOLDER SHIP WE'RE AWARE AND RETURNING VALUE AND HOW DO WE BEGIN TO TRANSLATE THESE FINDINGS BACK INTO THE COMMUNITY AND BACK INTO THE HANDS OF THE PATIENT TO DO A BETTER JOB OF PARTICIPATING IN THEIR CARE. LEGISLATIVELY CHANGING POLICY TAKE TIME BUT WE NEED TO CONTINUE TO BEAR DOWN ON THAT. THE LAST TIME I WAS HERE I WAS ABLE TO INTRODUCE FOLKS ON THE TEAM AND TELL YOU WE WERE WORKING WITH TO YOU HELP LEAD THAT AND SUPPORT HEALTH DISPARITIES AND MINORITY HEALTH. A BRIEF BACKGROUND ON THE ORGANIZATION AND THE NATIONAL ALLIANCE AGAINST DISPARITIES AND PATIENT HEALTH AND SO WE ARE VERY MUCH INVOLVED IN DOING RESEARCH BASED ON HEALTH DISPARITIES AND ALSO TRYING TO FOCUS ON THE IMPLEMENTATION OR TRANSLATION THROUGH OUR COMMUNITY HEALTH PROGRAM. AND THROUGH OUR ADVOCACY AND LEADERSHIP AND POLICY PROGRAM AND THE NECESSARY WORK WE'RE TRYING TO TAKE THE EVIDENCE-BASED RESEARCH TO HELP DRIVE THE CHANGES IN POLICY AND LEGISLATION THAT WILL SUPPORT AND THAT'S US OPERATING THROUGH THE THREE PROGRAMS PRIMARILY RESEARCH AND COMMUNITY HEALTH OUTREACH FOR POLICY. SO THANK YOU AGAIN FOR HAVING US AND ALLOWING US TO WORK WITH YOU TO SUPPORT THE MISSIONS. ELISEO MENTIONED EARLIER, ACTUALLY ABOUT A MONTH AGO WE HELD THROUGH THE FRIENDS PROGRAM A CONGRESSIONAL BRIEFING ON HEALTH DISPARITIES A NATIONAL CRISIS IN THE SUCH. WHAT WE TRIED TO FOCUS ON WAS IS THE FACT IT'S A HEALTH ISSUE THAT AFFECTS MANY IN THE COUNTRY. WE'RE AWARE OF SOME OF THE STRUCTURAL RACISM ELEMENTS AND SOCIOECONOMIC FACTORS THAT ARE RESPONSIBLE FOR CREATING HEATH DISPARITIES. WE'RE CATCHING UP TO THE SCIENCE OF THE HEALTH DISPARITIES AND UNDERSTANDING HOW THOSE INTERACT ON A BIOLOGICAL LEVEL. IT'S IMPORTANT TO DRIVE THE STAKEHOLDERSHIP AND WE'RE BRIEFING THE NEEDLE AND IN TERMS OF A MORAL ISSUES IN TERMS OF PEOPLE SUFFERING BECAUSE OF THESE DISPARITIES WE'RE UNDERSTAND IT'S CRITICAL FROM AN ECONOMIC PERSPECTIVE. COLLECTIVELY THE PROBLEMS ARISING BECAUSE OF DISPARITIES ARE DRIVING UNSUSTAINABILITY OF THE HEALTH CARE SYSTEM. WE WANTED TO BRING THAT HOME DURING THE BRIEFING SO FOLKS TAKE THE OPTICS AWAY FROM THIS BEING PERCEIVED AS A RACIAL OR ETHNIC PROBLEMS AND TRY TO MAKE THE POINT RACIAL DISPARITIES IS BEFORE AND ANY POPULATION DRIVEN BY RACE, GENDER, GEOGRAPHY, AGE, IT'S A HEALTH DISPARITY. AFFECTING EVERYONE ACROSS THE UNITED STATES. WE WANTED TO DRIVE THAT POINT HOME AND THINK WE DID A GOOD JOB AND STRONGLY ADVOCATED FOR CONTINUING SUPPORT OF THE NIMHD AND THE GREAT WORK IT'S TRYING TO CONTINUE TO DO THAT. MOVING FORWARD WE'D LIKE TO FOCUS ATTENTION ON HELPING RAISE AWARENESS ABOUT THE SCIENTIFIC RESEARCH BEING FUNDED HERE AND THE FUNDING OPPORTUNITIES ACROSS THE ACADEMIC AND RESEARCH COMMUNITY. PLEASED TO SEE WE'RE SEEING AN INCREASE IN THE AMOUNT OF GRANTS THAT ARE BEING AWARDED AND WE WANT TO CONTINUE TO IMPROVE ON THAT AND WILL REACH OUT ACROSS WITH FOLKS TO CONTINUE THAT WORK. WE'RE DEVELOPING A STRONG AGENDA. WE'LL LOOK TO REACH OUT AND GET INPUT FROM FOLKS. INITIALLY MOST THE EFFORT WAS FOCUSSED ON GETTING THE CONGRESSIONAL BRIEFING TO TAKE PLACE. WE'RE HAPPY ABOUT THAT. THANKS TO SENATOR RASKIN AND WE HAD A GOOD TURNOUT AND NOW THAT THAT'S PASSED WE'LL FOCUS ON OTHER WORK MENTIONED. WE'RE BUILDING A NATIONAL CAMPAIGN AS WE BUILD UP THE TEAM TO SUPPORT THIS. WE HAVE SOCIAL MEDIA MANAGER COMING ONBOARD STARTING JUNE 10 COMING ON BOARD FROM ONE OF THE NATIONAL PR FIRMS AND EXCITED ABOUT THAT AND WE'RE EXCITED ABOUT OUR NEW DIRECTOR OF ADVOCACY LEADERSHIP AND POLICY, DR. HELENE CLAYTON JETER I'D LIKE TO INTRODUCE HERE AND RESPONSIBLE FOR DIRECTING THE FRIENDS FRAM MOVING FORWARD. ON THAT NOTE I WANT TO CLOSE BY SAYING THANK YOU VERY MUCH AND WE LOOK FORWARD TO WORKING WITH YOU. I WANT TO INTRODUCE DR. MATTHEW GILLMAN. WE'VE TALKED ABOUT ECHO STUDY FOR SOME TIME AND IT NEEDED TO GET STARTED AND GOING. THIS WAS A GOOD APPROPRIATE MOMENT TO HAVE AN UPDATE AND SEE WHERE WE ARE AS WE LOOK FORWARD TO WORKING WITH THE DATA. MATT GILLMAN WAS BRUTH ON FOR THE CHILD HEALTH OUTCOMES PROGRAM FROM ECHO AND CAME FROM HARVARD DIRECTOR OF THE OBESITY AND POPULATION MEDICINE PROGRAM AT THE HARVARD SCHOOL OF PUBLIC HEALTH AND ALSO A PROFESSOR IN NUTRITION. HIS BACKGROUND IS INTERNAL MEDICINE, PEDIATRICS AND EPIDEMIOLOGY AND LED A NUMBER OF COHORT AND RANDOMIZED TRIALS AND PUBLISHED ACROSS THE LIFE COURSE. HE WON MENTORING AWARDS AT HARVARD AND SERVED IN SEVERAL INTERNATIONAL LEADERSHIP ROLES INCLUDING THE INTERNATIONAL SOCIETY OF HEALTH AND DISEASE FROM WHICH HE WON THE DAVID BARKER MEDAL IN 2017. HIS CLINICAL EXPERIENCE IS IN PRIMARY CARE IN CHILDREN AND ADULTS AND PREVENTIVE CARDIOLOGY AMONG CHILDREN. I FIRST MET MATT IN 1996 WARD A GENERALIST PHYSICIAN SCHOLARSAWARD A GENERALIST PHYSICIAN SCHOLARS AWARD FOR WHICH I SERVED ON THE COMMITTEE AND WAS ONE OF THE BEST OPPORTUNITIES I'VE HAD TO LEARN ABOUT DIFFERENT DISCIPLINES IN SCIENCE IN THIGHS AREAS OF INTEREST AND -- THESE AREAS OF INTEREST AND IT WAS A WONDERFUL OPPORTUNITY FOR MATT AND OTHERS WHO CAME THROUGH THE PROGRAM. AND A SUBSEQUENT RECIPIENT OF THE RWJ PHYSICIAN'S SCHOLAR AWARD AND MATT, WE LOOK FORWARD TO YOUR PRESENTATION. >> THANK YOU, ELISEO. IT'S A PLEASURE FOR HERE AND HERE WITH MY CHIEF OF STAFF. I WANT TO THANK EVERYONE AT COUNCIL I WANT TO THANK NIMHD FOR CLOSE COLLABORATION AND WE HAVE A GROUP AND IT'S A REAL PLEASURE TO BE HERE AND TALK TO ABOUT OUR PROGRAM, ECHO, WITH A FOCUS ON MINORITY HEALTH AND HEALTH DISPARITIES. TODAY I'M GOING TO BRIEFLY TALK ABOUT THE MISSION AND GOALS OF ECHO AND TELL YOU ABOUT THREE EXAMPLES WE THINK MIGHT BE INTERESTING AND IGNITE A DISCUSSION AND ONE IS A RECENT USE AGREEMENT WITH THE NAVAJO NATION. WE HAVE A NEW ANALYSIS FROM A COHORT ON THE INCIDENTS OF ASTHMA HIGHLIGHTING DIFFERENCES AND ON THE INTERVENTION SIDE WE HAVE SOME OBSERVATIONAL DATA ABOUT VARIATION IN THE OPIOID WITHDRAWAL SYMPTOMS. OUR MISSION IS TO ENHANCE AND THROUGH TEAM WORK AND IMPACT AND RESPONSIBILITY AND VALUE, WE TAKE THE VIEW THAT GOOD START TO LIFE CAN LAST A LIFE TIME. THIS IS THE PURVIEW OF THE LIFE COURSE APPROACH TO HEALTH AND DISEASE OR DEVELOPMENT ORIGINS OF HEALTH AND DISEASE WHICH POSITS THAT EVENTS THAT HAPPEN EARLY AT PERHAPS EARLY PERIODS OF PLASTICITY CAN HAVE SOMETIMES YEAR -- IRREVERSIBLE CONSEQUENCES AND WE NEED TO KNOW ABOUT POTENTIAL RISKS AND WHETHER IT'S OBESITY, GESTATIONAL DIABETES OR WHETHER IT'S THINGS WE FIND ON OUR SHELVES OR HEALTHFUL OR UNHEALTHFUL HABITS. AND TO WHOM THEY APPLY.IN WHEN SO WE CAN APPLY PRINCIPLES OF PRECISION PREVENTION FOR TAKING ACTION AND THE ACTION IS AMONG OUR CHILDREN AND FAMILIES. SUCH AS CLINICAL TRIALS TO IMPROVE THE HEALTH OF OUR CHILDREN AND THEIR ADOLESCENCE. AND ECHO IS A NATIONWIDE PROGRAM THAT INCORPORATED 44 STATES AND D.C. AND PUERTO RICO. WE HAVE FIVE SUPPORTING CENTERS AND THAT SUPPORT OUR COHORT AND INTERVENTION TRIAL NETWORK THE IDEA STATE NETWORK WHICH DOES CLINICAL TRIAL AMONG RURAL OR UNDERSERVED CHILDREN. FIRST ABOUT THE ECHO COHORTS. HERE YOU SEE THE PRIME AND AWARDEES THERE'S 31 GRANT AWARDS AND 71 COHORT AND MORE THAN 150 PERFORMANCE SITES. AND THE NUMBER STARTED PRENATALLY. RECRUITING MOMS PRENATALLY AND FOLLOWING THEIR KIDS. THE OVERALL GOAL IS TO UNDERSTAND EFFECTS OF A BROAD RANGE OF ENVIRONMENTAL EXPOSURES ON CHILD HEALTH EVERYTHING FROM SOCIETY TO BIOLOGY AND NOT PHYSICAL AND CHEMICAL EXPOSURE BUT SOCIETAL AND SOCIAL BEHAVIORS. SO WHAT ARE DEFINED IN THE COHORTS? THE EXPOSURE PERIOD CONCEPTION TO FIVE YEARS AND THE HEALTH OUTCOMES SPAN ALL OF CHILDHOOD AND ADOLESCENCE. THE FOUR WE STARTED WITH WERE PRE AND PERINATAL CONDITIONS AND OBESITY AND THE CONSEQUENCES AND AND WE ADDED POSITIVE CHILD NT HEALTH. THAT'S NOT THE ABSENCE OF DISEASE, IT'S ACTUALLY ON THE POSITIVE END OF THE SPECTRUM. IT FOCUSES ON HAPPINESS AND LIFE SATISFACTION AND MEANING AND PURPOSE, RELATIONSHIPS, ACHIEVEMENT AND SLEEP DURATION AND QUALITY. WHAT ARE WE DOING IN THE COHORTS? THE MAIN THING WE'RE DOING ALONG WITH SUPPORTING THE COHORTS AS INDIVIDUAL ENTITIES IS CREATING WHAT WE'RE CALLING THE ECHO WIDE COHORT. THAT WEAVES THE 71 EXISTING AND ONGOING COHORTS OF MOMS AND KIDS. SO ALL THE COHORTS ARE CONTINUING TO FOLLOW CHILDREN AND SOME ARE STILL RECRUITING DURING PREGNANT SPIN -- PREGNANCY. THE AIM IS TO CONDUCT RESEARCH. THAT REQUIRES ALL COHORT TO SHARE DATA ONTO THE PLATFORM. AN STANDARDIZE TO THE EXTENT POSSIBLE NEW MEASURES. WE HAVE MUCH DATA OVER MANY STAGES OF THE LIFE COURSE. THE PROMISE OF THE ECHO WIDE COHORT IS 50,000 PLUS CHILDREN AND THEY'RE FAMILIES TO ADDRESS RESEARCH QUESTIONS NO SINGLE COHORT CAN DO ALONE. AND THROUGH AND ADD VALUE TO THE DOMAIN IN THE AREAS. AND SOME OF OUR ELEMENTS OF DIVERSITY INCLUDE GEOGRAPHY, RACE, ETHNICITY, SOCIOECONOMIC STATUS. WE AIM FOR THE ECHO WIDE COHORT TO BE A NATIONWIDE COLLABORATION AND RESOURCE FOR THE ENTIRE SCIENTIFIC COMMUNITY TO PURSUE WHAT WE'RE CALLING SOLUTION-ORIENTED RESEARCH WHICH IS RESEARCH THAT INFORMS DECISION POLICIES, PROGRAMS AND PRACTICES. AND FOCUS ON BIOSPECIMENS, CONFLICT OF INTEREST. EVEN BEFORE THE DATA ON THE PLATFORM WE'VE BEGUN PRODUCTIVITY FROM THE ECHO WIDE COHORT THROUGH COLLECTIVE NAL -- ANALYSES AND INDIVIDUAL COHORTS HAVE CONTINUED TO BE PRODUCTIVE WITH 200-PLUS PUBLISHED PAPER. DATA SHARING. ONE OF THE COHORTS AMONG THE 71 IS THE NAVAJO BIRTH COHORT STUDY. THIS STUDY IS AIMING TO LOOK AT HOW PRENATAL AND INFANT EXPOSURE TO URANIUM AND OTHER METALS, OFTEN FROM BABANDONED MINES CAUSES EFFECT AND THE ECHO-WIDE COHORT. THE NAVAJO STUDY RECRUITED FROM ALL THE BLUE SECTIONS AND NAVAJO NATION IS A NATION AS LARGE AS WEST VIRGINIA AND IT'S IN THE FOUR CORNERS AREA OF THE SOUTH SOUTHWEST. AND LIKE ALL COHORTS IN ECHO, THE NAVAJO BIRTH COHART COHORT STUDY NEEDED TO NEAT MILESTONES FOR THE NEXT FUNDING PERIOD. THE CONDITIONS WERE SOMEWHAT COHORT SPECIFIC AND SOME COLLABORATIVE. AND SOME IS RATIFYING THE DATA SHARING POLICY. THE STUDY COULD NOT MOVE TO THE UH3 PHASE UNTIL THERE WAS IN PLACE A DATA SHARING AGREEMENT WITH NAVAJO NATION. DID I THAT DID THING INVESTIGATORS BUT NEVER BEFORE PARTICIPATED IN A NATIONWIDE STUDY REQUIRING DATA SHARING. WE EMPARKED ON E -- EMBARKED ON AN AGREEMENT TO SHARE INDIVIDUAL DATA ON THE DATA PLATFORM. NO CHANGE IN NIH AND NAVAJO NATION POLICIES. WE DECIDED TO START WITH DATA ONLY AND BIOSPECIMENS FOR NAVAJO AND MOST TRIBES IS A SPECIAL PART OF THE BODY. AND WE REQUIRE YOU TO SHARE THE BIOSPECIMENS AND SEND THE SPECIMENS FOR QC AND SINCE 2002 THERE'S BEEN A MORATORIUM ON ANN GENETIC ANALYSIS ON THE NAVAJO AND THEY'RE DISCUSSING LIFTING THAT MORATORIUM AS WE SPEAK. YOU CAN THINK OF TWO LEVELS OF DATA SHARING ONE IS THE RESTRICTED AREA AND ONE IS IN THE FUTURE IN ANONYMIZED PUBLIC USE DATA SET. HERE IN THE BLUE THE COHORTS PRODUCE THE DATA AND THEY SHARE THE DATA IN THE PLATFORM WHICH CONTAINS SOME PERSONAL IDENTIFYING INFORMATION. AND STACK YOUR ANALYSIS. AND THAT APPLIES TO ECHO INVESTIGATORS SO NOW WE'RE TALKING ABOUT DATA SHARING ON TO THAT LEVEL OF ECHO. AND THERE WAS A BENEFIT FOR AND A HALF -- NAVAJO MOTHERS AND CHILDREN AND THERE WERE RISKS BECAUSE ANALYSES MIGHT VIOLATE THE PRIVACY OF NAVAJO PEOPLE BY IDENTIFYING PEOPLE AND THEIR CHARACTERISTICS AND AN EXAMPLE IS GEOCODING. THE NAVAJO IS EXTREMELY RURAL AND HAVING ANY GEOCODE CAN PRETTY WELL IDENTIFY AN INDIVIDUAL. AND THE OTHER ISSUE IS LABEL ORG UNFAIRLY OFFENDING NAVAJO NATION AND THERE'S BEEN EXAMPLES IN THE RECENT HISTORY OF ALASKAN NATIVES THAT MADE TRIBAL NATIONS QUITE AND ON THE NAVAJO THERE'S AN OUTBREAK IN THE SOUTHWEST IN THE EARLY TO MID '90s AND BECAME KNOWN AS A NAVAJO DISEASE AND THAT WAS OFFENSIVE AND WHAT LED THEM TO CREATE THEIR IRB. MORE RECENTLY, AND A UNIVERSITY DID ANALYSES WITHOUT PERMISSION TO DO SO. THIS IS SOME OF THE HISTORICAL AND CULTURAL BACKGROUND WE TOOK INTO ACCOUNT AS WE DISCUSSED MOVING TOWARDS AN AGREEMENT. AND WE'RE COMMITTED TO CONSULTATION AND CLOLLABORATING TO TRIBAL SOVERENCY -- SOVEREIGNTY AND SERVE THE COMMUNITY DIRECTLY AND ENHANCE THE NATIONWIDE CONSORTIUM. PRINCIPLES OF ENGAGEMENT INCLUDE FINDING COMMON GROUND. DEVELOPING APPROACHES TOGETHER AND COMMITMENT AND THIS INCLUDES ENGAGEMENT IN NIH IN ECHO AND THE NAVAJO NATION. WE WORK CLOSELY WITH THE TRIBAL HEALTH RESEARCH OFFICE AND HAD DISCUSSIONS WITH THE COUNCIL AND ENGAGED OFFICES THAT WERE IMPORTANT ALONG THE WAY. ESPECIALLY OUR OFFICE OF THE GENERAL COUNCIL. IN ECHO WE HAVE A STAKEHOLDER WORKING GROUP WHICH ANNOUNCED PRINCIPLES OF ENGAGEMENT AND ALSO THE PRINCIPLE INVESTIGATOR OF THE STUDY HERSELF HAS A LONG HISTORY OF WORKING TOGETHER WITH NAVAJO NATION. SO WORKING WITH NAVAJO NATION WE WELCOMED SIX VISITS ABOUT TWO YEARS AGO TO EARLY THIS MONTH. WE PARTICIPATES AS A BROKER AND ECHO AWARDEES THE DATA ANALYSIS CENTER AND THROUGH IN-PERSON VISITS DISCUSSED CONTENT AND I SHOWED THIS BECAUSE ON OUR FIRST VISIT WE KNEW IT WAS IMPORTANT TO VISIT ABOUT THEISH IRB AND -- THE IRB AND WE MET HER IN A WAG JON WHEEL RESTAURANT AND LISTENED FOR WHO HOURS AND SAID WE DON'T BELIEVE IN DATA SHARING AND IN THE END SHE GOT IN HER TRUCK WITH HER HUSBAND AND SAID WELL, MAYBE WE CAN WORK SOMETHING OUT. WE'RE LEARNING AND TRIBAL HEALTH RESEARCH OFFICE WAS LEARNING AND NAVAJO WAS LEARNING ABOUT THEIR OWN GOVERNMENTS AND HAD FORTUNATELY AN ELECTION DURING THE TIME WE WERE NEGOTIATING WITH THEM SO THERE'S MANY PEOPLE AND MANY RELATIONSHIPS THREE THE LEGISLATIVE BRANCH AND EXECUTIVE BRANCH AND IT WAS IMPORTANT TO HAVE MULTIPLE STAKEHOLDERS IN ONE ROOM AND WHAT HAPPENS WHEN THERE'S AN ELECTION THE VICE PRESIDENT BECOMES THE PRESIDENT AND NEW DIRECTOR OF HEALTH AND THE HEALTH REPRESENTATIVE OF HEALTH IS AN INVESTIGATOR AND SUPERVISES DATA COLLECTORS IN THE FIELD ALL EMPLOYEES OF NAVAJO NATION. THE DEPARTMENT OF JUSTICE CONTACTED THEM ABOUT THE ELECTION. AND WE LEARN THE NAVAJO NATION IRB WHICH OPERATES RATHER INDEPENDENTLY IS PART THE EPIDEMIOLOGY CENTER AND THERE'S A MEDICINE MAN AND WESTERN TRAINED BASIC SCIENTIST. AND THE COUNCIL'S IMPORTANT BECAUSE THEY AUTHORIZE THE IRB AND ONE OF THEIR MEMBERS THAT'S GREAT AS A FACILITATOR DIDN'T GET RE-ELECTED. ALL THESE THINGS WE TAKE INTO ACCOUNT AS WE ARE NEGOTIATING. WHAT FINALLY CAME OUT IS THE DATA SHARING AND USE AGREEMENT AND PROTECTIONS THROUGHOUT THE DATA AND IT TALKS ABOUT WHICH INVESTIGATORS AND SUBMIT ANALYSIS PROPOSALS AND WHO'S ON THE COMMITTEE. THE FACT THE DATA ANALYSIS CENTER WILL NOT SHARE WITH OTHERS AND WHO DOES THE ANALYSIS AND WHO CAN REVIEW PUBLICATIONS BEFORE THEY GO OUT. I CAN SHOW THE DETAILS IN THE Q&A BUT THIS IS THE OVERALL KIND OF THING WE DEVELOPED WITH PROTECTIONS THROUGHOUT THE SPACE. THE AGREEMENT WAS SIGNED IN MARCH AND THAT ALLOWED THE DEPUTY DIRECTOR AND THE PRESIDENT OF THE NAVAJO NATION ALONG WITH THE P.R. OF THE STUDY. DIRECTOR OF COMMUNITY HEALTH AND DIRECTOR OF DEPARTMENT OF HEALTH AND IT'S AN AGREEMENT SIGNED BETWEEN NAVAJO NATION AND THE DATA ANALYSIS CENTER. AND WITH ALL THAT OVER TWO YEARS WE'RE JUST AT THE STARTING LINE. THIS AGREEMENT HAS TO BE IMPLEMENTED AND EVALUATED AND WE WANT TO GO SLOW AND SEE HOW IT WORKS AND BE IN CLOSE TOUCH WITH NAVAJO NATION AS WE ROLL IT OUT. AND HERE YOU CAN FIND THE 17 CLINICAL SITES AND DATA COORDINATED CENTER FOR THE ISPC10, AS WE LIKE TO CALL IT. THESE REPRESENT IDEA STATES. THEY'RE STATES WITH HISTORICALLY LOW RATES OF NIH FUNDING. THE GOAL IS TO PROVIDE ACCESS TO STATE OF THE ART CLINICAL TRIALS WITH UNDER SERVED POPULATION AND BUILD CAPACITY TO CONDUCT THE TRIALS THROUGH INFRASTRUCTURE SUPPORT. AND CAPACITY BUILDING IS EQUALLY IMPORTANT GOAL TO CONDUCTING THE TRIALS. THE FIVE TRIALS UNDERWAY ARE IN DEVELOPMENT AS WELL AS OTHER PROJECTS. I'M SHOWING YOU FIVE OF THESE RIGHT HERE TWO IN THE FIELD ARE PHARMACO KINETICS TRIALS AND THEN WE HAVE OUR OPIOID RELATED PROJECTS WHICH I WANT TO HIGHLIGHT IN THE NEXT FEW SLIDES. FIRST, I WANT TO SAY THAT WE DO THE WORK IN THE ISBC10 BECAUSE IT'S A NEW NETWORK, SOMETIMES WE IMPORT LOCK, STOCK AND BARREL PROTOCOLS FROM OTHER TRIAL NETWORKS. FOR EXAMPLE, FROM THE PEDIATRIC TRIALS NETWORK AT NICHD SOME ARE HOME GROWN AND THE OPIOID WORK IS A NEW COLLABORATION WITH THE NEATO NATAL NETWORK -- NEONATAL NETWORK AND WE LOOK AT OPIOID WITHDRAWAL SYNDROME AND IT TAKE THE ADVANTAGES OF THE NEONATAL RESEARCH NETWORK WHICH STARTED 30 YEARS AGO AND HAD A LOT OF EXPERIENCE AND YET INSIGHTS ARE LARGELY IN PLACES THAT DON'T HAVE HIGH PREVALENCE AND MARRY THAT WITH OUR ISBC10 WHICH STARTED RECENTLY WITH MANY RURAL SITES INCLUDING THOSE THAT OVERLAP WITH HIGH PREVALENCES. AND THIS IS UNDER THE NIH HEAL INITIATIVE HELPING END ADDICTION LONG TERM. TO DATE WE'VE HAD AN EXPERIENCE STUDY TO UNDERSTAND VARIOUS APPROACHES TO TREATMENT INCLUDING PHARMACOLOGIC TREATMENT IN THE NURSERY AND THE DATA ARE COLLECTED IN THE STUDY AND WE HAD OVER 1800 PARTICIPANTS IN A ONE-YEAR PERIOD, 2016 TO 2017. ALL ARE CASES AND IDENTIFIED THROUGH MEDICAL RECORD EXTRACTION. ONE NICE THING ABOUT THIS IS IT'S BEEN LED BY THREE EARLY STAGE NEONATOLOGISTS AND TWO OF THE THREE CAME AS CLINICIANS AND HAD A VERY SMALL PERCENT EFFORT. THROUGH THIS INITIATIVE THEY'VE BEEN ABLE TO INCREASE THEIR EFFORT, LEARN ABOUT CLINICAL TRIALS AND TAKE A LEADERSHIP POSITION. AND MANY 67% OF THE MOTHERS RECEIVED NAT. YOU SEE IN THE GRAPH IT VARIED IN SITES FROM 0 FORCE 80%. -- 0% TO 80% AND IN THE TOPOGRAPH YOU SEE THE MEDICATIONS AND YOU SEE THE PREFERENCES OF TREATMENT. AND THERE'S A LARGE VARIATION OF PHARMACOLOGIC TREATMENT IN NURSERIES. OVERALL 39% RECEIVED SOME KIND OF PHARMACOLOGIC THERAPY BUT THE RATE VARIED FROM 0% TO 80% AND THERE'S A DIFFERENCE IN THE MEDICATIONS USED. AND WHEN INVESTIGATORS LOOKED ACROSS VARIOUS ASPECTS OF POPULATION THERE'S VARIABILITY. WE DON'T KNOW THE DETERMINATES YET, THAT'S YET TO COME BUT WITH THIS MUCH VARIATION, NOT EERYONE CAN BE RIGHT AND THE TRIALS NOW GOING THROUGH THE DEVELOPMENT STAGE ARE ABOUT INSTITUTING BEST PRACTICES FOR EITHER A PACKAGE OF PHARMACOLOGIC AND NON-PHARMACOLOGIC THERAPY OR A TRIAL IN HOW FAST TO WEAN BABIES OFF MORPHINE OR METHADONE. AROUND THERE'S INTERVENTION RESEARCH THE NAVAJO ECHO USE AGREEMENT HAS NOW SIGNED AND ONTO THE EVALUATION FACE AND THIS CAN OFFER ONE EXAMPLE OF HOW TO WORK WITH TRIBAL NATION ON DATA SHARING. I'VE SHOWN RACIAL DIFFERENCES IN THE INCIDENTS OF ASTHMA THAT RAISES QUESTIONS ABOUT DISPARITIES AND RECOGNIZE ONCE WE HAVE THE INDIVIDUAL LEVEL DATA ON THE PLATFORM IT WILL OFFER MORE FLEXIBILITY AND FROM THE IDEA STATES NETWORK SHOWING EARLY FINDINGS FROM THE OBSERVATIONAL PILOT AND TRIALS AMONG THE UNDER SERVED CHILDREN ARE UNDERWAY NOW. SO THANKS AND I'M HAPPY TO ANSWER ANY QUESTIONS OR GET INTO DISCUSSION. >> I'M HAVE THE UNIVERSITY OF COLORADO. I DIRECT THE CENTERS FOR INDIAN AMERICAN AND ALASKAN NATIVE HEALTH. THANK YOU FOR GIVING ATTENTION TO THE NAVAJO DATA SHARING AGREEMENT. IT'S NOT TRIVIAL. BECAUSE OF A LITANY OF STUDIES FUNDED BY NIH AND SEVERAL YOU REFERENCED HERE, THERE'S BEEN A GREAT DEAL OF ACRIMONY AMONG TRIBAL NATIONS AND SPONSORS OF RESEARCH FOR GOOD REASON. WITH RESPECT TO NIH THERE'S BEEN CONFRONTATION OVER THE LAST TWO DECADES STEMMING FROM BILL CLINTON'S ORDER IN THE PROCESS THAT NIH WAS AMONG THE VERY LATEST PARTIES TO COME TO THE TABLE TO ACKNOWLEDGE THAT SO THAT IN THE PREVIOUS 20 YEARS WE FOUND EACH I.Q. -- I.C. THERE WAS AN APPROACH WITH NO UNIFORM METHOD TO ENSURING THE PROCESS. WHAT WE THEN SAW WAS THE DEVELOPMENT OF THE TRIBAL HEALTH RESEARCH OFFICE AND DIRECTOR'S OFFICE. WE SAW THE TRIBAL ADVISORY COMMITTEE AND THOUGH LOW TO START UP I THINK IT'S AN EARLY WIN OF THE NIH INVESTMENT AND THE EFFORTS TO ACCOMMODATE THE GOVERNMENT TO GOVERNMENT RELATIONSHIP. A NUMBER OF UNIVERSITIES HAVE STRUCK DATA SHARING AGREEMENTS WITH SPECIFIC TRIBES. WHAT MAKES THIS SO DIFFERENT AND THE "ALL OF US" RESEARCH PROGRAM THAT WAS MENTIONED EARLIER IS THESE ARE LARGE NIH SPONSORED EFFORTS SEEKING TO INCLUDE DATA IN THESE BROAD PLATFORMS WITH BROAD ACCESS TO INVESTIGATORS ACROSS THE COUNTRY OWITHOUT TRIBAL NATIONS BEING PART OF THE PROCESS OR SUBJECTS REVIEW PROCESS OR INPUT INTO THE RESEARCH PRIORITY SETTING PROCESS. BECAUSE THERE'S A WHOLE HOST OF ISSUES FOR US. AND THE POTENTIAL FOR ANCESTRY AND MIGRATION ARE EXTREMELY SENSITIVE IN TRIBAL COMMUNITIES IN WHICH NIH AND OTHER STAKEHOLDERS HAVE HAD NO AWARENESS. WHEN I THINK THE TWO YEARS OF INVESTMENT YOU DESCRIBED UNDERSCORES IS THERE ARE SYSTEMATIC PROCEDURES THAT CAN BE INVOLVED IN AUTHENTIC AND RESPECTFUL FASHION. YES, IT TAKE A LONG TIME BUT IT TOOK CENTURIES TO ERODE THE TRUST BETWEEN TRIBAL NATIONS AND THE FEDERAL GOVERNMENT AND BUILDING THAT TRUST BACK UP AND WASN'T TO APPLAUD YOUR OFFICE FOR PATIENTLY TAKING THE STEPS NECESSARY TO RE-ESTABLISH THE RELATIONSHIP BECAUSE I BELIEVE THE MUTUAL BENEFIT EXISTS TO THE TRIBES AND THE NATION OF THE SCIENCE NIH IS SPONSORING AND SEEKS TO ENSURE THERE'S VARIABILITY IN TERMS OF THE DATA IT COLLECTS TO ANSWER THE QUESTIONS. I THINK IT'S AN IMPORTANT FIRST STEP AND IT'S ONE OF A SERIES UNDERWAY NIH WIDE AND I HOPE THE "ALL OF US" PROGRAM WILL SIT DOWN AND LISTEN WITH OPEN EARS WITH THE LESSONS LEARNED. >> THANK YOU FOR SAYING THAT. I APPRECIATE IT. AND I FEEL LIKE THE TRUST IS FRAGILE BECAUSE OF THE THINGS YOU MENTIONED. IT'S SO IMPORTANT AND PAY ATTENTION TO IMPLEMENTATION AND EVALUATION AND HAVE OUR EARS OPEN TO THINGS THAT WE MAY BE DOING THAT ARE OFFENSIVE AND LISTENING IS IMPORTANT. >> ANY QUESTIONS? >> THE RELEVANCE OF ALL THIS DATA IS REALLY IMPORTANT FOR PEOPLE WHO WANTED TO GET INTO THE RESEARCH ARENA PARTICULARLY MINORITY THAT WOULD LIKE TO SEE THE METADATA. DO YOU HAVE A PROCESS IN THE PLAN OF HOW TO ENGAGE MORE OF THOSE INDIVIDUALS EARLY ON IN THEIR CAREERS. AND YOU SEE AN EXAMPLE OF WHERE THE NETWORK HAS REALLY SUPPORTED JUNIOR INVESTIGATORS TO GET MORE TIME TO DO RESEARCH. AND THERE'S FUNDS AT THE DCOC THAT ARE FUNGIBLE TO SUPPORT THINGS LIKE THAT. ON THE COHORT SIDE WE HAVE THE INFRASTRUCTURE FUND. EVERY YEAR WE PICK APPROXIMATELY 10 OF JUNIOR INVESTIGATORS FROM THE ECHO AWARDEE SITES TO PURSUE THESE ONE TO TWO-YEAR PROJECTS THAT MIGHT BE ABOUT NEW TECHNOLOGIES AND MIGHT BE ABOUT VALIDATION OR MIGHT BE ABOUT PILOT FEASIBILITY STUDIES FOR THE COHORT. THOSE SORTS OF THINGS. I'M ALSO AWARE SOME OF THE GRANTEES HAVE APPLIED FOR MINORITY SUPPLEMENTS. >> I'LL COMMENT YOUR DATA ON ASTHMA IS FASCINATING. I HOPE AS YOU GET BETTER DETAIL ON THE DATA YOU WON'T SEE 70% OF THE LATINOS OF UNKNOWN NATIONAL ORIGIN. >> INDEED. >> BECAUSE THERE ARE DRAMATIC DIFFERENCES IN ASTHMA INCIDENT AND MORTALITY AND SEVERITY BETWEEN PUERTO RICOS AND MEXICANS AND THEY'RE BOTH LATINOS. I LOOK FORWARD TO SEEING THAT. I THINK OUR ULTIMATE GOAL AND IT WILL TAKE NAVAJO-LIKE EFFORT TO GET THERE, I'M SURE. WHERE PEOPLE CAN CREATE A QUESTION AND YOU CAN CREATE A PROCESS FOR WHICH PEOPLE CAN APPLY AND GET AN ANALYTIC PROJECT APPROVED AND COLLABORATORS IDENTIFIED TO GET AN EARLY STAGE INVESTIGATOR LOOKING AT SOME OF THE QUESTIONS. WE'RE EXCITED ABOUT THE DIVERSITY OF THE SAMPLE. >> THANK YOU FOR WORKING WITH US AND WE LOOK FORWARD TO MORE COLLABORATION WITH YOU AND THE OTHER INSTITUTES ON THAT. >> THANK YOU VERY MUCH. [APPLAUSE] . WE'LL MOVE ON TO THE DIRECTOR HELEN LANGEVIN THE DIRECTOR OF NATIONAL CENTER FOR COMPLEMENTARY AND INTEGRATIVE HEALTH AND HAS BEEN A WONDERFUL COLLEAGUE AND CONTRIBUTOR AT THE I.C. DIRECTORS TABLE. PRIOR TO HER ARRIVAL AT NIH SHE WAS AT THE CENTER FOR INTEGRATIVE MEDICINE AT THE BRIG HIM -- BRIGHAM AND WOMEN'S CENTER AND WAS A PROFESSOR AT HARVARD SINCE 2012 AND SERVED AS A VISITING PROFESSOR OF NEUROLOGICAL SCIENCES AT THE UNIVERSITY OF VERMONT IN BURLINGTON. AS A P.I. OF SEVERAL NIH STUDIES, HER RESEARCH INTERESTS HAVE CENTERED AROUND TISSUE AND MUSCULOSKELETAL PAIN AND ACUPUNCTURE AND MOVEMENT-BASED THERAPIES AND RECENT WORK FOCUSSED ON HOW STRETCHING MY WORK ON INFLAMMATION RESOLUTIONS WITH CONNECTIVE TISSUE A TOPIC WITH THE CHRONIC PAIN EPIDEMIC RELATED TO OPIOID USE DISORDER. SHE'S HAD MANY PUBLICATIONS OF ORIGINAL WORK IN THE FIELD. A FELLOW OF THE AMERICAN FELLOW OF PHYSICIANS AND RECEIVED HER MEDICAL DEGREE FROM McGILL IN MONTREAL AND COMPLETE RESEARCH IN CHEMISTRY AT CAMBRIDGE AND RESIDENCY IN INTERNAL MEDICINE AND ENDOCRINOLOGY AT THE JOHNS HOPKINS HOSPITAL IN BALTIMORE AND OVERSEES RESEARCH ON IS THE FIRST SCIENTIST TO COME FROM THIS DISCIPLINE AND REFLECTS THE NOVELTY OF THE FIELD AND THE ACCEPTNESS OF NIH OF THIS KIND OF SCIENCE. -- ACCEPTNCE. HAVING PARALLELS WITH NIMD WELCOME AND LOOK FORWARD TO YOUR PRESENTATION. THANKS. >> THANK YOU. SO WHAT IS INTEGRATIVE HEALTH AND WHY IS IT IMPORTANT FOR MINORITY GROUPS AND PEOPLE WITH HEALTH DISPARITY. WE SOMETIMES THINK INTEGRATIVE HEALTH IS COMPLEMENTARY AND WHAT WE CALLED ALTERNATIVE APPROACHES LIKE ACUPUNCTURE OR CARE CARE PRACTIC CARE AND PEOPLE CAIRO -- KY -- CHIROPRACTIC CARE. AND WE THINK IT GOES BEYOND THAT. pHEALTH IMPORTANT TO ALL OF VE MEDICINE. ONE IS IT EMPHASIZES PREVENTING DISEASE AND HEALTH. THERE'S AN IMPORTANT DISTINCTION AND I'LL GET INTO THAT AND TREATS THE WHOLE PERSON. WE THINK THIS IS EXTREMELY IMPORTANT. ONE COMPLAINT PEOPLE HAVE IS PEOPLE SOMETIMES COMPLAIN THEY'RE TREATED LIKE A DIFFERENT SET OF BODY PARTS. YOU GO TO THE CARDIOLOGIST FOR YOUR HEART AND FOOT DOCTOR FOR YOUR FOOT AND REALLY MEDICINE SOMETIMES FORGETS THERE'S A PERSON THERE. I THINK THIS IS EXTREMELY IMPORTANT ESPECIALLY THERE ARE KINDS OF PROBLEMS THAT GO ACROSS THE ENTIRE MIND, BODY AND SPIRIT THAT DISPROPORTIONATELY BURDENS POPULATIONS WITH HEALTH CARE DISPARITIES AND MINORITY POPULATIONS AND YOU CAN'T GENERALIZE BUT THE TRIFECTA OF DIABETES, OBESITY, CHRONIC PAIN AND STRESS AND THEY'RE SOMETIMES THEY CAN BRING A PERSON DOWN AND THE FIELD OF INTEGRATIVE HEALTH HAS A ROLE TO PLAY IN SOLVING THIS VERY DIFFICULT PROBLEM. SET OF PROBLEMS. IN ORDER TO UNDERSTAND MORE WHY WHOLE PERSON HEALTH AND HEALTH RESTORATION HAVE TO DO WITH EACH OTHER, I THINK IT'S IMPORTANT TO GO BACK TO OUR TRADITIONAL DISEASE MODEL WHICH REALLY DOMINATES MEDICINE GOING BACK TO THE BEGINNING OF MEDICINE IN THE LATE 19th CENTURY, BEGINNING OF M MODE MODERN MEDICINE WHERE THE SYSTEMS WERE LAID OUT, CARDIOVASCULAR, ET -- SET ET RA AND THERE WAS -- ETCETERA AND THERE WAS SYSTEMS APPLIED TO THE ORGAN SYSTEMS AND SYMPTOMS AR AORGANIZED WHERE A PATIENT PRESENTING WITH FEVER, INVOLVEMENTI INVOLVEMENTING -- VOMITING AND ABDOMINAL PAIN WOULD GET MAPPED TO A SPECIFIC EDIOLOGY MODELS AND THE SYMPTOMS OF HEALTH ARE DIFFERENT FROM THOSE OF DISEASE. WE THINK OF, FOR EXAMPLE, EMOTIONAL OR PHYSICAL WELL BEING BUT THERE'S SOMETHING MISSING THE TWO SYSTEMS DON'T TALK TO EACH OTHER VERY WELL AND THERE'S A PIECE MISSING IN BETWEEN. IF YOU'LL INDULGE ME FOR A MINUTE, I WOULD INVITE YOU TO CONSIDER THESE THREE PLANTS. THE PLANTS ON THE LEFT LOOKS HEALTHY ENOUGH AND THE PLANT ON THE RIGHT LOOKS LIKE IT'S GOT SOME SORT OF DISEASE. YOU CAN'T QUITE SEE AND I CAN TELL YOU THE ONE IN THE MIDDLE DOESN'T LOOK QUITE SO HEALTHY. IT LOOKS LIKE IT MIGHT NEED PERHAPS A LITTLE BIT MORE SUNSHINE OR A LITTLE BIT LESS WATER PERHAPS BUT THERE'S SOMETHING THAT DOESN'T LOOK QUITE RIGHT WITH THIS PLANT. AND WE SOMETIMES TALK ABOUT BEING UNHEALTHY BUT WE DON'T OFTEN USE THE WORD UNHEALTH. IT'S ACTUAL LAY -- ACTUALLY A WORD AND IT'S NOT A FULL-FLEDGED DISEASE BUT WE HAVE A FEELING THERE'S PERHAPS A REVERSIBLE TRANSITION BETWEEN HEALTH AND UNHEALTH AND ONE ASPECT AND DISRESERVABLE WHEN YOU MOVE TO DISEASE AND IN PLANT THERE COULD BE THE RESULT OF THE ENVIRONMENT OR POOR CARE. THIS HAPPENS TO BE A HOUSE PLANT. SO IN OUR HEALTH CARE SYSTEM RIGHT NOW WE'RE VERY GOOD AT TREATING DISEASE AND THAT'S WHAT WE FOCUS ON AND OUR PRIMARY APPROACH IS CONTROLLING DISEASE THROUGH PHARMACOLOGIC TREATMENT OR SURGICAL. WE ADD A LOT OF DEVICES NOW TO THE MIX. DISEASE PREVENTION AND PREVENTIVE MEDICINE AND HEALTH PROMOTION HAVE A BROADER SPECTRUM THAT GOES ACROSS THESE PRIMARY AND SECONDARY AND TERTIARY PREVENTION. PRIMARY PREVENTION IS TYPICALLY PREVENTING DISEASE FROM HAPPENING IN THE FIRST PLACE SO ENVIRONMENTAL, NUTRITION, LIFESTYLE, THESE TYPES OF THINGS THAT DR. GILLMAN WAS TALKING ABOUT. TERTIARY PREVENTION IS WHEN DISEASE IS ESTABLISHED BUT ONE TRIES TO PREVENT DISABILITY AND LOSS OF FUNCTION. SECONDARY WE TRY TO PREVENT AND ARREST THE PROGRESS OF THE DISEASE. THE OTHER PART IS THE HEALTH RESTORATION. WE KNOW LESS ABOUT THAT. SO IN MEDICINE A LOT OF OUR EFFORTS GO TO EARLY DETECTION BUT WHEN YOU THINK ABOUT MEDICINE, IF YOU READ NOVELS FROM THE 19th CENTURY OR BEFORE THE ADVENT OF SAY ANTIBIOTICS, PEOPLE PAID A LOT OF ATTENTION TO WHAT WE USED TO CALL CONVALESCENCE. WHEN YOU'RE NOT QUITE SICK ANYMORE BUT NOT QUITE HEALTHY AND WE USED TO PAY ATTENTION TO DIET AND GRADUAL RETURN TO PHYSICAL ACTIVITY. BUT THERE WERE CON VERY WELL ESSENCE AND NOW WE TREAT -- CONVALESCENCE AND WE TREAT DISEASE WITH DRUGS AND THEY'RE POWERFUL AND IF YOU TAKE A COURSE OF ANTIBIOTICS, YOU NEED TO PAY ATTENTION TO RESTORING YOUR MICROBIOME. SO RETURN TO HEALTH AFTER AN ILLNESS IS SOMETHING THAT I THINK WE NEED TO PAY MUCH MORE ATTENTION TO. NOW, COMPLIMENTARY AND INTEGRATIVE HEALTH CARE VERY MUCH INHABITS THE SAME SPACE. WE SOMETIMES THINK ABOUT IT MOSTLY FOR SYMPTOM MANAGEMENT. FOR EXAMPLE, MANAGING PAIN. BUT HEALTH PREVENTION AND HEALTH RESTORATION ARE IMPORTANT AS WELL. FOR EXAMPLE, NATURAL PRODUCTS IS AN IMPORTANT PART OF WHAT WE DO IN RESEARCH IN INTEGRATIVE MEDICINE AND HEALTH. AND WHEN WE THINK ABOUT IT ON ONE END OF THE SPECTRUM, FOOD, DIET AND LOW-DOSE SUPPLEMENTS LIKE VITAMINS, FOR EXAMPLE, WE KNOW THEY'RE EXAMPLE FOR PREVENTION. AND AT THE OTHER END OF THE SPECTRUM WE GO AND EXTRACT, FOR EXAMPLE, MOLECULES FROM PLANT AND WE CAN GIVE THEM IN PHARMACOLOGIC DOSES AND THIS IS HOW DRUGS WE USE ARE DERIVED FROM PLANT IN THE FIRST PLACE, RIGHT? AND THERE'S A GROUP OF WHOLE HEALTH SYSTEMS THAT DERIVE FROM TRADITIONAL HEALTH PRACTICE. FOR EXAMPLE, AMERICAN INDIAN AND ALASKAN NATIVE TYPES OF HEALING PRACTICES. OR TRADITIONAL CHINESE MEDICINE, AYURVEDIC MEDICINE IN INDIA. A LOT OF THE WHOLE HEALTH SYSTEMS HAVE A COMPONENT WHERE THE USES OF MEDICINAL PLANT IS DERIVED FROM TRADITION AND THE PLANT TYPICALLY ARE USED IN COMBINATIONS IN WHAT THEY CALL FORMULAS AND WHAT WE'RE STARTING TO UNDERSTAND NOW IS THAT THERE CAN BE SYNERGIES BETWEEN THE DIFFERENT TYPES OF COMPOUNDS IN THE PLANT THAT CAN HAVE BENEFICIAL EFFECTS. WHEN YOU READ TRADITIONAL CHINESE MEDICINE AND USE OF HERBS, THE EXPLICIT USE IS FOR HEALTH TO BUILD UP THE PERSON'S CONSTITUTION AND TO BE MORE RESILIENT. THIS IS WHERE WE NEED TO DO MORE MACHINE. ANOTHER ASPECT WHERE HEALTH RESTORATION IS EXTREMELY IMPORTANT IS WITH BEHAVIORAL INTERVENTIONS. WE KNOW THAT WE ARE NOT PLANTS, RIGHT? WE CAN TO SOME EXTENT CONTROL OUR ENVIRONMENT IN WHAT WE DECIDE TO DO WHETHER WHAT WE DECIDE TO EAT OR NOT EAT OR ACTIVITIES WE DECIDE TO DO OR NOT DO. AN ASPECT OF BEHAVIORAL AND MEDITATION, YOGA AND TAI CHI WE KNOW THEY CAN BE HELPFUL FOR RESTORING A SENSE OF WELL BEING AND ANOTHER ASPECT WE HAVE TO UNDERSTAND MORE AND TRYING TO DO RESEARCH IN BASIC PHYSIOLOGICAL MODELS OF REPAIR AND RESTORATION AND ALL THE WONDERFUL WORDS THAT START WITH "R" AND HOW CAN BEHAVIOR MODIFICATION PROMOTE ENDOGENOUS MECHANISMS OF HEALING AND RESTORING ONE'S HEALTH? IF WE GO BACK TO COMMUNICABLE DISEASES AN PAIN AND STRESS HOW IS THIS RELEVANT TO THESE CONDITIONS?D PAIN AND STRESS HOW IS THIS RELEVANT TO THESE CONDITIONS? GOING BACK TO OUR MODEL WE KNOW IT'S CLEAR THAT FOR EXAMPLE TAKE A SITUATION LIKE DIABETES. DIABETES ALSO FOLLOWS THIS PODD PODDEL -- MODEL OF WHAT I CALL AN EARLY OR BEHAVIORAL DYSFUNCTIONAL STAGE WHERE THERE'S NOT AN ABNORMALITY DETECTABLE YET BUT THE DIET IS NOT RIGHT. THERE'S A SEDENTARY LIFESTYLE. YOU KNOW GOING DOWN THE LINE, THIS PERSON WILL BE AT RISK FOR NOT ONLY WEIGHT GAIN BUT ALSO INTOLERANCE IN PREDIABETES AND EVENTUALLY IF NOTHING IS DONE ABOUT IT TYPE 2 DIABETES. SO WE ALSO KNOW SEDENTARY LIFESTYLE AND WEIGHT GAIN ARE COMORBID WITH MUSCULOSKELETAL PAIN AND WE KNOWS THERE'S A SIMILAR TRAJECTORY STARTING WITH SEDENTARY LIFESTYLE TO CHRONIC MUSCULOSKELETAL PAIN AND DAMAGE TO THE TISSUES SUCH AS DEFEND -- DEGENERATIVE JOINT DISEASE. SOMETIMES WE THINK THE DEGENERATIVE JOINT DISEASE COMES FIRST BUT THE PAIN COMES LATER BUT I'LL SHOW YOU WHY THAT MAY NOT BE THE CASE. ONE OF THE PROBLEMS WITH PAIN RESEARCH IS IT TENDS TO BE SPLIT. TALKING ABOUT PUTTING THE BODY BACK TOGETHER. A LOT OF TIMES NOW WE HAVE TAKEN A VERY FRAEGMENTED -- FRAGMENTED APPROACH TO OUR INFORMATION OF PAIN AND THINK OF CHRONIC PAIN AS A DISEASE OF THE BRAIN. THERE'S A LOT OF THE ASPECTS OF THE BODY WE NEED TO UNDERSTAND BETTER AND TO INTEGRATE THOSE WITH OUR INFORMATION OF NEUROSCIENCE AND OF PAIN. ONE ASPECT OF THE BODY WHICH HAPPENS TO BE OF INTEREST OF MINE AS ELISEO POINTED OUT IS CONNECTIVE TISSUE AND THE REASON I MENTION THIS IN THE CONTEXT OF THE TALK IS CONNECTIVE TISSUE LITERALLY CONNECTS THE BODY TOGETHER. AND WE KNOW IT BY VARIOUS NAMES, IT'S EXTRA CELLULAR MATRIX TO INTERSITIUM TO FASCIA AND IT DETERMINE THE SHAPE OF THE BODY. IT CONNECTS EVERYTHING AND WOULD CONNECTIVE TISSUE THE BODY WOULD FALL APART. HOW CONNECTIVE TISSUE REMODELS CONSTANTLY IN RESPONSE TO THE MECHANICAL FORCES IT'S EXPOSED TO AND THESE FORCE GRAVITY, EXTERNALLY APPLIED FORCES AND MUSCLE TRACTION AND THE BRAIN DOESN'T HAVE A DIRECT EFFERENT OUTPUT BUT TO MUSCLES AND BY EXERTING THE FORCE IT REMODELS TO THE CONNECTIVE TISSUE AND WHAT WE DO SHAPES THE CONNECTIVE TISSUE OVER TIME AND IT APPLIES TO THE ACTIVITIES WE DON'T DO ALTERNATIVELY. IF A PERSON IS NOT ACTIVE BUT ADOPT AS A CHRONIC POSTURE THAT ALWAYS MOVES THE BODY IN A CERTAIN DIRECTION AND NOT OTHERS THE CONNECTIVE TISSUE WHERE WE MODEL AROUND THAT IT BECOMES IMPOSSIBLE TO DO THE MOVEMENT THAT IS NOT DONE HA PITCH -- -- ABICH YOU'LLY AND AS THE -- HA BISH -- HABITUALLY AND THIS IS A PROCESS DRIVEN BY THE CONNECTIVE TISSUE AND PREDISPOSES US TO INJURIES AND GRADUALLY THE PERSON WILL START TO INJURY WHAT WE CALL SOFT TISSUE INJURIES AND USUALLY FROM SHOVELLING TOO MUCH SNOW OR DOING TOO MUCH GARDENING WE EXPERIENCE BACK OR NECK PAIN THAT USUALLY LASTS A COUPLE DAYS, RESOLVES AND WE NOW KNOW WHAT WE CALL A SPRAIN ACCOMPANIED BY INFLAMMATION IN THE ACUTE CONNECTIVE TISSUE AND REDUCE THE MORBIDITY OF CONNECTIVE TISSUE OVER TIME. THIS CREATES AN ABNORMAL FORCE AND BALANCES THROUGHOUT THE TISSUES WHICH THEN PUTS JOINTS AND DISKS AT RISK OF SERIOUS INJURIES WHICH ARE THEN NOT SO REVERSIBLE. SO HOW CAN YOU INTERVENE WITH THIS? THE GOOD NEWS IS THAT CONNECTIVE TISSUE REMODELS IN THE OTHER DIRECTION. IT CAN RESPOND. AND IF THE MOVEMENT IS APPLIED IN THE DIRECTION THAT IS NON HABITUAL IN A GENTLE WAY AND IT CAN BE DONE WITH PHYSICAL THERAPY AND GIVE THE EXAMPLE OF YOGA AND THAT'S THE BENEFIT THAT'S DONE IN A MINDFUL WAY THAT DOES NOT FURTHER DAMAGE THE TISSUES BUT GENTLY STRETCHING THE TISSUE AND BRINGING THE TISSUE BACK TO HEALTH. SOMETIMES THE CONNECTIVE TISSUE BECOMES TOO STIFF OR PAINFUL THE MUSCLE ACTIVITY BY ITSELF IS NOT SUFFICIENT TO RESTORE IT BACK TO HEALTH. THIS IS WHERE WE CAN APPLY EXTERNALLY APPLIED FORCES AND HELP THEM STRETCH THE TISSUE AND RESTORE THE PROPER LENGTH THAT CAN BE TRAINED AT A MORE FAVORABLE LAENG -- LENGTH. WE KNOW SEDENTARY LIFESTYLE, POOR POSTURE AND POOR DIET IS ALSO COMORBID WITH PSYCHOLOGICAL STRESS AND HABITS. THIS HAPPENS IN THE SAME PEOPLE. THIS IS PARTICULARLY IMPORTANT, ESPECIALLY SLEEP. AS YOU KNOW IF YOU HAVEN'T HAD A GOOD NIGHT'S SLEEP AND WERE UP ALL NIGHT WORRYING ALL NIGHT IT'S DIFFICULT TO GET YOURSELF TO EXERCISE AND GO FOR THE POLITICAL OF COOKIES IN THE AFTERNOON. PEOPLE WHO HAVE -- CHRONICALLY POOR SLEEP AND CHRONIC STRESS, THIS IS A REAL HARBINGER OF A CHRONIC SYMPATHETIC ACTIVITY AND OVER ACTIVITY WHICH WE KNOW IS DETRIMENTAL TO THE BRAIN. DEMENTIA, COGNITIVE IMPAIRMENT AND DEPRESSION OCCUR MORE FREQUENTLY IN PEOPLE WITH CHRONICALLY POOR SLEEP AND STRESS. SO, WHAT DO ALL THESE CONDITIONS HAVE IN COMMON? THEY ALL HAVE A CHRONIC SYSTEMIC INFLAMMATION COMPONENT. WE KNOW THAT INFLAMMATION IS A GLOBAL PHENOMENON. IT DOES NOT STOP AT BOUNDARIES OF ORGAN SYSTEMS. IF YOU HAVE INFLAMMATION IN ONE SYSTEM, IT WILL AFFECT THE OTHER SYSTEMS. SO, THIS CONSTELLATION OF SYMPTOMS IS VERY SERIOUS. THE GOOD NEWS IS THAT A LOT OF THE SAME INTERVENTIONS GOOD FOR MUSCULOSKELETAL PAIN, HELPING WITH POSTURE AND MOVEMENT ARE ALSO GOOD FOR DECREASING PSYCHOLOGICAL STRESS. THEY'RE GOOD FOR HELPING SLEEP AND CAN ALSO HELP WITH EATING. THIS COMPONENT NOW WE CALL MINDFUL EATING WHICH IS NOT JUST SIMPLY OFFERING A BETTER DIET BUT HELPING THE PERSON BE CONSCIOUS OF HOW THEY EAT, HOW FAST THEY EAT AND WHEN THEY EAT AND HELPING PEOPLE TO COME TO GRIPS WITH FEEDING THEMSELVES IN A GOOD WAY. SO PUTTING ALL THIS TOGETHER YOU SEE THE POTENTIAL FOR REDUCING THE INFLAMMATORY BURDEN ACROSS THE HEALTH SPAN. IT'S VERY IMPORTANT TO START EARLY. IN SCHOOLS TEACHING KIDS RELAXATION TECHNIQUES, SIMPLE THINGS TO TEACH OUR CHILDREN TO HELP THEM WHEN THEY ENCOUNTER STRESS OVER THE COURSE OF THEIR LIFE. HELPING THEM WHEN THEY START TO DEVELOP PAIN, WHAT TO DO ABOUT IT. WE KNOW CHILDREN START TO DEVELOP BACK PAIN EXTREMELY EARLY IN LIFE. A LOT OF THE HABITS OF USING COMPUTERS AND VIDEO GAMES WHEN KIDS ARE ALWAYS IN THE FORWARD POSTURE DO NOT EXERCISE THEIR BODIES IN WAYS AND SOMETIMES SPORTS CAN MAKE THIS WORSE IF THERE'S NOT A GOOD ATTENTION TO BODY MECHANICS AND POSTURE BECAUSE CHILDREN AND ADOLESCENTS AND ADULTS WHEN YOU START EXERCISING BUT WITH POOR BODY ALIGNMENT CAN ACTUALLY CAUSE INJURIES. SO I WANT TO SHOW YOU HERE AN EXAMPLE OF A STUDY THAT NCCIH HAS FUNDED THAT WE'RE PROUD OF THAT WAS PUBLISH IN AANNALS OF INTERNAL MEDICINE A STUDY AT BOSTON MEDICAL CENTER IN THE COLLABORATION WITH THE UNIVERSITY OF PITTSBURGH AND GROUP HEALTH AND KAISER PERMANENTE AND SEATTLE, UNIVERSITY OF WASHINGTON AND RAND CORPORATION. IT LOOKED AT YOGA AND CARE AND IT LOOKED AT AN URBAN SOCIALLY DISADVANTAG DISADVANTAGED POPULATION OF MIXED RACE AND ETHNICITY AND SEE HOW FEASIBLE TO DEPLOY THE INTERVENTIONS AND HOW WELL ACCEPTED ARE THEY AND HOW BENEFICIAL ARE THEY WITH PEOPLE WITH LOW BACK PAIN AND WHAT WAS FOUND IS YOGA AND PHYSICAL THERAPY WERE BOTH EFFECTIVE EQUALLY COMPARED WITH THE USUAL CARE. AND THAT DIFFERENT PEOPLE SO THE IDEA IS WHILE THEY'RE BOTH EFFECTIVE, PHYSICAL THERAPY IS TYPICALLY REIMBURSED BY INSURANCE AND YOGA IS TYPICALLY NOT AND PATIENT PREFERENCE CAN MAKE A DIFFERENCE HERE IN WHAT SOMEBODY WILL PREFER TO DO OR NOT DO. I THINK THIS IS A GREAT EXAMPLE OF THE KIND OF STUDY THAT CAN HELP GUIDE INSURANCE REIMBURSEMENT FOR SOME OF THE TREATMENTS. ANOTHER THING THAT IS VERY IMPORTANT IN COMING TO THE FRONT NOW OF WHAT WE TALK ABOUT FOR THINGS LIKE ACUPUNCTURE IS A GROUP VISIT. WHAT ACUPUNCTURE IS TIME CONSUMING AND TAKE TIME WHEN DONE IN AN INDIVIDUAL WAY BUT PERFORMING ACUPUNCTURE IN A GROUP SETTING IS SURPRISINGLY BECOMING POPULAR IN A LOT OF DIFFERENT SETTINGS AND IS BECOMING MORE AFFORDABLE AND THERE'S BENEFITS LIKE FOR DIABETES EDUCATION GROUPS WHERE PEOPLE FIND BENEFITS IN BEING PART OF A SUPPORT GROUP ESSENTIALLY AND TO SHARE IN THEIR COMMON EXPERIENCE. AND SO THE SAME GROUP AT BOSTON MEDICAL CENTER IS ALSO NOW IN THE PROCESS OF INVESTIGATING GROUP AC PUNK -- ACUPUNCTURE AS A METHOD OF DELIVERY IN URBAN UNDER SERVED POPULATION. NCCIH IS ONE OF MANY CENTERS AT NIH. WE ARE I BELIEVE THE SMALLEST ONE OR ONE OF THE SMALLEST ONES AND WE RELY A LOT ON COLLABORATIONS OF NOT ONLY ACROSS THE ORGANIZATION AND WE PARTNERED FOR LOOKING AT BACK PAIN IN VETERANS AND MILITARY PERSONNEL. ONE THING THAT IS VERY IMPORTANT FOR US IS SOURCES OF FUNDING THAT CAN SUPPLEMENT OUR BUDGET SUCH AS THE HEAL INITIATIVE AND WE'RE ACTIVE PARTICIPANTS IN HEAL. THIS IS VERY IMPORTANT. IT'S A LOT OF OUR PORTFOLIO THAT INVOLVES PAIN MANAGEMENT AND ONE OF THE IMPORTANT PROJECT THAT WE I'M GOING TO MENTION IN PARTICULAR THIS PRAGMATIC RANDOMIZED CONTROL TRIAL OF ACUPUNCTURE FOR THE MANAGEMENT OF CHRONIC LOW BACK PAIN IN OLDER ADULTS IS FUNDED BY THE CENTER FOR MEDICARE SERVICES TO PAY FOR THE ACUPUNCTURE MEDICARE SERVICES IN THE OLDER ADULTS DURING THE COURSE OF THE TRIAL AND DETERMINE INSURANCE COVERAGE REIMBURSEMENT SO THIS IS IMPORTANT. AS FAR AS ASSURING THESE TYPES OF TREATMENTS WILL BE MORE AND MORE ACCESSIBLE FOR DIFFERENT TYPES OF HEALTH CARE COVERAGE. MEDICARE IS INFLUENTIAL AND OTHER INSURANCE SUCH AS MEDICAID AND PRIVATE INSURANCE WILL FOLLOW SUIT. WE'LL WATCH THE TRIAL CAREFULLY. THIS IS CURRENTLY UNDERGOING REVIEW. SO I'M GOING TO CLOSE BY BASICALLY ADVOCATING FOR INTEGRATIVE HEALTH FOR ALL. I THINK THAT PRACTICES THAT PREVENT DISEASE AND RESTORE HEALTH AND TREAT THE WHOLE PERSON ARE EXTREMELY IMPORTANT AND WE NEED TO DO EVERYTHING WE CAN AT NCCIH, WE'RE DEDICATED TO FUNDING THE SCIENCE AND BUILDING THE EVIDENCE BASE AND DISSEMINATING THE INFORMATION SO IT CAN GET IMPLEMENTED INTO OUR HEALTH CARE SYSTEM. THANK YOU. >> I THINK YOU TOUCHED ON GLOBAL ISSUE THAT RESONATES WITH ME PERSONAL AS A GENERAL INTERNIST. I LINING THE IMAGE OF ALL THE BODY -- LIKE THE IMAGE OF ALL THE BODY PARTS AS AN INTERNIST WE ALWAYS PROMOTE THE INTEGRATIVE CARE FROM THE MEDICAL SIDE. A COUPLE OF THOUGHTS AND I'LL OPEN IT UP. THE IDEA ORIGINALLY WAY BACK BEFORE THE CENTER EXISTED THINKING OF ACUPUNCTURE AND CHIROPRACTOR AS NON MAINSTREAM WAS ALIEN TO ME AS A DOCTOR BECAUSE I'D SEE PATIENTS ALL THE TIME GETTING ESPECIALLY CHIROPRACTOR AND EVENTUALLY MORE ACUPUNCTURE BECAUSE IT WAS SAN FRANCISCO CHINATOWN WITH A MODERATE AMOUNT OF EVIDENCE OF SUPPORT IN HUNDREDS IF NOT THOUSANDS OF USE IN EASTERN ASIA AND CHINA FOR ACUPUNCTURE AND THE HOME REMEDY AND THE HOMEOPATHY. YOU MENTIONED TRADITIONAL HEALING PRACTICES OF THE NATIVE POPULATIONS IN SOUTH ASIA AND CERTAINLY IN LATIN AMERICA, IT'S EVERYWHERE. IT'S A VERY COMMON IN ALL SECTORS. I DON'T KNOW WHETHER THE CENTER IS FOCUSSED OR THOUGHT ABOUT HOW THEY EMPHASIZE JUST A DESCRIPTIVELY WHAT IS THE DOMAIN OF WHAT WE WOULD CALL. >> THANK YOU FOR ASKING THE QUESTION. THIS IS AN AREA WHERE WE ARE MOVING MORE INTO WHAT WE CALL WHOLE HEALTH SYSTEMS. IF YOU LOOK AT, AS YOU SAID, THROUGHOUT THE GLOBE, THERE'S AN INTERESTING PAPER COMPARING WHOLE HEALTH SYSTEMS IN AFRICA VERSUS AMERICAN INDIAN POPULATIONS HERE AND IT WAS AMAZINGLY SIMILAR. A LOT OF THE SYSTEMS HAVE A COMPONENT OF NUTRITIONAL AND USING LOCAL HERBS. A LOT OF THEM HAVE A SPIRITUAL COMPONENT. A LOT OF THEM HAVE A COMPONENT OF HANDS-ON BODY TYPE WORK. IT'S UNIVERSAL AS YOU SAID. WE WANT TO STUDY THIS FOR SURE AND WE WANT TO ALSO BE RESPECTFUL OBVIOUSLY OF THE CULTURES THIS DERIVES FROM. I THINK A LOT OF KNOWLEDGE IS UNDER THREAT OF BEING LOST. A LOT OF THE CULTURES NOW ARE BEING ABSORBED INTO WESTERN HEALTH STYLE AND SO JUST AS COUNTRIES THROUGHOUT THE WORLD ARE NOW ADOPTING A LOT OF OUR DISEASES, OUR NON-COMMUNICABLE DISEASES BUT A LOT OF TIME pWAY OF LIFE AND TRADITIONAL NAL MEDICAL SCIENCES AND THERE'S THE PRACTICE WHERE PEOPLE NOTICE NOT ONLY ARE THE PLANT THROUGHOUT THE WORLD SOME DIVERSITY IS DISAPPEARING AND WE WANT TO WORK TOGETHER WITH THE ETHNOBOTANISTS AND WE'RE TRYING TO CREATE A DATABASE. >> THANK YOU SO MUCH FOR YOUR PRESENTATION. I WONDER IF YOU CAN TALK ABOUT THE ROLE OF INTEGRATIVE HEALTH. WHEN HE SEE THE INTERSECTION OF THE WORK OF YOUR INSTITUTE AND NIMHD AND WE TALKED ABOUT THE ROLE OF RACE AND HEALTH INEQUALITIES. AND WHAT IS UBIQUITOUS IS RACISM AS AN IMMUNOLOGIC FACTOR AND AS YOU BROADEN AND THINK ABOUT SEXUAL GENDER MINORITY AND DISCRIMINATION WHAT ARE THE ROLES FOR COMPLEMENTARY AND INTEGRATIVE HEALTH IN TERMS OF MITIGATING THAT INFLAMMATORY PROCESS THAT MAY LOOK TO HEALTH DISPARITIES. >> AS A SOURCE OF CHRONIC STRESS IT WILL FEED INTO THIS. I THINK IT'S A VERY INTERESTING QUESTION. HOW COULD IT BE STUDIED AS SUCH. I'M NOT AWARE OF ANY STUDIES THAT HAVE ACTUALLY ADDRESSED THAT SPECIFIC ANGLE BUT I THINK AS YOU MENTIONED, I THINK AS A SOURCE OF STRESS DISCRIMINATION BY ITSELF COULD CONTRIBUTE TO THIS. I DO AGREE. IT'S SOMETHING THAT NEEDS TO BE LOOKED AT. THANK YOU FOR THE SUGGESTION. >> THANK YOU FOR THE PRESENTATION. TWO THINGS THAT CAME TO MIND WHEN YOU WERE TALKING IS ONE IS ACCESS AND WE KNOW INSURANCE LAGS BEHIND SOMETIMES AND A LOT OF TIMES INSURANCE DOESN'T PAY AND IT'S SOMETHING SOMEBODY CAN DO OUTSIDE OF MEDICINE OR THE WAY WE DELIVER MEDICINE. IT REQUIRES FINANCES TO BE ABLE TO ACCESS AND THE OTHER THING I'M THINKING ABOUT IN RELATIONSHIP TO THE WORK OF NIM HD IS ACCEPTANCE IN SOME GROUPS. I WORK WITH THE V.A. AND WE'RE TRYING TO HAVE MORE YOGA AND ACUPUNCTURE AND STUFF LIKE THAT BUT THERE'S PEOPLE WHO FEEL THEY'RE BEING SHOULDN'TED OFF IF YOU SEND THEM IN THAT DIRECTION. -- SHUNTED OFF IF YOU SEND THEM IN THAT DIRECTION. >> WE CAN'T FORCE PEOPLE. >> A LOT OF THESE BLEED INTO EACH OTHER. IF YOU LOOK AT PEOPLE WHO DO PHYSICAL THERAPY A LOT OF THEM BORROW A LOT OF THINGS FROM WHAT WE USED TO CALL ALTERNATIVE MEDICINE, MASSAGE TECHNIQUES, CHIROPRACTIC SPINAL MANIPULATION. NOW THE LINE IS SO BLURRED, SOME PEOPLE WILL PREFER TO GO TO A PHYSICAL THERAPIST THOUGH WHAT THEY'RE DOING IS REALLY CHIROPRACTIC CARE. AND FOR EXAMPLE, COGNITIVE BEHAVIORAL THERAPY AND MEDICATION. THERE'S A LOT OF SIMILARITIES AND MORE AND MORE CBT AND MINDFULNESS RELAXATION TECHNIQUES. I THINK WHAT YOU'RE TALKING ABOUT THE ACCEPTANCE IS GRADUALLY GETTING FAMILIAR WITH THE CONCEPTS AND GRADUALLY I THINK IT WILL BECOME INCORPORATED INTO CONVENTIONAL CARE SO THERE WON'T BE A DIVIDE ANYMORE. IN TERMS OF ACCESS, SAME THING. I TALKED ABOUT INSURANCE COVERAGE. IT'S KEY. WE NEED TO PROVIDE THE SCIENTIFIC DATA SO IT GOES INTO THE HEALTH CARE RECOMMENDATIONS AND WE'RE MAKING PROGRESS. AND IMPLEMENTING THESE TREATMENTS IS ALSO VERY IMPORTANT AND WE'RE DOING A LOT OF IMPLEMENTATION SCIENCE. A BIG PART OF WHAT WE'RE DOING WITH THE HEAL INITIATIVE IS EXACTLY THAT. STUDYING HOW THE INTERVENTIONS CAN BE INCORPORATED INTO A HEALTH CARE SETTING AND HOW YOU DO IT. WE'RE WORKING ON IT. I >> TO ADD TO THAT WHAT I THINK JUDITH IS SAYING IS SOMETIMES THE UNDERSERVED MARGINALIZED COMMUNITIES SAY YOU'RE GIVING US SECOND-RATE STUFF. NOT THE NEW DRUG OR THE STUFF OVER HERE AND CERTAINLY IN MY PRACTICE AT UCSF THE LATINO PATIENTS WERE VERY OPEN TO NON-PHARMACOLOGIC THERAPY. IN FACT THEY WERE EAGER TO AVOID TAKE MEDICATION ALL THE TIME. I THINK IT'S VARIABLE BY CULTURE AND BACKGROUND AND YOU SAY, WELL, YOU CAN DO THIS THROUGH WHETHER IT'S NUTRITIONAL OR PHYSICAL THERAPY-TYPE INTERVENTIONS VERSUS TAKING THIS PHARMACOLOGY AND I THINK THAT CAN BE EFFECTIVE. GRESSI GREG IS NEXT. >> YOU HAVE THE PHYSICIAN'S WILLINGNESS TO ACCEPT THE ALTERNATIVE PRACTICES. AN INTERESTING PART ELISEO ALLUDED TO IS THE USE OF HOME REMEDIES AND I FOUND IT VERY INTERESTING THAT IT CAN ACTUALLY BE HARMFUL SOMETIMES BECAUSE IT THE PRACTICE MAY BE USED INSTEAD OF THE TRADITIONAL MEDICINE REMEDY SUCH AS GLUCOSE LOWERING AGENT AND THEY'LL GO TO THE EXTREME WITH THE CACTUS THERAPY AND NOPALES AT THE EXPENSE OF FOLLOWING YOUR GUIDELINES IN PHARMACOLOGIC THERAPIES. I THINK THAT'S WHERE THE CULTURAL COMPETENCY COMES IN MAYBE NOT SO MUCH WITH YOGA AND A LITTLE BIT WITH ACUPUNCTURE BUT WHEN IT COMES HERBAL USE AND DIABETES WE NEED MORE TRAINING WITH PHYSICIANS TO KNOW HOW TO DO THAT IN A CULTURALLY SENSITIVE FASHION. >> I COULDN'T AGREE MORE. IT'S AN AREA WE'RE ACTIVE IN IN THE NATURAL PRODUCT INTERACTIONS. SELF-CARE IS AN EXTREMELY IMPORTANT PART OF CARE BUT PATIENTS NIGHT TO BE COMPETENT. -- NEED TO BE COMPETENT AND THERE'S SO MUCH INFORMATION ABOUT NATURAL PRODUCTS AND IF YOU GO TO A HEALTH FOOD STORE IT'S HORRIFYING WHAT YOU SEE. TEACHING PATIENTS HOW TO SUPPLEMENT THEIR DIET WITHOUT ENDANGERING THEMSELVES OR HARMING THEMSELVES WITH MEDICATION. THE PATIENTS AN -- AND PHYSICIANS AND PROVIDERS NEED TO KNOW AND WE HAVE AN APP NOW FOR PEOPLE TO LOOK UP PRODUCTS AND IT'S VERY GOOD FOR LOOKING FOR SIDE EFFECTS OR ANY PRODUCT. >> GREAT TALK. HOW DO WE FIND BETTER WAYS FOR INTEGRATING THIS INTO DAILY LIFE IS SOMETHING WE NEED TO WORK ON IN SOME SCHOOLS WHERE SOME THINGS ARE BEING INTERDUFD -- INTRODUCED EARLY ON AS A PRIORITY. ARE THERE THOUGHTS ON THAT? >> KIDS FEEL SO MUCH PRESSURE TO GET INTO SCHOOLS AND PERFORM AND THERE'S SO MUCH SOCIAL MEDIA AND THEY SPEND SO MUCH TIME WITH THEIR COMPUTERS LATE AT NIGHT. THEY HAVE TROUBLE SLEEPING. I THINK THAT'S A BIG PIECE OF THIS. IF KIDS HAVE A GOOD NIGHT'S SLEEP THEY CANNOT GET SO TIRED AND STRESSED OUT AND LESS IS MORE SOMETIMES. THESE ARE PIECES OF COMMON SENSE THAT NEED TO BE PUT BACK INTO OUR EDUCATION BUT SOMETIMES THE PARENTS LACK COMMON SENSE TOO. IF THE PARENTS ARE TOTALLY STRESSED OUT AND NOT COPING WITH EVERYTHING THEY FEEL THEY HAVE TO DO OR NEED TO DO, AND PEOPLE WHO SUFFER BECAUSE THEY DON'T HAVE ACCESS AND FOR EXAMPLE THE PARENT HAS TO WORK TWO JOBS AND NOT THERE TO HELP WITH THE KIDS AND I THINK THIS IS THE -- WHERE THE SCHOOLS HAVE TO STEP IN. THIS IS DIFFICULT. WE'RE TALKING ABOUT UNHEALTH. I THINK THIS IS A SOCIETAL UNHEALTH WE HAVE NOW. THIS IS A SOCIETAL PROBLEM. AND I THINK IF WE RECOGNIZE IT AS SUCH AND ADDRESS IT AS A SOCIETY WE HAVE A BETTER CHANCE TO GETTING IT BECAUSES IT -- BECAUSE IT IS COMPLICATED. >> THERE'S POLICY ISSUES AND ADVOCACY THAT COULD BE INVOLVED. >> I THINK YOUR RIGHT. >> SECOND QUESTION IS THE CHRONIC INFLAMMATION IS HARD TO MEASURE. WHAT ARE THE BIOMARKERS YOU FEEL ARE MOST IMPORTANT TO LOOK INTO WHEN INTRODUCING THESE TYPES OF STUDIES AND FOLLOWING UP? >> IT'S RESEARCH THAT'S HAPPENING RIGHT NOW. WHAT IS THE BEST THING? A LOT OF PEOPLE LOOK FOR MARKERS. I USE CHRONIC INFLAMMATION AS MORE LIKE A WAKE-UP CALL OF SAYING, WOW, LOOK AT THIS. ALL THESE CONDITIONS ARE SORT OF LIKE ADDING TO YOUR BURDEN. I THINK IT'S GOING TO BE A WHILE BEFORE WE CAN REALLY UNDERSTAND THE COMMON MECHANISTIC THREADS. THE BIGGEST COMMON THREAD IS BEHAVIOR. IT'S MORE IMPORTANT TO THINK ABOUT IT THAT WAY. WHAT'S THE BEHAVIOR UNDERLYING ALL THIS AND HOW DO YOU ADDRESS THAT? OF COURSE METABOLIC DISTURBANCES, WE KNOW WHAT THEY ARE, RIGHT? WE KNOW THAT WHEN PATIENTS HAVE ELEVATED CERTAIN PROTEINS THEY'RE AT GREATER RISK OF DEVELOPING CORONARY DISEASE AND COGNITIVE IMPAIRMENTS. THERE'S THINGS WE KNOW. WE NEED A SYSTEMS BIOLOGY APPROACH AND IT WON'T TELL YOU THE CAUSE AND EFFECT BECAUSE IT'S TOO COMPLICATED. IT'S A VERY IMPORTANT AND INTERESTING ASPECT OF PHYSIOLOGY WE NEED TO UNDERSTAND BETTER. >> THESE APPROACHES ARE HARD IN THE IMPACT THEY'RE HAVING ON CHRONIC INFLAMMATION. >> YOU'RE NOT BE ABLE TO SAY I'LL DO THIS OR THAT AND WHEN WE TRY TO ENTVENE WITH DRUGS ALONG POINTS IN THE SYSTEM THE SYSTEM FINDS A DIFFERENT WAY OR REBOUNDS AND COMPENSATES. THAT'S WHY DRUGS ARE SO DISAPPOINTING TO TREAT HIGH CHOLESTEROL OR TREAT DIFFERENT TYPES OF PROBLEMS BECAUSE THE SYSTEM KIND OF GETS DISRUPTED. IT CREATES ANOTHER LAYER OF DISTURBED PHYSIOLOGY. NOW, SOMETIMS YOU NEED THE DRUGS. THAT'S WHY THAT LINE -- ONCE YOU CROSSED OVER INTO DISEASE, YOU'RE NOT GOING TO LEAVE HYPERTENSION UNTREAT. YOU'RE NOT GOING LEAVE DIABETES UNTREATED BUT WHERE IS THAT LINE AND WHERE SHOULD ITE. YOU'RE NOT GOING LEAVE DIABETES UNTREATED BUT WHERE IS THAT LINE AND WHERE SHOULD ITD. YOU'RE NOT GOING LEAVE DIABETES UNTREATED BUT WHERE IS THAT LINE AND WHERE SHOULD IT BE? SHOULD WE GIVE PEOPLE THE CHANCE AND TOOLS TO DO PROGRESSIVE INTERVENTION BEFORE THE ACTUAL DISEASE HAPPENS? I THINK THAT'S WHERE THE MONEY IS. >> GREAT, THANK YOU. >> ONE LAST COMMENTS FROM CARMEN? >> THANK YOU. IT WAS A WONDERFUL PRESENTATION. IT REMINDS ME OF THE JOURNEY I HAD AS A PROVIDER AND RESEARCHER AS PEOPLE WITH HIV. I STARTED WORKING WITH NO TREATMENT AT ALL OR NOTHING. WE LEARNED ABOUT ALL THE STRATEGIES AND THERAPIES AND COMPLIMENTARY ALTERNATIVE EVERYTHING. WE FELT THAT IF THERE'S NO MEDICATIONS AT LEAST THERE'S SOMETHING YOU CAN DO ON YOUR OWN TO BOOST YOUR IMMUNE SYSTEM AND TO KEEP ACTIVE. SO WE'RE NOW AT A POINT WHERE WE'RE TALKING ABOUT ENDING THE EPIDEMIC BECAUSE WE HAVE POWERFUL MEDICATIONS AND AT THE SAME TIME IN THE LONG HISTORY OF THE USE OF MEDICATIONS, WE STILL HAVE CHRONIC INFLAMMATION CAUSED BY THE INFECTION. SO MAYBE THIS IS A GOOD TIME A GOOD MOMENT IN HISTORY AT LEAST IN THE U.S. WHERE WE ARE TALKING ABOUT ENDING THE EPIDEMIC WHERE WE SHOULD REVISIT THE USE OF ALL THE COMPLIMENTARY THERAPIES AND STRATEGIES FOR EXAMPLE, COMBINE THEM WITH AN UNTRANSMITTABLE MESSAGE AND MAYBE THEY CAN REINFORCE PEOPLE'S ADHERENCE OR OUTLOOK ON THE INFECTION AND DISEASE AND SO IT WAS REFRESHING TO ME TO LOOK BACK AT WHERE WE WERE AND WHERE WE ARE AND WHERE NOW WE HAVE MORE INFORMATION. MAYBE KE WE CAN REVISIT THE USE OF ALL THESE STRATEGIES IN THE PRESENCE AND IN COMBINATION WITH MEDICATIONS THAT ARE SO POWERFUL BUT MAYBE USE TO END THE EPIDEMIC. >> I'M GLAD YOU MENTIONED THIS. A COUPLE WEEKS AGO I GAVE A SIMILAR TALK TO THE OFFICE OF AIDS RESEARCH ADVISORY COUNCIL AND MADE THE SAME ARGUMENT YOU MADE. THESE ARE PATIENTS LIVING WITH A CHRONIC INFLAMMATORY BURDEN BOTH FROM THEIR RESIDUAL INFECTION AND WITH THE MEDICATIONS THEY'RE TAKING AND YOU NEED TO DO EVERYTHING YOU CAN TO REDUCE THAT INFLAMMATORY BURDEN BECAUSE YOU KNOW IT'S THERE. THANK YOU FOR MENTIONING THAT. I THINK IT'S VERY IMPORTANT. ALSO, IT'S RELEVANT TO THIS GROUP AS WELL. THANK YOU. [APPLAUSE] OUR THIRD AND FINAL SPEAKER TODAY IS MARCELLA NUNEZ SMITH, WHO COMES TO US AS ASSOCIATE PROFESSOR FROM YALE. SHE HAS A NUMBER OF LEADERSHIP ROLES THERE WHICH I WON'T LIST ALL IN DETAIL. MARCELLA IS HERE TO TALK ABOUT HER SCIENCE. SHE HAS A -- HER RESEARCH PORTFOLIO FOCUSED ON PROMOTING HEALTH AND HEALTHCARE EQUITY IN HISTORICALLY VULNERABLE POPULATIONS WITH SPECIAL EMPHASIS ON REGIONAL STRATEGIES TO REDUCE GLOBAL BURDEN OF NON-COMMUNICABLE DISEASES. SHE'S PRINCIPLE INVESTIGATOR ON SEVERAL NIH AND FOUNDATION RESEARCH PROJECTS INCLUDING A PROJECT TO ASSESS THE TOOL TO PATIENT REPORTED EXPERIENCES OF DISCRIMINATION IN HEALTHCARE. IN 2011 SHE ESTABLISHED THE EASTERN CARIBBEAN HEALTH OUTCOMES RESEARCH NETWORK OR ECHORN. RESEARCH ACROSS FOUR EASTERN CARIBBEAN ISLANDS SUPPORTING SEVERAL CHRONIC DISEASE RESEARCH PROJECTS ENHANCING HEALTH OUTCOME RESEARCH AND LEADERSHIP CAPACITY IN THE REGION. THE COHORT STUDY RECRUITED AND FOLLOWING COMMUNITY DWELLING ADULT COHORT OF 3,000 INDIVIDUALS TO EXAMINE RISK AND PROTECTIVE FACTORS WITH A PRIMARY FOCUS ON CARD QUO VASCULAR AND METABOLIC OUTCOMES. THE PROJECT IS EXPANDED WITH MORE RECENT FUNDING IN 2018 TO INCLUDE A PEDIATRIC COHORT. SHE'S ALSO PI ON NIMHD FUNDED TRANSDISCIPLINARY COLLABORATIVE CENTER ON HEALTH DISPARITIES FOCUSED ON PRECISION MEDICINE ON FIVE OF THESE CENTER GRANTS, AND DR. NUNEZ SMITH HAS LEADING EFFORTS IN THAT AREA ON HYPERTENSION AND DIABETES. THE ISLANDS ARE PUERTO RICO, TRINIDAD, U.S. VIRGIN ISLANDS AND BARBADOS. NOT TOO BAD. DR. NUNEZ SMITH MENTORED DOZENS OF TRAINEES AND SINCE COMPLETING HER FELLOWSHIP, SHE'S ALSO A GENERAL INTERNIST AND HAVE BEEN RECOGNIZED WITH AWARDS AT THE SITE OF GENERAL MEDICINE WHERE SHE USUALLY ATTENDED AND PRESENTED HER WORK. SO MARCELLA. LOOK FORWARD TO HEARING YOUR PRESENTATION. >> THANK YOU SO MUCH. GOOD AFTERNOON, TO EVERYONE. MUCH GRATITUDE TO NIMHD FOR THIS OPPORTUNITY TO SHARE THE WORK THAT WE HAVE BEEN DOING THESE PAST YEARS. RELATED TO THE EASTERN CARIBBEAN HEALTH OUTCOMES RESEARCH NETWORK AND ALSO A BIG THANK YOU TO THE BROADER NIMHD FAMILY, WE HAVE BEEN FUNDED THROUGH TWO U MECHANISMS HERE, COOPERATIVE AGREEMENTS AND IT'S BEEN JUST A GREAT PLEASURE AND HELP TO WORK CLOSELY WITH PROGRAM IN THIS PROCESS. SO I'M HERE ON BEHALF OF THE FIVE PRINCIPLE INVESTIGATORS OF OUR CURRENT PRECISION MEDICINE U-54, TO SHARE WITH YOU MORE ABOUT THE NETWORK THAT YOU READ ABOUT IN THE INTRODUCTION. AND TO THINK ABOUT FUTURE DIRECTIONS. SO DURING OUR TIME TODAY, I HOPE TO GIVE YOU WHAT IS ESSENTIALLY A 30,000-FOOT OVERVIEW OF THE WORK THAT WE'RE DOING THROUGH THAT NETWORK IN THE EASTERN CARIBBEAN REGION UNDER THAT UMBRELLA MORE BROADLY OF THE YALE TCC. I'LL HIGHLIGHT SOME OF OUR SELECT SCIENTIFIC ACCOMPLISHMENTS AND DISCOVERIES TO DATE. ND A THEN HOPEFULLY LEADING INTO DISCUSSION SHARE SOME OF OUR IDEAS AROUND NEXT STEPS AND POTENTIAL OPPORTUNITIES FOR FUTURE DISCOVERY AND IMPACT IN THE WORK. SO OUR JOURNEY WITH IT BEGAN WITH INTEREST IN TERRITORIAL HEALTH. AND THIS IS NORMALLY THE PART WHERE I ASK PEOPLE TO NAME THE FIVE TERRITORIES, I'LL SPAR YOU TODAY BUT LET ME JUST SAY THAT FEW AUDIENCES GET TO ALL FIVE. BUT THE TERRITORIES HERE DISPLAYED ARE STRADDLED IN TWO DIFFERENT OCEANS AND YOU WILL SEE NORTHERN GUAM AND SAMOA IN THE PACIFIC. AND THEN IN THE ATLANTIC AND CARIBBEAN SEA PUERTO RICO AND THE U.S. VIRGIN ISLANDS. SO ALTHOUGH THESE ARE FIVE VERY DISTINCT CULTURAL PLACES, IN TERMS OF US FEDERAL POLICY, THEY TEND TO BE TREATED AS A POLICY COLLECTIVE WITH VERY IMPORTANT CONSEQUENCES, PEOPLE MAY BE AWARE FOR INSTANCE THAT RESIDENTS IN THE TERRITORIES DON'T HAVE THE RIGHT TO VOTE IN NATIONAL ELECTIONS SUCH AS FOR PRESIDENT BUT ALSO THERE ARE PARTICULAR POLICIES, PARTICULARLY WHEN IT COMES TO CMS AND REIMBURSEMENT AROUND CAPS THAT AFFECT THE DOLLARS FLOWING IN IN TERMS OF HEALTHCARE DOLLARS AND POSSIBLE EXPENDITURES IN THE REGION. SO WITH THAT QUESTION, WE SOUGHT TO EXPLORE AND EXAMINE THE QUALITY OF CARE IN THE U.S. TERRITORIES VERSUS QUALITY OF CARE ACROSS THE U.S. MAINLAND. WE LOOKED AT THREE CONDITIONS IN PARTICULAR, ACUTE MYOCARDIAL INFARCTION OR HEART ATTACK. HEART FAILURE AND PNEUMONIA AND USED CMS DATA SETS AND ADMINISTRATIVE DATA SETS TO COMPARE THE PERFORMANCE IN THESE LOCATIONS USING NQF ENDORSED MEASURES. AND THE BIG TAKE AWAY WHICH WAS SOMEWHAT SURPRISING, PERHAPS, WAS THE HOSPITAL MEAN MORTALITY RATES WERE SIGNIFICANTLY HIGHER IN THE TERRITORIES THAN IN THE STATES. SO FOR EVERY HUNDRED AMI DEATHS IN THE STATES THERE WERE TWO ADDITIONAL HEART ATTACK DEATHS IN THE TERRITORIES. ONE ADDITIONAL HEART FAILURE DEATH AND THREE ADDITIONAL PNEUMONIA DEATHS. SO WE HAD AN OPPORTUNITY TO THINK WITH BROAD STAKEHOLDERS AT THE TIME OPPORTUNITIES FOR HEALTHCARE SYSTEM STRENGTHENING BUT A LESSON WE LEARNED QUICKLY IN THESE CONVERSATIONS WAS THAT WHAT WE WERE OBSERVING IN QUALITY OF CARE METRICS WAS REALLY A SMALL PIECE OF WHAT WAS A MUCH BIGGER PUZZLE AND PROBLEM THE REASON THE REGION WAS FACED WITH AT THE TIME. WHICH WAS A TRANSITION OVER TO NCDs BROADLY AND NON-COMMUNICABLE DISEASE. THAT EPIDEMIC AFFECTING THIS REGION AND CARIBBEAN SIMILAR TO OTHER PLACES IN THE WORLD, THAT WE'RE MOVING AWAY FROM INFECTIOUS DISEASE CAUSES AND FACING THIS EXTREME BURDEN OF NCD. MANY OF THE SMALL ISLANDS STATES WE SPOKE WITH FELT UNDER SIEGE AND UNABLE TO RESPOND TO WHAT WERE INCREASING DEMANDS ON THE HEALTHCARE DELIVERY SYSTEM RELATED TO NCDs. AT THE TIME WE WERE PUBLISHING THAT WORK, THERE WAS AN INTERNATIONAL CALL FOR FURTHER ATTENTION AT NCDs. SO THIS IS A 2011 MEETING, THERE'S NOW TWO OTHER SUBSEQUENTLY. THAT WAS THE FIRST MEETING AT THE UN GENERAL ASSEMBLY, FOCUSED ON HEALTH THAT WASN'T SPECIFIC TO HIV AIDS. MANY PEOPLE EVEN IF YOU ARE AWARE THIS MEETING TOOK PLACE MAY NOT BE AWARE THAT IT WAS CARACOM, A GOVERNMENTAL CONGLOMERATE IN THE CARIBBEAN THAT CALLED FOR OR MADE THE REQUEST FOR THE HIGH LEVEL MEETING. LED AT THE TIME BY SIR GEORGE EILEEN. WE'LL COME BACK TO THAT BUT ONE OF THE MAJOR TAKE HOMES FROM THIS MEETING IS MANY COUNTRIES PARTICIPATING PARTICULARLY IN THE CARIBBEAN DIDN'T HAVE THE DATA INFRASTRUCTURE NECESSARY TO THINK ABOUT HEALTHCARE SYSTEM PLANNING OR STRENGTHENING. AND THERE WAS A GREAT CALL FOR WHAT WE MIGHT THINK OF AS STRENGTHENING BASIC SURVEILLANCE AND EPI WORK. SO WITH THAT BACKGROUND WE FOUNDED THE EASTERN CARIBBEAN HEALTH OUTCOMES RESEARCH NETWORK FOR ECHORN WITH FUNDING FROM NIMHD, AN INFRASTRUCTURE GRANT THAT ALLOWED US TO WORK WITH PARTNERS ACROSS THOSE FOUR ISLAND SITES TO THINK ABOUT WHAT WAS REALLY A FIRST OF ITS KIND COLLABORATION, BARBADOS AND TRINIDAD ARE SOVEREIGN NATIONS AND PUERTO RICO AND U.S. VIRGIN ISLANDS ARE TERRITORIES. WE WANTED TO BETTER UNDERSTAND WHAT WAS HAPPENING IN OUR U.S. TERRITORIES BUT WITHIN THEIR APPROPRIATE CARIBBEAN CULTURAL CONTEXT. THEREFORE RECRUITED TRINIDAD AS WELL AS BARBADOS. THE CORE RESEARCH PROJECT OF THE NETWORK IS COHORT STUDY. AS WAS MENTIONED, THIS IS A COMMUNITY DWELLING COHORT ACROSS ALL THE ISLAND SITES BE LOCAL SITE TEAMS LEADING THE WORK AND COMMUNITY BASED AND PLACED ASSESSMENT CENTERS. FROM THE VERY BEGINNING WE HAVE BEEN FOCUSED ON MAKING SURE THERE IS STAKEHOLDER ENGAGEMENT, COMMUNITY VOICE IN OUR WORK AND EACH OF THE ECHORN SITES RECRUITED TO THIS DAY STILL HAVE HIGH LEVEL POLICY DELEGATIONS AND COMMUNITY ADVISORY BOARDS THAT ARE COMPRISED OF LOCAL COMMUNITY RESIDENTS LEADERS AS WELL AS POLICY LEADERS IN THE REGION. FOR THE ECHORN STUDY ITSELF THE ELIGIBILITY CRITERIA INCLUDED ENGLISH AND SPANISH SPEAKING. WE RECRUITED OVER 40 AT THE TIME NOW EXPANDED AND RECRUITING YOUNGER MEMBERS. AND THEN LIKE TO POINT OUT THAT YOU HAVE TO HAVE BEEN EITHER A SEMIPERMANENT OR PERMANENT RESIDENT OF ONE OF THOSE ISLANDS FOR TEN YEARS WITHOUT PLANS TO PERMANENTLY RELOCATE WITHIN THE NEXT FIVE. PEOPLE WILL BE AWARE THAT THE REGION WAS STRUCK BY SEVERAL LARGE HURRICANES WHICH WE CAN TALK MORE ABOUT IN THE DISCUSSION BUT THAT CHANGED SOME OF THE PLANS IN TERMS OF WHERE PEOPLE LIVE AND CAN BE FOUND NOW. IN TERMS OF SAMPLING FOR THAT ADULT COHORT STUDY, IT DIFFERS BY SITE, I DON'T WANT TO BELABOR THE POINT NOW BUT WE'RE IN SITES WHERE THERE WERE PRE-EXISTING SAMPLING FRAMES IN ORDER TO ACHIEVE A REPRESENTATIVE SAMPLE WE ADAPTED BASED ON THAT. IN BARBADOS WE HAVE A HOUSEHOLD SAMPLING STRATEGY, ACROSS RANDOMLY SELECTED WORK ENUMERATION DISTRICTS OR REGIONS OF THE ENTIRE ISLAND. IN PUERTO RICO AND TRINIDAD, THOSE ARE LARGER ISLANDS AND GREATER POPULATION SIZE. AND SO THOSE ISLANDS ARE SAMPLING AS RESTRICTED TO TWO PARTICULAR AREAS, THE TWO AREAS CHOSEN ARE ONES THAT ARE NATIONALLY REPRESENT -- OR ISLAND WIDE REPRESETATIVE IN TERMS OF THEIR DEMOGRAPHIC COMPOSITION. AND THEN SAMPLE FROM WITHIN THOSE TWO AREAS. THE U.S. VIRGIN ISLANDS, THERE WERE FOUR U.S. VIRGIN ISLANDS, THE SAMPLING METHODOLOGY THERE IS BASED ON PHONE, WHAT'S PARTICULARLY NOVEL OR EXCITING FOR US IS WE WERE ABLE TO INCLUDE ALL MOBILE PHONE NUMBERS AS WELL AS LAND LINE NUMBERS IN OUR SAMPLING. SO IN WAVE ONE WE SUCCESSFULLY RECRUITED APPROXIMATELY 3,000 ADULTS, WHO WE PLAN TO FOLLOW OVER TIME. THOSE CONTRIBUTION TO THE COHORT THAT'S ROUGHLY PROPORTIONATE TO THE POPULATION OF THE ISLANDS THAT ARE PARTICIPATING. THE THREE PART BASELINE ASSESSMENT INCLUDED A SELF-ADMINISTERED QUESTIONNAIRE, AN EXAM, LABORATORY DATA AND THERE WAS OPTIONAL BIOBANKING AND 20% OF THE SAMPLE IS ENROLLED IN OUR BIOREPOSITORY. AT BASELINE THE COHORT DOES SKEW FEMALE AND DOES SKEW ABOVE THAT 40-YEAR-OLD CRITERIA FOR ENTRY AROUND 57 YEARS OF AGE. JUST A SNAP SHOT OF WAVE 1 DATA THAT HELPS INFORM SOME OF OUR SUBSEQUENT WORK. IF YOU LOOK ACROSS THE TOP, THESE ARE COHORT STUDIES THAT MANY WILL BE FAMILIAR WITH. SO SOLE AND ME IS A, IMPORTANT BECAUSE INTERNET PARTICULARLY WE HAVE A LARGE REPRESENTATION OF EAST ASIAN DESCENT PARTICIPANTS, SOUTH ASIAN. ING JACKSON HART REGARDS N HAYNES DATA. AND THEN IN YELLOW IS OUR SNAP SHOP FROM BASELINE PARTICIPANTS. JUST A REMINDER THESE ARE COMMUNITY DWELLING PARTICIPANTS, THIS IS A REGISTRY, WE WEREN'T SELECTING PEOPLE BASED ON PRIOR DIAGNOSIS. SO ALMOST ALL CASES YOU WILL SEE THAT WHAT WE SEE IS THE PREVALENCE FOR THESE HEAVILY BURDENED NCDs, ARE AS HIGH OR HIGHER THAN MANY OF THE COHORT STUDIES IN THE U.S. MAINLAND. WE LOOKED AT HYPERTENSION AND DIABETES OVERWEIGHT OBESITY, EITHER OF THEM, AND BOTTOM LINE IS SELF-REPORTED CBD TO BE CLEAR. WE WERE REALLY STRUCK BY THE BURDEN THAT WE FOUND AND OBSERVED IN THE BASELINE OF THE COHORT STUDY AND TRYING TO THINK THROUGH HOW TO RESPOND WHAT TO DO NEXT WITH HEALTH AND PARTNERSHIP OF THE GLOBAL HEALTH LEADERSHIP INSTITUTE AT YALE, WE WERE ABLE TO BRING TOGETHER FOR ONE WEEK THOSE HIGH LEVEL POLICY DELEGATIONS AS WELL AS COMMUNITY REPRESENTATIVES FROM THE ADVISE BOARDS TO CHART A STRATEGIC DIRECTION FORWARD ACROSS THE NETWORK: THERE WERE SEVERAL KEY RECOMMENDATIONS THAT AROSE FROM THAT INCLUDING REAL CALL FOR US TO THINK MORE ABOUT INTERGENERATIONAL RESEARCH, TO TAKE AT LEAST A PARTIAL PIVOT IMPLEMENTATION AT INTERVENTION SCIENCE, AND THEN FOR US TO BE VERY INTENTIONAL ABOUT DATA SHARING AND EVEN EXPANDING OUR STAKEHOLDER NETWORK MORE BROADLY. COMING OUT OF THAT MEETING, WE HEEDED ADVICE AND CHANGED OUR STRATEGIC DIRECTION SOMEWHAT. AND WE ARE ABLE TO AS WAS MENTIONED BEFORE RECEIVE FUNDING FROM NIMHD AS ONE OF FIVE CENTERS FOCUSE ON PRECISION MEDICINE. WITH A TARGETED ATTENTION TO EARLY DETECTION AND PREVENTION OF HYPERTENSION AND TYPE 2 DIABETES. IMPORTANTLY IN THE TCC WORK, WE WERE ABLE TO AS A REGION TWO CENTER EXPAND TO NEW YORK AND NEW JERSEY. THESE ARE TWO STATES ON THE MAINLAND WHERE THERE ARE QUITE SIGNIFICANT REPRESENTATION OF CARIBBEAN DESCENT POPULATIONS AS WELL. THEN CONTINUE OUR PARTNERSHIPS IN TRINIDAD AND IN BARBADOS. TRYING TO REFLECT AND MIRROR WHAT WE LEARNED FROM OUR STAKEHOLDERS WE SET FORWARD TO FIVE OVERARCHING GOALS OF THAT YALE TCC. INVESTIGATOR NETWORK WITH AN EYE TOWARDS EARLY STAGE INVESTIGATORS IN THE REGION AND ON THE U.S. MAINLAND TO EXPAND STAKEHOLDER NETWORK MORE BROADLY WE WERE ENGAGED WITH LOCAL GOVERNMENTS, MINISTRIES, HEALTHCARE SYSTEMS BUT REALLY ENGAGE MORE COMMUNITY BASED ORGANIZATIONS IN THE WORK. TO IMPLEMENT EVIDENCE BASED INTERVENTION, ACCOMPLISH IMPLEMENTATION SCIENCE AS ONE OUR CORE ACTIVITIES. AND EVEN THOUGH FOR TODAY WON'T TALK AS MUCH ABOUT THESE TWO, THEY ARE EQUALLY IMPORTANT, THINKING ABOUT DATA SHARING AND THE RESEARCH ETHICS THAT ARE RELEVANT. SO NOW WE ARE ACTIVELY IN WAVE 2 OF THE COHORT WHICH IS OUR FIRST FOLLOW-UP. SO FAR WE HAVE HAD ONLY TWO BASELINE PARTICIPANTS, WHO ARE A LOSS TO FOLLOW-UP AND 13 WHO REFUSE PARTICIPATION AND WE ARE ABOUT A QUARTER OF THE WAY IN TERMS OF REENROLLING EVERYONE FROM BASELINE, MANY OF THE COMPONENTS FROM BASELINE REMAIN BUT I WILL POINT OUT PARTICULARLY GIVEN OUR CONVERSATION EARLY ABOUT INFLAMMATION THAT WE ARE NOW ADDED DRY BLOOD CLOTS TO THE PROTOCOL WITH AN INTENTION TO CHECK FOR WHAT ARE KNOWN MARKERS, COMMENTS ABOUT THE COMPLEXITY THERE NOTWITHSTANDING BUT TO BE ABLE TO LOOK AT HIGH SENSITIVITY CRP, AS WELL AS CYTOKINES, CHANGES IN TELOMERE LENGTH AND SEVERAL OTHER PARAMETERS. DURING OUR WAVE TWO RECRUITMENT AND FOLLOW-UP WE NOW HAVE EXPANDED WITH ADDITIONAL SUBPROJECTS AS WELL. SO THE BIOBANK REPOSITORY WHICH AT BASELINE CONSISTED OF WHOLE BLOOD AND SERUM, WE WERE ABLE TO -- I LOVE THE TALK MORE ABOUT THAT IN THE QUESTION AND ANSWER PERIOD FOR THAT PROCESS BUT WE WERE ABLE TO RECRUIT TO OUR MAXIMUM IN TERMS OF RESOURCES, 600 PARTICIPANTS IN WAVE 1. FOLLOW UP NOW IN WAVE 2 OUR GOAL IS TO ESTABLISH A LONGITUDINAL BIOREPOSITORY AND SO THOSE PARTICIPANTS WHO BIOBANK BASELINE ARE INVITED TO BIOBANK AGAIN NOW AT FOLLOW-UP AND WE ARE ADDED YEAR-END TO THE BIOREPOSITORY AS A SPECIMEN. I'M GOING TO SPEND MORE TIME TALKING ABOUT THESE TWO SUBPROJECTS IN PARTICULAR. THE FIRST IS OUR HYPERTENSION PROJECT WHERE PARTICULARLY INTERESTED IN IDENTIFYING HARMFUL DANGEROUS PHENOTYPES OF HYPERTENSION THAT ARE ASSOCIATED WITH CARDIOVASCULAR DISEASE THAT WE MISS WHEN WE JUST USE CLINICAL MEASURES OR THOSE ONE OR TWO TIME MEASUREMENTS. THEN DIABETES SUBPROJECT WHERE THE CHALLENGE THERE IS ABLE TO IDENTIFY RISK FOR PROGRESSION TO TYPE TWO DIABETES EARLIER THAN OUR A 1C FASTING GLUCOSE REVEALED HISTORICALLY. HYPE TENSION SUBPROJECT IS LED BY EARLY STAGE INVESTIGATOR, DR. ERICA SPATZ, A CARDIOLOGIST. IN THIS WORK WE ARE USING 24 HOUR AMBULATORY BLOOD PRESSURE MONITORING ALONG WITH ECOLOGICAL MOMENTARY ASSESSMENT, ACTIGRAPHY TO LOOK AT SLEEP QUALITY AT THIS TIME DATA. THE SURVEYS WITHIN THE COHORT STUDY, ADDITIONAL QUESTION ITEMS, AND DATA ON THE BUILT ENVIRONMENT. OVER TIME, THE GOAL IS TO INTEGRATE THESE DATA ELEMENTS TO IDENTIFY PHENOTYPES OF BLOOD PRESSURE THAT MAY CONVEY RISK OR PROTECTION, VIS-A-VIS CARDIOVASCULAR DISEASE. SO FOR TODAY WE DID A SNAP SHOT OF WHAT WE ARE LEARNING WITHIN THIS HYPERTENSION SUBPROJECT. SO LOOKING AT THE FIRST 26 PARTICIPANTS WHICH WE HAVE CLEAN DATA IN THE SUBPROJECT, MANY READINGS ASSOCIATED WITH EACH PARTICIPANT, ANYWHERE FROM 19 TO 57 BLOOD PRESSURE READINGS, OVER THE 24 HOUR PERIOD. I WANTED TO DRAW YOUR EYE TO THE FIRST LINE AND BOTTOM LINE IN THIS TABLE. OF THOSE 26 PARTICIPANTS ONLY FOUR OF THEM NOW TO ENTER INTO THE SUBPROJECT YOU DON'T HAVE A DIAGNOSIS OF HYPERTENSION. WE DON'T THINK OR KNOW THAT YOU HAVE HYPERTENSION. OF THOSE 26, ONLY FOUR ARE DEEMED NORMAL IN TERMS OF THEIR IF YOU LOOK IN THE BOTTOM, 21 OF THE PARTICIPANTS ARE BOUND TO HAVE NOCTURNAL NON-DEEPING AND MANY CLINICIANS IN THE ROOM, BUT FOR EVERYONE A REMINDER THAT NOCTURNAL NON-DIPPING IS INDEPENDENT RISK FACTOR FOR CARDIOVASCULAR DISEASE AND NOT CAPTURE CLINICAL SETTING WITHIN THE NORMAL PRACTICE. SO ONCE AGAIN WE HAVE SORT OF TAKE PAUSE AS NUMBERS ARE SMALL BUT CERTAINLY SUGGEST AGAIN A BURDEN OF AT LEAST HYPERTENSION THAT MAY BE HIGHER IN THE REGION THAT WE REALIZE WHEN WE THINK ABOUT EXPANDED PHENOTYPES. SO MOVING FORWARD WE'LL CONTINUE RECRUITMENT AND ONCE WE HAVE A HUNDRED PARTICIPANTS ENROLLED WE'LL DO MORE WORK AROUND THE COMPREHENSIVE PHENOTYPE DEVELOPMENT. SO A LITTLE BIT OF A SWITCH TO THE DIABETES SUBPROJECT WHERE OUR GOAL THERE IS IDENTIFYING NOVEL BIOMARKERS WITHIN OUR COHORT THAT MIGHT HELP GIVE US EARLY SIGNALS FOR THE RISK FOR TYPE 2 DIABETES WITH LONGER TERM PLAN OF THINKING ABOUT THE POTENTIAL FOR POINT OF CARE TESTING AND ADDITIONAL ALGORITHMS WE CAN USE TO BOTH PREDICT AND HOPEFULLY MONITOR DIABETES DEVELOPMENT OVER TIME. SO THIS PROJECT IS ALSO LED BY EARLIER STAGE INVESTIGATOR DR. TOREED IN LABORATORY OF MEDICINE AND THE HIGHLIGHTS AND TAKE AWAYS FROM THIS SLIDE THAT THERE IS SOME EARLY EVIDENCE THAT LOOKING AT THE DISTRIBUTION AND RACIAL VARIOUS SPECIFIC AMINO ACIDS WITHIN THE BLOOD MAY GIVE US MUCH EARLIER INSIGHT INTO DIABETES CHANGES IN ME TABLYTIC CHANGES METHOD BOLLIC CHANGES AHEAD OF A 1C OR FASTING GLUCOSE. SO THE FIRST STEP THE LAB DID WAS TO IDENTIFY THE METHOD FOR QUANTIFYING AMINO ACIDS THAT ONLY USES A DROP OF SERUM, I'M APPRECIATIVE BECAUSE BIOREPOSITORY SAMPLES ARE PRECIOUS AND WE HAVE SMALL VOLUME AMOUNTS, FROM PARTICIPANTS. SO THIS IN AND OF ITSELF HAS BEEN AN AMAZING ADVANCEMENT AND DISCOVERY TO BE ABLE TO DO THIS KIND OF MASS SPEC WORK WITH SUCH A SMALL SAMPLE. AFTER A PERIOD OF VALIDATING ALL THE VARIOUS ASSAYS USING DISCARDED BLOOD SAMPLES FROM OUR HEALTH SYSTEM, AT YALE, WE HAVE NOW BEEN ABLE TO ANALYZE ALMOST ALL OF THE SERUM SAMPLES IN THE BIOREPOSITORY WITH VERY INTERESTING RESULTS SO HERE WE JUST SEE THE -- IN TERMS OF REPRESENTATION THERE IS AN ALMOST EVEN SPLIT AMONG PATIENT WHOSE ARE NORMAL GLYCEMIC BY A 1C, THOSE PRE-DIABETIC AND THOSE MEET CRITERIA FOR DIABETES. WE CAN SEE THE CURVES THAN THERE ARE BOTH AMINO ACIDS AND AMINO ACID RATIOS THAT ARE NOVEL AND WE ARE FURTHER EXPLORING THIS WORK AS MUCH OF WHAT WE ARE SEEING IN THE LAB WOULD BE NEW BUT THESE RATIOS ARE CORRELATING HIGHLY WITH THE BASELINE GLYCEMIC STATUS. WE HAVE AN OPPORTUNITY TO MOVE FORWARD IN A LONGITUDINAL WAY INTEGRATE OTHER DATA TYPES SUCH AS AGE AN SEX AND BMI TO THIS WORK. SO DURING THE COURSE OF OF TCC WE HOPE TO IDENTIFY THESE PROMISING BIOMARKERS AND DO ANNUAL TESTING OF URINE AND SERUM SAMPLES TO BETTER ESTABLISH DIAGNOSTIC CRITERIA. SOMETHING PARTICULARLY INTERESTED ABOUT, INTERESTED IN, I WANT TO BE SURE TO HIGHLIGHT IS THE PILOT PROJECT AWARDEES WHO ARE PART OF THE TCC. IN REGION WE ARE SUPPORTING EARLY STAGE INVESTIGATORS AT THE UNIVERSITY OF WEST INDIES AND TRINIDAD AND BARBADOS TO DO BASIC SCIENCE WORK TO ADVANCE WHAT WE HOPE WILL BE REALLY ADVANCE IN THE REGION CARE FOR BOTH PATIENTS WITH DIABETES AND HYPERTENSION. DR. OJ ARE LOOKING AT HYPERTENSION AND THE RAS SYSTEM AND DR. CLEMENT IS LOOKING AT SNPS ASSOCIATED WITH METFORMIN FAILURE IN TYPE TWO DIABETES. WHICH IS EXTREMELY IMPORTANT BECAUSE WE OFTEN THINK OF PATIENT NON-ADHERENCE TO MEDICATION, WE DON'T SEE IMPROVEMENT OVER TIME. WHICH IS NOT ALWAYS THE REASON. AS PART OF PLANNING STAKEHOLDER NETWORK THE -- WE HAVE GROWN NOW TO OVER 606 STAKEHOLDERS IN THE REGION. AND WE ARE VERY THRILLED TO HAVE A LEADERSHIP TEAM THAT IS COMMITTED TO THE WORK. PROFESSOR TREVOR HASSLE WHO FIRST BROUGHT TO THE UN ATTENTION THE NEED TO WORK ON NCDs AND DR. BAXTER, THE IMMEDIATE PAST PRESIDENT OF THE UNIVERSITY OF THE VIRGIN ISLAND. SO STAKEHOLDERS ACROSS FOUR WORK GROUPS ARE REALLY PROVIDING ONGOING STRATEGIC INPUT INTO THE WORK THAT WE ARE DOING TO CREATE A COLLABORATIVE LEARNING COMMUNITY TO BETTER SHARE DATA, TO BE ATTENTIVE TO OUR IMPLEMENTATION PROTOCOL AND REFINEMENT AND TO ATTEND TO WELL BEING OF THE ENFORCEMENT ITSELF. PART OF THE GOAL ENGAGED IN CROSS CUTTING WORK LIKE THIS IS TO MAKE SURE WE ARE LOOKING TO THAT NEXT GENERATION. FROM THE BEGINNING WE HAVE HAD FELLOWS AS PART OF OUR CONSORTIUM WHO WORK TO STAFF EACH OF THE WORK GROUPS, THESE ARE CURRENT CONSORTIUM FELLOWS THAT YIELD FROM ALL ECHORN SITES. THEY'RE PHENOMENAL. ONE MAJOR THRUST RIGHT NOW WITHIN THE CONSORTIUM IS THINKING ABOUT DATA SHARING AND HOW WE GET BETTER SHARE OF DATA RELATED NCDS ACROSS THE REGION. SO OF THE FIVE GOALS, THE LAST ONE I WANT TO SPEND MORE THAN A MINUTE ON IS TALKING WITH OUR DEMONSTRATION PROJECT PROGRAM, WHICH IS A CLINICAL TRIAL TO PREVENT THE TRANSFORMATION OF PRE-DIABETES TO DIABETES. METFORMIN ESCALATION OR THE ACRONYM FOR THE TRIAL IS LIME. THIS IS AN EVIDENCE BASED INTERVENTION THAT SEEKS TO REDUCE THE INCIDENCE OF DIABETES AMONG THOSE HIGHEST RISK. BY FIRST USING LIFESTYLE AND ESCALATING TO METFORMIN PER ADA GUIDELINES IF NO CHANGE IN A 1C OR WAVE. IMPORTANTLY TO SAY THE WORK WE ARE DOING IN LINE DOES NOT INVOLVE ECS PARTICIPANTS, THIS IS A CLINICAL BASED INTERVENTION. WE RECRUITED NEW PIs AND NEW CLINICAL PARTNERS FOR THAT. IMPORTANTLY THE LIFESTYLE INTERVENTION PIECE IS ADAPTED FROM WORK THAT WAS PRIOR -- WITH PRIOR FUNDING FROM NIMHD. THE TEAM AT MOUNT SINAI, THAT CREATED HE WHICH IS HELPING EDUCATE TO ELIMINATE DIABETES. AND THIS HAS BEEN A WONDERFUL PARTNERSHIP WITH DR. HOROWITZ ON THE TEAM. WE HAVE CLINICAL PARTNERS ACROSS THE SITES AND INCLUDING PARTNERS, CLINICAL PARTNERS IN NEW YORK CITY. THESE INTERVENTIONS ARE WELL UNDERWAY AND WE HAVE ALREADY COMPLETE THE WORK -- FIRST ROUND OF WORKSHOPS AND THAT'S ONGOING. SO FAR AS FAR AS IMPLEMENTATION OUTCOMES WE ARE LOOKING AT, RECENT ADOPTION WE ARE DOING WELL AND MEETING OUR RECRUITMENT TARGETS THERE. SO AGAIN JUST GIVEN TIME, I ONLY WANTED TO MENTION ACTIVITIES WE ARE DOING AROUND DATA SHARING AND RESEARCH ETHICS. AS IS A PRIORITY ACROSS NIH, WE WANT TO BE ATTENTIVE TO DATA SHARING NOT JUST BETWEEN INVESTIGATORS BUT TO EXTEND THAT TO THINKING ABOUT PARTICIPANTS ON OUR COMMUNITY BASED ORGANIZATION PARTNERS. SO WE HAVE CREATED AN INTERACTIVE VISUALIZATION PLATFORM THAT WILL ALLOW PEOPLE WHO DON'T NECESSARILY HAVE A STATISTICS OR EPI BACKGROUND TO BE ABLE TO SELECT VARIABLES AND DO ANALYSES AND DISPLAY ANALYSES, THAT'S USING RIGHT NOW PUBLIC DATA, PUBLICLY AVAILABLE DATA AND THEN WE WILL INCLUDE ECHORN COHORT STUDY ANONYMIZED OVER TIME. THEN ONE OF THE OTHER QUESTIONS COME UP THIS MORNING IS WHO IS STANDING GUARD IN TERMS OF THE IRB AND ETHICS? THIS IS A QUESTION WE ARE ASKING IN THE REGION AS WELL DOING A SURVEY TO DETERMINE EXTEND OF COMMUNITY VOICE IN THE RESEARCH ETHICS REVIEW PROCESS. SO THESE ARE SOME OF THE GENERAL IDEAS THAT WE HAVE IN DEVELOPMENT, WHERE MIGHT WE -- WHERE WE GO NEXT? WORKING WITH SOME OF OUR TCC PARTNERS, WE HAVE CERTAINLY GIVEN A LOT OF ATTENTION TO THINKING THROUGH WHAT EXACTLY IS FOR EXAMPLE RACE AND ETHNICITY IN THIS REGION. WHERE THEY DON'T HAVE THE SAME HISTORICAL ANCHORS IN THE MAINLAND. BUT ALSO THINKING ABOUT OTHER QUESTIONS, RELATED TO ANCESTRY, TO QUALITY OF CARE, TO THINKING ABOUT WHAT'S AVAILABLE IN TERMS OF MATCH COHORTS POSSIBILITIES WE DO WANT TO MAKE SURE THE WORK WE HAVE DONE IN THE CONTRIBUTION OF OUR PARTICIPANTS ARE RECOGNIZED AND SO OUR NEXT STEP IS TO STAND UP DATA USE WORKSHOPS AND BY OTHER AUTHORS -- INVITE OTHER AUTHOR TO JOIN IN THE DISSEMINATION WORK. SO THE SUMMARY OF WHERE WE HAVE BEEN, WHERE WE ARE IN YALE TCC, WE ARE THRILLED TO BE IN WAVE 2 OF THE ECHORT COHORT STUDY, AND HAVE SEVERAL SUBPROJECTS INCLUDING THE BIOBANKS AND HYPERTENSION SUBPROJECT AND DIABETES SUBPROJECT, THAT WILL GIVE US NEW DISCOVERIES AND NEW INSIGHTS. THE PILOT PROJECTS AND SUPPORTING EARLY STAGE INVESTIGATORS THINKING ABOUT IMPLEMENTATION SCIENCE VIS-A-VIS THIS CLINICAL TRIAL THAT'S LIME. THE WORK WE'RE DOING WITH DATA SHARE AND ETHICS. WITH FUNDING FROM NHLBI WE CAN EXTEND THIS COHORT AND MAKE IT INTERGENERATIONAL. MY SECTION CHIEF SAYS THIS IS THE FRAMINGHAM OF THE CARIBBEAN AND THAT IS CERTAINLY A MONIKER WE ACCEPT. IN THE INTERGENERATIONAL COHORT OUR GOAL IS TO LOOK AT RELATIONSHIPS BETWEEN SLEEP DEFICIENCY AND PEDIATRIC OUTCOMES RELATED TO FUTURE CBD DEVELOPMENT SUCH AS OBESITY, HYPERTENSION, HYPERLIPIDS AND DIABETES. GIVEN TWO SITES WERE PARTICULARLY DEVASTATED, BY THE RECENT HURRICANES IN 2017, WE NOW HAVE ADDITIONAL PILLAR THAT LOOKS AT POST HURRICANE RESILIENCY. WE ARE WORKING IN PARTNERSHIP WITH PAHO, A LATIN AMERICAN AND CARIBBEAN ARM OF THE WHO AND THE HEALTHY CARIBBEAN COALITION TO DEPLOY AN IMPLEMENTATION SCIENCE PROJECT TO DEPLOY NCD READINESS KITS ACROSS ISLANDS IN THE REGION. THAT'S A NEW INITIATIVE. WE ARE VERY GRATEFUL TO RECEIVE FROM THE ASSOCIATION FOR CLINICAL AND TRANSLATIONAL SCIENCE, THE 2019 TEAM SCIENCE AWARD THIS PAST MARCH. AND TO BE THE CONFERENCE KEY PLENARY AT THE UPCOMING CARIBBEAN PUBLIC HEALTH ASSOCIATE MEETING INTERNET AD THIS JUNE. THE LAST THING I WANT TO DO IS ACKNOWLEDGE THE TEAM THAT MAKES THIS WORK POSSIBLE INCLUDING THE COHORT STUDY PARTICIPANTS AND OUR WIDE VAST NETWORK OF STAKEHOLDERS. EACH PROJECT SITE AND THE OTHER PIs AS WELL. THANK YOU. [APPLAUSE] >> OPEN FOR COMMENT OR DISCUSSION. >> THANK YOU. THIS IS SO FASCINATING AND EXCITING. I HAVE ALWAYS BEEN INTERESTED IN THE ROLE OF COLONIALISM, COMING FROM A PREVIOUSLY COLONIZED COUNTRY IN THE PHILIPPINES. WE WERE ALL SITES WERE ALL PREVIOUS COLONIES, I'M WONDERING IF YOU ARE ABLE TO ASSESS PERCEPTIONS OF SECOND CLASS CITIZENSHIP OR SELF-EFFICACY AMONG A CURRENT US COMMONWEALTH PREVIOUS UN FORMER BRITISH AND THEN TH SECOND QUESTION HAD TO DO WITH THE RELATIONSHIPS WITH HAVING TRANSNATIONAL FAMILIES. >> THANK YOU FOR BOTH OF THOSE QUESTIONS. SO TO THE FIRST, FROM THE VERY BEGINNING ONE OF -- SO THERE'S A LOT OF -- I MENTION THIS THE FIRST OF ITS KIND BECAUSE EVEN THOUGH IN THE CARIBBEAN THE ISLANDS ARE SO CLOSE THERE ARE DIFFERENT FLAGS THAT FLY AND HAVE FLOWN HISTORICALLY SO IT'S NOT ALWAYS EASY TO CREATE PARTNERSHIPS ACROSS COMMUNITIES. BUT CERTAINLY ONE OF THE COMMONLY SHARED EXPERIENCES ACROSS SITES WAS THE HISTORY OF CLONALLISM. AND -- COLONIALISM AND THAT WAS OUR FIRST CONVENING THE TOPIC OF THE ENTIRE MEETING. WAS AROUND COLONIALISM, THERE ARE SOME ITEMS ON THE SURVEY QUESTION THAT LOOK AT THAT, THE EXPERIENCE PARTICULARLY WHEN THEY TRAVEL TO THE UK OR THE UNITED STATES AND CERTAINLY LOOK AT QUESTIONS AROUND HEALTHCARE SEEKING BEHAVIORS ON AND OFF ISLAND. BUT I THINK THAT WORK IS PRIMED FOR MORE QUALITATIVE ANALYSIS QUITE FRANKLY. WE DO HAVE SOME FACULTY OR PARTICULARLY INTERESTED IN THAT QUESTION AROUND COLONIALISM. TO YOUR SECOND ONE I THINK THIS IDEA OF TRANSNATIONAL AND GOING BACK AND FORTH, IS VERY SALIENT IN OUR COHORT. PEOPLE ARE TRAVELING BUT MORE IMPORTANTLY THEIR SOCIAL NETWORKS ARE ON AND OFF ISLAND. EPIWE DO THE FIRST PASS OF SOCIAL NETWORK ANALYSES THAT LOOK AT PROPORTION OF SOCIAL MET NETWORK MEMBERS ON ISLAND VERSUS OFF WE SEE CORRELATIONS WITH THE VARIABLES OF INTEREST AROUND N CD AND OUTCOMES. SO WE ARE HOPING TO BE ABLE THE DO MUCH MORE WITH THAT AND TO THINK ABOUT POTENTIALLY RECRUITING PEOPLE OF CARIBBEAN DESCENT TO ON THE MAINLAND AND DOING CROSS COMPETITIVE WORK THAT WAY. THANK YOU. FROM >> MARCELLA, THANK YOU SO MUCH FOR THIS TOUR DE FORCE THROUGH THIS INCREDIBLE PROJECT. IT'S BEEN WONDERFUL TO SEE HOW YOU HAVE TAKEN THIS AND JUST EXPANDED ON IT AND WILL PROVIDE REALLY IMPORTANT FINDINGS FOR THOSE OF US FROM -- OF CARIBBEAN DESCENT. SO I WANTED TO GO BACK A LITTLE BIT MORE AND ASK YOU ABOUT THE IDEA OF MOVING BACK AND FORTH ON AND OFF ISLAND. MY PARENTS IMMIGRATE TO THIS COUNTRY WHEN MY FATHER WAS YOUNG ADULT AND OFTEN HIS COHORT WILL TALK ABOUT GOING HOME AFTER THEY HAVE RETIRED. FROM CAN YOU SAY MORE ABOUT HOW YOU'RE LOOKING AT THEIR EXPERIENCES IN THIS COUNTRY BECAUSE HE VERY CLEARLY TALKS ABOUT WHAT IT FELT LIKE TO COME TO THIS COUNTRY AND EXPERIENCE THE SOCIAL ENVIRONMENT OF THE 50s AND '60s AND ALSO GOING BACK HOME WHICH IS A DIFFERENT ISLAND THAT HE GREW UP IN. >> SO THANK YOU FOR THE COMMENTS AND ON THE QUESTION, FOR THE MAJORITY OF PARTICIPANTS THERE IS MOVEMENT, THE CIRCULAR MOVEMENT BETWEEN HOME ISLANDS AND THE U.S. MAINLAND. WE HAVE INSIGHT THROUGH THE HEALTH LENS MORE SHARPLY IN TERMS OF WHERE PEOPLE SEEK CARE AND FOR WHAT AND WE ARE TRACKING THAT VERY CLOSELY. WE ALSO ARE TRACKING AND COLLECTING DATA ON THE PERIODS OF TIME PEOPLE SPEND IN DIFFERENT LOCATIONS. AND ASKING SPECIFIC QUESTIONS VIS-A-VIS SOCIAL REALITIES SUCH AS DISCRIMINATION AND HOW THAT CHANGES ACROSS THE SETTINGS. THERE IS FORMATIVE WORK THAT STILL NEEDS TO BE DONE TO CAPTURE THIS BECAUSE IN MANY WAYS THIS IS A NEW ASK WE ARE MAKING TO LOOK AT PEOPLE WHOLE ARE SIMULTANEOUSLY EXPERIENCING MULTIPLE CULTURES WITHIN THIS TIGHT GEOGRAPHY AND HOW THAT MIGHT RELATE TO HEALTH. FROM CERTAINLY I TAKE THE POINTS THAT EVEN THE TIME WHETHER YOU SPEND TIME IN THE U.S. MAINLAND IN THE 50s OR 60s VERSUS 80s OR '90s IS HIGHLY RELEVANT AND LIKELY PREDICTIVE. FROM >> I THINK YOU MAY HAVE ANSWERED -- FREIGHT PRESENTATION. THANK YOU. MY QUESTION IS MORE FOLLOW-UP TO THE QUESTION COLONIALISM TO START THE DIFFICULT CONSTRUCTS TO MEASURE AND SO FORTH. AND I DIDN'T SEE ON ONE YOUR SLIDES YOU LISTED THE MEASURES GIVEN INTEREST AND DISCRIMINATION. DIDN'T SEE DISCRIMINATION MEASURES, STILL ONE OF THOSE FORMATIVE PROCESS? >> NO, NO, NO. WE BOTH INCLUDE -- SO TO SAY A WORD ABOUT THE MEASURE THAT I THANK YOU, WE HAVE TRIED TO HARMONIZE WITH COHORTS THAT I LISTED BEFORE FOR DATA COLLECTION WHENEVER POSSIBLE AND ALSO TO USE PROMISE MEASURES THAT NIH ENDORSED. AS A BACKBONE. SOME OF THE -- SO IT WASN'T AN EXTENSIVE LIST THERE SO WE USE DATA DISCRIMINATION. ALSO NOW THROUGH DRY BLOOD SPOTS OVER TIME HAVE AN OPPORTUNITY TO LOOK AT TELOMERE LENGTH AS ONE POTENTIAL AVENUE. WE ARE VERY EXCITED TO HAVE PARTNERS WHO THINK WITH US MORE IN TERMS OF EPIGENETICS AND EPIGENOME AND DOING SOME OF THAT WORK AS WELL. >> THANK YOU, MY CONGRATULATIONS TO A LOVELY PRESENTATION AS WELL. I WANT TO TURN YOUR ATTENTION TO LIME. YOU KNOW OF COURSE IF DELIVERED -- LIME, RIGHT? >> YES. >> IF DELIVERED WITH FIDELITY THAT THERE'S EVERY REASON TO BELIEVE THAT IT WILL BE EFFECTIVE. I SEE YOU HAVE IT DOWN AS IMPLEMENTATION SCIENCE AND WE KNOW FROM THE DPP, WITH KNOW FROM FOLLOW-UP TO THAT SPECIAL DIABETES PROGRAM FOR INDIANS IT'S ABOUT ENGAGEMENT RECRUITMENT ADHERENCE RETENTION. AND THAT WITH RESPECT TO THOSE ELEMENTS, IT'S AT THE LEVEL OF PARTICIPANT FAMILY PROVIDERS PROGRAM AND COMMUNITY. SO I'M REALLY INTERESTED JUST TO HAVE YOU SPEAK FOR A MOMENT ABOUT WHAT ELEMENTS OF THAT CONTEXT ARE YOU EMPHASIZING CHRONIC IN TRYING TO UNDERSTAND WHAT CONTRIBUTES TO THE SUCCESSFUL IMPLEMENTATION OF THIS PARTICULAR INTERVENTION. >> THANK YOU SO MUCH. AND IT'S TRUE, THIS IS CERTAINLY THERE'S A LOT IN TERMS OF ROAD MAPS OUT THERE FOR US AND WHAT WE CAN DO AND WHAT WE CAN LEARN FROM. I WILL GO BACK TO SAY ONE OF THE THE GREAT THAT WE HAVE IS EXPERIENCE FROM IN THE BRONX OR HARLEM, FIRST IMPLEMENTED WHICH IS DIFFERENT FROM DPP, BASED ON THE STANFORD CHRONIC CARE MODEL. IN LIME IN PARTICULAR, WE HAVE THE PIs ARE PROVIDERS AT THE CLINICAL SITES, PIs OF EACH OF THE CLINICAL PARTNER SITES. WE HAVE COME TO CONSENSUS ON THAT LIME ADVISORY GROUP WHICH IS COMPRISED MOSTLY OF PATIENTS TO EMPHASIZE FAMILY PROBABLY OF THOSE. WE HAVE EXPANDED EVEN IN OUR IMPLEMENTATION PROTOCOL TO NOW HAVE FAMILIES INVITED TO BE PART OF THESE WORKSHOPS IN PARTICULAR AND THAT'S A CHANGE FROM THE PRIOR WORK. AND CAN SPEAK MORE TO WHY THAT IS. THAT'S RISEN TO THE TOP AS SOMETHING FOR US TO REALLY LEAN IN ON MORE THOUGHTFULLY AND INTENTIONALLY. BUT THERE HAS BEEN GREAT PARTICIPANT LEADERSHIP, THAT'S ALSO EMERGED SO MANY OF THE -- AT EACH SITE THERE'S PARTICIPANTS WHO HAVE TAKEN THE LEAD ON THAT RETENTION PIECE. THERE ARE TOOLS CREATED BY HEED SUCH AS AN APP WE CAN USE. BUT BY AND LARGE THIS HAS BEEN PARTICIPANT DRIVEN IN TERMS OF KEEPING CONNECTION AFTER THE WORKSHOP SERIES. AND I THINK THAT'S AN AREA WE MIGHT CONTRIBUTE SOME INTERESTING INSIGHTS OVER TIME. THANK YOU. >> GREAT PRESENTATION. ONE OF THE THINGS I'M INTERESTED IN IS AN INTERGENERATIONAL ASPECT. I BRING THIS UP BECAUSE WE DID A STUDY LOOKING AT DACA AND REDUCTION OF SOMEBODY THAT'S NOT THINKING ABOUT BEING DEPORTED ON AFFECTS WITH THEIR KID BUT WAS THEN'T THE PHYSICAL EFFECTS IT WAS ON THE MENTAL HEALTH EFFECTS. SO ONE THING I WONDER BECAUSE YOU HAVE A LOT OF SORT OF PHYSICAL ASPECTS UP THERE. WILL YOU BE -- COULD YOU MONITOR THE PHYSIOLOGICAL STRESS BY LOOKING AT ADJUSTMENT DISORDERS, OTHER THINGS THAT MAY COME OUT IN THE KIT BECAUSE AT THE END OF THE DAY, THE PROCESSING OF STRESS AND RACISM AND ALL THAT, GOES TO THE PARENT AND THE KIDS SEE THAT, THAT I THINK SETS UP AN ENVIRONMENT FOR GROWTH AND DEVELOPMENT OF CHILDREN. THAT CAN BE QUITE DIFFERENT WHEN THAT IS THERE AND WHEN THAT'S NOT. THE OPPORTUNITY TO DO THAT PARTICULARLY OF THOSE GOING BACK AND FORTH WITH THE KIDS GO WITH THEM OR STAY THERE WOULD BE VERY IMPORTANT. >> THANK YOU FOR THE COMMENT AND THE REFERENCE TO THE WORK. WE HAVE AN EXLY -- WE HAVEN'T EXPLICITLY LOOKED AT ADJUSTMENT DISORDERS AS AN OUTCOME, I THINK THAT'S HELPFUL TO TAKE BACK. DR. DAVID CHAI AND OTHERS HAVE BEEN VERY HELPFUL IN OUR THINKING ABOUT VICARIOUS RACISM AND IN PARTICULAR, SO THAT IS PART OF OUR WORK TO UNDERSTAND PARENTAL EXPERIENCE AND TO THINK ABOUT NEW ITEMS SUCH AS PARENTAL WORRY AROUND SAFETY OF THEIR CHILDREN. VIS-A-VIS POLICE BRUTALITY AND OTHER SOCIAL EXPERIENCES. WE CAN GO BACK AND LOOK MORE EXPLICITLY AT THOSE -- I THINK WE ARE DOING OKAY ON THE X SIDE THROUGH THESE OTHER MEASURES BUT LOOKING AT OTHER OUTCOMES POTENTIALLY LIKE ADJUSTMENT DISORDER. (OFF MIC) >> I THINK THE ONE MEASURE OF FAMILY'S ENVIRONMENT AND HOW THEY'RE DOING. >> THANK YOU. >> SO YOU SEEM TO BE DOING WELL WITH YOUR BIOSPECIMEN COLLECTION, CARE TO SHARE SOME STRATEGIES OR BEST PRACTICES IN THAT REGARD? >> THANK YOU FOR THAT QUESTION. SO IT HAS BEEN GOING WELL. I GIVE ALL THE CREDIT THERE TO THE PIs AND THE LOCAL TEAMS. AND THINKING THROUGH THAT STRATEGY BEFORE WE DEPLOYED FOR RECRUITMENT INTO THE BIOREPOSITORIES. WE DID ALMOST TWO YEARS OF QUALITATIVE WORK AHEAD OF THAT TO TRY TO IDENTIFY WHAT SOME OF THE BARRIERS AND FACILITATORS MIGHT BE TO ENTRY. AND THEN AS A TEAM THE PIs COLLECTIVELY DECIDED WE NEED TO TAKE A DIFFERENT APPROACH TO THE RECRUITMENT. SO THERE WAS DEVELOPMENT OF LOCAL VIDEOS AND SORT OF KIND OF WHAT IF PAM LETS TO SAY REALLY WHAT ARE THE BENEFITS TO BEING IN A BIOREPOSITORY, WHAT MIGHT COME OUT OF IT, WHAT'S PAST SUCCESSES THROUGH BIOREPOSITORIES AND HAVING THOSE AS ADJUNCTS TO THE VERY EXTENSIVE CONSENT FORMS I THINK IS VERY HELPFUL, NOT ALSO TO UNDERESTIMATE THAT THE TEAMS ARE ALL LOCAL AND THAT'S ARE PEOPLE'S NEIGHBOR WHOSE ARE TALKING TO THEM ABOUT JOINING THE COHORT STUDY. AND JOINING THE BIOREPOSITORY. BOTH CONTENT OF MESSAGE AND MESSENGER I THINK HAVE MADE ALL THE DIFFERENCE THERE IN TERMS OF PARTICIPATION, BUT PEOPLE CALLING US TO WANT TO PARTICIPATE, WE CANNOT. BUT THERE ARE PEOPLE NOW WHO WANT TO PARTICIPATE IN THE COHORT STUDY IN THE BIOREPOSITORY. >> THANK YOU VERY MUCH, MARCELLA. I'LL ADD TWO COMMENTS. ONE THAT WAS INTERESTING TO HEAR THE DISCUSSION ABOUT COLONIALISM. WHEN YOU THINK ABOUT THE CARIBBEAN HISTORY, IT'S ACTUALLY A REPOPULATION AFTER THE NATIVE POPULATIONS WERE DECIMATED. SO IT'S A TWO COLONIALIST BECAUSE OBVIOUSLY THE SPANISH COLONIZED AND SETTLED, THERE WAS A LARGE FORCED MIGRATION OF AFRICANS TO THE AREA. AND THEN YOU REMINDED US OF SOUTH ASIAN PREDOMINANTLY SECONDARY MIGRANTS THROUGH THE BRITISH EMPIRE IN THE ENGLISH SPEAKING COLONIES. THEN THERE ARE SOME OTHER EUROPEAN GROUPS THAT ARE SETTLED IN. SO I THINK THAT IS A DIFFERENT MODEL THAN YOU SEE EVEN IN NORTH AMERICA WHERE THE AMERICAN INDIAN NATIVE POPULATION SUSTAINED A PRESENCE AND IN THE REST OF LATIN AMERICA WHERE YOU HAVE A VERY BROAD SPECTRUM OF THAT MIXTURE AND SOME COUNTRIES WITH PREDOMINANT INDIGENOUS POPULATIONS. THAT IS THINKING ABOUT THE FRAMING OF QUESTIONS AND POTENTIAL DISCOVERY WOULD BE ELIMINATED BY THOSE ILLUMINATED BY PERSPECTIVES IN HISTORY AND SOCIAL STRUCTURE. THEN YOU DON'T HAVE THE TWO BIGGEST ISLANDS IN YOUR TARGET GROUP, SURE YOU WOULD LIKE TO, SO SOME OF US. BUT I THINK THE OPPORTUNITY WITH BOTH -- THE DOMINICAN REPUBLIC HAITI THAT PROVIDE MUCH BIGGER IMMIGRANT GROUPS IN THE U.S. OTHER THAN PUERTO RICO THAN THE REST OF THE CARIBBEAN COMBINED. THEN YOU HAVE THIS HISTORICAL LEGACY DIFFERENCE, THIS MIGRATION DIFFERENCE, PUERTO RICANS CAN COME AND GO, U.S. VIRGIN ISLANDS, THOUGH ONLY 100,000 OR SO PEOPLE THAT LIVE IN THOSE -- AND THEN YOU HAVE THE OTHER ISLANDS WHERE THEY WOULD HAVE THE SAME MIGRATORY IMMIGRANT BARRIERS THAT ANYONE ELSE WOULD FACE AND WHERE THE AMOUNT, NUMBER OF PEOPLE WHO HAVE COME VARIED AND HAITI HAS ITS OWN PARTICULAR TRAJECTORY IN HISTORY. SO KEEP UP ALL THIS GOOD WORK. I THINK HAVING SOME CURATION OR SOME LINKAGE TO THE US-BASED, YOU MENTIONED THE SOLE STUDY AND THE JACKSON HART STUDY, IT WOULD BE OF INTEREST TO US BECAUSE WE ARE SUPPORTING THEM SO I THINK THAT WAS ONE OF THE ORIGINAL INTENTS WHEN WE LAUNCHED THE CARIBBEAN INITIATIVE MOST RECENTLY YOU WERE FUNDED -- BEFORE THAT AND ON THAT ONE I THINK IT WAS THROUGH NHLBI. THANKS VERY MUCH AND WE'LL GO ON TO OUR LAST. >> THANK YOU, EVERYBODY. [APPLAUSE] >> NOW WE'RE GOING TO MOVE INTO THE CONCEPT CLEARANCE PHASE, DR. RAJAPAKSE WILL PRESENT A CONCEPT. SHE WILL DO THE PRESENTATION, I WILL THEN CALL ON THE COUNCIL REVIEWERS FOR THIS AND OPEN THE FLOOR FOR DISCUSSION. THEN WE WILL TAKE A VOTE. GOOD AFTERNOON, EVERYONE. SO THIS IS GOING TO BE VERY BRIEF PRESENTATION. I'M A PROGRAM DIRECTOR IN THE DIVISION OF INTEGRATIVE BIOLOGICAL AND BEHAVIORAL RESEARCH AND TODAY I'M HERE TO PRESENT A CONCEPT TO SUPPORT SPECIALIZED CENTERS OF EXCELLENCE WITH ENVIRONMENT HEALTH DISPARITIES RESEARCH THEME UNDER THE CURRENT NIMHD COE PROGRAM. I WOULD LIKE TO ACKNOWLEDGE MY COLLEAGUES DR. MICHAEL SAYRE AND DR. HUNTER WHO HAS COLLABORATED WITH ME ON THIS PROJECT. SO IN FEBRUARY IN FEBRUARY OF 2017, THE COE PROGRAM WAS REDESIGNED PRESENTED AND APPROVED BY NIMHD ADVISORY COUNCIL TO ESTABLISH SPECIALIZED CENTERS OF EXCELLENCE ON ENVIRONMENTAL HEALTH DISPARITIES RESEARCH. SO THE PROPOSED CENTERS OF EXCELLENCE WITH FOCUS ON ENVIRONMENTAL HEALTH DISPARITIES WILL SIGNIFICANTLY FILL A GAP WITHIN NIMHD COE PROGRAM PORTFOLIO AS WELL AS PROVIDE OFFICIAL TO COLLABORATE WITH N ISHHS. SO THE PROPOSED CENTERS ARE EXPECTED TO CONDUCT MULTI-DISCIPLINARY RESEARCH, RESEARCH TRAINING COMMUNITY ENGAGEMENT ACTIVITIES IN ALLEVIATING ENVIRONMENTALLY DRIVEN HEALTH DISPARITIES AND IMPROVE ACCESS TO HEALTHY ENVIRONMENTS FOR VULNERABLE POPULATIONS. IN 2017, 12 NEW COEs WERE FUNDED ON RFA MD 17005 THOUGH RFA ENCOURAGE APPLICANTS TO CHOOSE THEMATIC FOCUS THAT ADDRESSES MULTIPLE DOMAINS OF INFLUENCE INCLUDING THE PHYSICAL, THE SOCIO CULTURAL ENVIRONMENT AND NONE OF THE FUNDED CO,s HAS AN ENVIRONMENTAL HEALTH DISPARITIES THEME. SO THE COMPONENTS OF THE COEs BRIEFLY HAS ADMINISTRATIVE CALL WHICH PROVIDES OVERALL PROJECT AND OVERSIGHT AND EVALUATION, THERE'S ONE TO THREE REQUIRED RESEARCH PROJECTS RELEVANT TO THE THEMATIC FOCUS OF THE COES. AND THESE PROJECTS ARE SIMILAR TO RO1 APPLICATION. THE COMMUNITY ENGAGEMENT AND DISSEMINATION CO-DEVELOPS DEMONSTRATES AND EVALUATES STRATEGIES TO TRANSLATE SCIENTIFIC FINDINGS ON CENTER INTO INFORMATION FOR AFFECTED COMMUNITY MEMBERS, THE PUBLIC, AND POLICY MAKERS TO USE AND PROMOTE HEALTHY ENVIRONMENTS. AND THEN THE INVESTIGATOR DEVELOPMENT COHORT HAS A PILOT PROGRAM THAT FUND UP TO THREE TO TEN PILOT PROJECTS. WITH A BUDGET OF 150,000 MINIMUM. THE PUMP OF THIS PROGRAM IS TO SUPPORT SPECIALIZED CENTERS OF PROJECTS WITH ENVIRONMENTAL HEALTH DISPARITIES TEAM WITH CURRENT CEO PROGRAM IN PARTNERSHIP WITH NATIONAL INSTITUTE OF ENVIRONMENTAL HEALTH SCIENCES. THE PROPOSED CENTERS WILL CONDUCT MULTI-DISCIPLINARY RESEARCH, RESEARCH TRAINING, AND COMMUNITY ENGAGEMENT ACTIVITIES, IN ALLEVIATING ENVIRONMENTALLY DRIVEN HEALTH DISPARITIES AND IMPROVING ACCESS TO HEALTHY ENVIRONMENTS OF VULNERABLE POPULATIONS. SO THE EXISTING PROGRAMS ESTABLISHED INDEPENDENTLY AND COLLABORATIVELY BY THE HINS AND NIMHD FOSTERED COLLABORATION ACROSS DISCIPLINES AN ENABLED A QUITE A NUMBER OF RESEARCH PROJECTS, IN MULTI-DISCIPLINARY TEAMS OF COMMUNITY AND ACADEMIC EXPERTS FROM DIVERSE BACKGROUNDS TO CONDUCT RESEARCH IN THIS PARTICULAR AREA. SO BUILDING ON THESE PROGRAMS, OF THE NEW SPECIALIZED CENTER ON ENVIRONMENTAL HEALTH DISPARITIES WILL STIMULATE RESEARCH ON MULTIPLE FACTORS UNDERLYING HEALTH DISPARITIES, PROMOTE INNOVATIVE APPROACHES TO MITIGATING ENVIRONMENTALLY DRIVEN HEALTH DISPARITIES AND IMPROVE ACCESS TO VULNERABLE POPULATIONS. ANOTHER OVERARCHING PROGRAM GOAL WOULD BE THE ADDRESS EHDs THROUGH MITIGATION OR REDUCTION OF MODIFIABLE ENVIRONMENTAL FACTORS. IN ADDITION, BASED ON OUR -- SOME OF OUR DISCUSSION, YET, THE PROPOSED PROGRAM COULD ADVANCE STUDIES BY CONSIDERING EXHUME LATIVE EXPOSURE OVER LIFE COURSE AS WELL ADS EXAMINING RESULTS OF SYNERGISTIC EFFECTS OF EXPOSURE TO MULTIPLE ENVIRONMENTAL HAZARDS IN THE CONTEXT OF SOCIAL STRESSES, LIKE POVERTY, PSYCHOSOCIAL STRESS DISCRIMINATION. AND THE BUILT ENVIRONMENT. WITH THAT WE ARE SEEKING COUNCIL CONCURRENCE TO CONTINUE COLLABORATION WITH NIHS TO SUPPORT CENTERS OF EXCELLENCE WITH THE THEME OF ENVIRONMENTAL HEALTH DISPARITIES RESEARCH USING EXISTING COE PROGRAM THANK YOU FOR THE OPPORTUNITY TO PRESENT AND HAPPY TO TAKE QUESTIONS FOR THIS. >> THE COUNCIL REVIEWERS ARE >> >> THANK YOU. I WANT TO GO ON RECORD I'M HIGH LIE SUPPORTIVE OF THIS PARTICULAR CONCEPT AND PRINCIPLE. SOME OF THE QUESTIONS THAT I HAVE TEMPER MY ENTHUSIASM ABOUT IT AND SPEAK MATTERS OF IMPLEMENTATION WHICH I CAN'T GLEAN FROM WHAT THE MATERIALS WE HAVE BEFORE US. I THINK THAT THE TOPIC ITSELF IS HIGHLY PONDER AND TIMELY, I SUPPORT THE COLLABORATION OF NIEHS. THE MISSION OF THAT INSTITUTE, ITS EMPHASIS ON MINORITY HEALTH AND HEALTH DISPARITIES RESEARCH IN THE CONTEXT OF ENVIRONMENTAL HEALTH DISPARITIES, IS ON RECORD, I THINK IT IS A WONDERFUL SYNERGY BETWEEN THE TWO. ENTITIES. AND WITNESS I THINK THE EARLY PHASE MARRIAGE BETWEEN TWO AND CURRENT EFFORT THAT FUND FIVE CENTERS. A COUPLE OF CONCERNS THAT I HAVE WE CAN DISCUSS HERE OR SEE IN SUBSEQUENT AMENDMENT TO THIS, HAVE TO DO WITH THE FLOW, I'M CONCERNED FOR EXAMPLE, TWO OF THE FIVE CENTERS CURRENTLY FUNDED, I KNOW THIS COE AND SPECIALIZED THEMATIC FOCUS IS DIFFERENT BUT I'M CONCERNED TWO OF THE FIVE CENTERS DO NOT REALLY SPEAK TO THE INTERSECTION OF THE PHYSICAL ASPECTS OF TOXICITY EXPOSURE TO HAZARDS, ET CETERA, AND THE SOCIAL AND BEHAVIORAL CONTEXT IN WHICH THOSE EXPOSURES UNFOLD AND IMPLICATIONS FOR HEALTH. AND HEALTH DISPARITIES SO I THINK THERE NEEDS TO BE SPECIAL ATTENTION THE WORK OF THIS SPECIAL THEME OF COEs, ENSURES THAT THAT DOESN'T REOCCUR. IF IN FACT THE CONCEPT CAN BUILD IN THE NIMHD HEALTH DISPARITIES RESEARCH FRAMEWORK THAT EXPLICITLY REFERENCE IT WITHIN THE CONCEPT AND SUBSEQUENT FOA AND DRAW THE APPLICANTS' ATTENTION TO THE MULTI-DIMENSIONAL NATURE OF THIS, THAT WILL GO A LONG WAYS IN MY OPINION TOWARDS ENSURING PROPER WEIGHTNG TO EACH DIFFERENT ELEMENT THAT SHOULD BE REPRESENTED IN SUCH WORK. I HAVE A LITTLE CONCERN THE FACT THAT THOUGH IT WAS RECOMMENDED, AS POTENTIAL AREA OF FOCUS FOR THE 2017 SOLICITATION, OF COE, NONE OF THE FUNDED ONES IN FACT FOCUS ON HEALTH DISPARITY, I DON'T KNOW IF THAT MEANS THERE WERE PERHAPS SOME APPROXIMATELY CAN'TS THAT FOCUSED ON ENVIRONMENTAL HEALTH DISPARITIES BUT DIDN'T MAKE THE FUNDING. APPLICANTS. THAT SUGGESTED TO ME IF THERE ARE IF THERE WERE APPLICANTS THAT HAD FOCUS BUT DIDN'T MOVE FUNDING OR IF THERE WEREN'T AT ALL, THERE NEEDS TO BE A SPECIAL EFFORT AND COLLABORATION BETWEEN NIEHS AND THE INSTITUTE IN TERMS OF ENSURING THE PARTICULAR FOA THAT WOULD FOLLOW FROM THIS IS WELL UNDERSTOOD AND THAT THE INSTITUTE PREFERENCES AND PRIORITIES ARE WELL ADVERTISED. WITH RESPECT TO THE -- I HAVE A QUESTION ABOUT THE METRICS OF SUCCESS. THIS HAS IN THE TYPICAL COE MODEL, THE COMMUNITY ENGAGEMENT OUTREACH COHORT, I THINK THAT WE NEED TO DO BETTER IN TERMS OF ARTICULATEING WHAT THE METRICS OF SUCCESS ARE, NOT JUST IN TERMS OF REACHING OUT TO X NUMBER OF INDIVIDUALS OR KEY STAKEHOLDERS BUT TAKING TO THE NEXT LEVEL WHAT WE ARE SEEKIN TO DO IN TERMS OF EXPANDING REACH CONNECTION AND THE -- THAT FOLLOWS FROM THAT. I ALSO LIKE TO SEE A LITTLE BETTER CLOSER ATTENTION TO WHAT WOULD BE SOME OF THE METRICS OF SUCCESS WITH RESPECT TO THE PILOT STUDY. THE INVESTIGATORS THAT WOULD BE SUPPORTED IN AN INITIATIVE LIKE THIS. IN ALL TRANSPARENCY, WE CURRENTLY HAVE A COE, WE HAVE HAD ONE FOR 15 YEARS AND I THINK OURS AND OTHERS CAN DO BETTER IN THAT REGARD AND SHOULD BE PUSHED. AND I THINK THE PLACE TO MAKE THAT PUSH IS IN THE CONCEPT PROCESS AS WELL AS FOA THAT WOULD FOLLOW FROM IT. I REALLY FEEL STRONGLY LASTLY, THAT THE CENTERS THAT WOULD BE SUPPORTED IN COMMON THEME LIKE THIS, I QUESTION WHETHER OR NOT A P 50 IS ACTUALLY THE MECHANISM THAT'S BEST BECAUSE IT'S STILL ALLOWING THE PRINCIPLE INVESTIGATORS IN THE CENTERS AN ENORMOUS AMOUNT OF LATITUDE TO PAY ATTENTION OR NOT TO THE PRIORITIES AND EMPHASIS OF THE SPONSORS. AND I UNDERSTAND THE COOPERATIVE AGREEMENT SERIES PLACES GREATER BURDEN IN AN ALREADY BURDENED STAFF, SCIENTIFIC STAFF AT NIMHD BUT I THINK THERE NEEDS TO BE SPECIAL ATTENTION TO ASSURING COLLABORATION AND COOPERATION AMONG CENTERS IF IT MOVES FORWARD SO THEY CAN LEARN FROM ONE ANOTHER AND ADVANCE THE SCIENCE TOGETHER. I THINK WITHOUT THAT, I THINK THE LIKELY IMPACT WOULD BE SUBSTANTIALLY LESS THAN IT COULD BE. >> THANK YOU, DR.. >> I SHARE THE ENTHUSIASM FOR THIS OFFERING. AND SOME OF THE CONCERNS PREVIOUS REVIEWER MENTIONED BUT I'M OPTIMISTIC THAT THE WAY IT'S STRUCTURED AND USING COE FRAME WORK AND GOOD WORK OF THE INSTITUTE I THINK THAT THE ARE SUCCESSFUL SO I'M OPTIMISTIC AND I'LL LEAVE T AT THAT. -- IT AT THAT. >> THANK YOU VERY MUCH. I'LL OPEN THE FLOOR FOR COMMENTS FROM THE OTHER COUNCIL MEMBERS. SEEING NO HANDS RAIDED, AT THIS -- RAISED, AT THIS POINT MAY I HAVE A MOTION TO TO APPROVE THE CONCEPT TO MOVE FORWARD TO FOA DEVELOPMENT? SECOND? ALL IN FAVOR? ARE THERE ANY COUNCIL MEMBERS STILL ON THE PHONE? MOTION CARRIES. THE CONCEPT MOVES TO FOA DEVELOPMENT. THANK YOU VERY MUCH, DR. RAJAPAKSE. THANK YOU, COUNCIL MEMBERS. >> AT THIS TIME I'LL TURN THE MEETING BACK TO DR. PEREZ-STABLE. >> CAN WE ASSUME SOME OF THE CONCERNS THAT WERE VOICED COULD BE CONSIDERED AT LEAST IN THE DEVELOPMENT OF THE FOA? >> ABSOLUTELY. THAT'S WHAT THE STAFF WILL WORK ON. DR. SAYRE, DR. RAJAPAKSE AND WHO IS THE THIRD PERSON? I'M SORRY. FROM >> ABSOLUTELY. WE BRING THINGS TO COUNCIL FOR NOT JUST FOR PROCEDURAL RULES REASONS BUT TO GET CONTENT INPUT. IN THE ROBUST DISCUSSION YESTERDAY AND THIS SUMMARY YOU PRESENTED, I THINK ARE TO BE TAKEN TO HEART. IT'S UP TO MIKE SAYRE TO MAKE SURE IT'S IMPLEMENTED BY RAJAPAKSE AND THE STAFF AND UP TO ME AND LINDA TO AGREE ON HOW THIS GET SOLVED. I HEARD OTHER THINGS YOU DIDN'T MENTION SUCH AS THE IMPORTANCE OF PLACE AND DETERMINING ENVIRONMENTAL HEALTH DISPARITIES. AND HOW IT'S EVALUATED AND YOU EMPHASIZE SOCIAL BEHAVIORAL SIDE, I THINK YOU CAN ALSO MAKE A CASE FOR THE CLINICAL SIDE AS WELL, WHICH IS IN SOME OF THE CENTERS. AND SO -- AND I TRY TO NOT -- I DON'T RECALL ANY OF THE COE APPLICATIONS THAT WERE DISCUSSED IN 2017 HAVING A THEME OF ENVIRONMENTAL HEALTH DISPARITIES OR EVEN PROJECT THAT COULD BE LABELED AS SUCH IN THE FLAVOR OF THESE FIVE. I DON'T TRUST MY MEMORY ON THAT ONE. THANK YOU FOR ALL THE COMMENTS. AT THIS POINT I WOULD LIKE TO CALL ON DR. DERRICK TABOR TO -- (OFF MIC) >> PLEASE, COME TO A MIC NEXT TO SPIRO. >> GOOD AFTERNOON. IN MY ROLE AS A PROJECT SCIENTIST TO THE MOOREHOUSE SCHOOL OF MEDICINE TRANSDISCIPLINARY COOPERATIVE CENTER ON HEALTH POLICY, I WOULD LIKE TO ACKNOWLEDGE THAT WE HAVE SOME VISITORS HERE FROM THAT PROGRAM, SPECIFICALLY THE SATCHER HEALTH LEADERSHIP CENTER INSTITUTE. I WOULD LIKE MEGAN DOUGLAS, ASSISTANT PROFESSOR AT MOOREHOUSE SCHOOL OF MEDICINE TO INTRODUCE THE FELLOWS THAT HAVE ACCOMPANIED HER HERE. MEGAN. >> >> THANK YOU. REALLY ENJOYED FETING TO SEE THIS PROCESS AND -- GETTING TO SEE THIS PROCESS AND EXCITED TO BE HERE. I'M AN ALUM OF THE FELLOWSHIP PROGRAM AND CURRENTLY FACULTY AT MOOREHOUSE SCHOOL OF MEDICINE. EXCITE TO HAVE OTHER FELLOWS HERE, CHELSEA, AN ATTORNEY BY TRAINING, ROSE LYNN HIX, WHO IS A PEDIATRICIAN, DUMOND, AN INTERNAL MEDICINE PHYSICIAN AND DEBBIE VITALIS WHO HAS HER Ph.D. IN PUBLIC HEALTH. THANK YOU. [APPLAUSE] >> THANK YOU. IT'S GREAT TO SEE THIS DEVELOPMENT. SO AT THIS POINT ARE THERE ANY OTHER PUBLIC COMMENTS OR ANYBODY ELSE WHO WOULD LIKE TO SAY ANYTHING? OKAY. HEARING NONE, I WILL THEN TURN IT BACK TO DR. HUNTER, ANY FINAL THINGS TO SAY? OR JUST REMIND PEOPLE ABOUT THE NEXT MEETING? >> OUR NEXT COUNCIL IS IN SEPTEMBER AND I'LL LET YOU KNOW WHERE TO GO. >> WE DON'T DON'T KNOW WHERE WE'RE GOING YET? >> WE'LL BE IN THIS COMPLEX BUT DIFFERENT BUILDING.& >> >> GOT IT. THAT MAKES ONE PERSON. >> I LIKE TO THANK YOU ALL FOR YOUR COOPERATION AND PATIENCE WITH US AS WE GO THROUGH THIS PROCESS. SO THANK YOU, VERY MUCH. >> I WILL ADD THAT WE HAVE A NEW SET OF COUNCIL MEMBER THAT WILL JOIN US HOPEFULLY IF THEY GET ALL THEIR PAPERWORK DONE. FOR SEPTEMBER. UNTIL THAT GETS FINALIZED WE ARE NOT PRIVY TO REVEAL THEIR NAMES BUT THEY HAVE BEEN APPROVED THROUGH THE DEPARTMENTAL PROCESS. I WANT TO AGAIN THANK BRIAN RVERS FOR COMING AS AD HOC I GUESS FOR THIS MEETING. AND SANDRA WHO WAS AT LEAST PARTLY ON THE PHONE. AND ROSS HAMMOND, ALL GRADUATES OF THE COUNCIL. WE'LL I'M SURE SOME POINT WELCOME YOU BACK AND LOOK FOR YOU TO CONTINUE TO CONTRIBUTING TO OUR EFFORTS. THANKS, VERY MUCH AND WE'LL SEE EVERYONE IN SEPTEMBER. THE REST OF YOU IN SEPTEMBER I HOPE.