I'M CHRIS AUSTIN, DIRECTOR OF THE NATIONAL CENTER FOR ADVANCING TRANSLATIONAL SCIENCES. I HAVE THE PRIVILEGE OF BEING ONE OF THE THREE INSTITUTE CO-ORGANIZERS OF THE MEETING. WE HAVE SEVERAL HUNDRED PEOPLE WHO ARE GOING TO BE HERE IN PERSON, BUT AS OF LAST FRIDAY WE HAD 660 PEOPLE WHO WERE REGISTERED ONLINE. I WANT TO THANK OUR COLLEAGUES AT NIMHD AND NIMH FOR CO-ORGANIZING THIS EVENT. YOU'LL HEAR FROM THEM DURING THE COURSE OF THE DAY. I WANT TO PERSONALLY THANK XU XANG ON OUR STAFF, THE ONE WHO IS RUNNING AROUND IN THE PUBLIC HEALTH SERVICE UNIFORM, HE'S EASY TO PICK OUT. AND HE'S DONE A HUGE AMOUNT OF WORK TO MAKE THIS DAY POSSIBLE. IT'S A REALLY EXCITING DAY FOR US BECAUSE THOUGH IT'S NOT THE EXACT DAY, WHICH IS ACTUALLY THURSDAY, IT'S OUR FIRST OBSERVATION OF THE NATIONAL RURAL HEALTH DAY WHICH IS THE THIRD THURSDAY OF NOVEMBER. SO IT'S OFFICIALLY THE 21st OF THIS YEAR. I JUST WANT TO GIVE YOU A FEW SORT OF CONTEXTUAL POINTS FROM MY POINT OF VIEW. FIRST IS ALSO TO THANK DAWN MORALES AND PRISKA MAJORU WHO WORKED WITH XI ABOUT THIS, WE HAVE A LARGE NUMBER OF INSTITUTES WHO HELPED IN THIS, A LOT THROUGH THE RURAL HEALTH -- RURAL HEALTH INTEREST GROUP AT NIH, AND I'M NOT GOING TO SPELL OUT ALL OF THE ACRONYMS SO YOU'LL HAVE TO GO TO OUR NIH GLOSSARY TO FIND ALL OF THESE BUT IN ADDITION TO NIMH AND NIMHD, NCI, NHLBI, NIA, NICHD, NIDA, NIDCR, NIDDK, NLM WERE ALL INVOLVED -- HOW DID I DO? SO I WANT TO START OUT WITH A PERSONAL STORY, AND THIS IS MY PERSONAL STORY THAT I WAS REALLY PRIVILEGED EARLY IN MY CAREER TO WORK AT THIS PLACE, AN INDIAN HEALTH SERVICE HOSPITAL IN KOTZEBUE, ALASKA, RESPONSIBLE FOR THE CARE OF ABOUT 5,000 PEOPLE IN THE UPPER NORTHWEST QUADRANT OF ALASKA, THAT'S ABOUT 30,000 SQUARE MILES, 5,000 PEOPLE, LESS THAN THAT PROBABLY, SPREAD OVER THAT PERIOD OF TIME. AND THAT'S WHAT THE TOWN LOOKED LIKE IN WINTERTIME. THAT WAS THE HOSPITAL IN THE LOWER LEFT, BEFORE THAT I HAD COME DIRECTLY FROM TRAINING AT THE MASSACHUSETTS GENERAL HOSPITAL IN BOSTON, WHICH PROBABLY HAD MORE DOCTORS IN IT THAN THE ENTIRE CATCHMENT AREA OF THE STATE THAT I WAS WORKING IN. AND ON THE LOWER RIGHT THERE IS THE AMBULANCE SERVICE. IT'S A SLED PULLED BY A SNOW MACHINE. AND ACTUALLY MORE -- THAT WAS IF YOU WERE LOCAL, IN THE TOWN. BUT IF YOU WEREN'T, AND THIS HAPPENED VIRTUALLY EVERY DAY, WE WOULD HAVE TO TAKE A SINGLE ENGINE PLANE TO VILLAGES THAT COULD BE 150, 200 MILES AWAY. I DID THIS PERSONALLY MULTIPLE TIMES, OFTEN IN THE MIDDLE OF THE NIGHT, MINUS 20, MINUS 30-DEGREE WEATHER, WHICH I CAN TELL YOU IS NAIL-BITING INDUCING. AND IN A SERIOUS MEDICAL CONSEQUENCES HAD ENSUED, IT REQUIRED A TWO, TWO AND A HALF HOUR FLIGHT TO ANCHORAGE, WHICH I ALSO DID MULTIPLE TIMES WHILE I WAS THERE. AND IT REALLY GAVE ME AN APPRECIATION OF THE CHALLENGES THAT PEOPLE WHO LIVE IN THESE ENVIRONMENTS DEAL WITH EVERY DAY AND THEIR HEALTH, AND CHALLENGES THE HEALTH CARE WORKERS PLAY AS WELL, HAVE AS WELL. AND A FEW YEARS LATER I WAS PRIVILEGED TO HAVE A SIMILAR EXPERIENCE IN THE OTHER END OF THE WORLD, IN A RURAL PART OF SWAZILAND IN SOUTHERN AFRICA, WHICH HAD EVEN MORE CHALLENGES BECAUSE THERE WAS NO RUNNING WATER, NO ELECTRICITY OUTSIDE THE HOSPITAL. PEOPLE WHO COULDN'T WALK TO THE HOSPITAL ARRIVED BY WHEELBARROW. AND TREMENDOUSLY CHALLENGING ENVIRONMENT FOR BOTH PATIENTS AND THEIR CAREGIVERS. IT'S STARTLING NUMBERS, WHICH ALL OF US NEED TO KEEP IN MIND FOR RURAL HEALTH IN THIS COUNTRY IS THAT THE EXPERIENCES THAT I JUST MENTIONED TO YOU ARE MUCH MORE COMMON THAN WE MIGHT APPRECIATE. HERE AT THE NIH, WE'RE, WHAT, A COUPLE HUNDRED YARDS FROM THE WORLD'S BIGGEST RESEARCH HOSPITAL, LITERALLY ACROSS THE STREET FROM THE NAVY HOSPITAL, WHICH IS ANOTHER REMARKABLE AND TECHNOLOGICALLY ADVANCED INSTITUTIONED, AND ACROSS THE STREET IN THE OTHER DIRECTION IS SUBURBAN HOSPITAL, A VERY ADVANCED COMMUNITY HOSPITAL. AND SO WE'RE REALLY BLESSED HERE WITH MEDICAL CARE IN THE PROXIMITY. IT'S EASY TO FORGET THAT THESE DAYS MORE THAN 80% OF THE U.S. POPULATION FITS -- SQUEEZES INTO 3% OF THE TOTAL LAND MASS OF THE UNITED STATES, WHICH TELLS YOU THAT THE OTHER 20% OR ABOUT 60 MILLION PEOPLE OCCUPY THE OTHER 97%. YOU CAN DO THE NUMBERS IN POPULATION DENSITY THERE. RURAL AMERICANS FACE HEALTH DISPARITIES THAT ARE ROOTED IN ECONOMIC, RACIAL, GEOGRAPHIC, HEALTH WORKFORCE ISSUES. THEY EXPERIENCE HIGHER RATES OF POVERTY AND ACCESS TO HEALTH CARE. THEY ARE MORE LIKELY THAN THEIR URBAN COUNTERPARTS FROM DIE FROM HEART DISEASE, CANCER, CHRONIC LOWER RESPIRATORY DISEASE, STROKE, ADDICTION, SUICIDE, DRUG AND ALCOHOL OVERDOSE INCREASED IN THE LAST DECADE OR TWO. NCATS IS DEEPLY DEVOTED TO THIS SET OF ISSUES, AND WE'RE PARTICULARLY INTERESTED IN APPLYING OUR TRANSLATIONAL SCIENCE MODEL TO THIS PROBLEM, WHICH EMPHASIZES THINGS THAT YOU'LL HEAR ABOUT TODAY, ENGAGEMENT WITH PATIENTS, COMMUNITY MEMBERS, NON-PROFIT ORGANIZATIONS, TO DEVELOP AND DEMONSTRATE BEST PRACTICES FOR PATIENT-FOCUSED RESEARCH AND COMMUNITY-FOCUSED RESEARCH, ENABLES COLLABORATIONS WITH SCIENTISTS AT DIVERSE RESEARCH INSTITUTIONS THAT MAY BE DIFFERENT FROM ONES THAT YOU MIGHT NORMALLY THINK ABOUT. MOST OF THIS HAPPENS THROUGH OUR CLINICAL AND TRANSLATIONAL SCIENCE AWARD, CTSA PROGRAM, THAT'S RUN BY MIKE KURILLA, WHERE IS HE? SECOND ROW? OVER THERE. YOU WILL HEAR FROM HIM LATER, AS ONE OF THE FOLKS WHO IS RUNNING ONE OF THE LATER SESSIONS. AND THE REASON WE'RE SO EXCITED ABOUT THIS PROGRAM HAVING AN IMPACT ON THIS PROBLEM FOR MANY YEARS THE CTSA PROGRAM HAS REQUIRED AN INNOVATIVE COMMUNITY ENGAGEMENT COMPONENT TO EACH OF THE HUBS THAT WE FUND. SO OVER THE YEARS THEY HAVE DEVELOPED TRUSTING RELATIONSHIPS WITH COMMUNITIES OUTSIDE THE NORMAL -- MANY OF THE NORMAL URBAN SETTINGS, AND YOU'LL HEAR ABOUT THAT FROM MIKE LATER IN THE DAY. IF I CAN ENTICE YOU TO DO SO, AND YOU WANT TO HEAR MORE ABOUT WHAT NCATS IS DOING, WE JUST THREE DAYS AGO LAUNCHED A RURAL HELP WEB PAGE TO HIGHLIGHT THE RURAL HEALTH EFFORTS THAT WE HAVE AS PART OF THE CTSA PROGRAM. AND I COULD GIVE YOU THE COMPLICATE URL BUT THE EASIEST THING IS GO OUR WEBSITE AT NCATS AND TYPE IN RURAL HEALTH AND YOU'LL FIND IT. SO WE'RE EXCITED TODAY TO PUBLICIZE A LOT OF THIS WORK THAT I FIND SOMETIMES GETS SHORT SHRIFT. WE'RE AN INSTITUTION THAT LIKES TO TALK ABOUT MUTATIONS AND PROMOTER BASHING AND MOUSE MODELS AND IMPORTANT CLINICAL TRIALS SUCH AS THE ONE THAT GARY'S INSTITUTION REPORTED ON FRIDAY ABOUT STINTS AND MEDICAL CARE OF FOLKS WITH HEART DISEASE. BUT THERE'S A LOT GOING ON THAT WE'RE EXCITED TO BE ABLE TO PROMULGATE TO ALL OF YOU AND HOPEFULLY GET YOU EXCITED ABOUT JOINING. SO THE FIRST TWO TALKS ARE GOING TO BE GIVEN BY TWO OF MY COLLEAGUES, MY INSTITUTE DIRECTOR COLLEAGUES. FIRST IS ELISEO PEREZ-STABLE, DIRECTOR OF NATIONAL INSTITUTE FOR MINORITY HEALTH AND HEALTH DISPARITIES, AND THEN GARY GIBBONS, WHO IS THE DIRECTOR OF THE NATIONAL HEART, LUNG AND BLOOD INSTITUTE WILL SPEAK AFTER ELISEO. I'LL BE BACK TO INTRODUCE SHELLI AFTER THAT. >> GOOD MORNING. WE'LL GET THESE POINTS MADE REAL QUICKLY. SO, AS DIRECTOR OF NIMHD, WE FOCUS ON HEALTH DISPARITY POPULATIONS AND I WANT TO REMIND US ALL OF THE RACE ETHIC MINORITIES, POOR PEOPLE, UNDERSERVED RURAL RESIDENCE, AS WE QUALIFY THEM, SEXUAL GENDER MINORITIES, TARGET POPULATIONS, I WANT TO BRING UP THE POINT OF INTERACTIONALITY, CRITICAL FOR US TO DISCUSS AS WE PROCEED WITH THIS TOPIC, IF YOU'RE BLACK AND POOR AND LIVE IN RURAL AREAS, AND SO I THINK THIS IS AN AREA THAT HAS NOT BEEN WELL STUDIED. I'VE SHOWN THIS CHART MANY TIMES, INCOME PREDICTED MORTALITY, IT'S A CRITICAL PREDICTOR OF LIFE EXPECTANCY. IF YOU'RE POOR, UNDER $25,000, HOUSEHOLD INCOME, FAMILY OF FOUR, THREE TIMES MORE LIKELY TO DIE FROM ANY CONDITION COMPARED TO HOUSEHOLD WITH INCOME OF $115,000. WE HAVE A RESEARCH FRAMEWORK THAT WE HAVE DEVELOPED, OUR STAFF WORKED ON THIS IN MY FIRST YEAR HERE AS DIRECTOR. IT'S PUBLISHED. IT'S ON OUR WEBSITE. IT'S REALLY TO EMPHASIZE DIFFERENT COMPONENTS OF BIOLOGICAL BEHAVIORAL, THE BUILT ENVIRONMENT, SOCIAL AND CULTURAL ENVIRONMENT, HOW THEY INTERACT ALONG INDIVIDUAL INTERPERSONAL AND COMMUNITY AND SOCIETAL LEVELS AND HOW THIS DETERMINES HEALTH OUTCOMES. ANY OF THIS RESEARCH THAT WE'RE THINKING ABOUT IN MINORITY HEALTH AND HEALTH DISPARITIES WE TRY TO MAP TO OUR FRAMEWORK TO SEE WHAT PART THE INVESTIGATIONS ARE FOCUSING ON. IN TERMS OF PLACE, SINCE PLEURALITY BEGINS WITH PLACE, WORK PUBLISHED A FEW YEARS AGO SHOWS THE RELATIONSHIP OF INCOME TO LIFE EXPECTANCE BUT THEY REPORTED THAT THE BOTTOM QUINTILE INCOME IN SOME AREAS LIVED THREE TO FOUR AND A HALF YEARS LONGER THAN OTHER AREAS, AND SO WHAT ARE THESE COMMUNITIES AND AREAS DOING RIGHT THAT MOST VULNERABLE WERE DOING BETTER IN THOSE AREAS? IDENTIFYING THESE COMMUNITY COHESION OR RESILIENCE PROMOTES BETTER HEALTH IS AN IMPORTANT RESEARCH QUESTION WE HAVE TO ADDRESS. RURAL RESIDENTS IN GENERAL COMPARED WITH METROPOLITAN AREAS HAVE HIGHER DEATH RATES FOR FIVE LEADING CAUSES OF DEATH, MENTIONED BY CHRIS, RURAL POPULATIONS IN GENERAL ARE OLDER THAN METROPOLITAN POPULATION, 51 VERSUS 45 YEARS OF AGE, HAVE FEWER YEARS OF FORMAL EDUCATION. LIFE EXPECTANCY DIFFERENCE IS ABOUT 2 1/2 YEARS, AS YOU SEE THERE, ON AVERAGE. THIS WILL VARY OF COURSE BY OTHER FACTORS, AND THERE ARE GENERALLY FEWER PHYSICIANS AND HOSPITALS IN RURAL AREAS. THIS IS AN ILLUSTRATION OF INCOME BY GENDER AND RURAL RESIDENCE. URBAN MAN HAVE THE HIGHEST, FOLLOWED BY RURAL MEN, GENDER GAP TRUMPS RURALITY, URBAN WOMEN MAKE MORE THAN RURAL WOMEN BUT WELL BELOW RURAL MEN, BY AGE, AND THIS IS IN I THINK 2015. THIS IS DISTRIBUTION OF METROPOLITAN TO RURAL AREAS, AND WHEN WE THINK ABOUT RURALITY, WE'RE MOSTLY LOOKING OFTEN IN THIS PART OF THE COUNTRY WE THINK ABOUT APPALACHIA BECAUSE OF PROXIMITY TO WASHINGTON, D.C. BUT THE WESTERN PART OF THE UNITED STATES ILLUSTRATED BY DR. AUSTIN IN ALASKA AS WELL ARE QUITE RURAL, AND IN THE SOUTH THERE ARE SIGNIFICANT AREAS OF RURAL AREAS AS WELL, RURAL COUNTIES. SO WE THINK ABOUT 18% OF THE POPULATION, ABOUT 60 MILLION-PLUS PEOPLE, 65% OF COUNTIES, 445 OF THESE COUNTIES ARE CONSIDERED FRONTIER COUNTIES, THEY ARE VERY SPARSELY POPULATED. NOW, THERE IS AN IMPORTANT TO POINT OUT DISTRIBUTION OF RACE/ETHNICITY VARIES. FOCUSED ON APPALACHIA AREA, PRIMARILY WHITE, 90% OF WEST VIRGINIA, KENTUCKY, BUT AFRICAN-AMERICANS LIVE IN THE RURAL SOUTH, INCREASINGLY MEXICAN AMERICANS IMMIGRATED TO THE SOUTHEAST. MIDWEST AND SOUTH ARE WHITE. AMERICAN INDIANS, ALASKA NATIVES IN THE WEST AND MIDWEST, ASIAN AND PACIFIC ISLANDERS IN THE WEST. LESS COLORECTAL SCREENING IN THIS REPORT FROM THE CDC IN 2017, YOU CAN MAKE HEALTH EQUITY HAPPEN IN CERTAIN CONDITIONS. WE SEE MORE BINGE DRINKING WITH WHITES, CURRENT SMOKING AAMERICAN AMERICAN INDIAN AND ALASKA NATIVE, PHYSICAL ACTIVITY HIGHEST AMONG BLACKS AND LATINOS IN RURAL AREAS. BMI OVER 30, ALMOST HALF OF THE AFRICAN-AMERICAN POPULATION, A THIRD OF LATINO, 40% OF AMERICAN INDIAN, A THIRD OF WHITES IN RURAL AREAS OF BMI OVER 30. WHEN WE LOOK AT MORTALITY BY RACE, YOU SEE A GRADING FOR ALL RACE, PLATEAUS IN THE URBAN NON-METRO TO RURAL NON-MERIT, EXCEPT FOR IN THE AMERICAN INDIAN POPULATION WHERE YOU SEE THIS FAIRLY DRAMATIC INCREASE IN MORTALITY FOR THE MOST RURAL AREAS. AND I WOULD EMPHASIZE THAT'S WHERE THE GREATEST DISPARITY IS, IN TERMS OF PLACE OF RESIDENCE. WE ALSO SEE IT SORT OF GENERAL GRADIENT AMONG WHITES AND AFRICAN-AMERICANS, IT KIND OF LEVELS OUT OVER THE END. VERY LITTLE GRADIENT IN ASIAN, PACIFIC ISLANDERS, OR IN LATINO HISPANICS. THIS IS ONE EXAMPLE WHERE WE SEE A BIG GAP, CHRONIC OBSTRUCTIVE PULMONARY DISEASE, TWICE AS MUCH IN RURAL AREAS, MORE HOSPITALIZATIONS, HIGHER DEATH RATES BY FACTOR OF ALMOST DOUBLE IN RURAL COUNTIES. IT'S BEEN MENTIONED ABOUT THE OVERDOSE EPIDEMIC, AGAIN FOCUSED PRIMARILY IN THIS HOT AREA HERE IN THE EAST, WHERE APPALACHIA AREA, BUT NOTICE NEW MEXICO AND ARIZONA, AND NEVADA ARE ALSO QUITE DARK RED. THIS IS PRIMARILY DRIVEN BY A LOT OF AMERICAN INDIAN POPULATIONS IN THESE AREAS AND SO THE OVERDOSE EPIDEMIC AS OF 2016 ILLUSTRATED IN THAT MAP. WE KNOW RURAL AREAS HAVE HIGHER RATES. THEY WERE ACTUALLY LOWER 20 YEARS AGO, AND THEY CROSSED AROUND 2005, AND BY 2015 THEY WERE HIGHER. THE DIFFERENCES ARE NOT THAT DRAMATIC. MORTALITY RATES INCREASED THROUGHOUT THE COUNTRY, AND ACROSS LOW AND HIGH SOCIOECONOMIC POPULATIONS, 25 TO 64-YEAR-OLD AGE RANGE YOU SEE BIGGER IMPACT. DRUG POISONING MORTALITY INCREASED IN LOWEST AND RURAL COUNTIES, 3/4 OF DEATHS IN METRO AREAS, DISPROPORTIONATELY AFFECTING RURAL COMMUNITIES BUT MAJORITY OF DEATHS IN METROPOLITAN AREAS. IN STUDY THAT WAS PUBLISHED FROM NCI INTRAMURAL PROGRAM, THERE'S A LARGE SOCIOECONOMIC GRADIENT OBSERVED FOR WHITES, USING COUNTY LEVEL METRICS OF EMPLOYMENT INCOME AND EDUCATION BUT FOR AFRICAN-AMERICANS, LATINOS, THIS GRADIENT WAS NOT EVIDENT. IN FACT FOR AFRICAN-AMERICANS NUMBER ONE CAUSE OF OVERDOSE DEATHS ARE FROM COCAINE, AND NOT FROM OPIOIDS. ANOTHER EXAMPLE IS SUICIDE RATES BY RURALITY IN RACE/ETHNICITY, AMONG WHITES INCREASE IN RURAL AREAS OF SUICIDE. THERE'S NOT A CHANGE AMONG AFRICAN-AMERICANS BY RURAL AREA, OR ASIAN/PACIFIC ISLANDERS, YOU SEE INCREASE, NOT AS DRAMATIC, SIMILARLY FOR LATINOS, BUT FOR AMERICAN INDIANS AND ALASKA NATIVE IT'S DRAMATIC. STRUCTURAL DETERMINANTS, TRANSPORTATION LIMITED, EXTREME IN SOME AREAS, ONLY MODE OF TRANSPORTATION IS BY AIR TRANSPORTATION. BROADBAND ACCESS, MOBILE PHONE SERVICE IS LIMITED OR VARIABLE, OR ABSENT IN MANY OF THE MOST RURAL AREAS, AND I THINK THIS IS SOMETHING WE'VE BECOME HIGHLY DEPENDENT ON FOCUSING HEALTH PROMOTION AND CARE, HOW MUCH CAN A HOSPITAL CAN 10 OR 15 BEDS DO NO MATTER HOW GREAT THE DOCTORS ARE? THERE'S A LIMITED AMOUNT OF INTERVENTION, SO OFTEN THE OPTION IS TO HELICOPTER OR FLY THE SICK PATIENT OUT. ACCESS TO PREVENTIVE CARE MAY BE LIMITED. THERE'S THE ISSUE OF STIGMA IN SMALL COMMUNITY. EVERYONE KNOWS EVERYONE. IF YOU'RE SICK OR HAVE AN ISSUE RELATED TO BEHAVIORAL HEALTH, WHETHER PSYCHIATRIC OR SUBSTANCE USE, THEN EVERYONE WILL BE AWARE OF IT AND KNOWLEDGE, SO I THINK THIS IS A FACTOR THAT WE TEND TO NOT EMPHASIZE OR THINK ABOUT AS MUCH IN THE URBAN ENVIRONMENT. AND THEN BUILD ON SOME POTENTIAL POSITIVE FEATURES, GENERALLY LESS AIR POLLUTION, IT WASN'T ACTUALLY THAT LONG AGO THAT POPULATION LIVING IN RURAL AREAS HAD BETTER HEALTH THAN THOSE LIVING IN URBAN AREAS. SO SOMETHING CHANGED DRAMATICALLY IN THE LAST 50 YEARS IN THIS COUNTRY. AND THEN ACCESS TO HEALTHY FOOD. WE OUTLINED SOME STRATEGIES IN OUR AMERICAN GENERAL PUBLIC HEALTH ISSUE PUBLISHED IN JANUARY OF THIS YEAR, AND THANK YOU FOR YOUR ATTENTION. WE APPRECIATE THIS OPPORTUNITY TO SHARE IN THIS IMPORTANT AREA OF PRIORITY FOR NHLBI AS WELL AS NIH. THIS RURAL HEALTH ISSUE REALLY COMES TO THE CORE OF OUR MISSION. OUR MISSION IS TO TURN DISCOVERY SCIENCE INTO ENHANCING HEALTH, HUMAN HEALTH, FOR ALL COMMUNITIES IN OUR NATION. AND EMPHASIS IS ON "ALL COMMUNITIES." AS ACCOUNTABLE STEWARDS, AS PUBLIC SERVANTS, IT'S CRITICAL TO APPRECIATE THAT OUR MISSION IS NOT COMPLETE UNTIL IN FACT WE HAVE AN IMPACT ON ALL COMMUNITIES. AND WE'RE DRIVEN, NHLBI, BY THESE ENDURING PRINCIPLES OF OUR FOCUS ON VALUING INVESTIGATOR-INITIATED DISCOVERY SCIENCE THAT ENHANCES THAT MISSION, HAVING A BALANCED PORTFOLIO THAT SPANS THE SPECTRUM OF BASIC, TRANSLATIONAL, CLINICAL, POPULATION, AND IMPLEMENTATION SCIENCE, AND TRAINING THE NEXT GENERATION TO ADVANCE OUR MISSION. AND PARTICULARLY RELEVANT TO THE TOPIC OF TODAY, TWO ELEMENTS OF THOSE PRINCIPLES THAT I'M PARTICULARLY PASSIONATE ABOUT IS SUPPORTING IMPLEMENTATION SCIENCE THAT EMPOWERS PATIENTS AND ENABLES PARTNERS TO IMPROVE HEALTH OF THEIR COMMUNITIES AND OUR NATION AS WELL AS TO INNOVATE EVIDENCE-BASED ELIMINATION OF HEALTH INEQUITIES IN OUR COUNTRY AND AROUND THE WORLD. AND SO IT'S REALLY IN THAT SPIRIT THAT WE ARE TRYING TO ADDRESS THOSE COMMUNITIES THAT QUITE FRANKLY HAVEN'T BORNE ALL THE FRUITS OF OUR DISCOVERY SCIENCE. WE AT NHLBI ARE PROUD OF OUR LEGACY AFTER 70 YEARS OF THE 70% DECLINE IN CORONARY HEART DISEASE MORTALITY RATES THAT HAVE OCCURRED OVER THE LAST 50 YEARS. BUT WE ALSO APPRECIATE THAT NOT ALL COMMUNITIES HAVE BENEFITED FROM THAT DISCOVERY SCIENCE. AND IN FACT AS SHOWN ON THIS MAP, THERE'S STILL REGIONS THAT ARE EXHIBITING VERY HIGH RATES OF CARDIOVASCULAR MORBIDITY AND MORTALITY, NOTABLE THE RED SPOTS ARE RECURRING THEME THROUGHOUT THIS MORNING, I SUSPECT, IN AMERICA'S HEARTLAND, AS WE CALL IT, FOLLOWING THE OHIO RIVER VALLEY, KENTUCKY, MISSISSIPPI RIVER VALLEY, SOUTHEAST WHERE THERE ARE CLEARLY HOT SPOTS OF CARDIOVASCULAR DISEASE. AND MORE AS WE LOOK AT THESE MAPS, WE RECOGNIZE THE OVERLAPPING NATURE OF MANY OF THE RISK FACTORS FOR CARDIOVASCULAR DISEASE, TOBACCO SMOKING, OBESITY, DIABETES, AND IN FACT WE LOOK AT OTHER DISEASE ENTITIES LIKE LUNG DISEASE, IT FOLLOWS THESE SAME SORT OF PATTERNS, AND INDEED ELISEO AND CHRIS MENTIONED THE OPIOID CRISIS AND OTHER ELEMENTS FOLLOWS THESE SAME -- THE SAME PICTURE OF GEOGRAPHIC DISPARITIES SUGGESTING CLEARLY SOCIAL, ECOLOGICAL AND ENVIRONMENTAL DETERMINANTS. THIS ISN'T RELATED TO GENETIC PREDISPOSITIONS, PER SE. WE KNOW THIS IS A MANIFESTATION OF THE IMPACT OF THE SOCIAL DETERMINANTS OF HEALTH, AND CLEARLY THAT MUST BE A CRITICAL PART OF OUR RESEARCH AGENDA, REALLY FOCUSING ON HIGH RISK COMMUNITIES. INDEED A KEY PART OF OUR STRATEGY HAS BEEN TO ENGAGE THESE COMMUNITIES. PART OF THIS WAS THROUGH COPD ACTION PLAN, TONY HAS BEEN A KEY LIFE RECOGNIZING CHRONIC LUNG DISEASE IS AGAIN PARTICULARLY PROBLEMATIC IN RURAL AMERICA, AND AS WE ENGAGED THESE COMMUNITIES THEY HAVE GIVEN US THIS FEEDBACK, INDEED CAPTURED IN THIS GRAPHIC AS PART OF THAT DIALOGUE WE'VE HAD WITH COMMUNITIES, AND WHICH A KEY PART OF IT IS EMPOWERMENT, LISTENING TO THE COMMUNITY. ASCERTAINING THE WISDOM THAT THEY HAVE ABOUT THEIR LOCAL CONTEXT, AND APPRECIATING HETEROGENEITY AS WE GO ACROSS THE COUNTRY AND HOW THEY MUST BE EVENTUALLY DRIVERS OF THEIR LOCAL SOLUTIONS IN THEIR OWN CONTEXTUAL WAY. A KEY PART OF THAT IS TO, AGAIN, RECOGNIZE THESE PATTERNS, IN THE CASE OF COPD, THAT FOLLOWS THAT SAME HEARTLAND AND RURAL AREA OF FOCUS IS TO RESPOND. AND WE'VE TRIED TO DO THAT IN A NUMBER OF WAYS WITH OUR RESEARCH AGENDA AND PORTFOLIO, MOST RECENTLY TRIED TO TURN THE CURVE HERE WE'VE LAUNCHED A PROGRAM OF SOLICITING EVIDENCE-BASED STRATEGIES TO REALLY DRIVE THE GOAL OF HEALTH EQUITY IN THIS AREA, DECIPHER PROGRAM, IN WHICH WE'RE ENCOURAGING THE COMMUNITY TO COME UP WITH MULTI-LEVEL INTERVENTIONS THAT ARE COMMUNITY-BASED, COMMUNITY ENGAGED, AND CONTEXTUAL IN BOTH RURAL AND URBAN ENVIRONMENTS% WHERE AGAIN WE EMPOWER THE LOCAL INDIVIDUALS TO WORK WITH OUR INVESTIGATORS TO DEVELOP THE BEST STRATEGIES THAT WORK WITHIN THAT LOCAL CONTEXT, BOTH BY RACE/ETHNICITY AS WELL AS GEOGRAPHY, AND WE'RE LOOKING FORWARD TO ADVANCING STRATEGIES IN THE RURAL CONTEXT. ALTHOUGH WE'RE PROUD OF THAT REDUCTION IN CORONARY HEART DISEASE EVENTS, WE RECOGNIZE THERE ARE CERTAIN COMMUNITIES LAGGING BEHIND. THE DARK BLUE IN THIS ONE ARE THOSE THAT HAVE A GREAT DOWNWARD TRAJECTORY. BUT WE ALSO HAVE SEEN THOSE DECLINES ARE STARTING TO LEVEL OFF, PARTICULARLY AS YOU CAN SEE AGAIN IN AMERICA'S HEARTLAND. AND IN FACT THERE'S CERTAIN SUBGROUPS GOING IN THE WRONG DIRECTION. THIS RECENT STUDY JUST FOUND THAT FOR AMERICAN INDIANS AND NATIVE ALASKANS THE RATE FOR CARDIOVASCULAR DISEASE IS RISING, A CLARION CALL WE NEED TO DO MORE FOR SOME OF THESE POPULATIONS. ALSO NOTABLE THAT THERE'S DISTURBING TRENDS AMONGST WHITE WOMEN, IN PARTICULAR IN COUNTIES THAT TEND TO BE RURAL, LOW SES, WITH DIABETES AND TOBACCO SMOKING. SO INDEED BY TRACKING THESE WE CLEARLY APPRECIATE DISPARITIES THAT EXIST. ELISEO TALKED ABOUT THE CONVERGENCE OR CONFLUENCE OF FACTORS AND HOW THIS HAS PARTICULARLY DRAMATIC IMPACT ON CERTAIN POPULATION GROUPS, AND PERHAPS MOST NOTABLE AT LEAST FOR ME, THE NATIVE AMERICAN POPULATION IN THIS COUNTRY, IN WHICH THEIR RESERVATIONS ARE OFTEN IN RURAL CONTEXTS. AND WHERE THERE IS ALSO A LOT OF SOCIAL DEPRIVATION, AND INDEED ALMOST EVERY ONE OF THOSE INDICES OF HEALTH GOING FROM OBESITY AND DIABETES AND CORONARY DISEASE AND OPIOID ADDICTION PROBLEMS IS MAGNIFIED IN THAT CONTEXT. FOR THE LAST 30 YEARS THE NHLBI HAS BEEN DOING A STRONG HEART STUDY BASED IN -- INVOLVING 13, NOW 12 TRIBAL NATIONS IN THE NORTH, SOUTH DAKOTAS, OKLAHOMA REGION, ARIZONA. AND INDEED IT'S TAUGHT US A LOT ABOUT THE PARTICULAR CHALLENGES THAT THESE TRIBAL NATION COMMUNITIES FACE, AND IT PROVIDES HOPEFULLY A PLATFORM AND AN OPPORTUNITY TO START GOING BEYOND THE DESCRIPTION OF THE DISPARITIES AND DESCRIPTION OF THE CHALLENGES IN RURAL AMERICA, BUT ACTUALLY TRYING TO DEVELOP INTERVENTIONS AND STRATEGIES THAT WILL TURN THAT CURVE. SO I THINK WE HAD THAT OPPORTUNITY TO PIVOT FROM JUST DISCOVERY TO ENSURE WE HAVE PUBLIC HEALTH IMPACT. AS WE LOOK FOR THOSE STRATEGIES, ONE OF THE THINGS THAT HAS BEEN A RECURRING THEME OF THIS SOCIAL ECOLOGICAL FRAME AND SOCIAL DETERMINANTS OF HEALTH IS TO APPRECIATE HOW MUCH PLACE DOES MATTER, AND INDEED IN THIS CASE A MAP OF ACCESS TO GROCERY STORES AND FRESH FRUITS AND VEGETABLES, WHERE THERE IS ALMOST THIS PARADOX, AS SOMEONE WHO IS A CITY KID, THAT SOMEHOW IN AMERICA'S BREADBASKET, IF YOU WILL, IN THE HEARTLAND YOU HAVE SITUATIONS OF FOOD DESERTS, IN WHICH PARTICULARLY IF YOU HAVE -- DON'T OWN A CAR AND DON'T HAVE READY ACCESS TO TRANSPORTATION, AND YOUR TENS TO TWENTY MILES AWAY FROM ACCESS TO THESE THINGS THAT YOU INDEED ARE PREDISPOSED TO A DIET THAT MAY ENHANCE THE LIKELIHOOD OF DIABETES AND HEART DISEASE, AND MOREOVER WE'RE LEARNING FROM OUR DISCOVERY SCIENCE THAT THE ACCESS TO FRUITS AND VEGETABLES IS POTENTIALLY CHALLENGING IN TERMS OF SUSTAINING HEALTH. WE KNOW THERE ARE PARTICULAR CHEMICALS WITHIN FRUITS AND VEGETABLES THAT ACTUALLY FEED OUR GUT MICROBE BIOME, AND THAT INDEED MODULATES OUR WHOLE METABOLOME, OUR WHOLE BODY METABOLISM THAT MIGHT PREDISPOSE TO OBESITY, DIABETES, AND VASCULAR DISEAS. SO WE'RE APPRECIATING EVEN AT A MOLECULAR LEVEL HOW MUCH DIET AFFECTS OUR EPIGENOME, MICROBIOME, METABOLOME, IN WAYS THAT INFLUENCES OUR IMMUNE SYSTEM AND PREDISOSITION TO DISEASE. WHEN WE SEE THESE CONFLUENCE OF PATTERNS OF DISEASES BY GEOGRAPHY, AND PLACE, WE ACTUALLY ARE STARTING TO ELUCIDATE THE MOLECULAR BASIS OF IT AS WELL. THIS, AGAIN, IS -- PROMOTES A CALL TO ACTION, IN WHICH WE HAVE I -- I THINK WE'RE INSPIRED TO FOLLOW SUTTON'S LAW, AND THERE ARE MANY OF YOU WHO DON'T KNOW PERHAPS SUTTON'S LAW. IT'S NOT BY A PHYSICIST OR A MATHEMATICIAN. IT'S NAMED AFTER NOTORIOUS BANK ROBBER WILLIE SUTTON, WHEN WILLIE SUTTON WAS ASKED WHY HE ROBBED BANKS, HE SAID IT'S BECAUSE THAT'S WHERE THE MONEY IS. INDEED WE HAVE TO GET TO THE ROOT OF THE PROBLEM HERE. WE HAVE TO GO AND STUDY NOT ON THE COASTS WHERE OUR TOP TEN ACADEMIC INSTITUTIONS ON BUT WHERE THE PROBLEM AND CHALLENGES ARE, TO ENGAGE AND EMPOWER THOSE COMMUNITIES TOWARD THEIR OWN SOLUTIONS. AND IT'S IN THAT SPIRIT THAT WE'VE LAUNCHED A COUPLE OF NEW COHORTS, THE INSTITUTE HADN'T DONE A COMMUNITY-BASED COHORT IN ABOUT 20 YEARS. ALTHOUGH WE STILL HAVE FRAMINGHAM IN MASSACHUSETTS, WE THOUGHT IT WAS IMPORTANT TO HAVE AN ELEMENT SIMILAR OF A LONGITUDINAL COHORT FOCUSED IN ON RURAL AMERICA. AND PARTICULARLY IN THIS CASE THE COHORT WILL BE IN ALABAMA, KENTUCKY, LOUISIANA, AND MISSISSIPPI, FOLLOWING THAT OHIO RIVER/MISSISSIPPI DELTA AREA WHERE WE SEE THE HIGHEST BURDEN. AND WE'RE HOPING THAT THAT BECOMES A PLATFORM NOT ONLY TO FURTHER UNDERSTAND BUT ALSO TO ENGAGE THESE COMMUNITIES IN WAYS WHICH WE CAN PROMOTE EVIDENCE-BASED SOLUTIONS THAT TURN THE CURVE AND HAVE AN IMPACT. WE ALSO BELIEVE THAT THIS IS AN OPPORTUNITY AND CALL TO ACTION IN TRANS-NIH WAY WHERE WE'RE DOING BETTER AT ASSESSING OUR ABILITY TO MOVE THESE NEEDLES, BY UNDERSTANDING IN A DEEPER WAY HETEROGENEITY THAT'S ALREADY BEEN DESCRIBED. ONE RURAL COMMUNITY IS NOT A ONE-SIZE-FITS-ALL SOLUTION. SO APPRECIATING THE VARIOUS ELEMENTS OF BOTH DATA COLLECTION, MONITORING, AND INTERVENTION, HERE'S AN OPPORTUNITY FOR PERSONAL SENSE OF TECHNOLOGY, MOBILE HEALTH, E-HEALTH, CAN WE CREATE MECHANISMS OF DATA CHECK AND INNERVATION THAT'S DRIVEN, CAN WE INTEGRATE ANSWERS IN IMPLEMENTATION SCIENCE BUT DATA SCIENCE, IN NOVEL WAYS. THIS IS I THINK A RESEARCH OPPORTUNITY TO ADDRESS SOCIAL DETERMINANTS AND EMPOWER PEOPLE, BEHAVIORS, AND COMMUNITIES TO, AGAIN, IMPROVE OUTCOMES. SO TO CONCLUDE, WHAT WE ARE INDEED HOPEFUL FOR IS THAT WE CAN JOIN WITH OTHER INSTITUTES AND OTHER PARTNERS, PART OF THE ECOSYSTEM. THESE CHALLENGING COMPLEX PROBLEMS MUST BE ADDRESSED IN MULTI-LEVEL WAY. AND NIH ALONE CAN'T SOLVE THEM. BUT I BELIEVE THAT WE CAN CREATE THE EVIDENCE BASE TOWARD THE ELIMINATION OF HEALTH INEQUITIES IN COLLABORATIVE PARTNERSHIP, AND LOOK FORWARD TO WORKING WITH EVERYONE HERE TOWARD THAT END. SHELLI AVENEVOLI IS GOING TO DO THE NEXT INTRODUCTION, IF SHELLI COULD COME UP. I WANT TO ACKNOWLEDGE THAT NIMH IS HEAVILY INVEST IN REDUCING MENTAL HEALTH DISPARITIES IN RURAL AREAS, I WANT TO ACKNOWLEDGE MY COLLEAGUES DON MORALES AND ANDREA BECKEL-MITCHENER FOR CONTRIBUTING TO THE NIMH COMPONENT OF THIS SYMPOSIUM. THANK YOU. AND REALLY I'M PLEASED TO BE HERE TODAY BECAUSE I GET THE PRIVILEGE OF INTRODUCING OUR INVITED SPEAKER, DR. GENE BRODY. DR. BRODY IS REGENTS PROFESSOR OF CHILD AND FAMILY DEVELOPMENT, FOUNDER AND DIRECTOR FOR CENTER FOR FAMILY RESEARCH, AT THE UNIVERSITY OF GEORGIA. SINCE 2003 HE HAS SERVED AS PRIMARY INVESTIGATOR, DIRECTOR OF UNIVERSITY OF GEORGIA CENTER FOR TRANSLATIONAL AND PREVENTION SCIENCE. HIS TALK WILL FOCUS ON RESILIENCE AND EARLY ORIGINS OF DISEASE AMONG RURAL AFRICAN-AMERICANS. I'VE BEEN A FAN OF DR. BRODY'S FOR A NUMBER OF YEARS AND I'M EXCITED AND PRIVILEGED FOR US ALL TO SHARE IN THE NEXT HOUR WHEN WE HAVE THE OPPORTUNITY TO HEAR HIM TALK ABOUT HIS RIGOROUS MULTI-LEVEL AND TRANSDISCIPLINARY APPROACH TO UNDERSTANDING AND IMPROVING HEALTH AMONG RURAL RESIDENTS, LARGE SCALE AND SYSTEMATIC RESEARCH PROGRAM INCLUDES COLLECTION AND ASSAY OF BIOSPECIMENS FOR MORE THAN 3,000 AFRICAN-AMERICAN PARTICIPANTS, BUT WHAT'S REALLY EXCITING IS THAT HE INTEGRATES THAT WITH NEUROCOGNITIVE DEVELOPMENTAL AND CULTURAL ASSESSMENTS AS WELL, HAS A STRONG EMPHASIS ON OUR YOUTH AND IDENTIFYING MECHANISMS OF ACTION OF EFFICACIOUS INTERVENTIONS. AND THIS IS CRITICALLY IMPORTANT BECAUSE IT NOT ONLY FURTHERS OUR EVIDENCE BASE, OUR KNOWLEDGE, BUT ALSO PROMISES TO FACILITATE THE DEPLOYMENT OF EFFECTIVE INTERVENTIONS AND INFORM AND SHAPE POLICY. TODAY'S SYMPOSIUM IS REALLY A RECOGNITION OF WHAT'S NEEDED IN OUR COMMUNITIES TO MOVE OUR KNOWLEDGE BASE INTO COMMUNITIES AND IMPLEMENT THEM AS QUICKLY AS POSSIBLE. SO WITHOUT FURTHER HESITATION, PLEASE WELCOME AND JOIN ME IN WELCOMING DR. BRODY. [APPLAUSE] >> GOOD MORNING. >> GOOD MORNING. >> IT'S A GREAT HONOR FOR ME TO BE HERE AND SHARE OUR RESEARCH AT THE CENTER FOR FAMILY RESEARCH AT THE UNIVERSITY OF GEORGIA. I WANT TO GIVE A SHOUT OUT TO NIH ON BEHALF OF THE 60 MILLION RURAL AMERICANS WHO LIVE IN PLACES THAT ARE OFTEN CHALLENGING, AS YOU'VE HEARD. AND WE DO NEED SCIENCE-BASED SOLUTIONS TO HELP THIS POPULATION OUT. I ALSO WANT TO GIVE A SHOUT OUT AND RECOGNIZE SCIENTISTS AROUND THE NATION WORKING IN RURAL PLACES FROM THE FRONTIERS OF ALASKA TO THE DESERT SOUTHWEST, TO APPALACHIA, TO SMALL COMMUNITIES IN THE MIDWEST AND THE NORTHEAST, AND PLACES I HAVEN'T MENTIONED. THESE SCIENTISTS DO AMAZING WORK IN VERY CHALLENGING CONDITIONS, AND OFTEN WITH LITTLE RESOURCES. SO THE ORIGIN OF MY TALK TODAY AND DURING MY TALK I'LL WANDER AROUND A LITTLE BIT, BEGAN WHEN I DID A STINT AS A RESEARCH ADMINISTRATOR, AND PART OF MY PORTFOLIO WAS TO GO AROUND THE STATE AND ORGANIZE FOCUS GROUPS OF STAKEHOLDERS AND DIFFERENT COMMUNITIES AROUND GEORGIA, AND I ORGANIZED A HE CAN TO US GROUP FOCUS GROUP WITH ADMINISTRATORS AND SMALL BUSINESSMEN IN RURAL GEORGIA, NEAR SAINT SIMON'S ISLAND, BRUNSWICK, SOUTHEASTERN PART OF THE STATE. WE GOT TO TALKING, THEN POLITELY ONE OF THE MEMBERS OF THIS FOCUS GROUP SAID TO ME, WHEN YOU'RE AND I SAID, WELL, I'M A CHILD PSYCHOLOGIST, I DEVELOP TREATMENTS FOR KIDS WHO ARE HAVING EMOTIONAL AND BEHAVIORAL PROBLEMS, AND THEN ANOTHER ONE OF THE BUSINESSMEN SAID TO ME, WHAT DO YOU KNOW ABOUT OUR FAMILIES? MEANING, RURAL AFRICAN-AMERICAN FAMILIES. SO I WENT THROUGH THE ROLODEX IN MY MIND, AND I DIDN'T KNOW VERY MUCH. I SAID I WOULD FIND OUT, I WOULD GET BACK TO THEM, AND WHAT I FOUND OUT WASN'T VERY PROMISING, THERE WASN'T REALLY GOOD SCIENCE, AND THE SCIENCE THAT WAS THERE OPERATED FROM A DEFICIT MODEL. SO, IT IS CLEAR TO ME THAT AFRICAN-AMERICAN CHILDREN AND FAMILIES LIVING IN SOUTHERN RURAL PLACES WERE FORGOTTEN. THEY WERE FORGOTTEN BY THEIR COMMUNITIES. THEY ARE FORGOTTEN BY SCHOOL SYSTEMS. AND THEY WERE INVISIBLE IN PUBLIC HEALTH RESEARCH. SO, IT WAS AGAINST THIS BACKDROP, 20, 25 YEARS AGO, SCIENTIST SCIENTISTS AT THE CENTER FOR FAMILY RESEARCH BEGAN SYSTEMATIC STUDIES OF NORMAL DEVELOPMENTAL TRAJECTORIES OF AFRICAN-AMERICAN CHILDREN LIVING IN RURAL PLACES, PREDOMINANTLY WITHIN 40 COUNTIES IN GEORGIA. THIS RESEARCH ALONG WITH COLLABORATION WITH FOCUS GROUPS OF RURAL AFRICAN-AMERICANS ACROSS THE STATE OF GEORGIA RESULTED IN THE DESIGN OF PREVENTIVE INTERVENTIONS WHICH HAVE PROVEN TO BE EFFICACIOUS AND HAVE BEEN, AND NOW ARE BEING EMBEDDED AROUND THE NATION. THIS MORNING, I'M GOING TO DESCRIBE A RECENT EXPANSION OF THIS RESEARCH PROGRAM, THE TEST HYPOTHESES ABOUT ORIGINS AND PREVENTIONS FOR THE CHRONIC DISEASES OF AGING AMONG AFRICAN-AMERICAN YOUTH. LET'S SEE. OOPS. THERE WE GO. POVERTY AND ECONOMIC DISTRESS ARE PERVASIVE FEATURES OF THE 623 COUNTIES KNOWN AS THE BLACK BELT THAT STRETCHED FROM NORTH CAROLINA, SOUTH CAROLINA, GEORGIA, ALABAMA, MISSISSIPPI, AND LOUISIANA. 35% OF THE NATION'S POOR RESIDE HERE, AND UPWARDS OF 60% OF AFRICAN-AMERICAN CHILDREN AND ADOLESCENTS LIVE AT OR BELOW THE POVERTY LINE IN THESE PLACES. TYPICALLY, THESE PLACES SUFFER FROM CHRONIC ECONOMIC DISTRESS. THEY HAVE FEW PHYSICIANS, AND MENTAL HEALTH PROFESSIONALS. SCHOOLS ARE USUALLY POOR, NO PUBLIC TRANSPORTATION SYSTEMS, FEW RECREATION FACILITIES, AND FEW PREVENTION PROGRAMS. IT'S NOT SURPRISING THAT AFRICAN-AMERICAN CHILDREN IN THE RURAL SOUTH HAVE SOME OF THE SHORTEST LIFE EXPECTANCIES IN THE NATION. AND THEY ARE MORE LIKELY TO DIE EARLIER OF THE CHRONIC DISEASES OF AGING INCLUDING HEART DISEASE, DIABETES, STROKE, AND SOME CANCERS. IT'S AGAINST THIS BACK DROP THAT THIS MORNING'S TALK WILL FOCUS ON THREE TOPICS. FIRST THE WEATHERING HYPOTHESIS, THE IDEA THAT HEALTH DISPARITIES INCUBATE INVISIBLY IN THE BODIES AND BRAINS OF AFRICAN-AMERICAN ADOLESCENTS AND YOUNG ADULTS. SECOND I'LL TALK ABOUT SKIN-DEEP RESILIENCE, HIDDEN COST OF UPWARD MOBILITY AMONG RURAL AFRICAN-AMERICANS. AND FINALLY, I WANT TO END ON A LITTLE MORE OPTIMISTIC NOTE, WHICH HAS TO DO WITH HOW FAMILY-CENTERED DRUG PREVENTION PROGRAMS FOR RURAL AFRICAN-AMERICAN YOUTH HAVE HEALTH BENEFITS LATER ON IN THEIR LIVES DURING ADULTHOOD. WE'RE GOING TO TEST THE WEATHERING HYPOTHESIS. THIS IS THE IDEA THAT EXPOSURE TO CHRONIC WEAR AND TEAR OR EXPOSURE TO CHRONIC STRESS WEATHERS THE BODY, AND FOR YEARS TO EXPLAIN HOW HEALTH DISPARITIES DEVELOP, RESEARCH HAS FOCUSED ON POVERTY, LIMITED EDUCATIONAL AND OCCUPATIONAL OPPORTUNITIES, RACIAL DISCRIMINATION, LIMITED ACCESS TO HEALTH CARE IN DISADVANTAGED COMMUNITIES DURING ADULTHOOD. BUT IT'S BECOME VERY CLEAR THAT CONCURRENT HEALTH DETERMINANTS CANNOT ACCOUNT FOR RURAL AFRICAN-AMERICANS' HEALTH DISPARITIES. THESE HEALTH DISPARITIES ARE VIEWED AS CONDITIONS THAT DEVELOP OVER THE LIFE COURSE, PROBABLY BEFORE CONCEPTION. THEORETICALLY THERE LOTS OF NOTIONS ABOUT WEATHERING, BUT MANY REVOLVE AROUND THEORY WHICH SAYS THAT WHEN YOUTH ARE CONFRONTED WITH HIGH DOSE OF STRESSORS OVER TIME, THE HPA ACCESS AND SYMPATHETIC NERVOUS SYSTEM RELEASE CORTISOL, EPINEPHRINE, NOREPINEPHRINE, TO WRAP UP PHYSIOLOGIC SYSTEMS TO MEET COPING DEMANDS. AND THESE HORMONES BIND TO RECEPTORS IN MULTIPLE BODILY SYSTEMS. AND ALTHOUGH THEY ARE FUNCTIONAL IN THE SHORT RUN, IN THE LONG TERM IF CELLS AND TISSUES ARE BATHED IN THESE STRESS HORMONES THEY CONTRIBUTE TO WEATHERING BY CREATING PRO-INFLAMMATORY CONDITIONS SUCH AS YOU'D FIND IN C-REACTIVE PROTEIN OR PRO-INFLAMMATORY CYTOKINES. AND THESE IN TURN CONTRIBUTE TO METABOLIC SYNDROME DIABETES, STROKE, HEART DISEASE AND CANCER. SO TODAY WE'RE GOING TO FOCUS ON A FEW ENDPOINTS, AND THE RESEARCH I'M GOING TO TALK ABOUT WILL CONNECT STRESSORS IN THE LIVES OF THESE CHILDREN TO THESE INDICATORS. SO, ALLOSTATIC LOAD FROM 500 RURAL AFRICAN-AMERICAN YOUTH, OBTAINED OVERNIGHT, PARTICIPANTS ARE THREE HOURS AWAY, YOU HAVE TO HAVE A PROTOCOL TO CATCH THIS DATA. WE ASSAYED CORTISOL, EPINEPHRINE, NOREPINEPHRINE FROM OVERNIGHT URINE VOIDS, DID FASTING BLOOD DRAW FROM WHICH WE OBTAINED C-REACTIVE PROTEIN, WE LOOKED AT INDEXES OF ADIPOSITY, AND BLOOD PRESSURE, AND WHEN YOU COMBINE ALL THESE THINGS THEY DO A PRETTY DARN GOOD JOB OF FORECASTING OVER TIME HYPERTENSION, CARDIAC DISEASE, DIABETES, AND STROKE. ANOTHER THING WE DID THAT YOU'LL HEAR ABOUT IN A LITTLE WHILE IS CELLULAR AGING. AND ONE TENET OF THE WEATHERING HYPOTHESIS IS THAT THE FUNCTION OF EXPOSURE TO CHRONIC LEVELS OF ECONOMIC STRESS, RACIAL DISCRIMINATION, WHAT FOLLOWS PHYSIOLOGICALLY IS PREMATURE AGING OF CELLS AND TISSUES, AND THIS PREMATURE AGING IS HYPOTHESIZED TO SHORTEN LIFE EXPECTANCY. SO FROM A BLOOD DRAW AT AGE 20, WE OBTAINED GENOME WIDE METHYLATION ASSAYS ON 400 PARTICIPANTS, DERIVED INFORMATION ABOUT CELLULAR AGING ASSESSING CELL TYPES AN D FOCUSING ON IMMUNE CELLS. WE ALSO QUANTIFIED METABOLIC SYNDROME, AT AGE 25 WE WENT OUT, DID A FASTING BLOOD DRAW, AND ASSESSED BLOOD PRESSURE, ADIPOSITY. AND METABOLIC SYNDROME IS COMPRISED OF EACH OF THESE FIVE INDICATORS. AND A COMPLEX SET OF RISK FACTORS WHICH ARE INCREASING AMONG YOUNG AMERICANS AND PARTICULARLY AFRICAN-AMERICANS, AND THEY FORECAST HIGH RATES OF DIABETES, HEART DISEASE, AND STROKE LATER IN THE LIFE COURSE. I COULD USE THAT TIMEOUT. IN THE ANALYSES I'M GOING TO PRESENT, YOU'LL SEE BOTH DIAGNOSES OF METABOLIC SYNDROME AND THE NUMBER OF COMPONENTS THAT REACH CLINICAL SIGNIFICANCE. FROM 2007 TO 2009, THE COUNTRY UNDERWENT GREATEST ECONOMIC DOWN TURN IT HAD EXPERIENCED SINCE THE GREAT DEPRESSION. 10% OF AMERICAN HOUSEHOLDS WERE UNEMPLOYED. AMONG THE RURAL AFRICAN-AMERICAN COMMUNITIES WE STUDIED IN RURAL GEORGIA, WHICH ARE JUST LIKE THOSE IN THE BLACK BELT, THE UNEMPLOYMENT RATES REACHED 30%. AND MANY OF THOSE COMMUNITIES STILL HAVEN'T RECOVERED. FOLLOWING THE GREAT RECESSION, WITH THE SAMPLE THAT WE HAD FOLLOWED FROM AGE 11, WE OBTAINED MEASURES OF CARDIOMETABOLIC RISK, ALLOSTATIC LOAD, ACCELERATED CELLULAR AGING USING THE HANMUM FORMULATION AND HORVATH FORMULATION, AND ASKED PEOPLE, HOW IS YOUR HEALTH? AND WHAT WE FOUND IS THAT AFTER THE GREAT RECESSION WHEN PEOPLE WERE 19 TO 20, THE LONGER THEY WERE IN, THE LONGER THEY EXPERIENCED ECONOMIC HARDSHIP, THE WORST CARDIOMETABOLIC HEALTH WAS, THE GREATER THEIR CELLULAR AGING AND I'LL TALK ABOUT THE SELF-REPORTED HEALTH IN A SECOND. SO, WE ACTUALLY DEFINED THREE GROUPS. ONE GROUP WAS THE GROUP OF AFRICAN-AMERICAN FAMILIES WHO KIND OF WERE WORKING POOR AND REMAINED WORKING POOR ACROSS THE GREAT RECESSION. THE SECOND GROUP DOWNWARD MOBILITY DID NOT DIFFER IN ANY WAY FROM THE LOW ECONOMIC HARDSHIP GROUP, THEY DIPPED INTO POVERTY, AND BIOLOGICALLY AFTER TWO YEARS THOSE KIDS LOOKED WORSE THAN YOUTH WHO WERE STABLE WORKING POOR, AND FROM A HEALTH PERSPECTIVE THE GROUP THAT SUFFERED MOST WAS THE STABLE HIGH HARDSHIP GROUP, AND THESE WERE A GROUP OF PEOPLE WHO SLIPPED INTO DEEPENING POVERTY. AGAIN, WE'RE LOOKING AT SOME OF THE TENETS OF THE WEATHERING HYPOTHESIS, AND THIS WAS A PROOF OF PRINCIPLE DEMONSTRATION OF THAT. FIVE YEARS LATER, WE WENT BACK TO THE SAME FOLKS. THIS TIME WE LOOKED AT THEIR METABOLIC SYNDROME, SAME GROUPS OF PEOPLE, AND WHAT WE FIND AGAIN EXCEPT WITH METABOLIC SYNDROME IS THAT THOSE YOUNG PEOPLE WHO SLIPPED INTO POVERTY ACROSS THE GREAT RECESSION AND THOSE YOUNG PEOPLE WHO WERE AGE 25 AT THIS TIME HAD GREATER DIAGNOSES OF METABOLIC SYNDROME, AND HAD HIGHER COUNTS OF INDIVIDUAL INDICATORS OF THE DISEASE. ANOTHER TENET AND ANOTHER PROOF OF PRINCIPLE DEMONSTRATION I'M OFFERING TODAY OF THE WEATHERING HYPOTHESIS IS THE IDEA THAT WHEN COMMUNITIES FACE DOWNWARD MOBILITY THAT MAY HAVE HEALTH CONSEQUENCES. SOCIOLOGIST WILLIAM JUNES WILSON ARGUED IN SEVERAL BOOKS WHAT CAN HAPPEN TO MANY PEOPLE IS THEY COULD LIVE IN A COMMUNITY THAT OVER TIME THEIR ECONOMIC CIRCUMSTANCES HAVEN'T CHANGED, BUT THAT COMMUNITY ENVELOPES THEM AND CAN HAVE PSYCHOLOGICAL AND HEALTH COSTS. WE TESTED THAT NOTION IN THIS STUDY. AND WHAT WE DID, WE'VE BEEN STUDYING, FOLLOWING 420 YOUNG AFRICAN-AMERICAN PEOPLE IN RURAL GEORGIA. WE LOOKED AT THE POVERTY LEVELS IN THE COMMUNITIES WHICH THEY LIVED AT AGES 11 AND 19, AND TOOK A LOOK AT -- DID THEIR ALLOSTATIC LOAD VARY AS A FUNCTION OF THE COMMUNITIES BECOMING MORE POOR, AND WE STUDIED A SECOND HYPOTHESIS WHICH YOU'RE GOING TO SEE IN THE NEXT SEVERAL SLIDES, WHICH IS DERIVED FROM ANIMAL MODELS WHICH SUGGEST THAT CAREGIVING TENDENCIES THAT FEATURE NURTURANCE CAN OFFSET STRESS EFFECTS IN ENDOCRINE SYSTEMS, IMMUNE SYSTEMS, NEUROSYSTEMS, SO WE RENDERED THE HYPOTHESIS THOSE YOUTH WHO GREW UP IN COMMUNITIES WHICH GRADUALLY BECAME POORER BUT RECEIVED HIGH LEVELS OF EMOTIONAL SUPPORT WOULD SHOW LESS EFFECTS OF THOSE COMMUNITY CHANGES, AND THAT'S WHAT THIS -- THAT'S WHAT THESE DATA SHOW. SO, HERE ARE FOLKS, THE BLUE LINE REPRESENTS COMMUNITIES OVER EIGHT YEARS BECAME POOR, AND ALLOSTATIC LOAD LOOKS WORSE, AND THIS BLUE LINE HERE REPRESENTS PEOPLE WHO DID NOT HAVE COUNTERVAILING PROTECTIVE EXPERIENCES FROM THEIR FAMILIES. AGAIN, THAT'S A SECOND PROOF OF PRINCIPLE DEMONSTRATION OF THE EFFECTS OF -- I'M STRUGGLING A LITTLE WITH THIS. LET'S SEE. I WANT TO GET US TO THE NEXT SLIDE.. IS THERE SOMEBODY HERE WHO CAN HELP? YEAH, GOT IT. SURE. WE NEED TO GO TO THE NEXT ONE. SURE, THANK YOU SO MUCH. A CENTRAL TENET -- LET'S SEE. WE NEED TO GO TO THE NEXT ONE? YEAH. THERE WE GO. THANKS SO MUCH. I APPRECIATE IT. A CENTRAL TENET OF THE WEATHER HYPOTHESIS IS THAT OVER TIME, EXPOSURE TO RACIAL DISCRIMINATION AND CHRONIC EXPOSURE TO WEAR AND TEAR, PHYSIOLOGIC WEAR AND TEAR THAT COMES FROM ACTIVATION OF STRESS HORMONE SYSTEMS WILL ACTUALLY WEATHER CELLS AND TISSUES, RESULTING IN PREMATURE AGING AND SHORTER LIFE EXPECTANCIES. SO, WE DID TWO STUDIES. IN THE FIRST STUDY WE TOOK A LOOK AT PEOPLE WHO WERE 16 TO 18, AND ACROSS THAT TIME PERIOD WE ASSESSED THEIR LEVELS OF RACIAL DISCRIMINATION, EXPOSURE TO RACIAL DISCRIMINATION, AND WE WERE ABLE TO IDENTIFY TWO GROUPS OF PEOPLE, THOSE YOUTH 16 AND 18 EXPOSED TO HIGH AND STABLE LEVELS OF DISCRIMINATION, AND OTHERS WHO WERE EXPOSED TO LOAD INCREASING LEVELS, AND OBTAINED INFORMATION FROM THEIR PARENTS ON PROVISION OF EMOTIONAL SUPPORT. AT AGE 20, HIGH LEVELS OF DISCRIMINATION AND LOW LEVEL OF SUPPORT SHOWED THE GREATEST -- NO. YEAH. OKAY. SHOWED-- THIS IS NOT THE RIGHT ONE EITHER, YEAH. OKAY. PLEASE. OKAY. LET'S GO BACK ONE. OKAY. I'M SORRY ABOUT THIS, EVERYBODY. THIS IS GOOD. OKAY. SO THIS SAMPLE OF 330 YOUTH WHO EXPERIENCED HIGH LEVELS OF RACIAL DISCRIMINATION WITH LOW LEVELS OF COUNTERVAILING SUPPORT SHOWED HIGHEST LEVELS OF PREMATURE ACCELERATED CELLULAR AGING. WHAT WE WANTED TO DO, WHEN THE NEXT SLIDE CAME UP, WE WANTED TO REPLICATE THIS FINDING IN A TOTALLY DIFFERENT SAMPLE THAT WE ARE OF RURAL AFRICAN-AMERICAN YOUTH, AND FROM 17 TO 19 YEARS OLD WE OBTAINED MEASURES OF RACIAL DISCRIMINATION, AGAIN WE FOUND TWO LEVELS OF EXPOSURE TO RACIAL DISCRIMINATION, AND WE WERE ALSO ABLE TO OBTAIN DATA FROM CAREGIVERS ABOUT THEIR PROVISION OF EMOTIONAL SUPPORT, AND PER THE FIRST STUDY WE WERE ABLE TO FIND THAT THOSE YOUTH, SEVERAL YEARS AFTER EXPOSURE TO RACIAL DISCRIMINATION, A WHOLE BEVY OF COVARIATE EVENTS, THE HIGHEST LEVELS OF ACCELERATED AGING, AND EMOTIONAL SUPPORT FROM THEIR PARENTS WAS ABLE TO PROTECT THEM FROM THIS. OKAY. LET'S DO THAT. I THINK WE'RE HAVING BATTERY TROUBLES HERE. OKAY. SO, LET'S MOVE ALONG. I WANTED TO SHOW IN THIS PROOF OF PRINCIPLE STUDY THAT SOME OF THE WEATHERING EFFECTS CAN BE FOUND IN THE BRAIN, AND WHAT WE DID IS A PROOF OF PRINCIPLE STUDY WHERE WE LOOKED AT COHERENCE OF FUNCTIONING IN TWO BRAIN NETWORKS, CENTRAL EXECUTIVE NETWORK AND ONE IS THE EMOTIONAL REGULATION NETWORK. AND TO THE EXTENT THAT THERE'S COHERENCE IN THESE TWO SYSTEMS WORKING MEMORY IS BETTER, KIDS DO BETTER IN SCHOOL, TO THE EXTENT THEIR COHERENCE IN THOSE RESTING STATES, YOUTH ARE MORE RESISTANT TO STRESS REACTIVITY. THEY HAVE FEWER SYMPTOMS OF DEPRESSIVE SYMPTOMOLOGY, LESS LIKELY TO SUFFER FROM ANXIETY DISORDERS. TAKEN TOGETHER, OH. TAKEN TOGETHER, SORRY. SURE, SURE. >> I'LL ADVANCE THESE. >> OKAY. LET ME SUMMARIZE ALL THIS. I'M SORRY FOR ALL THE INTERRUPTION HERE. WHAT WE WERE ABLE TO SHOW IS THAT ECONOMIC DOWNTURNS ALONG WITH CHANGES IN NEIGHBORHOODS, ALONG WITH EXPOSURES TO RACIAL DISCRIMINATION, AND ORGANIZATION OF NEURAL NETWORKS WERE ASSOCIATED WITH CONTEXTUAL STRESSORS THAT WOULD BE PREDICTED BY THE WEATHERING HYPOTHESIS, PARTICULARLY FOR THOSE YOUNG PEOPLE WHO DIDN'T HAVE COUNTERVAILING PROTECTIVE FACTORS FROM THEIR FAMILIES. LET'S GO ON. ALL RIGHT. LET'S TALK ABOUT RESILIENCE IS SKIN DEEP. THERE'S THE WIDESPREAD ASSUMPTION THAT CHILDREN HAVE SUCCESSFULLY NEGOTIATED ADVERSITIES AND BEATEN THE ODDS AND BECOME RESILIENT IF THEY EXHIBIT INDICATORS OF GOOD JUDGMENT, FOR EXAMPLE EXCEL ACADEMICALLY, HIGH SELFES TEXT, EXHIBIT FEW BEHAVIORAL PROBLEMS, WE WANT TO KNOW WHETHER BEHAVIORAL RESILIENCE TRANSLATED TO GOOD HEALTH, AND THE ANSWER WAS NO. AND THE FIRST INDICATION OF THIS CAME IN THE STUDY OF 489 AFRICAN-AMERICAN YOUNG PEOPLE ACROSS THE AGES OF 11 AND 13, TEACHERS RATED THEM ON SELF CONTROL, GOAL ORIENTATION, HOW WELL THEY DID IN SCHOOL, AND WE ALSO HAVE INFORMATION AT THAT TIME ON THE DISADVANTAGE THAT THEY GREW UP IN. SO, AT AGE 19, THESE KIDS LOOK GREAT, PSYCHOSOCIALLY. VERY LOW LEVELS OF INTERNALIZING PROBLEM, LOW LEVELS OF EXTERNALIZING PROBLEMS, AND THIS WAS PARTICULARLY TRUE FOR THOSE KIDS WHO WERE WORKING AS HARD AS THEY COULD IN SCHOOL, AS EVIDENCES BY TEACHERS' RATINGS, AND WERE DOING IT, THEY WERE TRYING TO OVERCOME THE ODDS, WERE LIVING IN TOUGH CIRCUMSTANCES, AND THEY EVINCED LOWS LEVELS OF EMOTIONAL AND BEHAVIORAL PROBLEMS. THE EXACT OPPOSITE WAS TRUE WHEN WE OPENED THEM UP AND LOOKED AT THEIR ALLOSTATIC LOAD. THESE SAME CHILDREN WHO EVINCED PSYCHOSOCIAL COMPETENCE HAD HIGHER LEVELS OF CIRCULATING STRESS HORMONES, HIGHER LEVELS OF INFLAMMATION, HIGH LEVELS OF ADIPOSITY, AND HIGHER LEVELS OF BLOOD PRESSURE. SO, IT APPEARED FROM THIS ONE STUDY THERE WAS A COST TO BEATING THE ODDS. SO, WE LOOKED AT ANOTHER GROUP OF PEOPLE, ANOTHER GROUP OF AFRICAN-AMERICAN YOUTH, WHO YOU WOULD THINK WOULD BE RESILIENT. THEY LIVED IN TOUGH CIRCUMSTANCES, THEY WERE -- FAMILIES WERE EXPERIENCING A LOT OF ECONOMIC ADVERSITY. THEY GRADUATED HIGH SCHOOL, THEY WERE ATTENDING COLLEGE. WHEN WE LOOKED AT THEIR SUBSTANCE USE, THEY WERE USING LESS SUBSTANCE USE, EVEN THOUGH THEY LIVED IN AND CAME FROM DISADVANTAGED NEIGHBORHOODS. WHEN WE LOOKED AT THEIR ALLOSTATIC LOAD, ONCE AGAIN, UNDERNEATH THEIR HEALTH WAS FAILING. SO WE STARTED TO WONDER, IS OVERCOMING THE ODDS A DOUBLE-EDGED SWORD? FOR YOUTH FROM DISADVANTAGED CIRCUMSTANCES DOES IT PROMOTE PSYCHOSOCIAL CONFIDENCE BUT CREATE HEALTH VULNERABILITIES? SO WITH A TOTALLY DIFFERENT SAMPLE WE WANTED TO TEST WHETHER SELF CONTROL FORECASTS CELLULAR AGING. AND IN THIS SAMPLE WE HAD 350 YOUTH WHO FROM AGES 17 TO 19 WE HAD MEASURES OF SELF CONTROL, AT AGE 19 WE HAD MEASURES OF PSYCHOSOCIAL CONFIDENCE, AT AGE 20 HAD MEASURES OF PSYCHOSOCIAL COMPETENCE, AND AT AGE 22 WE HAD MEASURES OF CELLULAR AGING. WHAT WE FOUND IS THAT SELF CONTROL, AS YOU WOULD EXPECT, FORECASTS OVER TIMELESS DEPRESSIVE SYMPTOMOLOGY, COLLEGE ATTENDANCE -- YEAH -- AND THE ASSOCIATION BETWEEN SELF CONTROL AND SUBSTANCE USE BECAME NEGATIVELY GREATER. SO PARALLELLED ALL OUR OTHER FINDINGS, BUT AS YOU CAN SEE FROM BOTH OF THESE RED LINES THAT HIGHER SELF CONTROL FORECAST MORE CELLULAR AGING AMONG THOSE YOUTH FROM THE MOST DISADVANTAGED NEIGHBORHOODS. OR DISADVANTAGED COMMUNITIES. SO WE WANTED TO SEE, DOES THIS HAVE ANY CLINICAL IMPLICATIONS? SO WE WENT TO DATA FROM THE NATIONAL LONGITUDINAL STUDY OF ADOLESCENTS, WE IDENTIFIED YOUTH WHO AT 16 ARE WHAT WE CALL STRIVERS, THEY HAD HIGH EDUCATIONAL ASPIRATIONS, THEY WERE VERY PERSISTENT, THEY HAD A SINGLE-MINDED FOCUS, DETERMINATION TO SUCCEED, AND AT AGE 29 WE WANTED TO TAKE A LOOK AT WHETHER THEY HAD DIABETES OR NOT, WHAT WAS THEIR LIFE CIRCUMSTANCES LIKE, AND WHAT THE DATA SHOWED CLEARLY WAS THAT YOUNG PEOPLE AT 16 WHO WERE STRIVERS, WE LOOKED AT THEIR MENTAL HEALTH, THEY WERE LIGHTS OUT, THEY WERE DOING GREAT, THEY WEREN'T USING DRUGS. THEY HAD GRADUATED COLLEGE. THEY HAD EARNED HIGHER INCOMES BUT THEY WERE MORE LIKELY TO HAVE TYPE 2 DIABETES. NOW, SINCE THIS STUDY WE HAVE A NEW STUDY JUST WITH KIDS WITH ASTHMA, AND WE FIND INTERESTING RESULTS. WE LOOKED AT THEIR INFLAMMATORY PROFILES. AND THOSE KIDS WITH ASTHMA WHO WERE WORKING WITH ALLERGISTS, UNDER PHYSICIANS, HAD WORSE INFLAMMATORY PROFILES AND EXHIBITED LESS GLUCOCORTICOID SENSITIVITY IF THEY WERE EXPERIENCING HIGH LEVELS OF CONTEXTUAL STRESS, THEY WERE MORE SELF CONTROLLED, BUT THEY WERE SHOWING UP AT THEIR DOCTORS MUCH MORE OFTEN OVER THE COURSE OF THE YEAR BECAUSE THEY WERE HAVING NOT ONLY DIFFICULTIES WITH THOSE INFLAMMATORY PARAMETERS BUT THEY WERE HAVING A HARDER TIME MANAGING THEIR ASTHMA. SO WE WROTE THIS LITTLE PIECE THAT WAS IN THE SUNDAY REVIEW OF THE "NEW YORK TIMES." WE HAD A BUNCH OF DATA IN OUR BACK POCKETS. WE HAD REPLICATED FINDINGS, AND THE REASON WE DID THIS IS WE WANTED TO GET THE WORD OUT THAT THERE MIGHT BE A COST OF RESILIENCE, THAT PEOPLE COULD HAVE A SINGLE-MINDED DETERMINATION TO SUCCEED AND PSYCHOSOCIALLY BE DOING GREAT, BUT THE COST OF WORKING DILIGENTLY, LETTING YOUR HEALTH GO BY THE WAYSIDE, MAY UNDERMINE YOUR HEALTH, AND WE RECEIVED HUNDREDS OF E-MAILS FROM AFRICAN-AMERICAN PROFESSIONALS, THANKING US FOR GETTING THIS WORD OUT. AS A FOOTNOTE, THESE RESULTS THAT I PRESENTED TODAY ABOUT SKIN DEEP RESILIENCE HAVE BEEN REPLICATED IN FIVE OTHER SAMPLES FROM AROUND THE COUNTRY, AND WHAT I DIDN'T MENTION AND IS PARTICULARLY IMPORTANT IS THAT THE RESULTS WERE THE DIABETES PIECE AND ASTHMA PIECE, TO SKIN DEEP RESILIENCE, WAS FOUND ONLY FOR AFRICAN-AMERICAN YOUNG PEOPLE BUT NOT WHITE YOUNG PEOPLE IN THE SAME CIRCUMSTANCES. SO WE'RE TRYING TO UNPACK THAT, AND THAT FINDING WAS RECENTLY REPLICATED IN A PAPER IN PNAS, WITH A SAMPLE OF THOUSANDS OF YOUTH. SO, THERE'S SOMETHING VERY IMPORTANT HERE. WE NEED TO KNOW ABOUT WHAT'S THE ROLE OF SOCIAL ISOLATION, AS YOU'RE TRYING TO OVERCOME THE ODDS OF RACIAL DISCRIMINATION, AND HOW HEALTH PRACTICES MAY BE PUT ASIDE IF YOU HAVE A SINGLE-MINDED DETERMINATION TO SUCCEED AND DON'T WANT TO BE SIDETRACKED. I THINK WE NEED A LOT MORE WORK ON THAT. LET'S GO DO SOME WORK, TALK ABOUT SOME THINGS THAT ARE MORE OPTIMISTIC. IN 2000, THERE WERE NO PREVENTION PROGRAMS FOR RURAL AFRICAN-AMERICAN YOUTH. BASED ON A DECADE OF RESEARCH WITH A THOUSAND RURAL AFRICAN-AMERICAN FAMILIES, WE DEVELOPED THREE PREVENTION PROGRAMS, AND AS I SAID EARLIER THESE ARE BEING EMBEDDED AROUND THE NATION. THE FIRST PROGRAM IS CALLED THE STRONG AFRICAN-AMERICAN FAMILIES PROGRAM. IT WAS DEVELOPED FOR PRE-ADOLESCENTS, WHO JUST ENTERED MIDDLE SCHOOL. THE SECOND PROGRAM, STRONG AFRICAN-AMERICAN TEEN PROGRAM, WAS FOR YOUTH 15 TO 17 YEARS OLD. ADULTS IN THE MAKING WERE FOR YOUTH 19 AND 20 YEARS OLD, AS THEY LEFT PUBLIC SCHOOL AND WENT INTO COMMUNITIES WHERE THERE WERE FEW EDUCATIONAL AND OCCUPATIONAL OPPORTUNITIES. ALL OF THESE PROGRAMS SHARE COMMON THEMES. WE TRY TO STRENGTHEN DEVELOPMENTALLY APPROPRIATE PARENTING PRACTICES, BASED ON LONGITUDINAL DEVELOPMENTAL RESEARCH WE KNEW DETERRED DRUG USE AND ENGAGEMENT AND RISKY BEHAVIORS. AND IN THE WORLD OF PREVENTION, WE USUALLY THINK ABOUT PARTICULARLY DRUG USE PREVENTION, AND OTHER MENTAL HEALTH PREVENTIONS THAT IF WE GIVE PEOPLE ONE INOCULATION AT ONE POINT IN TIME THAT'S GOING TO LAST A LIFETIME. EVEN THOUGH THE RISK FACTORS THAT THESE YOUNG PEOPLE EXPERIENCE AS THEY GO THROUGH DIFFERENT DEVELOPMENTAL STAGES CHANGES, AND THESE PREVENTION PROGRAMS ARE DESIGNED TO ADDRESS THOSE DEVELOPMENTAL CHANGES AND HOW FAMILIES CAN DETER THOSE DIFFERING DEVELOPMENTAL CHANGES OVER TIME. SO RECENTLY, AND I JUST WANTED TO INCLUDE THIS, BECAUSE IT ILLUSTRATES THE DURABILITY OF ONE OF OUR PROGRAMS, SAFE, WHICH I'M GOING TO BE SPENDING THE REST OF THE TALK FOCUSING ON. EPIDEMIOLOGIC DATA WITH AT LEAST RURAL AFRICAN-AMERICANS SHOW THAT DURING THE YOUNG ADULTHOOD YEARS MALES ARE MORE LIKELY TO INCREASE THEIR DRUG USE, AND FEMALES ARE MORE LIKELY TO INCREASE ADIPOSITY. THAT THERE IS THIS DIFFERENTIAL WHAT MIGHT BE CALLED COPING STRATEGY THAT'S GENDERED. SO WE WANTED TO SEE FOR KIDS GROWING UP IN DIFFICULT CIRCUMSTANCES AT AGE 11 WHEN WE LOOKED AT THEM AT AGE 25, WHAT DID ADIPOSITY LOOK LIKE FOR WOMEN, AND WHAT DID DRUG USE LOOK LIKE FOR MEN? SO WHAT WE SEE HERE IS THAT DRUG USE OVER TIME, I MEAN ADIPOSITY FOR WOMEN OVER TIME -- ADIPOSITY FOR MEN OVER TIME STAYS RELATIVELY LOW. DRUG USE IS IN THE ADIPOSITY FOR WOMEN, IS IN THE MIDDLE RANGE, AND FOR THOSE PEOPLE WHO EXPERIENCE THE PREVENTION AT AGE 11 BUT ADIPOSITY FOR WOMEN WHO DID NOT EXPERIENCE THE PREVENTION PROGRAM AT AGE 11 WAS MUCH HIGHER. THE OPPOSITE SCENARIO WAS FOUND FOR WOMEN WITH DRUG USE, VERY LOW LEVELS OVER TIME. FOR MEN IN THE SAFE CONDITION, LOWER THAN THOSE YOUNG PEOPLE 14 YEARS LATER WHO WERE IN THE CONTROL CONDITION SHOWING SOME OF THE DURABILITY OF THE INTERVENTION AND SAFE OVER TIME. YEAH, THAT'S GOOD. THERE'S RECENT RESEARCH SHOWING THAT EXPOSURE TO PROTECTIVE PARENTING IS ABLE TO OFFSET SOME OF THE HEALTH RISKS OF LIVING IN LOW SES PLACES. SO, IN THIS STUDY WHAT WE WANTED TO DO WAS TEST TWO HYPOTHESES. ONE, EXPOSURE TO SAFE, YEARS LATER, WOULD FORECAST LOWER LEVELS OF CIRCULATING CYTOKINES, AND SECOND, THAT THIS FINDING IF SAFE ACTUALLY DID REDUCE CIRCULATING LEVELS OF CYTOKINES, WOULD BE MEDIATED BY SAAF'S IMPACT ON NURTURING PARENTING, DECREASES IN HARSH PARENTING. THAT'S WHAT WE FOUND. SAAF AT AGE 20, THAT WAS EXPERIENCED AT AGE 11, WAS ASSOCIATED WITH LOWER LEVELS OF CYTOKINES, AND THAT THESE FINDINGS WERE MEDIATED BY SAAF'S INCREASES IN PROTECTIVE PARENTING. ONE OF THE THINGS THAT HAPPENS IN RURAL AFRICAN-AMERICAN COMMUNITIES IS THE CAREGIVERS, AT LEAST THE SEVERAL -- FOUR OR FIVE THOUSAND THAT WE HAVE WORKED WITH, ARE OFTEN WORKING TWO OR THREE JOBS, FOR VERY LOW WAGES, AND RAISING A FAMILY IN PLACES THAT DON'T HAVE A LOT OF SUPPORT. AND ONE CONSEQUENCE OF THESE LIVES IS THAT SOMETIMES THEIR PSYCHOLOGIC FABRIC GETS RIPPED AND THEY START FEELING BADLY AND THEY START EXPERIENCING HIGHER LEVELS OF DEPRESSION SYMPTOMOLOGY, AND MANY SLIP INTO DEPRESSION, AND FORGO THEIR INDIVIDUAL NEEDS AND FOCUS ON THE NEEDS OF THEIR CHILDREN. AND WHEN THAT HAPPENS, WHEN PEOPLE SLIP INTO DEPRESSIVE SYMPTOMOLOGY AND THEY FEEL BADLY, AND THEY STILL WANT THE BEST FOR THEIR KIDS, ONE DYNAMIC THAT STARTS TO OCCUR IS THEY WANT TO LIMIT INTERACTIONS WITH THEIR KIDS. AND THEY DO THAT BY USING HARSH TACTICS, AND THEY ARE TRYING TO MAKE IT THROUGH THE DAY. SO IN THIS STUDY WE WANTED TO TEST A COUPLE HYPOTHESES THAT WE THOUGHT WERE IMPORTANT. SO FIRST WE PREDICTED THAT MOMS WHO WERE DEPRESSED WOULD HAVE KIDS OVER A DECADE LATER WHO HAD HIGHER ACCELERATED LEVELS OF CELLULAR AGING. AND SECOND, WE HYPOTHESIZED THAT THIS WOULD BE AMELIORATED BY THOSE FAMILIES WHO PARTICIPATED IN ONE OF OUR PREVENTION PROGRAMS, SAAF, AND THAT, THIRD, THIS WOULD BE DUE TO THE INTERVENTION'S EFFECT ON REDUCING HARSH PARENTING. WHAT THE TOP FIGURE SHOWS, YOUNG PEOPLE WHOSE MOMS WERE DEPRESSED IN THE CONTROL GROUP HAVE THE HIGHEST LEVELS OF ACCELERATED CELLULAR AGING. WHAT THE BOTTOM FIGURE SHOWS IS THOSE YOUNG PEOPLE IN THE FAR LEFT BAR SHOW THE LOWEST DECREASE IN HARSH PARENTING OVER TIME. AND WHAT THIS MODEL SHOWS IS THAT THE EFFECT OF PARTICIPATING IN THE INTERVENTION ON PROTECTING CELLULAR AGING WAS DUE TO THE INTERVENTION'S EFFECT ON DECREASING HARSH PARENTING. FINALLY, I ALSO WANT TO -- IN THIS MULTI-LEVEL PRESENTATION, I WANTED TO SHOW YOU THAT IT'S POSSIBLE NOT ONLY FOR THE PROTECTIVE PARENTING EFFECTS THAT WE'VE BEEN LOOKING AT, TO AFFECT DRUG USE, HARSH PARENTING, NURTURING AND INVOLVED PARENTING, CELLULAR AGING, BUT CAN WE FIND IT IN THE BRAIN? AND WHAT WE DID IN THIS STUDY IS WE PICK UP PARTICIPANTS IN SAAF, 14 YEARS AFTER THEY HAD THAT EXPERIENCE, HAD THAT PREVENTION PROGRAM, AND WE WANTED TO SEE DOES IT AFFECT -- DOES IT PROTECT AGAINST POVERTY WHERE STRESS IS COMMON AND RESOURCES ARE SCARCE ON THE BRAIN MATURATION OF RURAL AFRICAN-AMERICAN YOUNG PEOPLE. THIS TURNS OUT TO BE A PRETTY SIMPLE ANALYSIS. IT'S A LOT OF HARD WORK. BUT THE ANALYSIS IS VERY SIMPLE. WE JUST COUNTED THE NUMBER OF YEARS BETWEEN 11 AND 17 THAT CHILDREN GREW UP IN POVERTY. WE HAD THIS DATA OVER TIME. AND WE WANTED TO SEE IF THERE WAS AN ASSOCIATION BETWEEN GROWING UP IN POVERTY AND THE VOLUME OR MATURATION OF A COUPLE BRAIN AREAS THAT ARE CRUCIAL TO DEVELOPMENT. ONE IS THE AMYGDALA WHICH LAST A LOT TO DO WITH STRESS REACTIVITY, AND WE LOOKED AT TWO AREAS OF THE HIPPOCAMPUS, THAT ANIMAL WORK SHOWED US WERE ASSOCIATED WITH STRESS EFFECTS ON THEIR VOLUME. AND WHAT THE FIRST ANALYSIS SHOWS IS THE MORE YEARS BETWEEN 11 AND 17 THAT YOUNG PEOPLE LIVED IN POVERTY WHEN WE PUT THEM IN THE SCANNER AT AGE 25, IF THEY DID NOT HAVE THE BENEFIT OF PARTICIPATING IN THE INTERVENTION, WERE NOT RANDOMLY ASSIGNED TO THE INTERVENTION CONDITION, THAT THEIR BRAIN VOLUMES WERE SMALLER. THAT WAS NOT FOUND, THERE WAS NO EFFECT ON YEARS NO ASSOCIATION IN THIS PARTICULAR ANALYSIS ON THE YEARS LIVING IN POVERTY WITH THE AMYGDALA VOLUMES. WE THEN LOOKED AT TWO AREAS OF HIPPOCAMPUS, AND WE FOUND SIMILAR PATTERNS. MORE YEARS LIVING IN POVERTY, GREATER DECREASES GYRUS AND CA3, FOR THOSE PEOPLE IN THE CONTROL GROUP BUT NOT RANDOMLY ASSIGNED TO THE SAFE CONDITION. SO, HERE'S SOME STUFF WE FOUND, OVER THE LAST TEN YEARS, SHOW HOW EXPOSURE TO FAMILY ECONOMIC HARDSHIP AND RACIAL DISCRIMINATION WAS ASSOCIATED WITH BIOLOGICAL WEATHERING DURING THE THIRD DECADE OF LIFE. WE ILLUSTRATED THAT DESPITE CHALLENGING RURAL CONDITIONS, MANY RURAL AFRICAN-AMERICAN YOUNG PEOPLE MAINTAIN GOOD HEALTH IN PART DUE TO PROTECTIVE FAMILY ENVIRONMENTS. WE DESCRIBED HOW RESILIENCE MAY BE A DOUBLE-EDGED SWORD FOR RURAL AFRICAN-AMERICANS FROM ECONOMICALLY STRESSED BACKGROUNDS, THE SAME CHARACTERISTICS ASSOCIATED WITH ACADEMIC SUCCESS AND PSYCHOSOCIAL ADJUSTMENT FORECAST ELEVATED VULNERABILITY TO PHYSICAL HEALTH PROBLEMS. AND FINALLY, WE SUGGESTED THAT IMPLEMENTING PROGRAMS THAT CULTIVATE RESILIENCE THROUGH STRENGTHENING FAMILY RELATIONSHIPS HAS A POTENTIALLY IMPORTANT ROLE IN PROTECTING PUBLIC HEALTH, PARTICULARLY FOR PEOPLE WHO HAVE BEEN SOME SAY FORGOTTEN IN PUBLIC HEALTH RESEARCH. NEXT SLIDE. WE COULD NOT HAVE DONE THIS WORK WITHOUT SUPPORT FROM NICHD. I JUST RECEIVED A CONTINUATION FROM NICHD THAT GOES FROM YEARS -- THE SAME GRANT YEARS, 25 TO 29. I THINK THAT MAKES ME OLD. I COULD NOT HAVE DONE THIS WORK WITHOUT NOT ONLY FUNDING BUT GUIDANCE AND SUPPORT FROM NIDA. AND I ALSO WANT TO GIVE A SHOUT OUT TO NIAAA. I COULDN'T HAVE DONE THIS WORK WITHOUT RURAL AFRICAN-AMERICAN COMMUNITIES AND YOUNG PEOPLE AND ADULTS PLACING TRUST IN US. WE ACTUALLY HAVE HAD ABOUT 5,000 PARTICIPANTS WHO ALLOW US TO GO TO THEIR HOMES, COLLECT BIOLOGICAL SPECIMENS, GO TO OUR PROGRAMS, AND WITHOUT THEM NONE OF THIS WOULD BE PROBABLY. I HAVE GREAT COLLEAGUES IN EDITH CHEN AND GREG MILLER AT NORTHWESTERN, GREAT COLLEAGUE IN TIANYI YU AT GEORGIA, AND MY ADMIN EILEEN. HERE AT THE CENTER FOR FAMILY RESEARCH WHO IDENTIFIED FAMILIES, RECRUIT FAMILIES, MAINTAIN THESE FAMILIES AND YOUTH FOR 20 YEARS IN OUR LONGITUDINAL SAMPLES, THEY COLLECT BIOSPECIMENS, THEY SUPERVISE 60 OTHER PEOPLE. WITHOUT THEM, NONE OF THIS WOULD BE POSSIBLE. AND MANY OF THEM HAVE BEEN WITH ME FOR 15 OR MORE YEARS. SO, THANK YOU, ON BEHALF OF MY COLLEAGUES, AT THE CENTER FOR FAMILY RESEARCH. WE APPRECIATE THE HONOR. [APPLAUSE] WE'VE JUST HEARD BEING USED IN COMMUNITY HEALTH CENTERS IN RURAL AREAS, BECAUSE IT SOUNDS LIKE GOING BEYOND THE MEDICAL SERVICES THAT ARE TYPICALLY USED IN COMMUNITY HEALTH CENTERS, FUNDED BY THE FEDERAL GOVERNMENT, IS AN IMPORTANT AREA, GOING BEYOND THOSE MEDICAL SERVICES, AND HAVE YOU HAD ANY EXPERIENCE IN INFLUENCING THE WAY THOSE COMMUNITY HEALTH CENTERS FUNCTION, BASED ON THE KIND OF RESEARCH THAT YOU'VE JUST DESCRIBED? >> OUR PROGRAMS HAVE NOT BEEN NESTED IN THAT MANY COMMUNITY HEALTH CENTERS. THEY HAVE BEEN NESTED IN SOME COMMUNITY HEALTH CENTERS IN THE RURAL SOUTH, AND AROUND THE NATION. BUT THE VAST MAJORITY HAVE NOT. TWO WEEKS AGO WE WERE IN MOBILE, ALABAMA, AND SALMA, ALABAMA. WE WERE WELCOMED IN BOTH PLACES BY THE MAYORS OF THOSE COMMUNITIES, AND IN SOME OF THE POLICE CHIEF ALSO WELCOMED US. BUT FOR THE MOST PART, THERE ARE AGENCIES WITHIN COMMUNITIES WHICH HAVE SOUGHT OUT OUR PROGRAMS. TWO MONTHS AGO, OF ALL PLACES, WE WERE CONTACTED BY SOCIAL SERVICE AGENCIES, 27 OF THEM, IN HARLEM. WE WERE UP IN HARLEM, OF ALL PLACES, DOING -- EMBEDDING THESE PROGRAMS FOR FAMILIES IN THAT COMMUNITY. >> THANK YOU, DR. BRODY, AMAZING PRESENTATION. I GREW UP IN SHREVEPORT, LOUISIANA, AND AN AREA THAT COULD HAVE BEEN ONE OF THE SPOTS FOR THE BLACK BELT, AND I NEVER KNEW THAT MY MOM SPANKING MY TAIL WHEN I WAS A KID WOULD NOT ONLY ALLOW ME TO SUCCEED BUT NOW BE CAUSE OF CONCERN FOR MY LONG-TERM HEALTH. [LAUGHTER] MY QUESTION IS SERIOUS. HOW DO YOU DEFINE WHAT YOU CALL HARSH PARENTING AND HOW DO YOU DRAW THE LINE BETWEEN HARSH AND SUPPORTIVE PARENTING VERSUS ABUSE AND MORE, YOU KNOW, DETRIMENTAL PARENTAL BEHAVIOR? IF THAT MAKES SENSE. >> IT MAKES PERFECT SENSE. AND WE'RE IN A LITERAL HURRICANE ABOUT THAT ISSUE. I MEAN, IT WAS A FEW WEEKS AGO THAT THE AMERICAN ACADEMY OF PEDIATRICS SAID THAT PARENTS SHOULD SUSPEND SPANKING AND YELLING AT CHILDREN, AN THEY HAVE GOTTEN THIS WORD OUT TO PEDIATRICIANS AROUND THE COUNTRY. WHAT THAT TURNS OUT TO BE A LOT MORE AS GARY, YOU'RE SAYING, A LOT MORE COMPLICATED BECAUSE THERE ARE NORMATIVE DISCIPLINARY PRACTICES IN DIFFERENT COMMUNITIES, AND YOU'RE ASKING ME REALLY WHEN DOES HARSH PARENTING CREATE HEALTH VULNERABILITIES. AND WHAT WE'RE LOOKING AT IS THE VERY TOP OF OUR DISTRIBUTION. WHAT'S IN THE MIDDLE AND WHAT WORKS FOR PEOPLE IN DIFFERENT COMMUNITIES, WE DON'T HAVE REALLY GOOD EMPIRICAL DATA ON. BUT WHAT I CAN TELL YOU, WHAT PROTECTIVE PROCESSES ARE IN THE COMMUNITIES WE STUDY, IT INVOLVES VERY HIGH LEVELS OF CONTROL. AND VERY HIGH LEVELS OF EXPECTATIONS FOR WHAT BEHAVIORS YOU DO AND WHAT BEHAVIORS YOU DON'T DO, AND IF YOU DO THOSE THINGS YOU'RE NOT SUPPOSED TO DO THERE'S GOING TO BE SOME CONSEQUENCE FOR IT. WHAT OUR DATA SUGGESTS IS IF THOSE LEVELS ARE EXTREMELY HIGH ON A DISTRIBUTION OF FOUR AND FIVE HUNDRED FAMILIES, THERE MIGHT BE SOME HEALTH CONSEQUENCES BENEATH THE SKIN BUT I'M NOT GOING TO VENTURE BEYOND THAT. IS THAT FAIR? >> IT IS. >> (OFF MIC.) >> ABSOLUTELY. ABSOLUTELY. WE HAVE PEOPLE, AS YOU KNOW BETTER THAN PROBABLY I DO, IN THE BLACK BELT WHERE THERE ARE VERY FEW RESOURCES OR PEOPLE TO IMPLEMENT THE KINDS OF PROGRAMS AT LEAST THAT WE DO, AND WHEN WE DO PROGRAMS WE FEEL STRONGLY THAT THERE SHOULD BE A RACIAL MATCH BETWEEN THE PEOPLE WHO DELIVER THE PROGRAMS AND THE RECIPIENT OF THE PROGRAMS SIMPLY BECAUSE WE SPENT A LOT OF TIME WITH PARENTS FOCUSING ON RACIAL DISCRIMINATION AND PROTECTIVE PROCESSES AND THAT IS SOMETHING THAT ONLY WE FEEL AN AFRICAN-AMERICAN PERSON COULD DO IN A PREVENTION CONTEXT. SO CIRCLE BACK AND ANSWER YOUR QUESTION, THERE'S A POSSE, A FRAGILE INFRASTRUCTURE TO DELIVER THESE PROGRAMS. IT SEEMS TO ME THIS IS MORE THEORETICAL THAN EMPIRICAL THAT TELEMEDICINE STRATEGIES I THINK WOULD BE REALLY HELPFUL, AND OTHER DIGITAL STRATEGIES THAT WE HAVE NOT INVESTIGATED YET. BUT I THINK IT WILL BE VERY IMPORTANT. HERE'S-- AT THE END OF THE DAY, WE HAVE TO FILL THE SEATS. IN OTHER WORDS, WHEN WE OFFER THESE PREVENTION PROGRAMS THAT ARE EFFICACIOUS AND THERE'S SOME INDICATION, AND THESE ARE PROOF OF PRINCIPLE, HAVE IMPLICATIONS FOR HEALTH, AND WELL-BEING, WE HAVE TO GET PEOPLE EXPOSED TO THEM AND ONE WAY TO DO THAT MIGHT BE THROUGH THESE OTHER TECHNOLOGIES. WE WORK REALLY HARD ON FILLING THE SEATS AND GETTING PEOPLE TO ATTEND OUR PROGRAMS, AND WHAT WE KNOW IS IF WE CAN GET PEOPLE IN THE FIRST SESSION, FAMILIES AND KIDS, THEY -- THE LIKELIHOOD OF THEM ATTENDING THE REST OF THE SESSIONS, AND THESE PREVENTION PROGRAMS I DIDN'T HAVE A LOT OF TIME TO REALLY DETAIL THEM FOR YOU. THEY ARE A TOTAL OF 14 HOURS. AND 14 HOURS OF PREVENTION, YOU COULD SEE UNDER THE SKIN AND IN THE BRAIN, 14 YEARS LATER. NOW, WE JUST REPLICATED SOME OF THESE RESULTS IN A PAPER THAT CAME OUT RECENTLY. BUT THOSE ARE POWERFUL FINDINGS. WE NEED OTHER TRIALS. I DID NOT HAVE PRE-TEST LEVELS OF THE BIOMARKERS, YOU KNOW, SO I COULDN'T TALK ABOUT CHANGE. BUT THESE FINDINGS ARE STRONG PROOF OF PRINIPLE RESULTS THAT I THINK ARE WORTH NIH PAYING ATTENTION TO. >> [OFF MICROPHONE]. >> ALL RIGHT. >> LET ME THANK DR. BRODY AGAIN FOR A VERY INSIGHTFUL TALK AND PRESENTATION. I'M SURE THERE'S A LOT MORE QUESTIONS BUT WE'RE GOING TO MOVE TO THE PANEL DISCUSSION. FIRST LET ME INVITE ANYONE SEATED ON THIS SIDE OF THE ROOM, THERE ARE ACTUALLY MORE CHAIRS OVER HERE. THERE WON'T BE ANY PRESENTATION. SO IF ANYONE WANTS TO MOVE OVER TO SEE OUR PANELISTS FEEL FREE BECAUSE THERE'S PLENTY OF SEATS ON THIS SIDE. IF I TRIED TO INTRODUCE MY PANELISTS AND GIVE YOU -- I'M GOING TO INTRODUCE THE PANELISTS, DIRECTOR OF OFFER OF WORK FORCE DIVERSITY AT NIMH, DR. DIANA BIANCHI, DIRECTOR OF THE NICHD, DR. WILSON COMPTON DEPUTY DIRECTOR OF NIDA, DR. JON LORSCH DIRECTOR OF NIGMS, DR. ELISEO PEREZ-STABLE, DIRECTOR OF NIMHD, AND DR. MELISSA WALLS DIRECTOR OF THE GREAT LAKES HUB FOR JOHNS HOPKINS CENTER FOR INDIAN HEALTH, AMERICAN INDIAN HEALTH AT JOHNS HOPKINS UNIVERSITY. LET ME START OUT BY ASKING THE PANELISTS, WE CAN START AT THE FAR END, TO REALLY TALK ABOUT YOUR YOUR ORGANIZATION'S PRIORITIES AND MAJOR CHALLENGES IN RURAL HEALTH SPACE. >> TEST, TEST, TEST. GOOD MORNING, EVERYONE. I'M MELISSA WALLS. DR. BRODY AND I ARE IN AN ACRONYM SANDWICH. THAT'S MY JOKE TO START US OFF. AS YOU HEARD, I DIRECT THE GREAT LAKES HUB, CENTER FOR AMERICAN INDIAN HEALTH AT JOHNS HOPKINS. I DON'T LIVE IN BALTIMORE. I LIVE IN DULUTH, MINNESOTA. AND I DO THIS BECAUSE, WELL, I'M OJIBWAY AND WORK WITH TRIBAL COMMUNITIES IN OUR REASON. THE CENTER AT HOPKINS SAW TO DO THAT WORK YOU HAVE TO STAY WHERE YOU ARE, STAY IN COMMUNITY PARTNERSHIPS. AND SO I APPLAUD THE CENTER AND HOPKINS FOR SEEING THAT VISION. AND I NOTICED IN REMARKS THIS MORNING THAT DISTANCE AND SOMEONE MENTIONED THE TOP TEN UNIVERSITIES ON THE TWO COASTS, WE NEED TO BRING THAT MOLD, THAT'S THE FIRST CHALLENGE. I ALSO JUST WANT TO SAY I COULD GO ON AND ON ABOUT INEQUITIES, I'LL BE TALKING ABOUT THAT IN ANOTHER BUILDING, BUILDING 1 AT 1:30, THE OFFICE IS HAVING A NATIVE AMERICAN HERITAGE MONTH LECTURE, YOU CAN COME OVER TO THAT. I WON'T GO ON AD NAUSEAM NOW. I WAS THANKFUL DR. BRODY ENDED ON A POSITIVE NOTE, STRENGTH AND RESILIENCE AND CULTURE AND COMMUNITY THAT RULE AND AMERICAN INDIAN COMMUNITIES HAVE. WHEN WE REALLY TRIED TO SHIFT THE NARRATIVE AND MEASURE POSITIVE OUTCOMES, IN ADDITION TO INEQUITIES WE FACE, WE TELL A REALLY DIFFERENT STORY ABOUT WHAT HAPPENS IN THOSE COMMUNITIES. AND IT'S A SUPER POWERFUL NARRATIVE. I WOULD ENCOURAGE US TO BE BALANCED IN OUR APPROACH. WE NEED TO STUDY THE PROBLEM AT NIH. OUR PROGRAM OFFICIALS TELL US THAT ALL THE TIME, ESTABLISH SIGNIFICANCE AND DO ALL OF THIS, BUT AT THE SAME TIME WE CAN BALANCE WITH SOME POSITIVE THINGS, I'LL SAY IN TRIBAL COMMUNITIES WE SEE ASTRONDING RATES OF FLOURISHING MENTAL HEALTH STATUS, COMMUNITY CONNECTEDNESS THAT PROMOTE POSITIVE OUTCOMES AND CHRONIC DISEASE, MENTAL HEALTH AND OTHER CONDITIONS, I WOULD ENCOURAGE US TO THINK ABOUT THOSE AS WELL. >> I'M STACY ARNESON, NATIONAL LIBRARY OF MEDICINE. OUR MISSION IS TO COLLECT ORGANIZE AND DISSEMINATE HEALTH INFORMATION TO ALL. WE DO THIS THROUGH A NUMBER OF DIFFERENT RESOURCES, AND WE REALIZE EVEN THOUGH WE CREATE THESE RESOURCES AND PROVIDE ACCESS FOR FREE IT DOESN'T MEAN EVERYBODY HAS ACCESS TO THEM. OVER 25 YEARS WE'VE BEEN ACTIVELY ENGAGED IN MULTIPLE COMMUNITIES TO HELP THEM GET ACCESS, ACCESS IN WAYS THEY NEED AND PROVIDE THE INFORMATION AND WAYS AND FORMATS THAT THEY WOULD LIKE ACCESS TO. SO, WE STARTED WORKING IN AREA OF ENVIRONMENTAL HEALTH, HIV/AIDS, AND THEN HAVE EXPANDED MORE BROADLY TO FUND COMMUNITY-BASED ORGANIZATIONS AS WELL AS LIBRARIES WHICH ARE TRUSTED SOURCES OF INFORMATION. LIBRARIES ARE PART OF LOCAL GOVERNMENTS, THEY ARE NOT OFTEN SEEN AS GOVERNMENTS, SEEN AS TRUSTED RESOURCE TO GET THIS INFORMATION OUT. AND WE HAVE PLACED A FAIR AMOUNT OF EMPHASIS ON HEALTH LITERACY. WE NEED TO MAKE SURE PEOPLE CAN GET THE INFORMATION IN THE WAYS THEY NEED. ON THE RESEARCH END, NLM IS TAKING AN ACTIVE APPROACH TO TRYING TO HELP OTHER PARTS OF NIH COLLECT THE INFORMATION AND STANDARDIZE SOME INFORMATION SO WE HAVE COMMON DATA ELEMENT REPOSITORY WHICH SOME ICs ARE REQUIRING GRANTEES TO USE, THEY USE SURVEYS AND TOOLS AND QUESTIONNAIRES AND DATA COLLECTION MECHANISMS THAT HAVE BEEN USED BEFORE SO EVERYBODY DOESN'T RECREATE -- REINVENT THE WHEEL, THEY HAVE AN OPPORTUNITY TO FIND OUT WHAT'S BEEN DONE AND DOWNLOAD AND IMPORT TOOLS INTO THEIR OWN DATA COLLECTION MECHANISMS TO DO THAT, AND IF IT DOESN'T MEET THEIR NEEDS EXACTLY YOU CAN CUT AND PASTE AND COMBINE FROM MULTIPLE SOURCES TO DO THAT. WE'RE ALSO FOCUSING MORE NOW ON DATA SCIENCE AND IDEA OF THE FAIR PRINCIPLES, FINDABLE, ACCESSIBLE, INTEROPERABLE, COLLECTED ONCE AND USED BY MANY TO TRANSLATE RESEARCH QUICKLY. I'LL STOP THERE. . >> IN ADDITION TO OFFICE FOR DISPARITIES RESEARCH AND WORKFORCE DIVERSITY I RUN THE OFFICE OF RURAL MENTAL HEALTH RESEARCH. AND WE'RE THE ONLY LEGISLATIVELY MANDATED RURAL HEALTH OFFICE AT NIH, IT'S IN OUR AUTHORIZATION, SO WE'RE PLEASED THAT THIS DAY CAME AND AGAIN I WANT TO SHOUT OUT TO XINXI AND DAWN WHO COORDINATED. IN TERMS OF RESEARCH WE SUPPORT, WE'RE LOOKING AT NIMH TO REDUCE DISPARITIES, HOPEFULLY ELIMINATE DISPARITIES IN MENTAL HEALTH OUTCOMES, IN DISADVANTAGED POPULATIONS. WE DO THIS IN A NUMBER OF WAYS ACROSS THE INSTITUTE SUPPORTING AND PROMOTING RESEARCH, EVIDENCE-BASED PRACTICES, AND EVIDENCE-INFORMED PRACTICE. I HEARD THIS ISN'T ONE SIZE FITS ALL, THE SAYS FOR MENTAL HEALTH OUTCOMES. I APPRECIATE DR. WALLS' COMMENTS ON RISK AND PROTECTIVE FACTORS. WE HAVE MORE TO LEARN FROM COMMUNITIES AROUND THE COUNTRY, ABOUT BOTH OF THOSE ANGLES, AND AGAIN I COULD GO ON A LONG TIME BUT WE'RE SHORT ON TIME SO I'LL PASS THE MIC. >> WHEN I THINK ABOUT DRUG USE IN RURAL POPULATIONS I'M TRUCK WITH MYTH MANY OF US EXPERIENCED, DRUGS ARE A PROBLEM IN URBAN POOR AREAS. NOTHING COULD BE FURTHER FROM THE TRUTH. WE WE SEE PROBLEMS OF PRESCRIPTION DRUG MISUSE, OUTBREAKS OF HIV AND HEPATITIS C IN RURAL POPULATIONS, UNPREPARED FOR HEALTH ISSUES. WE HAVE AN ISSUE IN TERMS OF TOBACCO USE, AND I'M HERE INSTEAD OF DR. NORA VOLKOW BECAUSE WE HAVE ANOTHER MEETING AT NIDA ON METHAMPHETAMINE, ISSUES THAT HAVE AFFECTED RURAL AREAS DISPROPORTIONATELY. WHAT ARE WE DOING AT NIDA? WE HAVE MULTIPLE PROGRAMS, DIFFICULT SERVICE DELIVERY QUESTIONS BECAUSE OF THE ISSUES YOU'VE HEARD, LACK OF SERVICES, DISPERSION OF POPULATION AND SYSTEMS OF CARE WE NEED TO TAKE CARE OF COMPLEX PROBLEMS BUT WE'RE DOING THIS BY ENGAGING IN SERIOUS PARTNERSHIPS. WE HAVE A PARTNERSHIP WITH CENTERS FOR DISEASE CONTROL, APPALACHIAN REGIONAL COMMISSION, AN ECONOMIC DEVELOPMENT ORGANIZATION BUT THEY REALIZE THE ECONOMIC PROBLEMS IN THAT PART OF THE COUNTRY DEPEND ON HEALTH ISSUES, SO THEY ARE PARTNERING TO BRING NEEDED HEALTH CARE SYSTEMS TO ADDRESS. I'M THRILLED WE'RE SUPPORTING DR. GENE BRODY AND DR. MELISSA WALLS IN THEIR INNOVATIVE WORK TO IMPROVE HEALTH CARE SYSTEMS THROUGH IMPROVING TREATMENT AND PREVENTION SERVICES FOR NEEDY POPULATIONS IN RURAL AREAS. CAN WE ADDRESS POVERTY IN RURAL AREAS? THE ANSWER IS YES. WE MIGHT BE ABLE TO IMPLEMENT LOW INTENSITY INTERVENTIONS AND HAVE A LASTING IMPACT. THAT'S A VERY HOPEFUL MESSAGE AS WE THINK ABOUT LOU TO ADOPT, ADAPT, IMPLEMENT THESE WIDELY. THANKS VERY MUCH. >> I'M DR. BIANCHI FROM NATIONAL INSTITUTE OF CHILD HEALTH AND HUMAN DEVELOPMENT. OUR NAME IS SOMEWHAT OF A MISNOMER BECAUSE WE'RE NOT ALL OF CHILD HEALTH AT NIH. SIMILARLY OUR INSTITUTE FOCUSES ON REPRODUCTIVE HEALTH, CHILD HEALTH, AND REHABILITATION HEALTH. WE RELEASED OUR STRATEGIC PLAN, FIRST IN 20 YEARS. YOU CAN LOOK AT IT. IMPORTANTLY, HEALTH INEQUITIES, HEALTH DISPARITIES ARE WOVEN THROUGH EACH OF THE FIVE STRATEGIC THEMES. I WAS STRUCK BY DR. GIBBONS' PRESENTATION BECAUSE ALL OF THE RISK FACTORS THAT HE TALKED ABOUT IN THE SOUTHERN BLACK BELT ARE NOW SERIOUSLY AFFECTING WOMEN CONTEMPLATING PREGNANCY OR BECOME PREGNANT AND INCREASING MORBIDITIES ARE A BIG REASON FOR DISPARITY IN MATERNAL MORTALITY. THIS IS A MAJOR PUBLIC HEALTH PROBLEM, AND WE NEED TO DO SOMETHING ABOUT IT. THIS IS ON FOCUS IN OUR STRATEGIC PLAN, ALSO A FOCUS OF PARTNERSHIPS WITH OTHER INSTITUTES AND CENTERS. WE TAKE THE LONG VIEW. DR. BRODY WHOM WE'VE FUNDED FOR MANY DECADES ALLUDED TO EARLIER THAN EARLIER CHILDHOOD, WE BELIEVE THERE ARE DEVELOPMENTAL ORIGINS TO HEALTH AND DISEASE AND STRESS THAT PARTICULARLY AFRICAN-AMERICAN WOMEN ARE EXPERIENCING EVEN BEFORE THEY BECOME PREGNANT HAS LONG-TERM EFFECTS ON THE HEALTH OF THE CHILD AS WELL AS THE MOTHER. SO, THIS IS A MAJOR FOCUS FOR OUR INSTITUTE, IN PARTNERSHIP WITH THE ENVIRONMENTAL CHILD -- ENVIRONMENTAL INFLUENCES ON CHILD HEALTH OUTCOMES STUDY, AND THE RURAL HEALTH NETWORK THAT JON LORSCH I'M SURE IS GOING TO MENTION, WE'RE WORKING ON TREATING INFANTS WHO HAVE BEEN EXPOSED TO OPIOIDS IN UTERO, IN A STUDY CALLED "ACT NOW." SO WE'RE TRYING TO ADDRESS ANOTHER MAJOR PUBLIC HEALTH PROBLEM THERE WITH WHAT'S HAPPENING TO THE CHILDREN AND WHY ARE WOMEN OF REPRODUCTIVE AGE GETTING ON OPIOIDS. WE'RE FUNDING A NUMBER OF STUDIES TAKING THE LONG VIEW FOLLOWING COHORTS SUCH AS DR. BRODY'S TO LOOK AT THIS VERY COMPLEX INTERSECTION OF ECONOMIC STRESS, PSYCHOLOGICAL STRESS, INABILITY TO ACCESS HEALTH CARE AND WHAT DOES THAT DO TO CHILDREN AND FAMILIES OVER MULTIPLE GENERATIONS SO WE'RE REALLY LOOKING TRANSGENERATIONALLY AT A NUMBER OF THESE PROBLEMS, IT'S A MAJOR FOCUS OF OUR STRATEGIC PLAN. THANK YOU. >> GOOD MORNING AGAIN. I'M ELISEO PEREZ-STABLE FROM NATIONAL INSTITUTE ON MINORITY HEALTH AND HEALTH DISPARITIES. I HAD THE OPPORTUNITY TO EXPRESS OUR PERSPECTIVES EARLIER, SO I WILL LEAVE IT AT THAT FOR THE MOST PART. EMPHASIZE THAT PEOPLE IN RURAL AREAS ARE DISPARITY POPULATION, AS IS IN OUR LEGISLATION, SO WE'RE INTERESTED IN RURAL COMMUNITIES, THAT'S BUILT INTO OUR INSTITUTE. ALTHOUGH I DO WANT TO REEMPHASIZE THE IMPORTANCE OF FACTORING IN BOTH RACE/ETHNICITY AND SOCIOECONOMIC STATUS OF TWO PILLARS ON RESEARCH FROM OUR VIEW, FUNDAMENTAL LENS ON WHICH TO EVALUATE WHAT HAPPENS TO HUMAN BEINGS IN THEIR BOTH HEALTH TRAJECTORY, THE SAME TRUE FOR RURAL AREAS, WHEN YOU THINK ABOUT WHO WE'RE MOST INTERESTED IN IN RURAL AREAS, MOST ARE GOING TO BE MINORITIES OR POOR. AND THAT'S REALLY THE FOCUS OF IT AND HOW THESE THINGS INTERACT BECAUSE I DON'T THINK IT'S ALWAYS STRAIGHTFORWARD. I ALSO WANT TO SUPPORT THE IDEA WE SHOULD LOOK AT POSITIVE ASPECTS OF COMMUNITIES, NOT EVERY POOR COMMUNITY DOES POORLY, OR HAS ADVERSE HEALTH CONSEQUENCES, I THINK UNDERSTANDING THE MECHANISM OF THE FACTORS THAT CONTRIBUTE TO THAT ARE IMPORTANT. CERTAINLY WE THINK THAT GETTING PEOPLE NOT TO USE DRUGS AND BECOME MORE EDUCATED IS A GOOD THING, IF THERE ARE ADVERSE EFFECTS OF THAT PROCESS WE HAVE TO FIGURE OUT TO AMELIORATE THOSE RATHER THAN PREVENT PROGRESSION TO HAPPEN. LASTLY I'LL JUST PUT IN IMPORTANCE OF THE DIVERSITY IN BIOMEDICAL WORKFORCE, WE'RE FOCUS ON THAT, AS INSTITUTE AND AGENCY HAVING MORE UNDERREPRESENTED MINORITIES LEAD THIS WORK AND CERTAINLY INDIVIDUALS OF ANY RACE/ETHNICITY OF DISADVANTAGED BACKGROUND BE INVOLVED IN SCIENCE TO OUR COLLECTIVE BENEFIT AS A SOCIETY. THANK YOU. >> SO NIGMS HAS TWO MAIN PROGRAMS THAT INTERSECT WITH RURAL HEALTH RESEARCH, FIRST IS THE INSTITUTIONAL DEVELOPMENT AWARDS PROGRAM, THE IDEA PROGRAM. IF YOU'RE NOT FAMILIAR, IDEA FUNDS RESEARCH AND RESEARCH CAPACITY BUILDING IN STATES THAT HISTORICALLY HAVEN'T RECEIVED VERY MUCH NIH FUNDING, CURRENTLY 23 STATES AND PUERTO RICO WHICH ARE IDEA STATES, AND MOST OF THOSE STATES HAVE VERY SIGNIFICANT RURAL POPULATIONS. THESE ARE STATES LIKE MAINE, WEST VIRGINIA, MISSISSIPPI, WYOMING, ALASKA, ET CETERA. ALL STATES YOU HEARD ABOUT BEFORE. WITHIN THE IDEA PROGRAM, WE'RE TRYING TO INCREASE EMPHASIS ON RESEARCH THAT'S FOCUSING ON RURAL HEALTH AND RURAL HEALTH DISPARITIES, AND SO ONE AREA IS PRACTICE-BASED RESEARCH NETWORKS IN THE CENTERS WE FUND, SO TWO MAIN CENTERS WE FUND ARE THE CLINICAL AND TRANSLATIONAL RESEARC AWARDS, WHICH ARE ANALOGOUS TO, YOU KNOW, THE CTSAs AT NCATS, FOCUSED ON IDEA STATES, AND WITHIN THOSE TRYING TO INCREASE USE OF PRACTICE-BASED RESEARCH NETWORKS TO GET ACCESS TO POPULATIONS THAT GENERALLY DON'T COME AS READILY TO ACADEMIC MEDICAL CENTERS. THE ARCHETYPE IS REALLY CTR IN WEST VIRGINIA AT WVU WHERE THEY HAVE A PBRN THAT INCLUDES OVER 100 CLINICAL SITES ACROSS THE STATE, MANY IN VERY RURAL AREAS, IF YOU THINK ABOUT THE ACCESS NOW THAT ONE HAS TO PATIENTS IN THOSE RURAL AREAS, AND THE HEALTH CARE PROVIDERS THAT THEY TRUST HAVE RELATIONSHIPS THAT WE CAN EXPAND THE ABILITY TO DO RESEARCH IN THOSE AREAS. THAT'S ONE AREA. THE IDEA PROGRAM. THE OTHER IS NATIVE AMERICAN RESEARCH CENTERS FOR HEALTH, NARCH, WHICH NIGMS FUNDS, AND OTHER IC INSTITUTES AND CENTERS AT NIH CONTRIBUTE TO. THESE FUND RESEARCH THAT IS CONCEIVED AND CONDUCTED BY NATIVE AMERICAN ALASKA NATIVE TRIBAL ORGANIZATIONS, AND SO THOSE ORGANIZATIONS SET THE PRIORITIES FOR RESEARCH, THEY MAKES IT DIFFERENT THAN MANY FUNDING OPPORTUNITIES TARGETED AT NATIVE AMERICAN AND ALASKA HEALTH. THEY ARE IN CONTROL OF FUNDS AND SET RESEARCH AGENDA. AND SO I THINK THAT PROVIDES A LOT OF OPPORTUNITIES AGAIN FOR RESEARCH IN RURAL POPULATIONS. THE OTHER PROGRAM THAT WE'RE INVOLVED IN THAT DIANA MENTIONED, WHICH RELATED TO THE IDEA PROGRAM IS THE IDEA STATES PEDIATRIC CLINICAL TRIALS NETWORK RUN BY THE ECHO PROGRAM. THAT PROVIDES FUNDING TO SUPPORT RESEARCH CAPACITY BUILDING DEDICATED TO INFRASTRUCTURE FOR PEDIATRIC CLINICAL TRIALS IN IDEA STATES, THEY HAVE A HE CAN TO US AGAIN ON REACHING OUT INTO RURAL COMMUNITIES TO FIND SYNERGIES, OPPORTUNITIES FOR THOSE OF YOU INTERESTED EITHER WITHIN THE NIH OR PARTNERING WITH THE IDEA PROGRAM OR NARCH PROGRAM OR OUTSIDE FOR APPLYING FOR THOSE FUNDS. COUPLE OF QUESTIONS FROM THE AUDIENCE IF THERE ARE ANY. >> CAN YOU HEAR ME? YEAH? AS ELISEO JUST MENTIONED, MANY OF US ARE WORKING VERY HARD TO TRY TO INCREASE THE DIVERSITY OF BIOMEDICAL WORKFORCE. I WAS A BIT CHALLENGED BY ONE OF YOUR MAIN CONCLUSIONS FROM THE SKIN DEEP RESILIENCE STUDY THAT THE CONSEQUENCE OF STRIVING. >> YES. >> SO I JUST WONDER, SO MY QUESTION TO YOU, AS WELL AS OTHER LEADERS IN THE PANEL, IN OUR DAILY EFFORT WHAT WOULD BE YOUR ADVICE HOW TO ADDRESS THIS IF I DIDN'T KNOW THAT, GO AND DO MY JOB, NOW THAT I KNOW THIS HOW DO I DEAL WITH IT? >> THAT'S A QUESTION WE'VE GIVEN A LOT OF THOUGHT TO. WE THINK THAT EVERY CHILD, EVERY ADOLESCENT, EVERY YOUNG ADULT SHOULD HAVE A MEDICAL HOME. AND A MEDICAL HOME THAT MONITORS THEIR HEALTH AND WELL BEING. AND THERE ARE MANY PEOPLE, AT LEAST IN THE AREAS THAT WE STUDY, WHO DON'T HAVE A MEDICAL HOME. SO, A YEARLY PHYSICAL FOR STRIVERS, NON-STRIVERS, SKIN DEEP RESILIENCE, FOLKS NON-SKIN DEEP RESILIENCE FOLKS, EARLY WARNING SIGNS COULD BE PICKED UP. ONE OF THE THINGS THAT HAPPENS THAT WE WITNESS ANECDOTALLY IS THAT WHEN PEOPLE HAVE UNRELENTING SELF DETERMINATION, THEY LET THINGS LIKE DIET AND EXERCISE GO. NOT ONLY ARE THEY NOT BEING MONITORED HEALTH-WISE BUT THEIR HEALTH BEHAVIORS ARE ALSO FALLING BY THE WAYSIDE. WE DON'T HAVE A SOLUTION YET FOR THIS. WE'VE DESCRIBED THE PHENOMENON. WE AS RESEARCHERS HAVE TO GO BEYOND DESCRIPTION AND TO START IDENTIFYING THE MECHANISTIC INGREDIENTS THAT CAUSE SKIN DEEP RESILIENCE BUT SINGLE-MINDED DETERMINATION TO SUCK SEAT AT ALL COSTS PARTICULARLY IF YOU'RE THE FIRST CHILD IN THE FAMILY TO, SAY, ATTEND COLLEGE, YOU KNOW. THERE COULD BE THESE UNINTENDED CONSEQUENCES THAT AT THE VERY LEAST COULD BE PICKED UP WITH REGULAR HEALTH EXAMINATION. >> CAN I ADD? I'M A SOCIOLOGIST, SOMETIMES I CAN BE A LITTLE DRAMATIC. YOU HAD ME AT WILLIAM JULIUS WILSON. WE LIVE THIS IN OUR LIVES AS AN INDIGENOUS PERSON. WHAT IF WE TALKED ABOUT THE METRICS OF SUCCESS IN A DIFFERENT WAY. WHAT IF WE STOPPED -- STARTED TO REALIZE CAPITALISM IS KILLING US BUT KILLING PEOPLE OF COLOR, INDIGENOUS PEOPLE OF COLOR AND WOMEN MORE THAN WHITE MEN, THE SYSTEM WORKS THE WAY IT'S SUPPOSED TO WORK AND METRICS OF SUCCESS COULD BE BROADENED AND WE COULD EMBED STUDENTS, PEOPLE OF COLOR, INDIGENOUS PEOPLE, WOMEN, IN COLLECTIVE CULTURE LIKE I'M DOING LIVING BACK AT HOME THAT CAN BUFFER UNINTENDED CONSEQUENCES AND REDUCE STRESSFUL EFFECTS OF STATUS AND CONSISTENCY. I THINK THE MACHINE IS BROKEN. AND WE HAVE TO BE REALLY BOLD AND DRAMATIC AND REALLY REVOLUTIONARY IF WE'RE EVER GOING TO CHANGE THESE INEQUITIES. [APPLAUSE] >> I WANT TO AMPLIFY THAT FROM THE WORKFORCE DIVERSITY TRAINING OFFICE AS WELL THAT DATA ARE NOW SHOWING MORE NURTURING TRAINING ENVIRONMENT, MORE SUPPORTIVE BOTH FOR DIVERSE SCIENTISTS AND WOMEN IN GENERAL ARE PROVIDING THOSE SITUATIONS SO WE BRING THOSE PERSPECTIVES INTO SCIENCE. IT'S VERY REAL. I THINK THE NIH FROM OUR PERSPECTIVE HAS A RESPONSIBILITY TO ENSURE THAT OUR NEW TRAINING ENVIRONMENT HAS THOSE PROTECTIONS AND THAT SUPPORT AND NURTURING THAT'S NEEDED FOR THE NEXT GENERATION. >> FOR MEN TOO. >> I WAS GOING TO SORT OF MENTION SOME OF THE SAME ISSUES IN TERMS OF BRINGING IT BACK TO OUR OWN TRAINING PROGRAMS AN OUR OWN SUPPORT WE NEED TO BE THINKING ABOUT SELF CARE WITHIN THE TRAINING GRANTS THAT WE HAVE, WITHIN THE INDIVIDUAL CAREER AWARDS, SO IT'S NOT JUST ABOUT THE SCIENTIFIC AIMS, OUR PRIMARY GOAL, BUT THE LONG TERM GOALS FOR CAREERS AND FOR HEALTH FOR THE INDIVIDUALS INVOLVED CAN PLAY AN IMPORTANT ROLE. I DON'T THINK WE HAVE THOUGHT ABOUT THAT SO MUCH IN TERMS OF OUR TRAINING PROGRAMS, IT MIGHT BE SOMETHING TO RECONSIDER IN LIGHT OF THESE FINDINGS. >> LATER -- SORRY, CAN I CONTINUE TO ANSWER? LET THIS WEEK WE HAVE OUR ANNUAL LEADERSHIP FORUM, A RETREAT FOR THE INSTITUTE AND CENTER DIRECTORS AT NIH. WE TALK ABOUT A NUMBER OF VERY HIGH LEVEL TOPICS. ONE OF THE THINGS WE WILL BE TALKING ABOUT IS INCREASING DIVERSITY OF THE WORKFORCE. AND MY TOPIC WILL BE ON HOW DO WE HELP PEOPLE WITH CHILD CARE, SO IT'S NOT JUST ABOUT THE INDIVIDUAL BUT HOW DO YOU SUPPORT THAT INDIVIDUAL AND THEIR FAMILY? I MEAN, GRANTED YOU COULD TALK ABOUT ELDER CARE AS WELL, BUT AT THE AGE OF OUR YOUNG TRAINEES, WE DON'T WANT THEM TO HAVE TO CHOOSE BETWEEN THEIR CAREER AND EITHER HAVING A FAMILY OR TAKING GOOD CARE OF THEIR FAMILY. THE MORE I LEARN ABOUT THIS, I TALK WITH PEOPLE IN MY TRAVELS, THIS IS A HUGE ISSUE. AND OF COURSE IT REFLECTS OUR SOCIETY IN GENERAL. BUT I'M HOPING THAT WE CAN DO SOMETHING ABOUT IT AT NIH. >> SO TO WILSON' POINT, NIGMS HAS THE LARGEST TRAIN PORTFOLIO AT NIH. WE FUND HALF OF ALL THE GRADUATE STUDENT T32 PRE-DOCTORAL SLOTS THAT NIH GIVES. WE HAVE TWO YEARS AGO REWROTE AND WROTE OUR OWN FUNDING OPPORTUNITY ANNOUNCEMENT FOR OUR T32 PROGRAMS, AND WE INCORPORATE STRONG LANGUAGE IN THEM ABOUT THE SAFETY, INCLUSIVENESS AND SUPPORTIVE NATURE OF THE TRAINING PROGRAMS WHICH IS NOW PART OF THE REVIEW CRITERIA. I WOULD ENCOURAGE THOSE OF YOU FROM NIH INVOLVED IN TRAINING TO LOOK AT OUR NEW WAYS AND THINK ABOUT INCORPORATING THAT LANGUAGE INTO YOUR FOAs, BECAUSE IT'S NOW HAD TWO YEARS OF VETTING AND ROAD TESTING AND I THINK IT'S BEEN RECEIVED QUITE WELL BY THE COMMUNITY. >> I'M JUST COMMENT WHAT ELSE WOULD WE EXPECT? I MEAN, THIS IS THE PRIOR TRACK RECORD OF WHAT HAPPENED WITH ECONOMIC DEVELOPMENT. YOU KNOW, OBESITY, DIABETES, HEART DISEASE, MORE COMMON IN HIGHER INCOME SOCIETIES INITIALLY, 19th CENTURY ENGLAND, AS TUBERCULOSIS AND MALNUTRITION GOT DIMINISHED, INFECTIOUS DISEASES. SO, WE'RE SEEING IT REPLAY.% AND NOW WE KNOW WHAT TO DO BETTER. SO THERE ARE WAYS TO AMELIORATE THAT. YOU STILL HAVE TO SMOKE. YOU STILL HAVE TO GAIN WEIGHT. YOU STILL HAVE TO NOT BE ACTIVE IN ORDER TO REALLY MAXIMIZE THESE RISKS THAT WE'RE DELINEATING. CERTAINLY I THINK RECONNECTING OR STAYING CONNECTED TO CULTURE AND COMMUNITY ARE VERY POWERFUL INTERVENTIONS THAT WE DON'T REALLY UNDERSTAND THE MECHANISMS OF NECESSARILY, BUT ARE REALLY PROBABLY BASED ON ENOUGH OBSERVATIONAL DATA TO SAY WE OUGHT TO BE SUPPORTING THEM. SO, I THINK THE LONG TERM VIEW HERE, EDUCATION IS GOOD FOR THE POPULATION, EDUCATION IS GOING TO BE GOOD FOR THE COMMUNITY, FOR THE INDIVIDUALS, AND THEY ARE GOING TO RAISE COMMUNITY UP. SO I WOULDN'T -- I'M NOT SURPRISED AT THESE, YOU KNOW, INTERMEDIATE VARIABLE OUTCOMES BECAUSE PRIOR EXPERIENCE EPIDEMIOLOGICALLY SHOW THE SAME THING. AND EVENTUALLY THEY GOT BETTER. SO-- >> I TOTALLY AGREE WITH ALL THE SUGGESTIONS BUT THE BIGGEST CHALLENGE TO ME WAS THE SKIN DEEP PORTION OF IT. THE CELLULAR AGING BLACK ONLY, NOT IN YOUR STUDY, NOT SHOWING IN WHITE. I ASSUME THE CONTROL IS -- I THINK THAT IS THE BIG CHALLENGE. I KNOW YOU'RE STILL UNPACKING. I THINK MYSELF INCLUDED MANY PEOPLE ARE EXPECTING, WAITING FOR THE UNPACKING TO AM COULD. THANK YOU. >> INDEED FOR DR. BRODY, WAS INTERESTED IN THE PART YOU SAID THERE'S CELLULAR DAMAGE. THERE WAS -- CAN YOU GIVE US A LITTLE MORE THAN THAT? WHAT IS IT? >> SO, THESE INDICATORS ARE BASED UPON GENOME-WIDE METHYLATION ANALYSES, AND THE ALGORITHMS WHICH DETERMINE ACCELERATED CELLULAR AGING, BASICALLY LOOK AT CERTAIN CPG ISLANDS, WHAT HAPPENS WHEN A METHYL GROUP BINDS TO THOSE SO THAT THEY ACT LIKE A DIMMER SWITCH, NOT ALLOWING GENE EXPRESSION, AND WHEN PLACES ON THE GENOME HAVE THAT OCCURRENCE, THEN THE CELLULAR AGE BECOMES OLDER THAN THE PERSON'S BIOLOGICAL AGE. >> OKAY. I'LL MAKE THIS REALLY QUICK. I CAN'T TELL YOU HOW MOVED I AM BY THE DISCUSSION. CURIOUS ON TWO DIMENSIONS. GIVEN THAT ALL THE FUNDING EVENTUALLY EMANATES FROM CONGRESS, WHAT POLICY OR LEGISLATIVE GAPS DO YOU SEE AS HURDLES OR CHALLENGES TO ACHIEVING, YOU KNOW, THE ULTIMATE GOAL OF GETTING BETTER OUTCOMES AND MORE IMPORTANTLY HOW ARE YOU INTERACTING WITH OTHER GOVERNMENT AGENCIES THAT MAY HAVE A BIT OF A PARALLEL OBJECTIVE? FOR EXAMPLE, I KNOW AHRQ DOES A LOT AROUND MINORITIES AND THE IN THE WORKFORCE, PREPARING THE WORKFORCE. HRSA HAS AN EXTREMELY BROAD TELEHEALTH RESOURCE CENTER FOOTPRINT THAT COULD PROVIDE SOME OF THE -- THAT LAST MILE CONNECTIVITY TO THE PEOPLE IN THE LAST RURAL COMMUNITY, POSITIVE ACTIVITY AND WORKING WITH OTHER GOVERNMENT AGENCIES, WHAT ACTIONS ARE YOU TAKING TO MOVE THE NEEDLE? IF THAT MAKES SENSE. >> I'LL START HERE. PARTNERSHIPS WITH OTHER AGENCIES IS A KEY PART OF OUR WORK IN ADDRESSING THE OPIOID CRISIS AND OTHER ASPECTS OF DRUG USE AND DRUG ADDICTION ACROSS THE UNITED STATES. I HIGHLIGHTED PARTNERS, SAMHSA, HRSA. THE DEPARTMENT OF AGRICULTURE SUPPORT COOPERATIVE EXTENSION SERVICE UNIVERSITIES AND COOPERATIVE EXTENSION SERVICE MEMBERS ACROSS THE COUNTRY, HAVE BEEN INSTRUMENTAL IN IMPLEMENTING PREVENTION PROGRAMS AROUND THE COUNTRY. THEY ARE A HIDDEN RESOURCE WE DON'T THINK B THEY PAY FOR A LOT OF HOUSING AND MEDICAL CARE AND MEDICAL BUILDING IN RURAL PARTS OF THE COUNTRY. SO THAT'S ANOTHER ONE. I WOULD HIGHLIGHT INDIAN HEALTH SERVICE, MAYBE NOT THE PREVENTION BUT CERTAINLY FOR THOSE AREAS. >> I WOULD SAY THAT FOR MATERNAL MORTALITY, I SHOULD HAVE SAID THAT THE REASON WHY WE'RE VERY FOCUSED ON THIS IS THAT BLACK WOMEN HAVE FOUR TIMES THE RATE OF MORTALITY THAN WHITE WOMEN WHEN MATCHED FOR AGE. THERE'S ALSO AN EFFECTIVE AGE SO IF YOU'RE AN OLDER BACK WOMAN, YOU HAVE A MUCH HIGHER RATE OF MORTALITY, AS DO AMERICAN INDIANS AND ALASKA NATIVES. THIS HAS COME TO THE ATTENTION OF ASSISTANT SECRETARY FOR HUMAN HEALTH, THE SECRETARY IS INVOLVED, WE'RE PARTNERING WITH CDC, A GREAT SOURCE OF DEMOGRAPHIC INFORMATION, HRSA IS INVOLVED. INTERESTINGLY, CMS, THEY HAVEN'T REALLY FOCUSED ON THIS ISSUE BUT THERE ARE STATE -- TREMENDOUS STATE-TO-STATE VARIATIONS IN MATERNAL MORTALITY RATES, AND SOME OF THE WORST STATES ARE IN THE BLACK BELT, CALIFORNIA HAS SHOWN IT IS POSSIBLE TO SIGNIFICANTLY REDUCE THESE RATES. SO I THINK IT IS HOPEFUL THAT CERTAIN STRATEGIES CAN MAKE A DIFFERENCE, AND SO WE'RE TRYING TO LEARN BOTH FROM CALIFORNIA AND WE'RE ALSO TRYING TO ENCOURAGE CMS, FOR EXAMPLE, TO LINK MOTHER AND BABY RECORDS SO WE CAN GET A HANDLE ON INFANT MORTALITY WHICH DISPROPORTIONATELY AFFECTS BLACK INFANTS. ONE OTHER UNRELATED THING, THAT'S I THINK THERE'S A GREAT OPPORTUNITY WITH THE INTERNET IF WE CAN EXPAND COVERAGE, THAT IS A WAY OF GETTING MORE INFORMATION OUT TO PEOPLE IN RURAL COMMUNITIES. WE ALSO KNOW THAT AFRICAN-AMERICAN INDIVIDUALS ARE MUCH MORE ACTIVE ON TWITTER, AND THAT IS A WAY OF HEARING VOICES THAT WE DON'T TYPICALLY HEAR. SO I THINK THEY ARE POSSIBILITIES TWO WAY, GETTING INFORMATION TO PEOPLE IN RURAL COMMUNITIES AND GETTING OPINIONS, VOICES, BACK FROM THOSE COMMUNITIES. IF I WERE GOING TO ENCOURAGE POLICY I WOULD ENCOURAGE POLICY TO, YOU KNOW, EXPAND INTERNET COVERAGE IN RURAL AREAS. >> I WOULD LIKE TO EXPAND ON THAT BECAUSE DEPARTMENT OF AGRICULTURE WAS BROUGHT UP. THEY HAVE RURAL UTILITY SERVICE PROVIDING BROADBAND SERVICE TO RURAL COMMUNITIES. AND SO THAT'S SOMETHING THAT'S TRYING TO ADDRESS WHAT YOU'RE TALKING ABOUT. AND WE WORK WITH MULTIPLE AGENCIES, FEDERAL AGENCIES AS WELL AS STATE AND LOCAL. WE ALSO HAVE A NATIONAL NETWORK OF LIBRARIES OF MEDICINE WHICH HAS OVER 6,000 LIBRARIES THAT INCLUDES NOT JUST MEDICAL AND HEALTH SCIENCE LIBRARIES BUT ALSO PUBLIC LIBRARIES THAT WE WORK WITH. THEN ONE OF OUR MAIN AVENUES IS DIRECTLY FUNDING COMMUNITY-BASED ORGANIZATIONS SO THAT THEY CAN HELP DEFINE AND DESCRIBE AND IMPLEMENT PROGRAMS THAT ARE GOING BEST MEET THEIR COMMUNITY NEEDS THAT WE MAY NOT KNOW. >> WE HAVE HAD AN ACTIVE PROGRAM OF TRAINING POSTDOCTORAL MINORITY SCIENTISTS, AND THAT WORK HAS BEEN MADE POSSIBLE BY FUNDING FROM NIDA, AND WE'VE TRAINED THREE GENERATIONS OF AFRICAN-AMERICAN SCIENTISTS NOW, AND ONE OF THE THINGS WE HAVE BUILT INTO OUR TRAINING PROGRAM IS BALANCE IN LIFE AND SELF-CARE. ANOTHER THING THAT WE'VE DONE IS WE'RE PILOTING A MENTORING PROGRAM FOR FIRST GENERATION AFRICAN-AMERICAN COLLEGE STUDENTS WHERE WE PAIR THEM WITH OTHER COLLEGE STUDENTS WHO HAVE BEEN THROUGH THE PROCESS, ARE UNDERGOING THE PROCESS, AND THAT EMOTIONAL AND JUST INSTRUMENTAL SUPPORT STUDENTS HAVE FOUND VERY USEFUL. FINALLY, AS IS PART OF THE OTHER NIDA FUNDING I JUST MENTIONED, WE ARE DEVELOPING INFORMATIONAL PIECES THAT WILL GO OUT ABOUT SKIN DEEP RESILIENCE TO AFRICAN-AMERICAN FAMILIES, BECAUSE THIS IS SOMETHING IN DAILY LIVES PEOPLE DON'T THINK ABOUT. >> IF THERE ARE NO FURTHER COMMENTS FROM THE PANEL, I'LL CLOSE THIS SESSION AND THANK THE PANEL FOR A NICE LIVELY DISCUSSION. AND WE'LL MOVE TO CONCLUDING REMARKS. AS THE PANEL IS TAKING THEIR SEATS, LET ME INTRODUCE -- [APPLAUSE] LET ME INTRODUCE OUR CLOSING COMMENTS BY TOM MORRIS. I ENCOUNTERED TOM WHEN NCATS BEGAN REACHING OUT TO OTHER FEDERAL AGENCIES FOR PARTNERS, PARTICULARLY IN REGARDS TO RURAL HEALTH. TOM IS THE ASSOCIATE ADMINISTRATOR FOR RURAL HEALTH POLICY AT THE HEALTH RESOURCES AND SERVICES ADMINISTRATION, BETTER KNOWN AS HRSA, AND HE IS REALLY ONE OF THE MAIN MAJOR PEOPLE THAT IS INVOLVED IN ADVISING THE HHS SECRETARY ON RURAL HEALTH ISSUES. TOM IS A RELATIVE YOUNGSTER HERE BECAUSE HE WAS A 1996 PRESIDENTIAL MANAGEMENT INTERN, SO HE DOESN' -- SHOULDN'T BE THAT OLD BUT DID HAVE A CAREER AS A NEWSPAPER REPORTER AND EDITOR BEFORE COMING INTO THE FEDERAL GOVERNMENT. TOM? >> GOOD MORNING. THIS HAS BEEN A GREAT EVENT. MY OFFICE, WE LOCATED IN HRSA BUT HAVE A STATUTORY CHARGE TO ADVISORY SECRETARY ON RURAL ISSUES. IT'S A DUAL EXISTENCE. WE HAVE A LOT OF GRANT PROGRAMS AND RESEARCH PROGRAMS THAT FIT INTO WHAT HRSA DOES BUT WE HAVE THIS OTHER CHARGE TO SORT OF COORDINATE ACTIVITIES ACROSS THE DEPARTMENT. AND SO THAT'S WHY IT'S SO ENCOURAGING TO COME HERE TODAY AND HEAR ALL THIS. AND I HAVE TO SAY THIS IS A GREAT WAY TO KICK OFF NATIONAL RURAL HEALTH DAY, WHICH I THINK IS VASTLY BECOMING NATIONAL RURAL HEALTH WEEK, A SERIES OF EVENTS. LET ME PLANT A SEED IF YOU WANT TO LEARN MORE IN THE COURSE OF THE WEEK THERE WILL BE WEBINARS GOING ON TOMORROW, ONE ON MEDICATION-ASSISTED TREATMENT, NEONATAL ABSTINENCE, SUICIDE PREVENTION, AND NEW TOOLKIT AROUND COPD IN RURAL COMMUNITIES, TWITTER CHATS IN THE WEEK AND NATIONAL SERVICE CORPS DOING A VIRTUAL JOB WEBINAR WHERE THEY WILL TRY TO LINK PROVIDERS WHO WANT TO WORK IN RURAL COMMUNITIES WITH RURAL COMMUNITIES. THURSDAY, THE ACTUAL DAY, NATIONAL DAY, KICKING OFF AT HRSA, FEDERAL BADGE SHOULD WORK BUT YOU'RE NEVER SHUE IF YOU CAN GET INTO HHS BUILDING. BUT DEPUTY SECRETARY WILL KICK OFF THAT EVENT WITH LEADERSHIP IN OTHER AGENCIES AT 5600 IN ROCKVILLE. I HOPE YOU COME FOR THAT. IT'S A WONDERFUL OPPORTUNITY WITH NATIONAL HEALTH DAY TO, YES, ACKNOWLEDGE CHALLENGES AND SOME OF THE VERY DAUNTING ISSUES WE FACE IN RURAL COMMUNITIES BUT WE TRY TO PUT A POSITIVE FACE ON THIS AND THINK ABOUT WHAT CAN BE DONE, AND SO I THINK THE PRESENTATION FROM GEORGE TODAY IS A GREAT EXAMPLE IN THE FACE OF DAUNTING CIRCUMSTANCES, YOU KNOW, YOU CAN MAKE A DIFFERENCE BY INTERVENING. SO, ANYWAY, ALL OF THAT IS A LONG WAY OF SAYING WE'RE DOING A LOT IN RURAL. I THINK WE'RE HERE TO HELP PARTNER WITH YOU. IT'S CLEAR THAT WE CAN DO A LOT MORE TO LIFT UP THAT WORK AND MAKE SURE PEOPLE UNDERSTAND IT. REALLY APPRECIATE DR. BRODY'S PRESENTATION. I THINK THE EXAMPLE THAT THEY HAD OF STUDYING AND COMING UP WITH A RURAL INTERVENTION, NOT TRYING TO TAKE AN URBAN INTERVENTION AND APPLY BUT DEVELOP ONE SPECIFIC TO THE POPULATION IS A NICE MODEL TO THINK ABOUT MOVING FORWARD. WHAT Y'ALL ARE DOING, WHAT THE NIH IS DOING IS FANTASTIC. THANKS FOR ALL OF THAT. I THINK IT'S REALLY IMPORTANT. WE'VE HAD SOME NICE INDIVIDUAL PARTNERSHIPS AT NIH AT THE NATIONAL CANCER INSTITUTE, TONY AT NHLBI WITH WORK WITH COPD, AND MICHAEL AND XINGI WITH NCATS, AND LATERALLY DON MORALES AT NIMH, AND SO THERE ARE A LOT OF GREAT OPPORTUNITIES HERE. WE WOULD LOVE TO BE A PARTNER WITH YOU. WE DO RURAL 365 A YEAR, IF WE CAN HELP WITH ANYTHING LET US BE A RESOURCE. THINK ABOUT THAT DEPARTMENT-WIDE CHARGE WE HAVE. WE'RE YOU'RE FEDERAL OFFICE OF HEALTH POLICY SO IF YOU WANT TO TALK ABOUT WAYS TO TARGET RURAL WE CAN HELP YOU WITH THAT. THERE'S ONLY 70 DEFINITIONS OF RURAL. WE CAN HELP YOU WITH THAT. [LAUGHTER] POSSIBILITIES ARE QUITE ENDLESS. THERE'S A LOT OF INTEREST IN RURAL HEALTH RIGHT NOW, IT STARTS WITH THE DEPARTMENT LEADERSHIP. I'VE BEEN DOING THIS DESPITE WHAT MICHAEL SAID, A LONG TIME. THE SECRETARY, DEPUTY SECRETARY ARE COMMITTED TO RURAL HEALTH AS A PRIORITY AT HHS. THAT'S THE FIRST TIME THIS HAS HAPPENED IN MANY YEARS. SO WE HAVE A RURAL HEALTH TASK FORCE, WE GETTING ACTION PLANS WITH AN EYE TOWARDS WHAT CAN WE DO IN 2020 AND BEYOND. SO I'M LOOKING FORWARD TO WHAT WE GET IN NIH AND ALL THE DIFFERENT INSTITUTES. IF YOU BUILD ON WHAT WE TALKED ABOUT TODAY I THINK WE'LL HAVE A GREAT FIRST STEP TOWARD THAT. AT THE SAME TIME THERE'S BROADER INTEREST IN RURAL HEALTH, THE BIPARTISAN POLICY CENTER IS FOCUSING ON A REPORT ON RURAL, THEY WILL RELEASE IN THE COMING WEEKS. JUST LAST WEEK WE WERE ON THE CALL WITH FINANCE COMMITTEE, THEY HAVE AN INTEREST IN RURAL HEALTH ISSUES. WAYS AND MEANS COMMITTEE AT THE HOUSE HAS DEVELOPED A RURAL AND UNDERSERVED COMMITTEE, THE ONE THING THEY CAN AGREE ON BIPARTISAN BASIS WHICH IS THOSE COMMUNITIES FACE A LOT OF SIMILAR CHALLENGES. ALL OF THIS IS A LONG WAY OF SAYING THAT I THINK TIMING IS RIGHT TO REALLY LEVERAGE INTEREST IN RURAL AND MAKE A DIFFERENCE MOVING FORWARD. AND SO I KNOW WITH MY OFFICE WE'VE BEEN DOING THIS A LONG TIME. AND I THINK WE'VE MADE SOME NICE ADVANCES. YET WE KNOW WE REALLY CAN'T MAKE AN IMPACT UNLESS WE DO IT IN TERMS OF PARTNERSHIP. SO WE WORKED WITH CMS FOR A LONG TIME BECAUSE SO OFTEN WHEN YOU TALK ABOUT RURAL HEALTH IT'S DISCUSSIONS AROUND WORKFORCE AND FINANCE BUT JUST BASED ON PRESENTATIONS TODAY WE ALL KNOW IT'S MUCH MORE. SO BUILDING ON MORE PARTNERSHIPS IS CRITICAL. WE'VE WORKED WITH CDC, A GREAT PARTNERSHIP. AND NOW OUR GROWING OPPORTUNITIES WITH NIH WILL BE A FANTASTIC OPPORTUNITY MOVING FORWARD. I THINK ABOUT THE WORK YOU ALL DO. WE'VE DONE RURAL HEALTH SERVICES RESEARCH FOR 30 YEARS. WE BUILT UP A COMMUNITY OF RURAL HEALTH SERVICES EXPERTS THAT DIDN'T EXIST PRIOR TO THAT. BUT HEALTH SERVICES RESEARCH IS ONE THING. RESEARCH YOU ALL DO IS QUITE DIFFERENT. JUST LIKE WHEN CDC GOT INTERESTED IN THIS A COUPLE YEARS AGO ABOUT A 13-PART SERIES, MMWR PUBLICATIONS, AND EVEN THOUGH THERE ARE TOPICS RESEARCH CENTERS ARE FOCUSED ON, WHEN CDC FOCUSED, IT ELEVATED IT, SEEING IT IN NATIONAL MEDIA, SAME WITH NIH FOCUSED ON RURAL. WHEN YOU ALL RELEASE STUDIES, THE NATION PAYS ATTENTION. OKAY. YOU HAVE A CHANCE TO SET THE AGENDA. WE CAN REALLY BUILD RURAL INTO WHAT YOU DO. WE HAVE A CHANCE TO TURN THE CORNER MOVING FORWARD. AND SO I HOPE WE CAN REALLY DO THAT. THINK ABOUT THE EVIDENCE BASE WE HAVE IN THIS COUNTRY, TENDS TO BE URBAN AND SUBURBAN FOCUS BECAUSE THAT'S WHERE THE PEOPLE ARE, EASIER TO DO IT THERE. YET JUST THE DISCUSSION TODAY YOU SEE THESE THINGS PLAY OUT DIFFERENTLY IN DIFFERENT COMMUNITIES. SPECIFICALLY IN DIFFERENT RURAL COMMUNITIES. AND SO ONE OF THE OPPORTUNITIES WE REALLY HAVE IS TO THINK ABOUT WHAT SHOULD THE RURAL EVIDENCE BASE LOOK LIKE, HOW DO WE BUILD IT AND MAKE SURE INTERVENTIONS WE'RE DESIGNING WORK AS WELL IN RURAL COMMUNITIES AS THEY DO IN URBAN AND SUBURBAN COMMUNITIES. INFRASTRUCTURE IS DIFFERENT. THEY HAVE A DIFFERENT MIX OF PROVIDERS. WE KNOW CULTURE CAN BE DIFFERENT. VOLUME OF PATIENTS IS LOWER SO THAT MAKES IT CHALLENGING. WE SHOULDN'T LET THOSE THINGS BE THE HINDRANCE TO MOVING FORWARD. SO ALL OF THESE THINGS DO MATTER, I THINK THE OPPORTUNITY TO REALLY PARTNER WITH YOU ALL ON THIS IS REALLY GOING TO MAKE A DIFFERENCE, WITH THE INTEREST OF LEADERSHIP LEVEL WE HAVE A CHANCE. WITH THIS EVENT TODAY AND CREATION OF RURAL HEALTH INTEREST GROUP WE HAVE A CHANCE. I WOULD JUST SAY PLEASE FEEL FREE TO REACH OUT. WE WOULD LOVE TO PARTNER WITH YOU. WE HAVE GREAT INDIVIDUAL PARTNERSHIPS WITH INSTITUTES ALREADY. BUT THERE'S ALWAYS ROOM FOR MORE. AGAIN, I TAKE MY HAT OFF TO YOU FOR HAVING THIS EVENT, FOR STARTING NATIONAL RURAL HEALTH DAY, AND YOUR INTEREST IN RURAL HEALTH. THANK YOU. [APPLAUSE] >> THANK YOU, TOM. THAT WAS GREAT. SO CONCLUDES OUR INAUGURAL WHICH I GUESS IMPLIES WE'RE GOING TO BE REPEATING THIS NEXT YEAR. NIH RURAL HEALTH SEMINAR. SO THANK YOU ALL FOR ATTENDING. AND I HOPE THIS LEADS TO LOTS OF PRODUCTIVE DISCUSSION. THANK YOU.