>> WELCOME EVERYBODY OUT THERE WATCHING. THIS IS OUR ANNUAL NIH TRIBAL ADVISORY COMMITTEE MEETING. I WANT TO WELCOME EVERYBODY THAT IS HERE. AND START WITH DOING ROLL CALL SO WE CAN HAVE KENDRA DO THE ROLL CALL FOR US TODAY. I'M LISA SUNBERG. >> THANK YOU. GOOD MORNING, GOOD AFTERNOON. I'M CONTRACTOR SUPPORT FOR NIH TRIBAL ADVISORY COMMITTEE. WE'LL GO THROUGH THE ROLL CALL, IHS AREAS AND THEN NATIONAL AT LARGE. ALASKA. >> GOOD MORNING. DENICE DILLARD, ALASKA AREA. >> THANK YOU, DR. DILLARD. ALBUQUERQUE AREA. >> GOOD MORNING, MICHELE SUINA, ALTERNATE FOR ALBUQUERQUE AREA. >> THANK YOU, DR. SUINA. BEMIDJI AREA? >> (INDISCERNIBLE) SAULT STE. MARIE TRIBE. >> AM I AT LARGE OR BEMIDJI? >> AT LARGE. >> ALL RIGHT. BILLINGS AREA. CALIFORNIA AREA. >> HERE. >> THANK YOU, LISA. GREAT PLAINS AREA. >> NASHVILLE AREA. >> THIS IS (INDISCERNIBLE) WITH THE (INDISCERNIBLE). >> THANK YOU, PATTY. NASHVILLE AREA. >> BEVERLY COOK, OFFICE OF MOHAWK. >> THANK YOU, CHIEF COOK. NAVAJO. >> MORNING, RAMONA AN TONES WITH NAVAJO AND TECHNICAL ADVISER. >> THANKS FOR BEING WITH US. OKLAHOMA AREA. >> GOOD MORNING, I DON'T SEE BOBBY ON BUT THIS IS DAVID, I'M THE ALTERNATE FOR OKLAHOMA. >> THANK YOU FOR BEING WITH US DAVID, BOBBY WILL BE ON SHORTLY. HAD HE AN IRB MEETING HE HAD TO CHAIR SO HE WILL JOIN US. >> THAT'S RIGHT, HE DID TELL ME HE WOULD BE LATE TODAY. THANK YOU FOR REMINDING ME. >> YOU'RE WELCOME. PHOENIX AREA. I THINK I SAW GATEWOOD ON HERE. PORTLAND AREA? >> PAM LUTZ. >> TUCSON AREA. >> GOOD MORNING. THIS IS (INDISCERNIBLE) REPRESENTING TUCSON AREA. >> THANK YOU, COUNCILWOMAN. >> LISA SOLOMON, TECHNICAL ADVISER TO COUNCILWOMAN. >> THANK YOU. NASHVILLE AT LARGE DEBBIE DANFORTH. DO WE HAVE ANYONE REPRESENTING DEBBIE? I KNOW SHE'S ON MEDICAL LEAVE RIGHT NOW. NATIONAL AT-LARGE, DONNA GALBREATH. >> PRESENT, ATHABASCAN. >> THANK YOU. >> THIS IS TIM THOMAS, TECHNICAL ADVISER FOR DR. GALBREATH. >> THANK YOU, DR. THOMAS. NATIONAL AT-LARGE SEATS, LYNN MALERBA? I BELIEVE SHE WAS JOINING US A LITTLE LATE TODAY AS WELL. >> GREETINGS, I'M HERE. I THOUGHT I WAS GOING TO BE LATE BUT HERE I AM SO GREETINGS TO ALL OF MY COLLEAGUES. >> WELCOME, THANKS, CHIEF MALERBA. AND NATIONAL AT-LARGE AARON PAYMENT >> I AM HERE, I WAS EAGER EARLIER, JOINED BY YVETTE ROBEIDEAUY. >> AND GWENDELENA, I'M HERE. >> AND DR. ANDERSON, ARE YOU WITH US? >> I WILL START, KENDRA. DR. DAVE WILSON, DIRECTOR OF NIH TRIBAL HEALTH RESEARCH OFFICE, MEMBER OF THE NAVAJO NATION, AND UNFORTUNATELY DR. ANDERSON IS UNABLE TO JOIN US TODAY WITH COMPETING EVENTS, I THINK ALL OF US CAN RELATE TO WHAT'S GOING ON RIGHT NOW. HE WILL DEFINITELY BE WITH US TOMORROW AND WITH THAT I'LL TURN IT OVER. >> JULIANA BLOOM, TRIBAL HEALTH RESEARCH OFFICE. >> GOOD AFTERNOON. SELENA KARETI. >> WE HAVE DETAIL, DR. SARAH HALL. >> GOOD AFTERNOON, EVERYONE. GREAT TO BE HERE WITH YOU. >> WE HAVE OUR COMMUNICATIONS DIRECTOR AND PROGRAM SPECIALIST MR. TED KEENE. >> HELLO, EVERYONE. TED KEENE, ALSO WITH THE TRIBAL OFFICE. >> WE HAVE MELODY DELMAR. >> MELODY DELMAR, HEALTH SCIENCE POLICY ANALYST. >> AND THAT IS OUR NIH TEAM. BACK TO YOU, KENDRA. >> WE HAVE A QUORUM. THANKS FOR YOUR PARTICIPATION. I WANT TO GO THROUGH A FEW HOUSEKEEPING NOTES BECAUSE THIS IS A VIRTUAL MEETING, BEING VIDEOCAST, IT WILL ALSO BE RECORDED FOR THE WEBSITE. WE HAVE A FEW ITEMS TO KEEP IN MIND. A LITTLE BIT MORE FORMAL THAN OUR TYPICAL MONTHLY MEETINGS. WHILE WE HAVE OUR PRESENTERS THAT ARE COMING IN TO US, WE ASK YOU KEEP YOUR TECH DELEGATES AND TECHNICAL ADVISORS KEEP YOUR CAMERA AND AUDIO OFF. WHEN YOU HAVE QUESTIONS, RAISE YOUR HAND VIA FUNCTION AT THE BOTTOM, THERE'S A RAISE HAND FUNCTION YOU CAN RAISE AND LOWER YOUR HAND WHEN YOU HAVE QUESTIONS AND PLEASE TURN ON YOUR CAMERA AND YOUR AUDIO AT THAT TIME. YOU CAN ALSO USE THE CHAT FUNCTION, THAT'S NOT BEING SHOWN LIVE ON THE VIDEOCAST. IF YOU HAVE QUESTIONS, ADDRESS US DURING THE MEETING. OVER TO YOU, LISA. >> GREAT. >> ACTUALLY, KICK IT BACK TO ME. I HAVE SOME INFORMATION THAT I NEED TO SHARE BEFORE WE LAUNCH THE MEETING. AND SO AS EVERYBODY IS AWARE, THIS IS SOMETHING THAT DR. PAYMENT USUALLY DOES BUT I'LL DO IT IN HIS STEAD. THE FEDERAL ADVISORY COMMITTEE ACT FACA PROVIDES EXEMPTION FOR INTERGOVERNMENTAL COMMITTEES TO MEET. UNDER THIS EXEMPTION, MEETINGS HELD ARE EXCLUSIVELY BETWEEN FEDERAL OFFICIALS AND ELECT THE OFFICERS OF STATE, LOCAL, OR TRIBAL GOVERNMENTS, DUGS NOT TRIGGER FACA IF SPECIFIC CRITERIA ARE MET, ONE IS THAT MEETINGS MUST BE HELD EXCLUSIVELY BETWEEN FEDERAL OFFICIALS AND ELECT THE OFFICERS OF STATE, LOCAL, TRIBAL BAL GOVERNMENTS OR DESIGNATED REPRESENTATIVES. ELECTED OFFICERS MUST BE ACTING IN THEIR OFFICIAL ELECTED CAPACITY. THE COMMITTEE LIKE THE NIH TAC ARE DESIGNED TO BE FACA EXEMPT. BECAUSE OF THE GOVERNMENT-TO-GOVERNMENT RELATIONSHIP. NIH TAC MEMBERS CAN GIVE UP TIME TO ALTERNATES, TECHNICAL REPRESENTATIVES, AND/OR GUESTS TO SPEAK ON THEIR BEHALF AND WE WANT TO MAKE SURE WE'RE FOLLOWING THESE RULES TO OUR BEST OF OUR UNDERSTANDING. SO THANK YOU. WITH THAT I'LL TURN IT BACK OVER TO LISA. >> THANK YOUU DAVID. A GOOD INTRO, I APPRECIATE THAT. WE HAVE A CLOSED SESSION NOW THAT WE'RE GOING INTO OUR CAUCUS, SO IF YOU COULD TAKE US THERE, WE'D APPRECIATE THAT. >> THANK YOU VERY MUCH. THE CAUCUS ROOM WILL OPEN IN A MOMENT AND CLOSE AT THE TIME INDICATED ON THE AGENDA. >> THANK YOU. >> FOR THOSE WHO ARE VIEWING THIS REMOTELY, AND ARE NEW TO THE NIH TRIBAL ADVISORY COMMITTEE MEETINGS, WHAT'S HAPPENING NOW IS THE NIH DELEGATES, TAC DELEGATES ARE MEETING IN PRIVATE TO DISCUSS SOME OF THE PRIORITIES THAT THEY WISH TO BRING TO THIS MEETING AND THIS EVENT. SO WE USUALLY GIVE THEM THAT SPACE TO HAVE THESE CLOSED DOOR DISCUSSIONS, LEADER TO LEADER, AND THEN THEY WILL SHARE THOSE ONCE THEY COME OUT OF CAUCUS AND RETURN BACK TO THE MEETING. THANK YOU. WE ARE PLEASED TO BE ABLE TO WELCOME DR. EMILY ERBELDING, DIRECTOR OF DIVISION OF MICROBIOLOGY AND INFECTIOUS DISEASES, NATIONAL INSTITUTE OF ALLERGY AND INFECTIOUS DISEASES, NIAID. SHE'S RESPONSIBLE FOR THE STRATEGIC AND SCIENTIFIC VISION FOR THE DIVISION'S COMPLEX NATIONAL AND INTERNATIONAL RESEARCH PROGRAM. THE PROGRAM SUPPORTS BASIC, PRE-CLINICAL, AND CLINICAL INVESTIGATIONS INTO THE CAUSES, DIAGNOSIS, TREATMENT AND PREVENTION OF A BROAD RANGE OF PATHOGENS, INCLUDING THOSE RELATED TO BIODEFENSE AND EMERGING INFECTIOUS DISEASES. SO, THANK YOU VERY MUCH. WE'RE PLEASED TO HAVE YOU HERE TODAY. WE LOOK FORWARD TO YOUR TALK. >> WE CAN'T HEAR YOU. WE CAN'T HEAR YOU. CAN YOU TAKE YOURSELF OFF MUTE, EMILY? EMILY? >> CAN YOU HEAR ME NOW? >> GREAT. NOW I HAVE TO GO BACK TO -- YEAH . IT'S DOWN HERE, ISN'T IT? OKAY. WELL, THANK YOU FOR THE INVITATION TO SPEAK TODAY AND GIVE YOU AN UPDATE ON COVID-19. I'M GOING TO FOCUS ON THE UNITED STATES LARGELY. I'M GOING TO GIVE SOME TRENDS, EPIDEMIOLOGIC TRENDS, FOR THE WHOLE UNITED STATES AND IN COVID-19 CASES. I'M GOING TO TALK A LITTLE BIT ABOUT DECISIONS PENDING RIGHT NOW ON VACCINATION OF CHILDREN AND ALSO BOOSTING. SO, SHOWN ON THIS SLIDE ARE DAILY TRENDS IN SARS-COV-2 CASES, OR COVID-19 CASES, IN THE UNITED STATES REPORTED TO THE CDC. AND YOU CAN SEE -- I DON'T KNOW IF YOU CAN SEE MY POINTER BUT WE'RE COMING OFF WHAT WAS REFERRED TO AS THE FOURTH WAVE OF THIS EPIDEMIC. WITH THE DOWNWARD TRAIN IN CASE RATES NOW THAT WE'RE INTO OCTOBER, NOT THIS LAST FOURTH WAVE DIDN'T PEAK AS HIGH AS THE THIRD WAVE, BACK IN LAST WINTER, SO WE'RE HOPEFUL THAT WITH THE NEW TOOLS WE HAVE IN OUR ARMAMENTARIUM AND MORE PEOPLE GETTING VACCINATED THAT WE'RE ON OUR WAY TO PUTTING THIS PANDEMIC BEHIND US. BUT EVERYONE REMAINS CAUTIOUSLY OPTIMISTIC ON THAT FRONT BECAUSE WE'VE BEEN WRONG BEFORE. OKAY. SO, LET'S SEE. ADVANCE. SO, SORT OF PARALLEL, IN PARALLEL WITH CASE RATES ARE THE DAILY TRENDS OVER THE PAST SEVERAL MONTHS IN COVID-19 DEATHS. DEATHS ALWAYS LAG A LITTLE BIT BEHIND THE NUMBERS, AND THE TRENDS IN OVERALL CASES, IN OVERALL HOSPITALIZATIONS. YOU CAN SEE THE FOURTH WAVE WAS FAIRLY DEADLY FOR MANY PEOPLE IN THE UNITED STATES. LARGELY, DEATHS IN THE UNITED STATES IN THIS FOURTH WAVE WERE AMONG PEOPLE WHO REMAINED UNVACCINATED OR PEOPLE WHO ARE VACCINATED BUT HAD COMPROMISED IMMUNE SYSTEMS AND WERE UNABLE TO RESPOND TO THE VACCINE. SO, A LOT HAS BEEN -- YOU HEARD THE DISCUSSIONS ABOUT THE VARIANTS IN CIRCULATION IN THE UNITED STATES, WITH THIS MOST RECENT WAVE, FOURTH WAVE BEING LARGELY DUE TO THE SPREAD OF THE DELTA VARIANT THAT FIRST EMERGED LAST APRIL REALLY IN INDIA, WHERE THERE WAS A VERY SIGNIFICANT EPIDEMIC THROUGHOUT THE COUNTRY, AND THIS PARTICULAR B .1.617.7 EMERGED, IN A SHORT PERIOD OF TIME OUTCOMPETED THE OTHER VARIANTS AND WAS RESPONSIBLE FOR NEARLY ALL CASES IN THAT COUNTRY. THEN IT WAS NOTED IN THE REST OF THE WORLD, IN THE U.K., IN MOST PLACES OF THE WORLD WHERE ANY SORT OF VARIANT SEQUENCING HAS BEEN DONE. IT APPEARED IN THE UNITED STATES IN THE LATE SPRING BUT YOU CAN SEE OVER IN A VERY SHORT PERIOD OF TIME JUST AFTER JUNE, INTO JULY, IT ACCOUNTED THIS B .1.617 VARIANT ACCOUNTED FOR MOST ALL CASES IN THE UNITED STATES. VIRUSES MUTATE AND REPLICATION, AND MUTATIONS CONFER PATHOGENESIS OR IN THE CASE OF DELTA MORE EASILY TRANSMISSIBLE. IT'S BEEN PRETTY WELL DESCRIBED NOW THAT THE AMOUNT OF VIRUS IN SOMEBODY'S NASOPHARYNX WITH DELTA IS AT LEAST FROM TWO TO FIVE TIMES THE CONCENTRATION IN INFECTED CASES AS PREVIOUS VARIANTS, AND IF THIS IS MORE TRANSMISSIBLE PROBABLY RELATED TO CHANGES IN RESPIRATORY BINDING DOMAIN OF THE SPIKE PROTEIN. WE DON'T KNOW WHAT'S COMING NEXT RIGHT NOW. EVERYTHING IN THE UNITED STATES IS STILL DELTA. BUT WE KNOW THIS VIRUS HAS THE CAPACITY TO EVOLVE AND IT WILL PROBABLY, IF ONGOING REPLICATION IN THE POPULATION IS ALLOWED, WILL PROBABLY EVENTUALLY REACH ITS MOST FIT STATE AND IT WILL -- THAT MIGHT BE THE VARIANT THAT PREDOMINATES INTO THE FUTURE. ONE THING YOU MIGHT HAVE HEARD FROM MEDIA REPORTS IS THAT THERE'S VARIANTS CALLED DELTA PLUS. THESE AREN'T TRACKED SEPARATELY FROM THE CDC SO IN THIS GRAPH DOWNLOADED THE FORECASTING FROM THE CDC DELTA PLUS ISN'T REALLY DEPICTED AS A SEPARATE CATEGORY. THE VARIANTS IN THAT CATEGORY HAVE BEEN FOLLOWED, AY VARIANTS, AY, RIGHT NOW, WHAT IS CALLED DELTA PLUS IS AY 4.2. AND IT MIGHT BE THAT THAT WILL EVOLVE INTO A DISTINCTLY DIFFERENT VARIANT SOMETIME SOON BUT IT IS BEING MONITORED. SO, THIS SLIDE DEPICTS HOSPITALIZATION OF PATIENTS WITH COVID-19 IN YOUNGER AGE GROUPS, UNDER 18 OR PEDIATRIC POPULATION. I MENTIONED EARLIER THAT HOSPITALIZATIONS AND DEATHS WITH THIS FOURTH WAVE LARGELY OCCURRED AMONG THE UNVACCINATED, THIS WAS AN EPIDEMIC OF THE UNVACCINATED. AND NOTING -- WE'LL NOTE THAT MANY PEOPLE IN THE YOUNGER AGE GROUP, UNDER 17 ARE NOT ELIGIBLE FOR VACCINATION, ONLY THE PFIZER mRNA VACCINE IS AUTHORIZED FOR USE IN AGE 12 AND UP. SO THIS LAST DELTA WAVE HIT THE PEDIATRIC POPULATION MORE SEVERELY THAN PRIOR WAVES HAD. SO, IT'S NOW I THINK PROBABLY FAIR TO SAY, AND I KNOW ROHAN HAZRA WILL TALK ABOUT THE PEDIATRIC COVID ISSUES SEPARATELY IN AN UPCOMING TALK THIS AFTERNOON BUT IT'S PROBABLY FAIR TO SAY THAT RIGHT NOW MORE CHILDREN HAVE DIED FROM COVID, WE THINK OF THEM AS BEING RELATIVELY SPARED BUT THAT'S REALLY ONLY RELATIVE TO THEIR GRANDPARENTS, NOT NECESSARILY RELATIVE TO OTHER INFECTIOUS DISEASES IN CHILDREN. MORE CHILDREN HAVE DIED OF THIS IN THE PAST YEAR THAN DIE IN A TYPICAL BAD INFLUENZA SEASON. SO IT'S IMPORTANT TO KEEP THAT IN MIND AS WE THINK ABOUT AUTHORIZING USE FOR PEDIATRIC VACCINE AND PUBLIC HEALTH OFFICIALS THINK ABOUT HOW THAT CAN ROLL OUT. SO, TWO COMPANIES, BOTH PFIZER AND MODERNA, HAVE ANNOUNCED THAT THEY HAVE POSITIVE DATA SHOWING THAT THE VACCINE IS EFFECTIVE, SAFE AND WELL TOLERATED AND EFFECTIVE IN SCHOOL-AGE CHILDREN. SO IN THE CASE OF PFIZER THEY ENROLLED A COHORT AGE 5 TO UNDER 12, IN THE CASE OF MODERNA IT WAS AGE 6 TO 11. SIMILAR STUDY DESIGNS, THE WAY PEDIATRIC TRIALS TYPICALLY MOVE FORWARD, THEY START WITH A DOSE RANGING STUDY, IN A SMALL NUMBER OF CHILDREN. IN EACH CASE THESE COMPANIES TESTED DOSES THAT WERE LESS THAN THE ADULT DOSE. AND THEN WHEN THEY FIND THE RIGHT DOSE, IMMUNOGENIC DOSE, THEY EXPAND ENROLLMENT TO A LARGER COHORT OF CHILDREN, AND RANDOMIZE THEM TO RECEIVE PLACEBO OR ACTIVE VACCINE, WITH THE VACCINE PRODUCT BEING WHATEVER WAS SELECTED IN THE EARLY STAGE OF THE TRIAL. SO PFIZER AND MODERNA HAVE CONDUCTED THESE STUDIES, BOTH ANNOUNCED THEIR RESULTS TO BE SAFE, WELL TOLERATED, EFFECTIVE IN THIS AGE GROUP. AND PFIZER WAS FIRST TO MAKE THIS ANNOUNCEMENT AND SUBMIT DATA PACKAGE, REQUESTING AMENDED AUTHORIZATION TO THE FDA. AND THIS MEETING, VRBPAC, VACCINE AND RELATED PRODUCTS BIOLOGY COMMITTEE IS MEETING TODAY AND WILL VOTE THIS AFTERNOON ON WHETHER OR NOT TO RECOMMEND AMENDED AUTHORIZATION FOR THE PFIZER VACCINE TO BE ALLOWS, AUTHORIZED FOR USE IN THIS AGE GROUP. VERY EXCITING NEWS WILL COME OUT, I HOPE EXCITING NEWS, AT THE END OF THE BUSINESS DAY TODAY FROM THIS VRBPAC MEETING. SO, A LOT HAS BEEN IN THE PAST COUPLE WEEKS, A LOT HAS BEEN IN THE NEWS ABOUT BOOSTER DOSES AS WELL. I THINK THE FIRST MENTION OF NEED FOR BOOSTER DOSES CAME OUT OF ISRAEL, IN EARLY SUMMER. WHERE THEY WERE EXPERIENCING A SURGE IN CASES RELATED -- HIGHLY VACCINATED POPULATION, ALMOST ENTIRELY WITH THE PFIZER VACCINE, AND THEY WERE NOTING THAT INDIVIDUALS WHO HAD BEEN VACCINATEs ABOUT FIVE TO SIX MONTHS EARLIER, SO THIS WAS PROBABLY THE MOST FRAIL OR VULNERABLE POPULATION, BECAUSE THAT'S THE WAY EVERYBODY ROLLED OUT THEIR EARLY VACCINE PROGRAM, EVERYONE THAT HAD GOTTEN THE PFIZER DOSE EARLY IN THOSE AGE GROUPS WERE NOTING AN UPTICK IN CASES, AND IN HOSPITALIZATIONS, AND OVER THE SUMMER AND THEN IT WAS ALSO BECOMING CLEAR THAT THE DELTA VARIANT WAS TAKING OVER TRANSMISSION THROUGHOUT THE COUNTRY. SO, PFIZER EARLY ON ANNOUNCED THAT THEY WERE GOING TO SUBMIT DATA TO VALIDATE OR ASK FOR AN AMENDED AUTHORIZATION, FDA AND REGULATORY AGENCIES, AUTHORIZED USE OF THE THIRD DOSE IN THEIR VACCINE PRODUCT, BASED UPON OBSERVATIONS FROM ISRAEL AND THEN OBSERVATIONS FROM ELSEWHERE IN THE WORLD THAT CAME LATER. RECENTLY, PFIZER, THIS WAS JUST A FEW DAYS AGO, ANNOUNCED WITHIN THEIR PHASE 3 CLINICAL TRIAL THEY HAD CONDUCTED A SUBSTUDY WHERE 10,000 PARTICIPANTS WERE ENROLLED, RANDOMIZED EITHER TO RECEIVE THE ACTIVE PRODUCT VACCINE, THIRD DOSE, OR PLACEBO. AND THEY ANNOUNCED THAT THE GROUP GETTING ACTIVE VACCINE BENEFITED IN TERMS OF REDUCED COVID ILLNESS. SO THIS IS THE STRONGEST DATA SO FAR THAT A THIRD DOSE OF THE mRNA VACCINES PREVENTS DISEASE, PREVENTS FURTHER COVID DISEASE. IT MIGHT BE THAT DISEASE OCCURS DUE TO WANING IMMUNITY, MIGHT BE IT'S DUE TO MORE AGGRESSIVE DELTA VARIANT, OR MIGHT BE BECAUSE THE PEOPLE THAT WERE ORIGINALLY VACCINATED FIRST WERE FRAIL AND ELDERLY AND SIMPLY NEED A THIRD DOSE. THIS IS THE SUBJECT OF A LOT OF DELIBERATION AT THE VRBPAC AND CDC'S ADVISORY GROUP, ACIP, OVER THE PAST SEVERAL WEEKS. WE NOTED BACK IN -- THIS IS WE, MEANING THE NATIONAL INSTITUTE OF ALLERGY AND INFECTIOUS DISEASES, WE NOTED BACK IN SPRING THAT THIS PROBABLY -- IT WAS PROBABLY GOING TO BECOME IMPORTANT DOWN THE ROAD IF PEOPLE WERE THINKING ABOUT GETTING VACCINATED WITH THE THIRD DOSE SOMETIME IN 2021 THAT WE WOULD NEED TO KNOW WHETHER OR NOT IT WAS SAFE AND EFFECTIVE TO MIX UP THE USE OF AUTHORIZED VACCINES, WHICH IS REFERRED TO AS HETEROLOGOUS PRIME BOOST APPROACHES. WE HAD KNOWN FROM OTHER VACCINES THAT SOMETIMES MIXING UP PLATFORMS, FOR EXAMPLE, STARTING WITH mRNA AND FOLLOWING THAT WITH EITHER PROTEIN OR ADENOVECTOR, SOMETHING DIFFERENT THAN THE ORIGINAL PRIMING SERIES, THAT THE BREADTH OF PROTECTION THAT SORT OF APPROACH MIGHT AFFORD IS BROADER AND PERHAPS IN SOME CASES A BETTER ANTIBODY RESPONSE THAN IF HOMOLOGOUS PLATFORM WAS USED. THIS MIX AND MATCH TRIAL, WE ENROLLED COHORTS OF PARTICIPANTS WHO HAD GOTTEN ANY OF THE EARLY AUTHORIZED VACCINES, EITHER MODERNA, PFIZER, OR JANSEN SINGLE DOSE TO MIMIC WHAT THE U.S. POPULATION WOULD BE GETTING AS PRIMING SERIES OF VACCINATION AND THEN WE IN TURN, EACH OF THESE COHORTS WERE RANDOMIZED TO GET ANOTHER, EITHER THE SAME -- BOOSTED WITH THE SAME VACCINE, SO THEY COULD ENTER AS GETTING PRIMED WITH EITHER PFIZER, MODERNA, OR JANSSEN AND ALL GET MODERNA BOOSTING, GETTING ANOTHER OF THE THREE VACCINES JANSSEN AS A BOOST, LASTLY PFIZER AS A BOOST. COMBINATIONS WERE WELL TOLERATED IMMUNOGENIC, ALL COMBINATIONS WERE SAFE. AND WE CONCLUDED THAT BOOSTING WITH A THIRD DOSE IN THE CASE OF mRNA VACCINES OR IN THE CASE OF IT'S JANSSEN VACCINE, A SECOND DOSE COULD EXPAND THE BREADTH OF THE VARIANTS OF CONCERN, TESTED AGAINST VARIANTS OF CONCERN. LAST WEEK, THE PAST SEVERAL WEEKS, VRBPAC AND ACIP MET AND LOOKED AT THESE DATA, BOTH DATA FROM PRESENTED BY THE COMPANIES WHICH WAS HOMOLOGOUS BOOSTING AND HETEROLOGOUS MIX AND MATCH APPROACH THAT NIAID GENERATED DATA ON. THEY AUTHORIZED AND RECOMMENDED THAT EITHER PFIZER, BION TECH OR MODERNA, PRIMED, 65 OR OLDER, OR HIGH RISK SITUATION, CONGREGATE LIVING FACILITIES, UNDERLYING MEDICAL CONDITION, OR WORKED AT A HIGH RISK SETTING SUCH AS HEALTH CARE WORKERS, WERE ELIGIBLE TO RECEIVE A BOOST. AND IT WAS OKAY TO BOOST WITH -- IF MORE CONVENIENT OR PREFERRED, FOR SOME CLINICAL REASON, IT WOULD BE OKAY TO BOOST WITH A VACCINE THAT WASN'T A VACCINE GIVEN IN THE ORIGINAL PRIMING SERIES. IT WAS RECOMMENDED ALSO THAT EVERYBODY WHOSE ORIGINAL VACCINE WAS JANSEN SINGLE DOSE WOULD RECEIVE ONE SIX MONTHS OUT. THIS IS THE SITUATION NOW. WE ACKNOWLEDGE THAT OVER TIME AND AS MORE DATA EMERGES, IT MIGHT BE THAT THIS AGE, 65 YEARS AND OLDER, OR THESE SPECIFIC CONDITIONS MIGHT CHANGE AND CONDITIONS FOR ALLOWING OR RECOMMENDED FOR BOOSTING MIGHT EXPAND. SO THAT CONCLUDES MY PREPARED TALK. I'M HAPPY TO TAKE QUESTIONS, IF THERE'S TIME. THANK YOU AGAIN FOR INVITING ME TO SPEAK TO THIS GROUP. >> HI, EMILY. YES, WE HAVE A QUESTION FROM CHIEF BEVERLY COOK. GO AHEAD. WE CAN'T HEAR YOU. >> THANK YOU. I WAS WONDERING IF THERE WAS A CHANGE IN THE 70% TARGET FOR HERD IMMUNITY, GIVEN THE DIFFERENT VARIANTS THAT ARE ARISING. >> YEAH, HERD IMMUNITY IS KIND OF A -- IT'S NOT NECESSARILY -- SO 70% WAS ALWAYS SOMETHING THAT PEOPLE CITED A WHILE AGO. I THINK THAT IDEALLY WE'D LIKE LIKE -- YOU KNOW, PARTICULARLY WITH VARIANTS THAT MIGHT BE MORE TRANSMISSIBLE WE'D LIKE TO BE PROTECTED, FEEL PROTECTED IF WE HAD HIGHER THAN 70% IMMUNITY. SO, A LOT OF STATES CURRENTLY, A LOT OF GEOGRAPHIC SUBGROUPS ARE FALLING SHORT OF THAT RIGHT NOW SO I THINK ALL I CAN SAY IS THAT I THINK MORE PEOPLE PROTECTED THROUGH VACCINATION IS A BETTER THING BUT I COULDN'T NECESSARILY SET A BENCHMARK. YOU MIGHT BE RIGHT, IT MIGHT BE IMPORTANT WITH THE DELTA VARIANT IN PARTICULAR TO HAVE A HIGHER POPULATION COVERAGE OF VACCINES. >> THANK YOU. >> I SEE SOME OTHER HANDS. SHOULD I JUST CALL ON PEOPLE? >> I'M SORRY, YEAH, MICHELE. I'M SORRY, I WAS ON MUTE THAT TIME. >> THANK YOU. I HAVE A QUESTION ABOUT THE BOOSTER. IT WAS A QUESTION I RECEIVED FROM A COMMUNITY MEMBER. I DIDN'T QUITE KNOW HOW TO ANSWER THIS QUESTION. WHEN I LOOKED FOR INFORMATION, LOOKED AT CDC WEBSITE, I COULDN'T FIND ANYTHING THAT REALLY PROVIDED A SATISFYING RESPONSE TO THE QUESTION. SO I WAS ASKED IF THE BOOSTER SHOT, LIKE HOW SOON DOES IT TAKE FOR IT TO KICK IN BECAUSE INDIVIDUALS WHO CAN GET A BOOSTER SHOT ALREADY FULLY ARE VACCINATED, AND SO IS IT LIKE A TWO-WEEK PERIOD, LIKE WHEN YOU GET YOUR SECOND SHOT, OR IS THERE ANYTHING WE NEED TO KNOW IN TERMS OF, YOU KNOW, HOW EFFECTIVE IT IS AND HOW SOON? >> YEAH, I THINK FROM WHAT WE KNOW THAT THE IMMUNE RESPONSE DOES KICK IN MORE QUICKLY, PROBABLY MORE QUICKLY THAN WITH THE ORIGINAL PRIMING SERIES. SO I DON'T KNOW THAT ANYBODY SET THAT PARAMETER. I THINK TWO WEEKS WOULD CERTAINLY BE A SAFE OUTER -- YOU KNOW, OUTER BOUNDARY. BUT IT'S LIKELY THAT WITH THE BOOST ANTIBODIES ARE GENERATED BECAUSE THERE'S MEMORY T CELLS BEING RECRUITED, MEMORY B CELLS BEING RECRUITED MUCH MORE RAPIDLY. >> THANK YOU. CHIEF LYNN MALERBA. >> THANK YOU. THAT WAS HELPFUL. ALL THE THINGS YOU TALKED ABOUT HAVE BEEN ON OUR MINTS. ONE OF THE THINGS I WONDERB IT GOES BACK TO CHIEF BEVERLY COOK'S QUESTION, IS IF WE TOOK THE PEOPLE THAT HAVE BEEN INFECTED AND ALL OF THE PEOPLE THAT HAVE GOTTEN VACCINES, DO WE THINK WE'RE A LITTLE BIT CLOSER TO HERD IMMUNITY? I KNOW THAT PEOPLE INFECTED ARE NOT NECESSARY THE ONES THAT WILL GET A VACCINE NOW EITHER BUT I JUST WONDER IS THERE SOME CALCULATION THERE? AND, YOU KNOW, IF WE GET THE VACCINE, ARE WE STILL ABLE TO BE CARRIERS OF DELTA VARIANT? THAT'S BEEN A HUGE CONCERN OF MINE. AND LASTLY, JUST FOR THIS GROUP TO KNOW, I'VE PARTICIPATED IN AN ANTIBODY STUDY, AND IN THREE MONTHS FROM JUNE UNTIL AUGUST, MY LAST -- MY SECOND SHOT WAS AT THE BEGINNING OF FEBRUARY, MY ANTIBODIES LEVELS FELL BY HALF. AND SO I EITHER JUST -- I ENCOURAGE EVERYONE TO THINK ABOUT A BOOSTER BECAUSE OF THAT. >> THANKS. I THINK YOUR QUESTION ON COVERAGE, YOU KNOW, YEAH, I THINK WE SHOULD BE CLOSER TO HAVING MORE OF THE POPULATION PROTECTED JUST BY THE FACT THAT MANY PEOPLE HAVE BEEN NATURALLY INFECTED NOW AND THAT DOES OFFER SOME PROTECTION. AND MANY -- AND MORE ARE GETTING VACCINATED OVER TIME. I'M SORRY, I THINK YOU HAD A QUESTION SORT OF RELATED TO BREAKTHROUGH INFECTION. YES, BREAKTHROUGH INFECTIONS DO OCCUR. AND THAT BREAKTHROUGH INFECTIONS REFER TO VACCINE -- PEOPLE PREVIOUSLY VACCINATED AND THEN GET SARS-COV-2 INFECTION. IN MOST CASES IT SEEMS THAT IT'S SYMPTOMS ARE NOT AS SEVERE, NOT AS LIKELY TO RESULT IN HOSPITALIZATION. SO, IT'S BETTER TO BE VACCINATED. THE VACCINES ARE STILL PROTECTING. WE JUST KNOW THERE APPARENTLY IS WANING IMMUNITY OVER TIME. I THINK YOU HAD -- DID I ADDRESS ALL YOUR QUESTIONS? >> JUST WITH THE THIRD VACCINE, OR BOOSTER, CAN WE STILL BE CARRIERS OF DELTA STILL? BECAUSE THAT'S BEEN MY BIGGEST CONCERN. NOT THAT I'LL GET SICK BUT THAT I WOULD PERHAPS MAKE SOMEONE IN MY FAMILY ILL BEYOND THAT. >> PEOPLE THAT MIGHT HAVE REPLICATING VIRUS DUE TO DELTA AFTER VACCINATION, IF THEY HAPPEN TO BE A SARS-COV-2 CASE, IT'S PROBABLY LOWER LEVELS OF VIRUS AND LESS LIKELY TO TRANSMIT. BUT SO YOU COULD BE A CARRIER BUT PROBABLY LESS LIKELY TO TRANSMIT JUST DUE TO VIRUS QUANTITY THAN HAD YOU NOT BEEN VACCINATED. THE DATA ON THAT, WE'RE STILL ACCUMULATING DATA TO BE MORE DEFINITIVE ON WHAT WE SAY ABOUT THAT. >> ALL RIGHT. THANK YOU. BOBBY SAUNKEAH. >> THANK YOU, LISA. OKLAHOMA AREA DELEGATE. THANK YOU FOR THAT PRESENTATION. I JUST HAD A QUESTION, RELATED TO WHAT ARE -- >> YOU NEED TO UNMUTE. THANK YOU. >> WE HAVE A VACCINE MANDATE HERE, I WORK FOR CHICKASAW NATION DEPARTMENT OF HEALTH IN OKLAHOMA. WE HAVE A VACCINE MANDATE FOR OUR HEALTH CARE DEPARTMENT. ALL OF OUR HEALTH CARE WORKERS, PROBABLY ONE OF THE BIGGEST OBJECTIONS IS FROM PEOPLE WHO HAVE ALREADY BEEN INFECTED, CLAIM THEY HAVE NATURAL IMMUNITY, AND WE KNOW THAT THAT -- THE RECOMMENDATION IS STILL TO GET A VACCINE, EVEN WITH THAT. BUT I DO KNOW THERE'S BEEN MORE STUDY ON THIS NATURAL IMMUNITY AND DO YOU KNOW KIND OF WHERE THAT IS? I KNOW OBVIOUSLY IT MUST WANE BUT DO YOU KNOW WHERE THE NEWER STUDIES ARE ON NATURAL IMMUNITY AND IS THAT REALLY KIND OF GOING TO BE A VALID EXEMPTION REQUEST FROM VACCINATION DOWN THE ROAD AS WE GET MORE INFORMATION? THANK YOU. >> YEAH, I DON'T KNOW. I THINK IT'S A LEGITIMATE QUESTION. TO WHAT DEGREE PEOPLE WHO HAVE RECOVERED FROM SARS-COV-2 INFECTION HAVE LONGER-LASTING PROTECTION, WE KNOW THAT PEOPLE GET REINFECTED, AND WE KNOW THAT TIMES CAN BE -- SECOND INFECTION CAN BE RELATIVELY -- HEAVILY SYMPTOMATIC EVEN IN PEOPLE WHO APPEAR TO BE HEALTHY. SO, THAT MIGHT BE BECAUSE OF VARIANTS. THAT MIGHT BE BECAUSE OF SOME UNIQUE CIRCUMSTANCE THAT THAT INDIVIDUAL -- THEIR IMMUNE SYSTEM HAS SOME SORT OF UNIQUE VULNERABILITY. I THINK WITH NATURAL INFECTION ONE OF THE TOUGHEST THINGS WOULD BE TO PROVE SOMEBODY WAS AS PROTECTED AS SOMEBODY WHO ACTUALLY GOT VACCINATED, AND I THINK THAT'S FOR PUBLIC POLICY, THAT WOULD REMAIN A CHALLENGE, RIGHT? YOU KNOW, WHAT TESTS DO WE USE TO SHOW SOMEBODY'S -- THAT SOMEBODY'S LEVEL OF IMMUNITY FOLLOWING NATURAL INFECTION IS GOOD ENOUGH, IS AS GOOD AS A VACCINE, SO THAT THEY ARE NOT A HAZARD TO THEIR PATIENTS, IF THEY ARE HEALTH CARE PROVIDER, FOR EXAMPLE. WE SIMPLY DON'T KNOW. >> THANK YOU. >> SO, I HAD MYSELF ON MUTE. GO AHEAD. >> NO PROBLEM. THANK YOU FOR YOUR PRESENTATION. WE APPRECIATE GETTING MORE INFORMATION ON COVID-19. I DID HAVE A QUESTION, I'M HEARING THERE'S A PUSH TO GET THE RAPID TEST OUT MORE. BUT THE ACTUAL EXPERIENCE WITH THE RAPID TESTING IS A LOT OF PEOPLE ARE FALSE NEGATIVE. LIKE THEY HAVE CLEAR SYMPTOMS OF COVID, CLEARLY LOST THEIR SMELL AND TASTE AND COULDN'T BE ANYTHING ELSE BUT THERE'S LOTS OF FALSE NEGATIVES. AND UNFORTUNATELY, A LOT OF THESE RAPID TESTS ARE GOING INTO UNDERSERVED COMMUNITIES LIKE TRIBAL COMMUNITIES. WHAT WORK IS BEING DONE TO ENSURE THAT THE TESTS ARE MORE ACCURATE AND THAT TO GET THOSE TESTS TO OTHER COMMUNITIES? >> YEAH, THE VALUE OF TESTING, PARTICULARLY AT POINT OF CARE, IS, YOU KNOW, IT'S A TOUGH PROBLEM. YOU KNOW, MOST OF THE TESTS THAT HAVE BEEN DEVELOPED ARE ANTIGENS, IT'S NOT LIKE PCR WHERE THEY CAN BE SENSITIVE BECAUSE THEY AMPLIFY VIRUS PRODUCT, THAT THAT LATTER TYPE OF PEST, PCR TEST, USUALLY TAKES MORE TIME. I DON'T THINK THE POINT OF CARE AVAILABILITY -- IT'S NOT THERE YET TECHNOLOGICALLY. SO, ANTIGEN-BASED TESTING DEFINITELY YOU HAVE TO HAVE A FAIRLY HIGH VIRAL BURDEN IN ORDER TO HAVE RELATIVE TO PCR AT LEAST, IN ORDER TO HAVE A POSITIVE TEST RESULT. WHAT'S BEING DONE? THERE'S A LOT OF U.S. GOVERNMENT MONEY BEING PUT INTO DEVELOPING BETTER TESTS AND BETTER POINT-OF-CARE TESTS WOULD BE ONE, ONE OF THE TYPES OF TESTS. AND I CAN'T -- I CAN'T SPEAK TO HOW SOON THOSE WILL COME, BUT IT'S RECOGNIZED TO BE A PROBLEM, A SIGNIFICANT CHALLENGE. AND AN IMPORTANT THING TO BRING OUT INTO ANY COMMUNITY INCLUDING UNDERSERVED. >> DOES ANYBODY ELSE HAVE QUESTIONS? I DO BUT I WANT TO MAKE SURE EVERYBODY ELSE HAS AN OPPORTUNITY TO ASK QUESTIONS. ALL RIGHT, GREAT. EMILY, SO I HAVE TO ASK ONE OF THE HARDER QUESTIONS, I HAVE TO REPRESENT -- YOU HAVE THE VACCINE AND UNVAXED PEOPLE OUT THERE, CREATING AN IMPACT ON HEALTH CARE SYSTEMS BECAUSE THE VACCINE MANDATES, ET CETERA. AND THERE'S -- THE CONVERSATION IS IF COVID IS HERE TO STAY, THE PEOPLE THAT WANT TO GET VACCINATED, GET VACCINATED. PEOPLE THAT GOT IT, FEEL VACCINATED, AND/OR ARE JUST NOT GOING TO DO IT SO THEY ARE GOING TO GO THROUGH A REGIMEN OF HEALTHY EATING AND TAKING CARE OF THEIR IMMUNE SYSTEM. DO WE FEEL LIKE IF WE GET HERD IMMUNITY AND EVERYBODY IS VAXED OR IN A CERTAIN CATEGORY IT'S GOING TO IMPACT WHETHER OR NOT COVID IS HERE OR NOT, BECAUSE COVID SEEMS TO BE HERE TO STAY, DOESN'T SEEM TO BE A WAY TO KILL COVID, I FEEL LIKE COMPETING FEELINGS AND THEORIES, IT'S HERE TO STAY, I THINK THAT'S AN IMPORTANT THING TO ACKNOWLEDGE. >> YEAH, I THINK MOST PEOPLE WHO STUDY VIRUSES AND THEIR EPIDEMIOLOGY THINK IT IS HERE TO STAY. THE WORD IS ENDEMIC, SORT OF THE WAY, YOU KNOW, VIRUSES CIRCULATE, THERE MIGHT BE RISES AND FALLS IN CASE RATES, IF THE POPULATION PROGRESSIVELY HAVE GREATER AND GREATER LEVELS OF IMMUNITY MAYBE IT WILL BE RARE FOR SOMEBODY TO DIE FROM COVID, AS ENDEMICITY BECOMES ESTABLISHED. MY FEAR IS WE'LL ALWAYS HAVE IMMUNOCOMPROMISED PEOPLE IN OUR WORLD, PEOPLE WITH SOLID ORGAN TRANSPLANTS, PEOPLE ON DIALYSIS, PEOPLE GETTING CHEMOTHERAPY, AND THOSE PEOPLE ARE GOING TO BE AT RISK FOR GETTING KNOCKED OUT EVEN IF IT'S A RARE EVENT BECAUSE THE VIRUS IS GOING TO BE AROUND. SO WE ALSO NEED BETTER THERAPEUTICS, I THINK, FOR THOSE INDIVIDUALS. I DIDN'T SPEAK VERY MUCH ON THAT COUNTER-MEASURE THAT WE ALSO HAVE TO MAKE INVESTMENTS IN BUT I THINK IT IS HERE TO STAY AND I THINK WE NEED BETTER TOOLS ON ALL FRONTS. >> JUST IN THEORY, IF IT'S HERE TO STAY, AND WE ALL COULD BE CARRIERS, WHETHER WE GOT THE VACCINATION OR NOT, CORRECT? IS THAT CORRECT? >> YEAH, ALTHOUGH I HOPE THAT IT WOULD BE SHORT-TERM ILLNESS, AND MILD, FOR PEOPLE WHO GOT THE FULL VACCINE SERIES. >> RIGHT. IS THERE ANY KIND OF RECOMMENDATIONS THAT YOU GUYS HAVE FROM YOUR PERSPECTIVE OF KIND OF THINGS THAT PEOPLE CAN DO TO BOOST THEIR IMMUNITY, IF THEY ARE NOT VACCINATED? >> OH BOY. HEALTHY LIVING. GOOD NUTRITION. YOU KNOW, IT MIGHT BE THAT INTO THE FUTURE WE SEE PEOPLE WEARING MORE MASKS DURING RESPIRATORY VIRUS SEASON. IT'S SORT OF BECOME COMMON. YOU DON'T THINK OF THAT AS WEIRD ANYMORE. IT MIGHT BE THAT BECOMES A COMMON PRACTICE DOWN THE ROAD, BECAUSE THEY PROBABLY WILL PROTECT AGAINST OTHER THINGS LIKE INFLUENZA AND RESPIRATORY VIRUS AND OTHER THINGS THAT CIRCULATE. THAT MIGHT BE SOMETHING THAT BECOMES COMMON. >> RIGHT, BECAUSE THE BIG NEWS WAS COLIN POWELL PASSED AWAY AFTER GETTING VACCINATED, AND SO IT KIND OF -- IT GOES AGAINST THE URGENCY TO GET EVERYBODY VACCINATED, THAT YOU'RE SOMEHOW PROTECTED FROM GETTING COVID, AND WE KNOW THAT IS NOT TRUE. >> HE HAD SIGNIFICANT COMORBIDITIES TOO. SO THAT ILLUSTRATES THE NEED FOR US TO GET VACCINATED TO PROTECT PEOPLE WHO HAD COLIN POWELL'S CONSTELLATION OF ILLNESS. >> NOT COVERED WELL IN THE NEWS, IT'S CRITICAL TO COMMUNICATE TO PEOPLE THAT IT'S HERE, AND WE HAVE TO DEAL WITH IT SOMEHOW. AND BUT ARE THERE ANY OTHER QUESTIONS DOWN THE PATH WITHOUT ASKING OTHER PEOPLE, BOBBY AND YVETTE BOTH HAVE YOUR HAND UP. DO YOU HAVE COMMENTS? >> I HAD ANOTHER QUICK QUESTION . RELATED TO THE KIND OF VACCINE HESITANCY THAT WE TALKED A LITTLE BIT ABOUT A WHILE AGO. YOU KNOW, IN THE AREA OF THE COUNTRY WHERE I LIVE IS VERY BIBLE BELT AND SO A LOT OF THE RESISTANCE TO VACCINE HAS TO DO WITH TESTING AND DEVELOPMENT USING THE FETAL CELL LINES, RIGHT? SO, REGARDLESS OF HOW REMOTE THAT MIGHT BE, AND WHETHER OR NOT YOU AGREE IF THAT'S REALLY A VALID, YOU KNOW, OBJECTION, ARE THERE EFFORTS UNDERWAY THAT YOU'RE AWARE OF TO DEVELOP ALTERNATE WAYS TO TEST VACCINES? THERE'S A PLETHORA OF MEDICINES ALSO NORMAL EVERYDAY MEDICINES TESTED USING THE SAME METHODOLOGY THAT PEOPLE AREN'T AWARE OF TOO MUCH OR IGNORE, THEY DON'T WANT TO GO DOWN THAT PATH, BUT ARE THERE OTHER THINGS THAT BEING TESTED TO MAYBE GET AWAY FROM THAT PARTICULAR, YOU KNOW, ABORTED CELL LINE METHODOLOGY OF TESTING MEDICATIONS AND VACCINES AND THINGS LIKE THAT? >> YES, THERE ARE INVESTMENTS IN THAT AREA TO AVOID CELLS DERIVED FROM FETAL TISSUES. BUT AS IT STANDS RIGHT NOW, THEY ARE PROBABLY A CRITICAL COMPONENT OF MANY -- YOU KNOW, MANY PRODUCT DEVELOPMENTS IN A LOT OF DIFFERENT AREAS, AND THAT REMAINS TRUE. YES, TO EXTEND THAT SOME PEOPLE WOULD LIKE US TO AVOID ANIMAL TESTING ALTOGETHER TO, WOULD LIKE US TO HAVE OTHER TYPES OF TOXICITY TESTING AND THOSE MIGHT BE YEARS, DECADES AWAY IN DEVELOPMENT. >> THANK YOU. >> YVETTE, DO YOU HAVE A QUESTION? YOUR HAND IS UP. >> YES. IT'S JUST A RECOMMENDATION. I THINK THE QUESTIONS HERE AND QUESTIONS WE GET, RECOMMEND THAT NIH DO A LOT MORE IN TERMS OF EDUCATION OF THE PUBLIC ABOUT THE FACT THAT VACCINES DO NOT PROVIDE 100% COVERAGE. THAT IT HELPS REDUCE SEVERE ILLNESS AND DEATH BUT IT'S NOT 100% PROTECTIVE. AND I WORRY THAT, YOU KNOW, THERE NEEDS TO BE AN EMPHASIS ON GETTING MORE PEOPLE VACCINATED THAT ARE NOT VACCINATED, AND THE RACE TO GET THE BOOSTER TO RAISE YOU AS HIGH AS POSSIBLE IS NEVER GOING TO GET ABOVE 95 OR 96% EFFICACY, THERE'S ALWAYS GOING TO BE THE RISK THAT YOU'RE GOING TO GET IT, JUST THE VACCINE HELPS REDUCE YOUR CHANCE OF BEING IN THE HOSPITAL AND HELPS REDUCE CHANCE OF DYING BY A SIGNIFICANT AMOUNT, LIKE BY TENS OF TIMES AS SOME OF THE DATA HAS SHOWN. I JUST WANT TO RECOMMEND SPECIALLY FOR VULNERABLE POPULATIONS, NEED TO HAVE MORE BASIC EDUCATION FROM NIH, FURTHER REALITY SUPPORT WHAT VACCINE COVERAGE MEANS AND MORE EDUCATION ON WHAT VACCINES ACTUALLY DO. BECAUSE IF PEOPLE THINK THEY ARE GOING TO GET VACCINATED, TOTALLY PROTECTED, IT'S NOT TRUE. IT MEANS THAT THEY ARE MORE PROTECTED THAN IF NOT VACCINATED AND THEY CAN, YOU KNOW, AVOID GETTING IN THE HOSPITAL AND AVOID DYING. I WONDER IF THERE'S ANY RESEARCH GOING ON NOW TO TRY TO FIGURE OUT THE MOST EFFECTIVE MESSAGES FOR VARIOUS POPULATIONS. >> YEAH, I THINK YOU'RE RIGHT. I THINK THAT THE CDC HAS CONDUCTED, YOU KNOW, A LOT OF FOCUS GROUPS AND WAYS TO TAILOR MESSAGES SO THAT THEY REACH PEOPLE AND MOTIVATE THEM TO TAKE ACTION, TO TAKE PUBLIC ACTION. SO THERE'S ONGOING RESEARCH I THINK. THERE'S SO MANY DIFFERENT REASONS THAT PEOPLE DON'T GET VACCINATED AND THERE'S PROBABLY A LOT OF DIFFERENT WAYS THE MESSAGE HAS TO BE TAILORED. BUT YOUR POINT IS ON TARGET. IT IS AN IMPORTANT EFFORT WE NEED TO WORK HARDER ON. >> ANYONE ELSE? I WOULD LIKE TO COMMENT ON THAT AS WELL, BECAUSE I THINK THE LANGUAGING IS GOING TO BE CRITICAL. I THINK THESE LIKE THAT KIND OF MESSAGE THAT I KIND OF FEEL LIKE CHATTERING WE HEAR IN OUR COMMUNITIES AND ON SOCIAL MEDIA, ET CETERA, ABOUT THE VULNERABILITY OF PEOPLE, IF YOU HAVE A FEAR OF GETTING THAT, YOU KNOW, OF GETTING COVID, THEN GO GET VACCINATED. YOU KNOW, AND THE CONCERN THAT I HAVE, BECAUSE I'VE BEEN ON A CLINIC BOARD, AND SERVED NINE TRIBES IN NORTHERN CALIFORNIA AND SOME THINGS I'M HEARING, SOME OF THE MANDATES AND POLICIES IMPACTING HEALTH CARE FACILITIES BECAUSE SOME PEOPLE ARE HARD STOP NOT GOING TO TAKE THE VACCINE AND THEREFORE NOW THEY ARE EXITING THESE HEALTH CARE FACILITIES, IT'S IMPACTING OUR ABILITY TO GET HEALTH CARE, TIMELY HEALTH CARE, JUST IN GENERAL BECAUSE WE DON'T HAVE THE WORKFORCE SHOWING UP BECAUSE THE VACCINE MANDATES, AND UNDERSTANDING COLLECTIVELY FROM GOVERNMENT OFFICIALS, YOU KNOW, WE HAVE TO LOOK AT WHO OUR AUDIENCE IS WHEN WE TARGET THESE MESSAGES SO WE CAN GET TO A PLACE WHERE EVERYBODY CAN HAVE A PEACEFUL RESOLVE AND SOVEREIGNTY IN PEOPLE'S CHOICE. I BELIEVE WE HAVE TO GET THERE BUT AGAIN WE'RE MESSAGING -- MESSAGING IS CRITICAL. IF COVID IS IS HERE TO STAY DOES IT MATTER IF WE'RE VACCINATED OR NOT? THAT'S THE QUESTION. FOR ME AT LEAST. ANY OTHER COMMENTS? WE HAVE -- SINCE WE'RE BEING RECORDED, AND WE HAVE FIVE MORE MINUTES, WE HAVE TIME FOR ANY OTHER KIND OF OPEN DISCUSSION. EMILY, DOES THIS INSPIRE YOU IN ANY WAY TO COMMENT? >> WELL, THANK YOU FOR YOUR COMMENTS AND THANKS FOR THE OPPORTUNITY TO DISCUSS THIS WITH YOU. >> I JUST HAVE ONE MORE QUESTION, I GUESS. I KNOW WE HAVE A LOT OF YOUNGER PARENTS IN OUR COMMUNITY, AND THEY SWEAR BY, YOU KNOW, I TAKE VITAMINS, ALL THESE THINGS, I'M HEALTHY, I TAKE GOOD CARE OF MY IMMUNE SYSTEM, I USE ELDERBERRY AND ALL THAT. BUT THEY ARE AGING EVERY DAY. AND AT ANY POINT CAN COME DOWN WITH SOME UNDERLYING HEALTH CONDITION, OR AN AUTOIMMUNE DISORDER. AND EVENTUALLY, THEY ARE NOT GOING TO BE HEALTHY. AND ON TOP OF THAT, SOME OF THESE YOUNGER PARENTS WHO HAVE FELT THEMSELVES PROTECTED BECAUSE OF THE WAY THAT THEY EAT, TAKE CARE OF THEMSELVES, HAVE IN FACT COME DOWN WITH COVID. AND MAYBE A FEW OF THE CHILDREN HAVE COME DOWN WITH COVID. AND THEY HAVE RECOVERED. AND -- BUT MY CONCERN, WHAT WHIRLS AROUND IN MY MIND ALL THE TIME IS ... AND THEN WHAT? WHAT DOES THAT MEAN? DOES THAT MEAN YOU GOT OFF SCOTT FREE, OR DOES THAT MEAN YOUR CHILD IS GOING TO DEVELOP SOME KIND OF HEALTH CONDITION LATER ON AS A SEQUELAE TO COVID-19 INFECTION OR YOU YOURSELF AREN'T GOING TO HAVE A FLARE-UP, AND WE KNOW BECAUSE WE HEAR ABOUT PEOPLE WHO GOT COVID AND THEN THEY GOT COVID AGAIN, DID THEY REALLY OR WAS IT A FLARE-UP OF THE VIRUS THEY HAD IN THE FIRST PLACE. I DON'T KNOW, THOSE ARE THE THINGS THAT I THINK THERE ISN'T A LOT OF CONVERSATIONS ABOUT, AND I'M NOT SURE WHAT RESEARCH IS BEING DONE. I'M SURE THERE'S SOME AND IT'S EARLY IN THE PANDEMIC, SO I KNOW WE'RE NOT GOING TO HAVE A LOT OF ANSWERS BUT THOSE ARE THE REALLY FRIGHTENING PART TO ME, THEN WHAT, TEN YEARS FROM NOW WHAT ARE WE GOING TO SEE? >> SO I DON'T KNOW IF THAT WAS A QUESTION. >> I DON'T HAVE A CRITICAL BALL FOR TEN YEARS FROM NOW, I'M SORRY. >> HERE'S ANOTHER QUESTION. ISN'T COVID JUST ANOTHER SPINOFF OF SARS? I MEAN, I'VE HEARD THIS BUT I DON'T KNOW, IS IT RELATED TO SARS IN SOME WAY? THERE WOULD BE SOME KNOWLEDGE ABOUT SOMETHING, BECAUSE THAT HAPPENED IN CHINA AND A WHILE BACK, OR I THINK, THERE SHOULD BE SOME RESEARCH ON THAT. >> YEAH, THE SARS-COV-2 VIRUS, THE CAUSE OF COVID, IS -- I THINK PROBABLY 90% RELATED TO THE SARS 1. I THINK THE DIFFERENCE BETWEEN THE TWO IS THAT SARS-COV-2, YOU'RE MORE LIKELY TO HAVE MILD EVEN ASYMPTOMATIC ILLNESS AND MORE LIKELY TO BE ABLE TO SPREAD THE VIRUS BEFORE BECOMING SYMPTOMATIC AT ALL. SO WHAT THAT LEADS TO IS PEOPLE WALKING AROUND WITH A WHOLE LOT OF VIRUS IN THEIR NOSE, BREATHING IT OUT, AND THEY DON'T FEEL SICK ENOUGH TO STAY HOME IN BED THE WAY THEY WOULD HAVE WITH SARS 1. SO, YES, THEY ARE RELATED. YES, THEY PROBABLY CAME FROM SIMILAR, MAYBE SIMILAR ZOONOTIC RESERVOIRS, WE DON'T ACTUALLY KNOW. YES, IN ASIA, MAYBE CHINA SPECIFICALLY, AND THEY ARE RELATED VIRUSES. LESS OF A RELATIONSHIP WITH THE OTHER CORONAVIRUS THAT HAS CAUSED SIGNIFICANT OUTBREAKS, THE MERS VIRUS, MIDDLE EASTERN RESPIRATORY SYNDROME VIRUS, BUT THAT ONE IS -- HAS SOME SIMILARITIES IN GENETIC SEQUENCE AS WELL TO THE SARS VIRUSES. >> GREAT. EMILY, WE'RE AT THE TOP OF THE HOUR. WE WOULD LIKE TO THANK YOU FOR YOUR PRESENTATION, AND SPENDING TIME ON THE Q&A WITH US. AND WE HOPE YOU HAVE A BEAUTIFUL REST OF YOUR DAY. AGAIN, WE'RE GOING ON BREAK NOW, SO THANK YOU. WE ARE NOW PAUSING FOR A 10-MINUTE BREAK. THANKS AGAIN, EMILY. >> I'M GOING TO ASK MR. DAVE WILSON, EXECUTIVE DIRECTOR, FOR THE THRO, TO INTRODUCE OUR NEXT GUEST. >> ABSOLUTELY. IT'S MY PLEASURE TO INTRODUCE DR. ROHAN HAZRA, HE COMES TO US FROM THE NATIONAL INSTITUTE OF CHILD HEALTH AND HUMAN DEVELOPMENT, DR. HAZRA WAS NAMED ACTING DIRECTOR OF THE DIVISION OF EXTRAMURAL RESEARCH IN FEBRUARY OF 2020, BUT SINCE 2008 HAS OVERSEEN A STUDY ON AIDS, PERINATALLY INFECTED YOUTH, WITH INFANTS, CHILDREN AND YOUTH, AND HAS OVERSEEN THIS LARGE STUDY AND ACTIVELY IN HIV -- - PEDIATRIC CLINICAL TRIALS AND OBSERVATIONAL STUDIES, HERE IN THE U.S., ALSO ABROAD. WITH THAT I'D LIKE TO WELCOME DR. HAZRA. >> THANK YOU FOR THE KIND INTRODUCTION AND INVITATION TO SPEAK TO ALL OF YOU. LET ME GET SET UP HERE. YOU WOULD THINK BY NOW WE WOULD KNOW HOW TO DO ALL OF THIS. CAN YOU SEE MY SLIDES? >> YEP. LOOKS GOOD. >> I'M HERE TO SPEAK WITH COVID-19 IN CHILDREN AND GIVE AN UPDATE. LET ME GET STARTED. IN CASE YOU'RE NOT SO FAMILIAR WITH OUR INSTITUTE, WE'RE NAMED AFTER EUNICE KENNEDY SHRIVER. PRESIDENT COUNTRY'S SISTER HERE IS OUR HAD MISSION STATEMENT. EVEN THOUGH PREGNANCY IS NOT IN OUR NAME, WE IN FACT ARE THE LARGEST SUPPORTER OF PREGNANCY-RELATED RESEARCH AT NIH, AND THAT MAKES UP ABOUT 30% OF OUR BUDGET. CONTRAST, WHILE CHILD HEALTH IS IN OUR NAME, AND WE ARE THE LARGEST FUNDER OF CHILD HEALTH RESEARCH AT NIH, WE ACTUALLY ONLY SUPPORT ABOUT 18% OF CHILD HEALTH RESEARCH AT NIH. COLLECTIVELY ALL THE OTHER INSTITUTES AND CENTERS SUPPORT THE VAST MAJORITY OF IT AS WELL. WE HOUSE NATIONAL CENTER FOR MEDICAL REHABILITATION RESEARCH AND INTELLECTUAL DISABILITIES BRANCH, 18% TOWARDS RESEARCH ON INDIVIDUALS WITH INTELLECTUAL AND PHYSICAL DISABILITIES. COVID-19 IN CHILDREN, THIS IS A GRAPH OF JUST THE NUMBER OF CASES OF SARS-COV-2 INFECTION OR COVID-19 IN CHILDREN BY BEGINNING OF THE PANDEMIC. IN CONTRAST TO WHAT EMILY SHOWED EARLIER, ALL CASES IN THE UNITED STATES, WHAT'S STRIKING IS ON THE FAR RIGHT WITH THIS LAST DELTA WAVE WE WERE SEEING PER WEEK MORE CASES IN CHILDREN THAN WE HAVE THROUGHOUT THE WHOLE PANDEMIC. AS YOU CAN SEE, LATE AUGUST, EARLY SEPTEMBER, THE NUMBER OF CASES IN CHILDREN WERE HIGHER THAN AT ANY OTHER TIME IN THE PANDEMIC. THESE GENERATED EVERY WEEK OR TWO BY THE AMERICAN ACADEMY OF PEDIATRICS AND HOSPITAL ASSOCIATION, THEY GO TO ALL OF THE STATE WEBSITES AND JURISDICTIONS AND PULL DATA TO GENERATE PEDIATRIC-SPECIFIC REPORT. A GREAT SERVICE TO THE PEDIATRIC RESEARCH AND PUBLIC HEALTH COMMUNITY. THESE ARE OTHER DATA FROM THEIR MOST RECENT REPORTS. ON THE RIGHT YOU CAN SEE THE STATE RATE BUT JUST NUMBERS HERE THAT I WANT TO JUST -- FIRST THERE HAVE BEEN MORE THAN 6 MILLION TOTAL CASES IN THE UNITED STATES OVERALL, THAT REPRESENTS AT THIS POINT OVER 16% OF ALL CASES. BUT BECAUSE THE NUMBER OF CASES IN CHILDREN CONTINUE TO RISE WHILE THE NUMBER OF CASES IN ADULTS FALLS, CURRENTLY PER WEEK THE NUMBER OF CASES IN CHILDREN REPRESENT ABOUT A QUARTER, 25%, OF ALL CASES FORTUNATELY IN GENERAL CHILDREN MANAGE THE INFECTION QUITE WELL. YOU CAN SEE CHILDREN ONLY MAKE UP ABOUT 1.6 TO 4% OF TOTAL HOSPITALIZATIONS. AND ONLY .1 TO 2% OF CHILDREN WITH COVID-19 END UP IN THE HOSPITAL. VERY FEW DIE, BUT THAT'S ON THE BACKGROUND OF WE DON'T EXPECT YOUNG HEALTHY CHILDREN TO DIE. THE FACT THAT, I LIKED HER LINE, STILL THE NUMBER OF DEATHS DUE TO COVID ARE STILL MORE THAN VERY BAD FLU SEASONS, AND DEATHS FROM FLU IN CHILDREN. HOSPITALIZATION IN CHILDREN, WE'RE SEEING A PEAK IN NUMBER OF HOSPITALIZATIONS DURING THIS DELTA WAVE THAT IS MUCH HIGHER THAN AT ANY OTHER POINT IN THE PANDEMIC. ONE OF THE OUTSTANDING QUESTIONS RELATED TO THIS PEAK THOUGH IS THIS JUST PURELY A MATTER OF SEEING MORE INFECTIONS IN CHILDREN, IF THERE'S A STABLE RATE OF THOSE THAT ARE HOSPITALIZED IF THERE ARE MORE INFECTIONS WE'LL SEE MORE HOSPITALIZATIONS OR IS THIS A QUESTION THAT THE DELTA VARIANT CAUSES MORE SEVERE DISEASE IN CHILDREN? WE'RE STILL WAITING FOR SOME DATA. YOU CAN SEE THAT GRAY BAR ON THE RIGHT IS AN INDICATION FROM THE CDC THAT THERE'S STILL UNCERTAIN DATA THERE BECAUSE THEY ARE STILL WAITING FOR DATA TO BE REPORTED BECAUSE WE'RE STILL TALKING ABOUT OCTOBER. SO THE CURRENT MONTH. IN THE NEXT FOUR TO SIX WEEKS WE HOPEFULLY WILL BE ABLE TO DETERMINE THAT QUESTION WHETHER THE DELTA VARIANT IS JUST SIMPLY CAUSING MORE INFECTIONS OR DOES IT CAUSE MORE SEVERE DISEASE IN CHILDREN. THIS IS LOOKING AT VACCINATION RATES. EMILY SHARED THE FDA PHYSICAL COMMITTEE IS MEETING AS WE SPEAK. THE DELIBERATIONS, THEY HELD THEIR PRESENTATIONS AND ARE NOW IN DELIBERATION PHASE OF THE MEETING, AND WILL BE VOTING ON THE AUTHORIZATION WITHIN THE NEXT HOUR OR HOUR-AND-A-HALF. WHAT THE CURVES SHOW ARE THE RATE OF VACCINATIONS ACROSS THE DIFFERENT AGE GROUPS, AND A COUPLE THINGS I WANT TO HIGHLIGHT, I'LL LOOK AT THE FAR RIGHT WITH THE FULLY VACCINATED, THIS IS WAY DOWN HERE, THE ALMOST ZERO OR OF COURSE THE CHILDREN UNDER AGE 12, WHAT WE'RE HOPING IS TO GET GOOD RECOMMENDATIONS TODAY ABOUT THE ABILITY FOR CHILDREN 5-11 TO BE VACCINATED. YOU CAN SEE THE NEXT TWO CURVES ARE ALL IN THE LOW END WHICH ARE THE 12-15 YEAR OLDS AND 16-17 YEAR OLDS, SO VACCINATION AMONG CHILDREN AND YOUTH DOES LAG BEHIND ADULTS. ONE OF THE REASONS THAT'S IMPORTANT IS OF COURSE TO TRY AS SOME OF THE DISCUSSION IN THE PREVIOUS AFTER EMILY'S TALK WAS ABOUT PREVENTING DISEASE, BUT I WAS ALSO STRUCK BY THESE DATA FROM CDC SHOWING THE IMPORTANCE OF, AGAIN, WHAT CALL HERD IMMUNITY, THE FACT WHEN YOU DO GET VACCINATED YOU'RE GETTING VACCINATED NOT JUST TO PROTECT YOUR OWN HEALTH BUT TO PROTECT OTHERS AS WELL. THESE WERE DATA FROM THE CDC AND THEY WERE FEATURED IN A REALLY NICE "NEW YORK TIMES" ARTICLE. WHAT YOU HAVE HERE ON THE LEFT ARE DATA FROM THE 10 STATES WITH THE HIGHEST VACCINATION RATES, AND YOU LOOK AT DISEASE IN CHILDREN ACROSS THE SPRING AND SUMMER, YOU SEE REALLY NO RISE IN DISEASE. BY CONTRAST, ON THE RIGHT ARE THE TEN STATES WITH THE LOWEST VACCINATION RATES, SO THAT MEANS ADULTS HAVE THE LOWEST VACCINATION RATES, AND THEREFORE THEN ARE TRANSMITTING VIRUS TO CHILDREN. YOU CAN SEE THERE'S A FOUR TIMES GREATER RATE OF CHILDREN GETTING HOSPITALIZED IN THESE TEN STATES, VERSUS THESE TEN STATES SO US DOES SPEAK TO IMPORTANCE OF GETTING VACCINATED AS ADULTS, AS ALL INDIVIDUALS, NOT JUST FOR YOUR OWN HEALTH BUT ALSO TO PROTECT THE HEALTH OF OTHERS. AS I MENTIONED BEFORE SARS-COV-2 GENERALLY CAUSES ASYMPTOMATIC OR MILD DISEASE IN CHILDREN BUT CAN CAUSE QUITE SEVERE DISEASE, I'M GOING TO TOUCH ON THAT IN A SUBSEQUENT FEW SLIDES ABOUT SEVERAL SYNDROMES THAT CAN BE QUITE -- CAUSE QUITE A BIT OF MORBIDITY. MAJORITY OF CHILDREN HAVE ASYMPTOMATIC OR MILD DISEASE, SOME END UP IN ICU WITH SEVERE VIRAL PNEUMONIA, RESPIRATORY DISTRESS SYNDROME. THERE'S ALSO MUCH MORE GASTROINTESTINAL DISEASE, AMONG CHILDREN, AND THEY ALSO HAVE DIFFERENT MANIFESTATIONS WHERE THEY CAN PREVENT -- PRESENT WITH SERIOUS CARDIAC PROBLEMS, THEY COULD ALSO HAVE CEREBROVASCULAR PROBLEM, HIGHLIGHTED IN THIS SERIES OF PATIENTS HERE THAT WERE REPORTED. AND VASCULAR COMPLICATIONS. OCCASIONALLY WE SEE ACUTE KIDNEY INJURY, SHOCK SYNDROME, PROBLEMS WITH BLEEDING. AND THEN I WILL TALK ABOUT MIS-C, IN A FEW SLIDES. IN GENERAL AS I SAY THOUGH MOST CHILDREN THAT DO END UP IN THE HOSPITAL OR WITH SEVERE ILLNESS DO HAVE UNDERLYING CONDITIONS. SO OFTENTIMES THEY WILL HAVE GENETIC -- HEART DISEASE, NEUROLOGIC OR METABOLIC COMORBIDITIES, OBESITY IS A MAJOR COMORBIDITY THAT RESULTS IN MORE SEVERE DISEASE IN CHILDREN, JUST LIKE IT DOES IN ADULTS. DIABETES IS A RISK FACTOR. ASTHMA, CHRONIC LUNG DISEASE, SICKLE CELL DISEASE. LIKE ADULTS, UNFORTUNATELY RACIAL AND ETHNIC MINORITIES ARE DISPROPORTIONATELY IMPACTED. BOTTOM LINE THOUGH IS THERE'S STILL HEALTHY CHILDREN WITH SARS-COV-2 INFECTION THAT DEVELOP SEVERE DISEASE AND CAN DIE OF IT. BEFORE I MOVE FROM THIS SORT OF EPIDEMIOLOGY OVER TO SOME OF THE MORE DISCUSSION ABOUT MIS-C AND LONG COVID, I DO WANT TO STRESS OTHER ISSUES HERE, THIS IS JUST ONE SLIDE BUT I THINK FRANKLY THIS COULD BE A WHOLE TALK ALSO. WE TALK AND SPEND TIME AND EFFORT THINKING ABOUT THE EFFECT OF THE VIRAL INFECTION ON CHILDREN. BUT WE REALLY NEED TO ALSO ACKNOWLEDGE THE TREMENDOUS IMPACT THE PANDEMIC AS A WHOLE HAS HAD ON THE HEALTH AND WELL BEING OF THE CHILDREN, NOT JUST IN THIS COUNTRY BUT AROUND THE WORLD AS WELL. THIS IS REGARDLESS OF WHETHER THEY ACTUALLY DEVELOP THE INFECTION, WE KNOW THAT JUST ABOUT EVERY CHILD IN THIS COUNTRY HAS BEEN IMPACTED. THERE ARE ISSUES AROUND FAMILY AND ECONOMIC STRESS, LOSS OF CAREGIVERS AND GRIEF. SO WHEN WE THINK ABOUT THERE'S 700,000 APPROXIMATELY ADULTS THAT HAVE DIED OF SARS-COV-2 INFECTION, HOW MANY OF THOSE PEOPLE ARE MOTHERS, FATHERS, UNCLES, AUNTS, GRANDPARENTS, OF THESE CHILDREN? AND TO HAVE THAT EARLY LOSS AND SUBSEQUENT GRIEF AND FAMILY LOSS THAT OCCURS FROM THAT. WE ALSO KNOW THERE ARE DATA THAT CHILDREN WERE MISSING ROUTINE VACCINATIONS, SO WHILE THEY MAY NOT BE GETTING COVID-19, THEY ARE ALSO NOT GETTING THEIR ROUTINE VACCINATIONS AND THEN ARE AT RISK FOR OTHER VACCINE PREVENTIBLE ILLNESSES. WE HAVE DATA TO THOUGH THAT IT SEEMS AS IF CHILD ABUSE AND NEGLECT REPORTS ARE WAY DOWN AS WELL. WE WOULD ASSUME THEN THAT MEANS THOSE ARE REALLY GOING UNDETECTED AS OPPOSED TO THAT SOMEHOW WE'VE SOMEHOW SOLVED THE CRISIS OF CHILD ABUSE AND NEGLECT. THERE ARE NEURODEVELOPMENTAL, COGNITIVE AND EDUCATIONAL IMPACT THAT CAME WITH SCHOOL SHUTTING DOWN AND STAY-AT-HOME ORDERS. HUGE IMPACTS ON MENTAL HEALTH. YOU'LL HEAR ABOUT THAT IN MUCH MORE DETAIL FROM DR. GORDON LATER, THERE ARE ISSUES ABOUT INCREASED SUBSTANCE USE AMONG YOUTH. AND THEN ALSO DECREASED PHYSICAL ACTIVITY AND POTENTIALLY INCREASES IN RATES OF OBESITY. I JUST WANT TO -- I'M NOT GOING TO TALK ANY MORE ABOUT THIS BUT I THINK ANY DISCUSSION IN CHILDREN HAS TO ACKNOWLEDGE TREMENDOUS IMPACT THE PANDEMIC AS A WHOLE HAS HAD ON THE HEALTH AND WELL-BEING OF CHILDREN. SO NOW I'M GOING TO CONCENTRATE ON THIS INTERESTING BUT CAN BE LETHAL SYNDROME CALLED MULTI-SYSTEM INFLAMMATORY SYSTEM IN CHILDREN, MIS-C, AND OTHER FORMS OF WHAT WE AT NICHD CALL -- OR NIH CALL POST-ACUTE SEQUELAE OF SARS-COV-2, CDC CAUSE IT POST-COVID CONDITIONS, AND THE PRESS CALLS IT LONG COVID. SO AS I MENTIONED, BACK IN MARCH AND DAVID MENTIONED, I TOOK OVER AS ACTING DIVISION DIRECTOR IN FEBRUARY, LITERALLY AS THE PANDEMIC WAS GETTING STARTED. I'VE SPENT ALL OF MAYBE SIX OR SEVEN DAYS ACTUALLY MY OLD OFFICE BEFORE WE WERE ALL SENT HOME AND HAVE BEEN TELEWORKING EVER SINCE, SO EVER SINCE MID-MARCH OF 2020. BUT INITIALLY IN THOSE FIRST COUPLE MONTHS OF THE PANDEMIC, THE THOUGHT AGAIN WAS CHILDREN WERE RELATIVELY SPARED FROM SEVERE DISEASE. IT WAS ONLY ABOUT MID TO LATE APRIL WHEN REPORTS FROM THE U.K. AND EUROPE AND THEN ABOUT A WEEK OR TWO LATER WITHIN THE UNITED STATES ESPECIALLY FROM NEW YORK AND BOSTON, NORTHEAST, WHERE THE PANDEMIC REALLY TOOK OFF FIRST AT THE HIGHEST LEVEL, THAT THERE WERE DESCRIPTIONS OF CHILDREN DEVELOPING THIS PERPLEXING SYNDROME THAT LED FOR THE MAJORITY OF THEM TO END UP IN THE INTENSIVE CARE UNIT. AND THIS IS A CURVE SHOWING THE RATE IN THE DARK BLUE LINE, THE RATES OF MIS-C, AND IN THE DASHED BLACK LINE THE OVERALL COVID-19 RATES. IF YOU CAN APPRECIATE, I THINK, THAT WHAT YOU DO IS YOU SEE THE UPTICK IN COVID-19, AND THEN JUST SEVERAL WEEKS LATER YOU SEE THIS RISE IN MIS-C. FOR THOSE OF THE CHILDREN THEY END UNHAVING INCIDENTAL OR AMATTIC INFECTION, DIDN'T EVEN KNOW THEY HAD SARS-COV-2 INFECTION, INCIDENTAL OR ASYMPTOMATIC, AS COVID-19 WAS GOING THROUGH A COMMUNITY 2 TO 6 WEEKS LATER THERE WOULD THEN BE THIS RISE IN NUMBER OF CHILDREN PRESENTING WITH THIS SHOCK-LIKE SYNDROME. INTERESTINGLY THOUGH, WITH THIS MOST RECENT DELTA WAVE, SO FAR AT LEAST WE'RE NOT SEEING THAT. I THINK AGAIN THERE'S THAT GRAY BAR I SHOWED YOU IN THE OVERALL HOSPITALIZATION RATE PER EARLIER, I THINK THERE'S STILL THE -- THE JURY IS STILL OUT. THE QUESTION BECOMES, ARE WE GOING TO SEE A SIMILAR SURGE IN MIS-C CASES BECAUSE OF THE DELTA WAVE? OR IS THERE SOMETHING BIOLOGICALLY DIFFERENT ABOUT DELTA THAT WHILE IT MAY CAUSE A LOT OF HOSPITALIZATION IN CHILDREN, FOR WHATEVER REASON IT DOES NOT CAUSE THE INFLAMMATORY SYNDROME CALLED MIS-C. OUR THE NEXT FOUR TO SIX WEEKS WE'LL SEE WHAT HAPPENS TO THE BLUE CURVE. THIS IS A REPORT THAT THE CDC BRINGS OUT ABOUT THE BEGINNING OF EVERY MONTH, AND THEY ACTUALLY HAVE A CLINICAL TEAM THAT ADJUDICATES EACH OF THE CASES. THIS IS NOT JUST PASSIVE DATA REPORTING BUT THEY ARE REALLY TRYING TO REALLY VERIFY WHETHER THESE ARE TRULY CASES OF MIS-C OR NOT. WE SHOULD HAVE THE ANSWER, SOME SENSE OF THE ANSWER, ABOUT THE DELTA VARIANT AND MIS-C WITHIN THE NEXT MONTH OR TWO. SO THIS IS JUST A NICE CARTOON FROM A EUROPEAN GROUP ON WHAT IS MIS-C, IN EUROPE THEY CALL IT PIMS, POST INFLAMMATORY -- I'M NOT GOING TO REMEMBER WHAT THAT IS, RELATED TO COVID, RELATED TO SARS-COV-2. BUT OF COURSE WE CALL IT MIS-C. BUT THESE ARE CHILDREN, THIS GROUP LOOKED AT ALL OF THE PUBLISHED REPORTS AS OF SORT OF FALL OR LATE SUMMER 2020, WHAT THEY FIND IS ALMOST ALL CHILDREN HAVE FEVER, MEDIAN AGE IS ABOUT 8, DOES SEEM TO BE DISPROPORTIONATE IMPACT ON NON-HISPANIC BLACKS, FOUND NOT JUST IN THE UNITED STATES BUT ALSO U.K. AND EUROPE. UNLIKE ACUTE SARS-COV-2 INFECTION RESPIRATORY SYSTEM IS RELATIVELY SPADE BUT EFFECT ON GASTROINTESTINAL AND CARDIAC, MOST HAVE A SEVERE DISEASE COURSE, END UP IN THE ICU, BUT FORTUNATELY WITH TREATMENT ACTUALLY RECOVER QUITE WELL. BUT I THINK OUTSTANDING QUESTION THAT SPEAKS TO SOME OF THE QUESTIONS YOU ALL HAD IN THE PRIOR SESSION IS WHAT ARE THE LONG-TERM IMPACTS OF HAVING THIS ACUTE INFLAMMATORY SYNDROME. FORTUNATELY, IT DOES SEEM AS IF WITH APPROPRIATE INTENSIVE CARE AND TREATMENT THAT MOST OF THEM GET BETTER. I MISSED A SLIDE. I HAD A SLIDE OF THE NUMBERS. MUST HAVE LOST THAT SLIDE. HERE IT IS. SORRY. THERE HAVE BEEN OVER 5200 CASES BUT FORTUNATELY 46 DEATHS, SO LESS THAN 1% RATE OF MORTALITY IN THE UNITED STATES. AND THIS GROUP SAW MORTALITY RATE OF ALL THESE REPORTS FROM ALL OVER THE WORLD OF UNDER 2%. SO AT THE NIH WE ACTUALLY LAUNCHED A PROGRAM, ON MOTHER'S DAY OF 2020. THAT WAS WHEN DR. COLLINS, NIH DIRECTOR, CALLED MY DIRECTOR, DR. DIANA BIANCHI, AND DR. GARY GIBBONS FROM THE HEART, LUNG AND BLOOD INSTITUTE TO ASK THE TWO INSTITUTES TO LEAD AN EFFORT TO TRY TO UNDERSTAND THIS MIS-C. ONE OF THE FASTEST WAYS WE COULD LAUNCH SOMETHING WAS TO ACTUALLY SUPPLEMENT EXISTING NETWORKS, SO EACH OF THE THREE INSTITUTES THAT WERE INVOLVED, TWO CO-LEADS NHLBI AND US AT NICHD AND NIAID, SUPPLEMENTED OUR EXISTING NETWORKS TO FUND STUDIES OF MIS-C WHICH I'LL TALK ABOUT IN A SECOND. WE HAD A FUNDING OPPORTUNITY ANNOUNCEMENT AND LAUNCHED A NEW PROGRAM CALLED PREVAIL KIDS WHICH I'LL TOUCH ON BRIEFLY BUT DR. PEREZ-STABLE WILL TALK ABOUT, GIVEN IT'S PART OF THE RADx PROGRAM. SO, AS I MENTIONED, WE CAPITALIZED ON STRENGTHS OF EXISTING NETWORKS AND NIAID HAD SOLID -- PEDIATRICS SOLID ORGAN TRANSPORT AND AUTOIMMUNITY CENTERS OF EXCELLENCE PROGRAM AND THEY OF COURSE HAVE VERY GREAT EXPERTISE IN IMMUNOLOGIC PROFILING. SO THEY LAUNCHED A PROTOCOL TO LOOK AT THIS. HEART, LUNG AND BLOOD HAS A LOT OF STUDIES LOOKING AT LONG-TERM CARDIAC EFFECTS, LAUNCHED THROUGH THEIR PEDIATRIC HEARTNETWORK AND WE LOOKED AT PHARMACOKINETICS AND STUDIES DRUGS USED TO TREAT COVID-19 BUT NOT LABELED FOR CHILDREN SO WE WERE ABLE TO UPON THAT PLATFORM STUDY MIS-C. THE PLAN IS NOW THAT EVEN THOUGH THESE ARE THREE SEPARATE EFFORTS, WE'LL HARMONIZE DATA AND MAKE THEM AS INTEROPERABLE AS POSSIBLE SO HOPEFULLY THE WHOLE WILL BE GREATER THAN SUM OF THE PARTS. THERE IS A PLAN TO FOLLOW CHILDREN FOR UP TO FIVE YEARS AS WE MENTIONED, AGAIN, GIVEN IMPORTANCE OF THE LONG-TERM SEQUELAE OF THIS, CURRENTLY ACROSS THREE PROTOCOLS WE HAVE A THOUSAND CHILDREN ENROLLED WHICH IS REALLY GREAT. AND IMPORTANTLY, THIS HAS BEEN A THEME AT NIH THROUGHOUT THE COVID PANDEMIC IS THAT WE NEED DATA TO BE OUT AND AVAILABLE SO THAT PEOPLE BROADLY WAY BEYOND SCOPE OF AN INDIVIDUAL STUDY ARE ABLE TO ACCESS DATA, BRING THEIR SPECIAL INSIGHTS AND POTENTIAL DISCOVERIES TO THE DATA AS WELL. AND SO THAT'S BEEN AN ASPIRATIONAL GOAL BUT WE'VE AT LEAST ACHIEVED THE FIRST STEP OF THAT IN THAT THROUGH THIS PROGRAM THAT WE CALL CARING FOR CHILDREN OF COVID WE HAVE THE FIRST DATA RELEASE FROM THE NICHD PORTION OF THE STUDY. I'M NOT GOING TO GO OVER THE NEXT SLIDE ABOUT THE DETAILS BUT JUST ENOUGH TO KNOW THAT THE FIRST BATCH OF DATA ARE NOW AVAILABLE FOR OTHER INVESTIGATORS NOW TO BE ABLE TO BRING THEIR SPECIAL INSIGHT AND CREATIVITY AND POTENTIALLY MAKE DISCOVERIES BEYOND WHAT THE INITIAL STUDY TEAM CAN DO. SO AS I MENTIONED, THERE'S THE RADx PROGRAM, I'M GOING TO HIGHLIGHT ONE ASPECT OF WHAT WAS RADx RAD PROGRAM, ALSO FOCUSED ON MIS-C. I'M NOT GOING TO TALK ABOUT A VERY IMPORTANT PROGRAM WITHIN THE RADX-up ABOUT RETURN TO SCHOOL BECAUSE HE WILL BE TALKING ABOUT THAT IN THE NEXT TALK. PREVAIL KIDS IS A NEW OPPORTUNITY THAT WE LAUNCHED, JUST IN DECEMBER AND JANUARY. THESE ARE EIGHT TEAMS, PREDICTING VIRAL ASSOCIATED INFLAMMATORY DISEASE SEVERITY IN CHILDREN WITH LABORATORY DIAGNOSTICS AND ARTIFICIAL INTELLIGENCE, AND JUST TO SAY THAT EVEN THOUGH THESE TEAMS HAVE BEEN STOOD UP IN LESS THAN A YEAR, THEY ARE WORKING TOGETHER VERY WELL AND GENERATING REALLY IMPORTANT DATA ON TRYING TO UNDERSTAND FUNDAMENTAL BIOLOGY OF MIS-C. AND FINALLY I WANT TO TOUCH ON THIS LONG COVID, OR POST-ACUTE SEQUELAE OF COVID. THERE HAVE BEEN THESE REPORTS, AND SO THIS IS ONE FROM THE SPRING AT THE TOP, "NEW YORK TIMES," AND THEN ONE MORE RECENTLY JUST FROM A COUPLE MONTHS AGO, AGAIN FROM THE "NEW YORK TIMES," ABOUT MOST YOUNG PEOPLE RECOVER QUICKLY, DOCTORS ARE SEEING SOME CHILDREN AND TEENS WITH LINGERING FATIGUE AND OTHER CHRONIC PROBLEMS. AND THIS IS A SCHEMATIC FOR HOW WE KIND OF THINK ABOUT THIS POST-ACUTE SEQUELAE OF COVID. WHAT YOU HAVE HERE IS VIRAL LEVELS IN RESPIRATORY TRACT AND IN THE NASOPHARYNX, THOSE CAN GO VERY HIGH AND THEN COME DOWN AND THAT'S WHEN SOMEONE IS PCR POSITIVE AND HAS THE ACUTE ILLNESS. FORTUNATELY FOR CHILDREN, MOST CHILDREN THEN RECOVER AND WE WON'T HAVE VIRUS IN THEM, THEY ARE BACK TO NORMAL. BUT THERE SEEM TO BE SOME CHILDREN THAT DEVELOP THESE LINGERING SYMPTOMS, AND THIS HAS BEEN DESCRIBED FRANKLY MORE FREQUENTLY IN ADULTS THAN IN CHILDREN BUT AS YOU CAN SEE FROM THOSE REPORTS I JUST SHOWED IN THE PREVIOUS SLIDE WE'RE SEEING IT IN CHILDREN AS WELL. WE ALSO THINK OF MIS-C AS A FORM OF POST-ACUTE SEQUELAE OF CHILDREN AND I THINK THAT'S WHAT MAY HAVE PROMPTED THIS LAST BULLET ON A RECENT DEFINITION THAT W.H.O. HAD OF THE POST-COVID CONDITION. SO WHAT YOU CAN SEE HERE, THIS WAS A VERY LARGE EFFORT THAT THEY HAD WITH INVESTIGATORS, PATIENTS, AND OTHER STAKEHOLDERS FROM AROUND THE WORLD TO DEVELOP THIS CLINICAL CASE DEFINITION. THEY DID NOT REALLY ADDRESS PEDIATRICS OTHER THAN TO SAY A SEPARATE DEFINITION MAY BE APPLICABLE FOR CHILDREN. WE'RE NOT SURE THAT A SEPARATE DEFINITION SHOULD BE NECESSARILY APPLICABLE. WE WANT TO MAKE SURE THAT MIS-C IS ACKNOWLEDGED AS A POST-COVID CONDITION. AND SO THAT'S SOME OF THE FEEDBACK WE'RE GIVING THE W.H.O. THE NIH HAS LAUNCHED AN OVER ONE MILLION DOLLAR PROGRAM, DOLLARS ALLOCATED TO THE NIH LAST DISEASE BY THE CONGRESS TO TRY TO UNDERSTAND THIS POST-ACUTE SEQUELAE, OR LONG COVID, INCLUDING A PEDIATRIC COMPONENT SO THAT WE CAN TRY TO UNDERSTAND HOW OFTEN THIS OCCURS IN CHILDREN AND BEST WAYS TO PREVENT, MANAGE, AND TREAT IT AS WELL. THIS IS CALLED RECOVER, RESEARCHING COVID TO ENHANCE RECOVERY, HERE'S THE WEBSITE. AND REALLY A LOT OF ACTIVITIES HERE AS WE ROLL OUT THIS VERY LARGE PROGRAM TO TRY TO UNDERSTAND LONG COVID. FINALLY I WANT TO SAY THAT THERE'S LOTS AND LOTS GOING ON WITH CHILDREN AND COVID, AND SO WE TRY TO KEEP OUR WEBSITE UPDATED. THIS IS THE SITE, IT'S ON OUR WEBSITE, BUT WE AT NICHD AS I MENTIONED CO-LEAD MIS-C EFFORTS WITH NHLBI AND CO-LEAD OTHER EFFORTS WITH THE DRUG ABUSE INSTITUTE, AND SO WE'VE ACTUALLY FEATURED SOME OF THOSE ACTIVITIES HERE AS WELL. THIS IS NOT JUST NICHD RESEARCH. IT'S REALLY COVID-19 RESEARCH FOR OUR POPULATIONS WHICH IS PREGNANT, LACTATING PEOPLE, INFANTS, CHILDREN, ADOLESCENTS, THOSE WITH INTELLECTUAL AND PHYSICAL DISABILITY, SO A LOT OF GOOD SUMMARIES AND INFORMATION HERE. >> I HAVE TO CUT YOU OFF. SORRY. ONE QUESTION, WE'RE INTO THE NEXT SEGMENT. I WANT TO GIVE AN OPPORTUNITY TO ASK. THANK YOU FOR YOUR PRESENTATION. MINNIE? >> THAT'S OKAY, LET'S GO TO THE OTHER PRESENTER. I'M GOOD. >> OKAY. ALL RIGHT. GREAT. ROHAN, THANK YOU SO MUCH FOR YOUR TIME AND INFORMATION. I PRESUME WE'LL BE ABLE TO ACCESS THESE PRESENTATIONS AFTERWARDS, DAVID. I'M JUST CHECKING. >> YEAH, ABSOLUTELY. WE'LL PUT THEM IN THE NIH BOX TO HAVE ACCESS. >> FANTASTIC. IF COULD YOU INTRODUCE THE NEXT GUEST PLEASE. >> YEAH, ABSOLUTELY. MOVING RIGHT ALONG WE HAVE A JAM-PACKED AGENDA SO NEXT PRESENTER IS DR. ELISEO PEREZ-STABLE, DIRECTOR OF NIMHD. THIS INSTITUTE CONDUCTS AND SUPPORTS RESEARCH PROGRAMS TO ADVANCE KNOWLEDGE AND UNDERSTANDING OF HEALTH DISPARITIES TO IDENTIFY MECHANISMS TO IMPROVE MINORITY HEALTH AND DEVELOP INTERVENTIONS TO REDUCE HEALTH DISPARITIES IN COMMUNITY AND CLINICAL SETTINGS. DR. ELISEO PEREZ-STABLE IS GOES TO TALK ABOUT THE RADx INITIATIVE WHICH INCLUDES THE BACK-TO-SCHOOL INITIATIVE, I WILL TURN IT OVER TO YOU, ELISEO. >> THANK YOU SO MUCH, DAVE. THANK YOU FOR THE OPPORTUNITY TO PRESENT TO COLLEAGUES, TRIBAL ADVISORY COMMUNITY. ARE YOU RUNNING THE SLIDES OR SHOULD I SCARE SCREEN? >> WHY DON'T YOU GO AHEAD AND SHARE. >> OKAY. SORRY ABOUT THE DELAY. IT SHOULD BE -- OKAY. IS EVERYBODY ABLE TO SEE THEM? >> YES. >> SO I'M GOING TO -- THIS IS ACTUALLY -- I'M APPRECIATIVE THAT DAVE WILSON ASKED ME TO PRESENT BECAUSE I THINK IT'S A NICE POINT OF WHEN RADx-UP FOR UNDER SERVED POPULATIONS WAS CREATED, DR. TARA SCHWETZ PRESENTED ABOUT THE RAD ACCIDENT OCCURS-- RADx PROGRAM ABOUT MAY, AND IT'S BEEN A YEAR SINCE WE FUNDED THE FIRST GROUP OF GRANTS. YOU MAY ALREADY KNOW THIS, BUT THIS IS THE OVERALL PICTURE OF RAPID ACCELERATION OF DIAGNOSTICS INITIATIVE, SPECIAL APPROPRIATION FROM CONGRESS IN APRIL OF 2020. THIS HAS BEEN SORT OF COMBINED WITH OTHER APPROPRIATION LATER, EARLIER THIS YEAR, AMERICAN RECOVERY ACT. ESSENTIALLY THE BIG NEWS WAS THAT THE DEVELOPMENT OF THE TESTS DONE BY THE NATIONAL INSTITUTE OF BIOMEDICAL ENGINEERING AND IMAGING AND WE HAVE REALLY DOZENS OF VERY ACCURATE TESTS FOR PCR IN BOTH SALIVA AND RESPIRATORY MUCOSA. ALSO POINT-OF-CARE TESTS, LATERAL FLOW ANTIGEN TESTS INCREASING IN IMPORTANCE IN HOW WE, AS AN INTERVENTION, CONTROL THE PANDEMIC. I'LL TALK MORE ABOUT RADX-up, RADx-RAD IS NON-TRADITIONAL APPROACHES WITH IMPORTANT EARLY RESULTS. THIS WAS A COMPONENT OF RADx, TECHNOLOGIES READY TO BE IMPLEMENTED. DATA MANAGEMENT SUPPORT, IMPORTANT, CREATION OF CENTRALIZED DATA HUB, RELEVANT TO THIS GROUP AND WE WILL -- I'LL COME BACK TO THIS IN A MINUTE. AT-HOME TEST, POINT-OF-CARE TEST, DEVELOPED AND NOW PROMOTED, AND DOES APPEAR THAT THE ADMINISTRATION, CURRENT ADMINISTRATION, IS REALLY INTERESTED IN PROMOTING MUCH WIDER USE OF THIS. THIS IS A SNAPSHOT OF HOW WE PLANNED RADX-up, PLANNED AS A COMMITMENT TO ADDRESS THE INCREDIBLE DISPARITIES AND INEQUITIES THAT WERE REVEALED BY COVID-19 PANDEMIC IN AFRICAN AMERICAN, LATINO AND AMERICAN INDIAN AND ALASKA NATIVE COMMUNITIES IN A WAY THAT WAS STARTLING. IN A WAY THAT REALLY HAD NOT BEEN SEEN IN MOST ANY OTHER CONDITIONS THAT WE WERE FAMILIAR WITH. I'M SORRY. AND IT WAS ALSO BASED ON THE PRINCIPLE OF COMMUNITY ENGAGEMENT, SO WE WERE NOT GOING TO JUST SAY, OKAY, HERE'S SOME GRANTS TO DO RESEARCH OR TO DO THIS TESTING. WE WANTED TO GO TO INVESTIGATORS, TO GROUPS, TO ORGANIZATIONS, THAT ALREADY HAD COMMUNITY ENGAGED PERSPECTIVE AND HISTORY WITH THEIR COMMUNITIES, WHATEVER THAT MAY BE. UNDERSERVED POPULATIONS, THAT'S VERY BROAD. AND TO CREATE AN ABILITY TO UNDERSTAND WHY WE WERE SEEING THESE DISPARITIES BEYOND THE ONES WE WERE ALL HYPOTHESIZING OR OBSERVING BASED ON THE DATA THAT EMERGED EARLY ON. THE COMPONENTS FOCUSED ON FUNDING TESTING INTERVENTIONS, SO PROPOSALS CAME IN, THEY WERE SHORT, TWO YEARS, SIGNIFICANT FUNDING, OVER $2 MILLION EACH, TO INCREASE TESTING ACCESS AND UPTAKE. REMEMBER, IT'S A COMMUNITY-ENGAGED PROJECT, SO THE PROPOSAL HAD TO BE GROUNDED IN A COMMUNITY WITH ESTABLISHED PARTNERSHIPS. AND THIS, THE DATA COMING FROM THESE PROJECTS, WOULD HELP US UNDERSTAND THE DISPARITIES TO PREVENT THEM, ADDRESS THEM AND PREVENT THEM AT A FUTURE PANDEMIC. WE ALSO FUNDED A SMALLER NUMBER OF PROJECTS MORE RESEARCH, ON SOCIAL ETHICAL BEHAVIORAL IMPLICATIONS, AS MENTIONED BEFORE EARLY IN 2021, CALENDAR 2021, THE IMPORTANCE OF KIDS BEING OUT OF SCHOOL FOR A SECOND YEAR REALLY MANDATED WHAT CAN WE DO TO GENERATE DATA ABOUT RETURN, SAFE RETURN TO SCHOOL. SO RETURN TO SCHOOL PROGRAM WAS FUNDED FROM RADX-up, MANAGED BY THE NATIONAL INSTITUTE OF CHILD HEALTH AND DEVELOPMENT, AND TO REALLY LOOK AT DIAGNOSTIC TESTING AND APPROACHES IN EDUCATIONAL SETTINGS, FUNDING 16 PROJECTS IN THIS CASE AND I'LL TALK MORE ABOUT ONE PARTICULAR ONE. ONE OF THE THINGS ABOUT RADX-up, SHOWING THESE MAPS, THIS ILLUSTRATES COMMUNITIES SERVED, CURRENTLY SERVED BY RADX-up PROJECTS, ALL THE PHASE 1 PROJECTS. WE WILL FUND A SMALLER NUMBER OF PHASE 2 PROJECTS SOON, PROBABLY IN NOVEMBER. YOU CAN SEE WE'RE COVERING MUCH OF THE COUNTRY, I'LL GET INTO MORE DETAIL ABOUT THE ONES TARGETING NATIVE COMMUNITIES. HERE ARE CATEGORIES DESCRIBING WHAT PROJECTS ARE GOING TO WORK IN THESE COMMUNITIES, LATINO, HISPANIC, BLACK, OLDER ADULTS, CHILDREN, PACIFIC ISLANDERS, PREGNANT, AMERICAN INDIANS, HAWAIIANS, PEOPLE WHO WERE INCARCERATED, SOME WILL GO UP AS A CONSEQUENCE OF PHASE 2. WE FUNDED A LARGE CENTER, COORDINATING -- A COORDINATING DATA COLLECTION CENTER, CDCC, I HAVE TO REMEMBER WHAT THE ACRONYM STANDS FOR, BASED AT DUKE UNC AND THIS IS ALL COOPERATIVE AGREEMENTS SO WE'RE VERY INVOLVED IN ALL OF THE PROJECTS AND VERY MUCH INVOLVED IN WORKING, COORDINATING WITH THE CDCC. THEY ARE REALLY -- THEY HAVE DONE A REALLY TERRIFIC JOB OF HELPING NIH AND HELPING EACH OF THE FUNDED PROJECTS ESTABLISH THEMSELVES IN THIS FIRST YEAR. WE'RE VERY MUCH ATTENTIVE TO DATA SOVEREIGNTY, PROTECTION, SHARING WITH COMMUNITIES AND PARTICIPANTS, THIS IS A BIG ISSUE FOR AMERICAN INDIAN AND ALASKA NATIVE COMMUNITIES BUT NOT EXCLUSIVELY. IT'S AN ISSUE FOR ALL COMMUNITIES. AND WE HAVE TO BE ATTENTIVE TO DOING THE RIGHT THING IN ALL OF THESE AREAS. THE INTENTIONAL SUPPORT, SO THEY CREATE A STUDY TEAM TO HELP SUPPORT EACH OF THE STUDIES, AND THIS I THINK HAS BROUGHT, YOU KNOW, A BROAD ARRAY OF PROJECTS COUNTING THE SOCIAL ETHICAL BEHAVIORAL ONCE AT 85 PROJECTS, YOU CAN IMAGINE THE MAGNITUDE, NIMHD NEVER INVOLVED IN ANYTHING OF THIS SIZE AND I THINK WITH MY CO-CHAIR DR. RICHARD HODES AND INITIALLY DR. TARA SCHWETZ, NOW ON DETAIL AT THE WHITE HOUSE, WE HAVE STEERED THIS TO AS MUCH SUCCESS AS POSSIBLE BUT WE HAVE A LONG WAYS TO GO. WE'RE PROUD OF WHAT HAS BEEN ACCOMPLISHED, WE HAVE A LONG WAYS TO GO. VERY FOCUSED ON STRATEGIC PARTNERSHIPS, WITH COMMUNITIES, AND REALLY ON THE IMPACT WE'LL BE ABLE TO HAVE ON THE DISPARITIES. FOCUSING ON THE TEN, THIS MAP ILLUSTRATES MORE THAN TEN, THE TEN FUNDED PROJECTS THAT ARE EXCLUSIVELY CONCENTRATING ON AMERICAN INDIAN AND ALASKA NATIVE, I THOUGHT IT WOULD BE USEFUL FOR THIS GROUP TO HEAR WHAT THEY ARE. AND YOU CAN SEE THE COVERAGE GEOGRAPHIC REALLY. THESE WERE COMPETITIVE APPLICATIONS. WE REVIEWED THEM. WE ANALYZED AND SELECTED THE ONES WITH MANY PRIORITIES IN MIND INCLUDING POPULATIONS, GEOGRAPHICAL DISTRIBUTION, SO THIS WAS NOT EXCLUSIVELY DONE ON THE BEST SCORE OR THE QUOTE/UNQUOTE BEST SCIENCE. AND SOME ARE FUNDED AT AN INSTITUTION, SUCH AS STANFORD. FOCUSED ON POPULATIONS IN SOUTH DAKOTA, JOHNS HOPKINS FOCUSED ON POPULATIONS IN THE -- NATIVE POPULATIONS IN THE SOUTHWEST. LET ME TELL YOU A LITTLE BIT ABOUT EACH OF THE TEN. FIRST ARIZONA STATE, LOCATION IS IN ARIZONA, PERFORMING SARS-COV-2 TESTING IN TESTING DESERTS IN ARIZONA, COMPARE AFFECTED INDIVIDUALS WHO UNDERGO TESTING THROUGH EDUCATIONAL PROTOCOL, THOSE WHO RECEIVE THE SAME TESTING THROUGH STANDARD SYSTEMS. AND SO COMPARISON GROUP. CHEROKEE NATION RECIPIENT OF AWARD UNDER DR. KAHN'S LEADERSHIP WILL ENHANCE COVID-19 WITH RESIDENTS OF CHEROKEE NATION, POINT OF CARE TESTING, ANTIGEN TESTING, ANTIBODY TESTING AND CONTACT TRACING AS WELL AS PCR TESTS. WE'LL DEVELOP EDUCATION MATERIALS FOR THE COMMUNITY. AND JOHNS HOPKINS AMERICAN INDIAN CENTER HAD A LONG HISTORY OF PARTNERSHIP WITH NAVAJO NATION, LEVERAGED INTO A SUCCESSFUL RADX-up APPLICATION, EAST CENTRAL ARIZONA, WESTERN NEW MEXICO, PARTICULARLY NAVAJO HAVE BEEN AFFECTED EARLY ON AND RECEIVED A FAIR AMOUNT OF ATTENTION WITH THE COVID-19, WITH LIMITED AREAS WITH LIMITED INFRASTRUCTURE AS YOU KNOW INCLUDING ADEQUATE PLUMBING AND POWER ACCESS. THE GOAL WAS TO INCREASE SPEED OF THE TESTING WITH SYMPTOMS AND IMPROVE ADHERENCE TO RECOMMEND STRATEGIES. I MUST SAY IN MANY OF THESE COMMUNITIES, THE RESPONSE TO THE CRISIS HAS BEEN SPECTACULAR, COMMUNITIES HAVE MOBILIZED WITH YOUR LEADERSHIP, OF EACH OF THE COMMUNITIES, NOT ONLY IN JOINING AND GETTING TESTING BUT ALSO IN UPTAKE OF VACCINATIONS AND I THINK THIS IS A GREAT MODEL FOR ALL OF US TO LEARN FROM. AND OUT OF THE BOSTON MASSACHUSETTS GENERAL, RESEARCH ON THE LAKOTA TRIBES IN SOUTH DAKOTA AND WESTERN PLAINS OF DAKOTA, THERE'S ANOTHER PROJECT IN SOUTH DAKOTA, IN MONTANA STATE UNIVERSITY BOZEMAN FOCUSED ON RESERVATIONS IN MONTANA AS WELL AS YAKIMA VALLEY IN THE STATE OF WASHINGTON. AND WE'LL STUDY PRAGMATIC RANDOMIZED TESTING, HOME TESTING APPROACH THROUGH COMPARING COMMUNITY HEALTH WORKERS WITH MALE AT-HOME TESTING AND RELATED FEASIBILITY. HOME TESTING AND MAILING AND REPORTING, SELF-REPORTING OF RESULTS I THINK IS NOW GOING TO BE INCREASINGLY IMPLEMENTED SO WE'LL LOOK FORWARD TO LEARN FROM THIS GROUP AS TO GENERALIZED TO MANY COMMUNITIES. IN NORTH CAROLINA, THE LUMBI TRIBE AND HOPI AND CUMBERLAND FOR UPTAKE. DR. MALDONADO WILL LEAD THE EFFORT OUT OF STANFORD FOCUSED ON THE GREAT PLAINS TRIBES IN SOUTH DAKOTA. AGAIN, A RELATIONSHIP THAT HAS BEEN BUILT OVER TIME, NICHD FUNDED A PRIOR CENTER GRANT THAT INCLUDED A PROJECT THAT FOCUSED ON BUILDING A BIODATA CONSORTIUM IN SOUTH DAKOTA, AND THIS -- THIS SAME RESEARCH GROUP IS NOW ENHANCING TO FOCUS ON COVID-19 AND RADX-up PROGRAM. DR. BOOKWALD LET A SUCCESSFUL FOCUS ON URBAN INDIANS, AND I THINK THIS IS PARTICULARLY RELEVANT BECAUSE MOST OF THE TIME MANY SORT OF NIH MAINSTREAM SCIENTISTS ARE THINKING ABOUT AMERICAN INDIAN COMMUNITIES AND ALASKA NATIVE COMMUNITIES, NATIVE LANDS AND RESERVATIONS, YES URBAN INDIANS AS YOU WELL KNOW MAKE UP A MAJORITY OF THE POPULATION AND ARE SCATTERED BUT IS RUN OUT OF WASHINGTON STATE ALL RIGHT LOOKING AT SEVERAL URBAN INDIAN COMMUNITIES JURISDICTIONS, DR. JUDITH JAMES IN OKLAHOMA FOCUSED ON CHICKASAW NATION, TESTING TWO SCHEMES, LEVERAGING ACCESS TO HEALTH CARE AND PRIMARY CARE, FOCUSING ON RURAL UNDERSERVED COMMUNITIES. FINALLY, THE RETURN TO SCHOOL PROJECT THAT DR. BARLOW IS LEADING AGAIN OUT OF JOHNS HOPKINS, IN ARIZONA AND NEW MEXICO, AND I'LL TALK MORE ABOUT THIS PROJECT IN A MINUTE. I WANT TO EMPHASIZE THAT ALL OF THESE PROJECTS ARE FOCUSED ON CONDUCTING RESEARCH WITH THE AMERICAN INDIAN ALASKA NATIVE COMMUNITIES INCLUDING LETTERS OF SUPPORT FROM APPROPRIATE TRIBAL LEAD RESPECT AND TRIBAL HEALTH BOARDS WITH WHOM THEY ARE COLLABORATING. ALL OF THIS IS DONE IN FULL PARTNERSHIP WITH COMMUNITIES. AND FROM THE BEGINNING, WE HAVE PAID ATTENTION TO THE IMPORTANCE OF TRIBAL SOVEREIGNTY, TRIBAL IRB PROCESSES, AND THE IMPORTANCE OF GOVERNANCE OVER DATA. IN 2020 I REMIND YOU TRIBAL ADVISORY COMMITTEE HEARD DR. SCHWETZ PRESENT, HERE WE ARE ALMOST A YEAR AND A HALF LATER TO PRESENT WHERE WE ARE, AND WE'RE PROUD OF THE ACCOMPLISHMENTS SO FAR. WE HAVE A LONG WAYS TO GO, I HOPE ARE YOU AS WELL BECAUSE I THINK THIS PARTNERSHIP WOULD NOT HAVE BEEN POSSIBLE WITHOUT THIS. QUICKLY, THE BARLOW PROJECT IN RETURN TO SCHOOL, SAFE SCHOOLS, THE CHALLENGE OF SCHOOLS IS REALLY ONE THAT WE CAN GO BACK AND LOOK AT WHAT WERE WE THINKING, KEEPING KIDS OUT OF SCHOOL FOR A YEAR AND A HALF, TESTING IS ACCEPTABLE, WE'VE SHOWN THAT, KIDS ARE QUITE ABLE TO -- ABOVE A CERTAIN AGE ABLE TO DO THIS, STAFF AND ADMINISTRATIVE STAFF WOULD SUPPORT, ALSO ABLE TO DO. CASES ARE NOT SPREADING IN SCHOOLS. WE LEARNED THAT EARLY. KIDS ARE NOT A CONDUIT FOR TRANSMISSION AT THE SUPER SPREADER LEVEL WE SEE IN EITHER OLDER ADOLESCENTS OR YOUNG ADULTS, OR OF COURSE IN ADULTS. AND RATES IN SCHOOL PARALLEL WHAT'S GOING ON IN THE COMMUNITY. AND THEY ARE NOT A SIGNIFICANT DRIVER FOR TRANSMISSION. SO THIS IS PRE-VACCINATION, SO WE EXPECT THIS EVEN TO DECREASE FURTHER WITH VACCINATION. THIS GROUP HAS DEVELOPED COMMUNICATION MATERIALS THAT I THINK ARE GOOD EXAMPLES, WEBSITE AND TOOL KIT, RESOURCES FOR SCHOOLS TO USE THAT ARE CULTURALLY APPROPRIATE, CULTURALLY TAILORED FOR THEIR COMMUNITIES, AND WE'VE BEEN SUPPORTING THIS FROM THE BEGINNING. AGAIN, SUPPORTING RETURN TO SCHOOL IS IMPORTANT. USING MULTIPLE APPROACHES, SO SALIVA IN ONE CASE, NASAL IN ANOTHER, OR MUCOSAL IN ANOTHER, AND I THINK THE POINT OF CARE TEST, LATERAL ANTIGEN TESTS WHICH ARE NOT YET AUTHORIZED FOR KIDS UNDER AGE 5 WOULD BE ANOTHER APPROACH. SPREAD IS RARE. RETURNING TO SCHOOL IS IMPORTANT. YET WE STILL SEE A FAIR AMOUNT OF PARENTAL AND SOME STAFF, MOSTLY PARENTAL, HESITANCY ON RETURN TO SCHOOLS AND I THINK THIS IS IMPORTANT ISSUE TO ADDRESS. ALL OF THIS RELATES TO MENTAL HEALTH, BECAUSE THIS IS -- DR. GORDON IS PRESENTING AFTER ME, AND THIS IS ALL AN OVERRIDING CONSEQUENCE AND ISSUE, CHRONIC ONE, OF THE PANDEMIC. SO WE NEED TO CONTINUE TO SUPPORT SCHOOLS FOR IMPLEMENTING AND WORK WITH PEOPLE FAMILIAR WITH THE SITUATION. AND MORE RESOURCES. THIS IS RETURN TO SCHOOL PROGRAM, FUNDED IN TWO YEARS, AND HOPEFULLY IF WE AR ABLE TO LEVERAGE RESOURCES FOR RADX-up WE'LL LOOK TO EXPAND THAT PROGRAM. SO JUST TO FINISH, THE RADx TRIBAL DEPOSITORY IS SOMETHING WE PRESENTED EARLIER THIS YEAR. WE HAVE NOW COMPLETED A TRIBAL CONSULTATION. WE'RE BUSY WRITING FUNDING OPPORTUNITY ANNOUNCEMENT. THIS WILL BE PARALLEL TO BUT INDEPENDENT OF THE NIH RADx DATA HUB, CDCC THAT RADx-UP WILL ALSO WORK, THIS IS FOR DE-IDENTIFIED DATA, NOT BIOSPECIMENS, IT WILL BE TRIBAL GOVERNED, AND WE WILL ENABLE CURRENT AND FUTURE APPLIED RESEARCH AS NIMHD DIRECTOR I LOOK FORWARD TO CONTINUING TO WORK WITH YOU AND SUPPORT THIS EFFORT FOR YEARS TO COME. YES, SUSTAINABILITY IS GOING TO BE A QUESTION, ALWAYS, AND WE HEARD THAT LOUD AND CLEAR. AND WE'RE PREPARED IN PARTNERSHIP WITH THE OFFICE OF DATA SCIENCE AND OTHERS AT NIH TO CONTINUE THIS EFFORT. THIS IS JUST AN EXAMPLE OF TESTING, PARTICIPANTS ENROLLED, TESTING DONE, NOTICE THE VERY LOW RATE OF POSITIVITY, WE'RE SEEING THAT ACROSS ALL OF THE RADX-up. THESE ARE TESTS CONDUCTED IN ELECTRONIC HEALTH RECORDS. SO TO END, IRB APPROVAL IS VERY INTENTIONAL WITHIN THE TRIBES, AND SPECIFIC TRIBAL NATION IRB AND DATA SOVEREIGNTY TIMELINES SOMETIMES DON'T ALIGN WITH WHAT CDCC WOULD LIKE US TO DO. SO WE PAUSE AND WAIT AND WE CERTAINLY GO AT THE SPEED OF TRUST, THAT'S BEEN ONE OF OUR MANTRAS. RELATIONSHIPS IN PARTNERSHIPS ARE PARAMOUNT, HAVE TAKEN YEARS TO BUILD. WE DO NOT WANT TO DISRUPT THAT IN ANY WAY, AS A FORMER COMMUNITY ENGAGED SCIENTIST FROM CALIFORNIA, I CAN VOUCH THAT THIS IS NOT SOMETHING THAT ANY OF US ARE WILLING TO RISK AND I'M VERY SUPPORTIVE OF THESE EFFORTS. AND WE NEED TO CONTINUE ADDRESSING SHARING AGGREGATE DATA TO LEARN, AND YOUR COMMUNITIES, YOUR SCIENTISTS, CAN HELP UNDERSTAND THE FACTORS THAT LEAD TO DIFFERENCES. SO I WILL STOP SHARING AND, DAVE, YOU'RE MODERATING, RIGHT? LET ME END THE SLIDE SHOW FIRST. >> LISA, GO AHEAD. >> HI. THANK YOU, THAT WAS BEAUTIFUL. AND I JUST WANT TO OPEN THE FLOOR TO ANY OF OUR TAC MEMBERS WHO MAY HAVE QUESTIONS. I THINK WE'RE GOOD. IF THERE'S ANY OTHER COMMENTS YOU'D LIKE TO MAKE AS WE CLOSE OUT, WE APPRECIATE YOU PREPARING FOR YOUR TALK HERE TODAY AND SPENDING TIME WITH US. >> ONLY THAT WE ARE 100% COMMITTED TO SUPPORTING YOU. YOU KNOW, THIS IS A HIGH PRIORITY FOR NIMHD FOR SURE. I'M THE DIRECTOR SO I CAN SAY THAT UNEQUIVOCALLY BUT CERTAINLY I THINK ALL OF NIH IS ON BOARD WITH THIS AND WE LOOK FORWARD TO CONTINUING TO MAKE A DIFFERENCE IN OUR COMMUNITIES THROUGH THESE PROGRAMS. THANK YOU. >> THANK YOU SO MUCH. SO, DAVE, YOU HAVE MORE TIME FOR THE INTRODUCTION OF THE NEXT GUEST IF HE'S AVAILABLE. >> YES, HE IS. SO THANK YOU, ONCE AGAIN, DR. ELISEO PEREZ-STABLE FOR JOINING US, WONDERFUL TALK. ONE OF THE THINGS THAT'S REALLY NICE IS HOW COMPLEMENTARY EACH OF THE PRESENTATIONS HAS BEEN, SO ALL THE QUESTIONS RAISED AND MAYBE NOT FULLY ANSWERED IN THE PREVIOUS PRESENTATIONS ARE ANSWERED THROUGH THE SUBSEQUENT PRESENTATIONS. SO THE NEXT SPEAKER WHO I HAVE THE PLEASURE OF INTRODUCING, WE'VE WORKED TOGETHER ON SEVERAL DIFFERENT EFFORTS, DR. JOSH GORDON, DIRECTOR OF THE NATIONAL INSTITUTE OF MENTAL HEALTH. SO NIMH IS THE LEAD FEDERAL AGENCY FOR RESEARCH ON MENTAL HEALTH ELEMENTAL DISORDERS, OVERSEES PORTFOLIO OF BASIC AND CLINICAL RESEARCH THAT SEEKS TO TRANSFORM THE UNDERSTANDING AND TREATMENT OF MENTAL ILLNESSES. THIS WILL BE DISCOVERIES PAVING THE WAY FOR FUTURE PREVENTION, RECOVERY, AND CURES RELATED TO MENTAL HEALTH. SO WITH THAT I WANT TO WELCOME YOU, DR. GORDON, AND I WILL TURN IT OVER TO YOU NOW. >> THANK YOU, DR. WILSON. THANK YOU, EVERYONE FOR INVITING ME TO PARTICIPATE IN THIS COUNCIL MEETING. IT'S REALLY A PLEASURE FOR ME TO BE HERE AND WE'VE HAD MANY CONVERSATIONS INCLUDING ISSUES MORE RECENTLY AROUND COLD F RONT -- COVID AND MENTAL HEALTH. I'M GOING TO SHARE MY PRESENTATION HERE. HOPEFULLY YOU'RE SEEING THAT. LET'S SEE. THERE IT GOES. SO, I'M HERE TO TALK ABOUT COVID-19 AND MENTAL HEALTH, GENERALLY ABOUT IT, ALSO HOPEFULLY YOU'LL SEE THE POTENTIAL IMPACT OF THE WORK WE'RE DOING ON TRIBAL COMMUNITIES AS WELL AND HAPPY TO TAKE ADDITIONAL QUESTIONS AT THE END. I DON'T THINK I'LL NEED ALL OF MY 45 MINUTES SO WE SHOULD HAVE TIME FOR A CONVERSATION AFTERWARDS. STRUCTURE OF THE TALK AS FOLLOWS. FIRST I'LL TALK ABOUT WHAT WE KNOW FROM PRIOR DISASTERS, TRAUMATIC EVENTS, PANDEMICS, ET CETERA. WE KNEW QUITE A LOT BEFORE COVID-19 STARTED, ABOUT WHAT TO EXPECT. AND WE'LL TALK ABOUT RISK FACTORS AND RESILIENCE FROM THAT DATA WE KNEW BEFOREHAND. THEN I'LL DISCUSS EMERGING DATA AROUND THE EFFECTS OF COVID-19, PANDEMIC, MITIGATION, FALLOUT, EFFECT FROM A VARIETY OF COMMUNITIES, WHICH MORE OR LESS MATCH OUR EXPECTATIONS BUT OF COURSE GIVEN THAT COVID-19 IS AN UNPRECEDENTED EVENT SOME DATA ARE ALSO UNPRECEDENTED. THEN I'LL TALK ABOUT WHAT WE'RE DOING NOW TO ADDRESS MENTAL HEALTH IMPACTS FROM COVID-19 FROM RESEARCH PERSPECTIVES, STUDIES ONGOING, BOTH IN TERMS OF HELPING RESOLVE THE LASTING POTENTIAL EFFECTS AND ALSO PREPARING FOR FUTURE PANDEMICS AND EVENTS. WHAT DO WE KNOW FROM PRIOR DISASTERS AND TRAUMATIC EVENTS? THIS IS JUST MEANT TO REMIND US OF THE SEVERITY OF THE COVID PANDEMIC, 7-DAY CASE RATE AS OF SEPTEMBER 15, THE MAP LOOKS DIFFERENT NOW. BUT WE KNOW THE CORONAVIRUS PANDEMIC HAS BEEN A LONG LASTING ONE. AND ONE WHERE WITH THE ACTION IS CONSTANTLY MOVING. SO EVEN IN THE MONTHS SINCE THIS GRAPH NORTHERN STATES HAVE BECOME MORE AFFECTED, NORTHWESTERN STATES AS OPPOSED TO SOUTHERN STATES. WE KNOW THE DELTA VIRUS WAVE SEEM TO BE WANING BUT WE DON'T KNOW WHAT'S GOING TO COME NEXT. OF COURSE ALL THAT UNCERTAINTY AND SERIOUSNESS OF THE PANDEMIC CREATES STRESSFUL SITUATIONS. AND THOSE INDIVIDUALS ARE GOING TO EXPERIENCE SYMPTOMS OF THAT DISTRESS. WHAT HAVE WE LEARNED FROM MASS DISASTER AND TRAUMA AND PANDEMICS IN THE PAST? MOST EXPOSED TO TRAUMATIC EXPERIENCES HAVE INITIAL SYMPTOMS OF DISTRESS, SYMPTOMS OF ANXIETY, DEPRESSION, AVOIDANCE, HEIGHTENED SENSITIVITY, ALL THE KINDS OF THINGS THAT YOU ARE MOST LIKELY FAMILIAR WITH, EITHER FROM PERSONAL EXPERIENCE OR FROM KNOWING PEOPLE WHO HAVE BEEN AFFECTED BY STRESSFUL TRAUMATIC SITUATIONS OR FROM READING ABOUT THESE. FOR MOST SYMPTOMS WILL IMPROVE WITH TIME, ILLUSTRATED BY THIS DOTTED LINE IN THE CURVE WHERE WE HAVE, SAY, SOME SYMPTOMS IN THIS CASE SYMPTOMS OF POSTTRAUMATIC STRESS DISORDER AND WITH HIGH SYMPTOMS IN THE BEGINNING, SYMPTOMS RESOLVE, AS THE TRAUMA RESOLVES AND RECEDES. HOWEVER, SIGNIFICANT MINORITY OF INDIVIDUAL MAY HAVE LONG TERM OR CHRONIC EXPERIENCE RESULTING IN POTENTIAL OF DIAGNOSIS WITH NEW ONSET MENTAL ILLNESS. THOSE CAN BE ILLUSTRATED HERE BY THESE BLACK AND GRAY LINES WHERE BLACK LINE MIGHT BE INDIVIDUALS WITH SYMPTOMS THAT LAST OUT SEVERAL MONTHS TO A COUPLE YEARS AND GRAY LINE MIGHT INDICATE SOMEONE WHO IS DEVELOPING CHRONIC MENTAL ILLNESS THAT WILL NEED CARE FOR A LONG TIME. WHAT DIFFERENTIATES? SOCIAL INEQUALITIES AND HEALTH DISPARITIES INCREASE EXPOSURE, SIGNIFICANCE OF EXPOSURE TO TRAUMA AS WELL AS SUBSEQUENT MENTAL HEALTH VULNERABILITY AND ISSUES AROUND ACCESS TO CARE AND QUALITY OF CARE. I'LL REPEAT THAT. INDIVIDUALS WITH SOCIAL INEQUALITIES AND HEALTH DISPARITIES HAVE INCREASED EXPOSURES TO TRAUMA AS WELL AS INCREASED RISK OF SUBSEQUENT MENTAL HEALTH VULNERABILITY AND POOR ACCESS TO CARE. WE SEE THIS ABSOLUTELY IN THE CONTEXT OF PANDEMIC, I'LL SHOW SOME DATA BUT YOU KNOW THAT MORE VULNERABILITY COMMUNITIES, MINORITY COMMUNITIES, RURAL COMMUNITIES, TRIBAL COMMUNITIES, WERE HARDEST HIT BY THE PANDEMIC, ESPECIALLY EARLY ON IN THE PANDEMIC, FACED THE MOST DIRECT EXPOSURE TO THE TRAUMA OF THE PANDEMIC AS WELL AS ECONOMIC EFFECTS OF THE MITIGATION MEASURES AND THEREFORE OFTEN HAVE MOST SIGNIFICANT SYMPTOMS. WE WANT TO GUARD AGAINST RESIDUAL SYMPTOMS AND ENSURE PEOPLE GET THE CARE THEY NEED TO LOOK LIKE THE DOTTED LINE TO REMIT AS SOON AS THE TRAUMA RECEDES. LET'S GO INTO RISK AND RESILIENCE FACTORS MORE DEEPLY. RISK FACTOR FOR WORSENED MENTAL HEALTH OUTCOMES IS NATURE AND SEVERITY OF EXPOSURE. CAR CRASH OR AIRPLANE CRASH OR HURRICANE, THOSE EXPOSED DIRECTLY TO DEATH OR INJURIES AT GREATEST RISK, TRAUMA TYPE MATTERS. WITH THE PANDEMIC WE HAVE NOT ALL BEEN EXPOSED EQUALLY. PEOPLE WHO LOST LOVED ONES, WATCHED LOVED ONES IN THE HOSPITAL ON RESPIRATORS, SEPARATED BECAUSE OF THE ILLNESS, LOST JOBS, WHO ARE EXPERIENCING FOOD INSECURITY, HOUSING INSECURITY BECAUSE OF THE EFFECTS, THEY ARE THE ONES WHO HAVE BEEN MOST SEVERELY AFFECTED OR EXPOSED TO TRAUMA AND AT GREATEST RISK. IN ADDITION TO THE LEVEL OF EXPOSURE, INDIVIDUAL DIFFERENCES CAN INCREASE OR DECREASE RISK. FOR EXAMPLE, HISTORY OF TRAUMA OR PREEXISTING MENTAL ILLNESS RAISES RISK. ONGOING STRESSORS, OCCUPATIONAL AND FINANCIAL STRAIN, A AND SUBSTANDS USE OR ABUSE CAN RAISE RISK AS CAN FEMALE GENDER AND NON-WHITE ETHNIC OR RACIAL STATUS. ENVIRONMENTALLY FEW SOCIAL SUPPORTS INCREASE RISK. I WANT TO POINT OUT NO SINGLE VARIABLE DETERMINES INDIVIDUAL OUTCOMES. IT'S THE SUM TOTAL OF AN INDIVIDUAL'S RISK AND RESILIENCE FACTORS. THIS PAGE HAS RISK FACTORS. LET'S TALK ABOUT RESILIENCE. ONE OF THE THINGS WE KNOW WE CAN DO TO BUILD RESILIENCE IS MEET THE IMMEDIATE NEEDS OF PEOPLE IN THE CONTEXT OF DISASTER. IF YOU LOST YOUR HOME, LET'S GET YOU A HOME. HAVING TROUBLE FEEDING YOUR FAMILY, LET'S GET YOU SOME FOOD. ECONOMIC ASSISTANCE. AND FIRST AND FOREMOST, THAT'S BEEN OPERATIONAL IN THE CONTEXT OF THIS PANDEMIC, RIGHT? WITH EXTENDED UNEMPLOYMENT INSURANCE, AND ENHANCED DONATIONS TO FOOD BANKS, AND EFFORTS TO TRY TO SHORE UP PEOPLE'S IMMEDIATE NEEDS. IN ADDITION, PEOPLE WHO PRACTICE HEALTHY COPING STRATEGIES CAN BUILD RESILIENCE. SO IF YOU ARE GETTING APPROPRIATE SLEEP, GETTING APPROPRIATE AMOUNT OF NUTRITIOUS FOOD, OF EXERCISE, IF YOU FIND WAYS TO KEEP YOURSELF CALM THROUGH YOGA, CONVERSATIONS WITH SOCIAL SUPPORTS, ET CETERA, THESE ARE GOOD HEALTHY COPING STRATEGIES AND THEY CAN ALL BUILD RESILIENCE. FOR THOSE WHO ARE STRUGGLING WITH PREEXISTING ILLNESS OR NEW ONSET, TREATING THAT ILLNESS CAN BE SUPPORTIVE RESILIENCE BUILDING EXERCISE. THEN THERE ARE THINGS WE CAN ALL DO, MANY OF US HAVE BEEN DOING IN THE CONTEXT OF THE PANDEMIC, THAT BUILD RESILIENCE INCLUDING FINDING WAYS TO HELP OTHERS, WHICH PROMOTES SENSE OF EFFICACY AND PROMOTES CONNECTEDNESS. I WANT TO MENTION THAT FOR THOSE PARTICIPATING EVEN IN WEARING MASKS, GETTING VACCINATED, BUT EVEN ONE STEP BEYOND THAT, VOLUNTEERING TO HELP OTHERS GET VACCINATED, VOLUNTEERING TO HELP AT A LOCAL FOOD BANK, ET CETERA, FINDING WAYS TO HELP OTHERS BUILDS RESILIENCE AS WELL. THIS IS ALL INFORMATION THAT WE KNEW BEFOREHAND, THAT POLICYMAKERS, GOVERNMENT, TRIBAL LEADERSSHIP HAVE BEEN PUTTING IN PLACE IN THE CONTEXT OF PANDEMIC TO ENSURE AGAIN IF WE GO BACK TO THE CURVES THAT WE TAKE AS MANY PEOPLE WHO MIGHT HAVE SUFFERED LONG LASTING OR SEVERE SYMPTOMS OF MENTAL ILLNESS TO HELP THEM REMIT AS HAPPENEDLY AS POSSIBLE AND REDUCE THEIR LIKELIHOOD OF LONG-TERM NEGATIVE OUTCOMES OF THE MENTAL HEALTH SPHERE. THAT'S WHERE WE KNEW FROM PREVIOUS DISASTERS. WE ALSO KNOW IN THE CONTEXT OF EXISTING DISASTER, ACCESS TO CARE IS A CHALLENGE. AND THAT PEOPLE WITH NEW ONSET DISORDERS IN CONTEXT OF THESE CHALLENGES OFTEN DON'T RECEIVE TREATMENT. SO I WANT TO PAY ATTENTION TO JUST TWO PARTS HERE. IN PURPLE ARE DATA FROM PEOPLE WHO HAD PREEXISTING MENTAL ILLNESSES PRIOR TO HURRICANE KATRINA IN SURROUNDING AREAS, IN GREEN PEOPLE WHO HAD NEW ONSET MENTAL ILLNESSES IN THE CONTEXT OF HURRICANE KATRINA, HALF WERE GETTING CARE PRIOR TO THE HURRICANE. AFTER THE HURRICANE, FEWER OF THEM FROM 60 TO 40% IN NEW ORLEANS, THEY WERE HAVING TROUBLE GETTING CARE AND ABOUT THE SAME NUMBER OF PEOPLE OUTLYING AREAS WERE ABLE TO GET CARE. ENABLING FACTORS LIKE TRANSPORTATION, WHETHER THE PLACE THEY WERE GETTING CARE WAS OPEN WITH THE RIGHT HOURS, WHETHER THEY COULD AFFORD TO GO, WHETHER THEY HAD CHILD CARE, ENABLING FACTORS ARE PRINCIPAL REASONS FOR DROP IN ACCESS TO CARE FOR MENTAL HEALTH DISORDERS IN NEW ORLEANS AFTER KATRINA. FOR THOSE WITH NEW ONSET DISORDERS THE STORY IS WORSE. 80% OF PEOPLE DID NOT RECEIVE POST HURRICANE TREATMENT AND A BIG REASON WHY, THEY DIDN'T RECOGNIZE THEY NEEDED TO GET HEALTH CARE, DIDN'T RECOGNIZE IT WOULD BENEFIT THEM. WE NOWACK -- KNOW THAT ACCESS IN THE CONTEXT OF TRAUMATIC EVENTS IS A PROBLEM. LET'S TALK ABOUT COVID-19, ENOUGH OF HISTORY. WHAT ARE WE GO THROUGH NOW? YOU'VE KNOWN A SUBSTANTIAL MINORITY OF AMERICANS ARE SUFFERING FROM SYMPTOMS OF MENTAL ILLNESS, NOT NECESSARILY DIAGNOSES BUT SYMPTOMS OF MENTAL ILLNESS IN THE CONTEXT OF PANDEMIC, 30% OF AMERICANS REPORTING ANXIETY, DEPRESSIVE SYMPTOMS, 26% SYMPTOMS OF STRESS DISORDER, 13% INCREASE PATTERNS OF SUBSTANCE USE, AND 11% SERIOUSLY CONSIDERED SUICIDE, JUNE OF 2020. 40% OF U.S. ADULTS AT THAT TIME REPORTED STRUGGLING WITH A MENTAL HEALTH ISSUE. THE CONDITIONS HAVE ONLY GOTTEN WORSE FROM THE BEGINNING OF 2021, ACCORDING TO THE CDC DATA, REPORTS OF ANY SYMPTOM OF ANXIETY REPRESSION REMAINED CONSTANT OR IF ANYTHING ROSE SLIGHTLY AS THE PANDEMIC WORE ON. IN FACT, IT'S NOT JUST PEOPLE REPORTING MILD DEPRESSION OR MILD ANXIETY BUT THERE ARE GREATER PROPORTION OF AMERICANS REPORTING MODERATE, MODERATELY SEVERE OR SEVERE SYMPTOMS OF DEPRESSION AND ALSO ANXIETY. AND OF COURSE THESE ARE FOLKS THAT WE'RE WORRIED ABOUT FOR CHRONIC MENTAL ILLNESS, THAT WILL BENEFIT FROM ACCESS TO TREATMENT. WHAT ARE SOME RISK FACTORS? WELL, JUST LIKE WE TALKED ABOUT BEFORE, THERE ARE MANY SOCIOECONOMIC AND DEMOGRAPHIC RISK FACTORS FOR ADVERSE MENTAL HEALTH OUTCOMES OF THE PANDEMIC, INCLUDING FOOD INSECURITY, IF YOU'RE NOT RECEIVING FREE GROCERIES OR MEALS, HIGHER LEVELS OF ANXIETY, WORRY, ANHEDONIA OR LOWER INTEREST IN ACTIVITIES, HIGHER LEVELS OF DEPRESSION, OF ANY SYMPTOM OF POOR MENTAL HEALTH COMPARED TO INDIVIDUALS RECEIVING FREE GROCERIES OR MEALS. NUMBER ONE, FOOD INSECURITY MATTERS. NUMBER TWO, SOCIETAL EFFORTS TO REDUCE FOOD INSECURITY IN THIS CASE GIVING OUT GROCERIES OR MEALS CAN MAKE A DIFFERENCE IN TERMS OF MENTAL HEALTH SYMPTOMS IN THE U.S. NOW, I ALSO MENTIONED THAT THERE ARE RACIAL AND ETHNIC DIFFERENCES IN RISK AND RESILIENCE, AND WE'RE SEEING THAT HERE AS WELL. ONE AREA THAT WE'RE SEEING IT IN IS SUICIDE RATES. SO, AMONG WHITE INDIVIDUALS THROUGH 2019 THERE HAD BEEN CONSISTENT INCREASE IN SUICIDE RATES IN THE U.S. WITH SLIGHT DECREASE IN 2019 THAT IN FACT I HOPE I'LL SHOW IN A MINUTE, NOT SURE I HAVE THE DATA IN THE SLIDE, CONTINUED INTO 2020. INDIVIDUALS FROM BLACK, ASIAN COMMUNITIES, FROM AMERICAN INDIAN AND ALASKA NATIVE COMMUNITIES SAW INCREASE IN RATES OF SUICIDE OR ESSENTIALLY WERE FLAT. NOW, IT'S IMPORTANT WE UNDERSTAND THE FACTORS THAT LEAD TO SUICIDE. THERE'S BEEN A NUMBER OF MODELING STUDIES IN CONTEXT OF THE PANDEMIC TO EXAMINE SUICIDE RISK, WHAT'S LEADING TO IT. FOR EXAMPLE EARLY IN THE DAYS OF PANDEMIC WITH STAY-AT-HOME ORDERS, MODELERS DEEMED STAY-AT-HOME ORDERERS COUPLED WITH LONELINESS AND LACK OF BELONGING RESULTED IN ENHANCED SUICIDE RISK, RECENT JOB LOSS AS WELLER WITH RECEIVED BURDENSOMENESS LED. SOCIAL FACTORS IMPACT WITH REAL EVENTS THAT ARE HAPPENING IN THE CONTEXT OF THE PANDEMIC TO RAISE RISK FOR SUICIDE, THIS IS THE RISK WE NEED TO MITIGATE. OF COURSE, WE KNOW THIS IS MORE THAN JUST ABOUT SUICIDE. MENTAL HEALTH SYMPTOMS IN VULNERABLE POPULATIONS PRE-PANDEMIC HAD STRIKING DISPARITIES IN TERMS OF PREVALENT DRIVEN BY SOCIAL DETERMINANTS OF HEALTH INCLUDING RACISM, HOUSING AND FOOD INSECURITY, ACCESS TO AND QUALITY OF CARE. DURING THE PANDEMIC VULNERABILITIES WERE ENHANCED, FOLKS EXPERIENCING THE BIGGEST CHALLENGES IN THE CONTEXT OF THE PANDEMIC. THAT'S WHAT WE KNOW. WE KNOW THAT AMERICANS ARE SUFFERING. WE KNOW THAT WE NEED TO MEET THE NEEDS OF THOSE WHO ARE SUFFERING. WE KNOW NOT EVERYONE IS SUFFERING EQUALLY. HOW DO WE ADDRESS THESE FROM A RESEARCH STANDPOINT? AS I MENTIONED, WE WANT TO WORK ON PROMOTING RESILIENCE. WE WANT TO DO RESEARCH THAT HELPS US FIGURE OUT HOW BEST TO PROMOTE THAT RESILIENCE IN THE CONTEXT OF THE PANDEMIC AND MAKE SURE THAT WE FOCUS ON INDIVIDUALS MOST AT RISK INCLUDING VULNERABLE POPULATIONS LIKE RACIAL AND ETHNIC MINORITIES, FRONT LINE WORKERS AT INCREASED RISK BECAUSE OF EXPOSURE, PRE-EXISTING MENTAL ILLNESS, ET CETERA. ONE OF THE WAYS WE'VE SHOWN TO BE ABLE TO EXPAND ACCESS TO MENTAL HEALTH CARE IN THE CONTEXT OF DISASTERS IS THROUGH TELEHEALTH. WE KNOW IN MARCH OF 2020 AS THE PANDEMIC INCREASED A LOT OF HEALTH CARE PROVIDERS SHUT DOORS AND OPENED UP THEIR LAPTOPS. AND THERE WAS A REAL SHIFT OF TELEHEALTH. WE HAVE TO EXAMINE WHAT'S THE EFFECT ON MENTAL HEALTH. WE KNOW THAT MENTAL HEALTH ACCESS THROUGH TELEHEALTH CAN BE AS EFFECTIVE AS IN-PERSON MENTAL HEALTH CARE WHEN DELIVERED PROPERLY. BUT WE DON'T KNOW ABOUT ACCESS. THERE'S SOME ENCOURAGING STUDIES WITH A TWIST. FOR EXAMPLE, PUBLISHED EARLIER THIS YEAR WAS THIS STUDY FROM FEDERALLY QUALIFIED HEALTH CARE CENTERS IN CALIFORNIA, EXAMINING THE SHIFT FROM IN-PERSON VISITS IN ORANGE TO TELEMEDICINE, WHETHER AUDIO OR VIDEO, IN BLACK AND GRAY. IN THE CONTEXT OF THE PANDEMIC IN EARLY MARCH TO APRIL OF 2020 IN CALIFORNIA. WHAT YOU CAN SEE IN BLUE IS THE TOTAL NUMBER OF VISITS FOR PRIMARY CARE AND FOR BEHAVIORAL HEALTH, GIVEN BY THESE CLINICS WHICH ARE OF COURSE SEEING LOW SOCIOSOCIOECONOMIC STATUS. TOTAL NUMBER OF VISITS STAYED THE SAME THROUGH THE BEGINNING PART BUT MOST VISITS SHIFTED FROM BEING IN PERSON, IN ORANGE, TO BEING AUDIO OR VIDEO IN BLACK AND GRAY. BEHAVIORAL HEALTH INTERESTINGLY ENOUGH WITH THE ONSET OF THE PANDEMIC, THE TOTAL NUMBER OF BEHAVIORAL HEALTH CARE VISITS ACTUALLY INCREASED, REFLECTING THE FACT THAT MORE PEOPLE WERE EXPERIENCING MENTAL HEALTH SYMPTOMS IN THE CONTEXT OF THE PANDEMIC. THAT'S GOOD. OUR HEALTH CARE SYSTEM WAS ABLE TO AT LEAST SOMEWHAT MEET THIS INCREASE IN DEMAND, AT LEAST IN CALIFORNIA IN THE FEDERALLY QUALIFIED HEALTH CARE CENTERS. YOU SEE A DROP-OFF OF IN-PERSON VISITS REPLACED BY AUDIO AND VIDEO VISITS. AUDIO OUTNUMBERED, ONE POTENTIAL CAUSE IS LACK OF ACCESS TO EQUIPMENT AND/OR HIGH-SPEED INTERNET, IN THE COMMUNITIES SERVE THE BY FEDERALLY QUALIFIED HEALTH CARE CENTERS BUT TELEHEALTH PLAYS AN IMPORTANT ROLE. WE'RE DIRECTLY TESTING THE ROLE OF NOVEL APPROACHES TO REMOTE MENTAL HEALTH CARE THROUGH DIFFERENT STUDIES, THIS ONE, FOR EXAMPLE, DIGITAL HEALTH APP THAN AIMS TO MONITOR AND IMPROVE MENTAL HEALTH DURING THE PANDEMIC, THIS IS A STUDY WE FUNDED TO DEVELOP AND TEST DIGITAL THERAPEUTIC FOR REDUCING ANXIETY IN THE CONTEXT OF THE PANDEMIC. YOU HEARD ABOUT THE RADX-up INITIATIVE, EARLIER. IT IS AN INITIATIVE TO ENSURE WE UNDERSTAND THE FACTORS ASSOCIATED WITH DISPARITIES IN COVID-19 MORBIDITY AND MORTALITY BUT WE'RE ALSO CONCERNED WITH OUTCOMES IN THESE UNDERSERVED OPPORTUNITIES FROM MENTAL HEALTH PERSPECTIVE AND IN ADDITION TO SUPPORTING THE RADX-up INITIATIVE THE NIMH IS SUPPORTING A NUMBER OF DIFFERENT INITIATIVES AIMED AT UNDERSTANDING THE IMPACT OF COVID-19 IN MENTAL HEALTH BOTH DIRECTLY ON MINORITY HEALTH AND HEALTH DISPARITIES AS WELL AS IN POPULATIONS THAT EXPERIENCE HEALTH DISPARITIES. REALLY THE CENTRAL EFFORT IN TRYING TO UNDERSTAND AND MITIGATE THE MENTAL HEALTH IMPACTS OF COVID PANDEMIC, THAT NIMH HAS BEEN ENGAGED IN IS THROUGH COLLABORATIVE EFFORT, DR. PEREZ-STABLE AND OTHERS HAVE BEEN ENGAGED IN REALLY INVOLVING A NUMBER OF INSTITUTES ACROSS NIH TO EXAMINE AND TEST AND DEVELOP INTERVENTIONS TO REDUCE SOCIAL, BEHAVIORAL, ECONOMIC IMPACT OF THE COVID-19 PANDEMIC. OVER 60 WORK GROUP MEMBERS FROM ACROSS NIMH HAVE BEEN INVOLVED IN THIS, AT THE TIME THIS SLIDE WAS PUT TOGETHER WE FUNDED OVER 52 SUPPLEMENTS, ADD TO THAT NOW FUNDING OF DOZENS OF GRANTS, ALL OF THEM AIMED AT HEALTH DISPARITY POPULATIONS AND VULNERABLE POPULATIONS, INCLUDING THOSE WITH PREEXISTING MENTAL ILLNESS, TRIBAL COMMUNITIES, LOW SES COMMUNITIES, FRONT LINE WORKERS, ET CETERA, THIS RESEARCH AIMS TO UNDERSTAND THE FACTORS WHETHER THE DIRECT FACTORS FROM THE PANDEMIC ITSELF OR MITIGATION MEASURES, THAT LEAD TO ADVERSE IMPACTION, AND WE'VE INVESTED A GREAT DEAL OF RESEARCH TRYING TO UNDERSTAND AND MITIGATE MENTAL HEALTHOUT COMES IN THIS CONTEXT. WITH THAT I'M GOING TO CLOSE MY TALK, WITH THE NIMH MISSION WHICH I HOPE YOU CAN SEE RELATES DIRECTLY TO WHAT I'VE BEEN TALKING ABOUT TODAY. NIMH AIMS TO TRANSFORM UNDERSTANDING AND TREATMENT MUCH MENTAL ILLNESS THROUGH BASIC AND CLINICAL RESEARCH, PAVING THE WAY FOR PREVENTION, RECOVERY AND CURE. WE RECOGNIZE RESPONSIBILITY TO ENSURE THAT OUR RESEARCH PLAYS A ROLE IN MITIGATING MENTAL HEALTH IMPACT OF THE COVID PANDEMIC AND IMPORTANTLY DOING SO IN VULNERABLE POPULATIONS INCLUDING TRIBAL COMMUNITIES THAT, NUMBER ONE, HAVE BORNE THE BRUNT OF THE PANDEMIC AND NUMBER TWO FACE DUE TO MANY RISK AND RESILIENCE FACTORS FACE INCREASED RISK FOR MENTAL ILLNESS AND PROMISE OF ABILITY TO BUILD RESILLANCE AND I'LL CLOSE MY PRESENTATION AND BE HAPPY TO TAKE QUESTIONS. THANK YOU. >> THANK YOU, JOSHUA. GREAT PRESENTATION. I'D LIKE TO OPEN THE FLOOR TO ANYONE THAT HAS ANY QUESTIONS FOR JOSHUA. >> I SEE A QUESTION FROM RAMONA, OH, COVID-19 TRACING CONTEXT. MAYBE YOU CAN ASK VERBALLY BECAUSE I'M NOT SURE I UNDERSTAND THE QUESTION FULLY. >> CAN YOU GO AHEAD AND -- >> I SEE, THERE ARE OTHER FOLKS. GREAT. >> THANK YOU FOR THE PRESENTATION. I HAVE A QUESTION. YOU KNOW, IT IS GOOD TO SEE THAT THERE'S EVIDENCE FOR WHAT -- RESEARCH DATA THAT SHOWS WHAT A LOT OF PEOPLE ARE FEELING DURING THE PANDEMIC AND SIGNIFICANT IMPACT IT CAN HAVE, WE'RE SEEING THAT IN OUR COMMUNITIES AND FAMILY MEMBERS, SO IT'S REALLY IMPORTANT INFORMATION. I KNOW SOME TRIBAL COMMUNITIES ARE INVOLVED IN RESEARCH OR PROGRAMMATIC WORK TO TRY TO INCORPORATE TRADITIONAL PRACTICES OR BELIEFS OR METHODS TO TRY TO HELP PEOPLE COPE WITH THESE ISSUES. AND I KNOW THERE'S DATA ON THAT. AND WHAT IS NIMH DOING -- YOU KNOW THE CHALLENGING THING THOUGH IS THESE TRADITIONAL CULTURAL PRACTICES ARE INTELLECTUAL PROPERTY OF THE TRIBAL NATION. AND SO THERE'S A GOOD DEAL OF SENSITIVITY AND CARE THAT NEEDS TO BE DONE IN THAT KIND OF RESEARCH. DO YOU HAVE EXAMPLES OF HOW THAT'S BEEN HANDLED IN SOME OF THE PROGRAMS THE RESEARCH PROMISE YOU FUNDED? AND HOW YOU'VE BEEN ABLE TO DEAL WITH THAT DICHOTOMY OF THESE PRACTICES LIKELY WILL BE HELPFUL BUT PUT IN THE RESEARCH PROJECT FRAME WITH INTELLECTUAL RIGHTS AND ALL THOSE OTHER THINGS. >> THANKS FOR THE QUESTION. IN ALL THE RESEARCH WE DO IN TRIBAL COMMUNITIES, WE ENSURED WE'RE ENGAGED WITH THE LOCAL -- WITH THE TRIBES THEMSELVES, RIGHT? FOR EXAMPLE, WE HAVE A PROJECT BASED ON SUICIDE PREVENTION IN ACTUALLY ONE IN THE SOUTHWEST, ONE IN THE NORTHWEST WHERE WE ARE ENGAGING WITH PEERS WITHIN THE TRIBES TO DEVELOP AND TEST MEASURES AIMED AT ENHANCING BELONGING TO THE TRIBE AND RESILIENCE SPECIFICALLY IN YOUTH AT RISK FOR SUICIDAL IDEATION. I'M SORRY, RISK FOR SUICIDE. AND THESE INTERVENTIONS ARE BEING DESIGNED IN CONCERT WITH MEMBERS OF THE TRIBE, BEING CARRIED OUT, RESEARCH CARRIED OUT WITH DIRECT INVOLVEMENT, AND LIKE PREVIOUS PRESENTATION DONE IN THE CONTEXT OF TRIBAL IRBs AND INSURING THE DATA REMAIN IN THE HANDS OF TRIBES WHERE APPROPRIATE. WE AT NIMH REALLY TRY TO WORK FOR SOLUTIONS THAT WILL ENABLE RESEARCH -- CONTINUE THE RESEARCH TO BE A BENEFIT TO TRIBES AND WHERE POSSIBLE WHERE THE DATA CAN BE SHARED, RIGHT? MAYBE WE CAN'T SHARE EVERYTHING BUT AT LEAST WE CAN SHARE THE OUTCOMES. HOPEFULLY WE CAN SHARE DATA BEYOND THAT, THAT'S SOMETHING WE WORK OUT ON A CASE-BY-CASE BASIS. I DON'T KNOW IF THAT'S A SATISFACTORY ANSWER TO THE QUESTION BUT I KNOW WE'VE -- YOU KNOW, WE'VE WORKED WITH THE TRIBAL OFFICE OF NIH AND WITH OTHER INSTITUTES TO ENSURE THAT WE RESPECT THE AUTONOMY OF THE TRIBES, THEIR INTELLECTUAL PROPERTY, THEIR OWNERSHIP OF THE DATA AND NONETHELESS GIVE THE BEST WE CAN OF OUR RESOURCES TO ANSWER QUESTIONS OF RELEVANCE TO THE TRIBE IN THE MENTAL HEALTH SPACE. >> THANK YOU. >> RAMONA, ARE YOU ABLE TO GET ONLINE? >> GOOD AFTERNOON, CAN YOU HEAR ME? >> YES. >> THANK YOU FOR YOUR PRESENTATION. I WANT TO ELABORATE ON YOUR PRESENTATION, SLIDE 23 I BELIEVE. AND THIS IS THE ONE THAT HAS A DIFFERENCE IN TELEHEALTH MODALITIES MAY INDICATE BARRIERS FOR LOW INCOME PATIENTS, FOCUSING IN ON THE SECOND SIDE OF THE GRAPH YOU HAVE THERE, BEHAVIORAL HEALTH, YOU SEE WHEN THE PANDEMIC STARTED IN JANUARY, FEBRUARY, MARCH, THERE'S A BIG CHANGE BETWEEN HOW PATIENTS WERE PROVIDED CARE AND/OR SOUGHT CARE WITH THE BLACK, THE AUDIO AND VIDEO. MY QUESTION IS ABOUT COVID-19 AND CONTACT TRACING WHEN THAT BECAME EFFECTIVE IN RESPONSE TO PANDEMIC FOR MITIGATION EFFECTS. I WAS JUST WONDERING IF -- HOW IF THERE'S A CORRELATION WITH THE PANDEMIC RESPONSE WITH CONTACT TRACING USING TELEHEALTH AND HOW PERHAPS PROVIDERS, NOT ASSUMING OR NOT ASSUMING THAT THEY ARE CONTACT TRACING BUT DID THAT HAVE -- IS THERE ANY CONNECTION THERE OR IS THERE NOT? THAT'S MY QUESTION. >> YEAH, IT'S A GREAT QUESTION. LET ME PUT THAT DATA UP. I CAN TAKE IT OFF NOW. THE-- SORRY, I'M HAVING TROUBLE WITH MY COMPUTER. OKAY. SO, THE DATA I SHOWED YOU IS ABOUT BEHAVIORAL HEALTH VISITS THAT ARE TYPICALLY INITIATED BY THE INDIVIDUAL MAKING THE APPOINTMENT, ET CETERA, SO -- BUT YOU RAISE AN EXCELLENT POINT, WHAT IS THE RELATIONSHIP BETWEEN THE VARIOUS MEASURES THAT WERE PUT IN PLACE TO TRY TO CONTROL THE PANDEMIC AND EFFECTS ON BOTH MENTAL HEALTH SYMPTOMS AND ON ACCESS TO CARE. AND I THINK THERE ARE VERY LIKELY CORRELATIONS BETWEEN MITIGATION MEASURES AND MENTAL HEALTH EFFECTS BOTH POSITIVE AND NOTHING CORRELATIONS. AND WE DON'T REALLY UNDERSTAND THEM. THE SBE EFFORT THAT SOCIAL BEHAVIORAL ECONOMIC EFFORT I MENTIONED EARLIER, MOST OF THE NIH INDUSTRIES ARE COLLABORATING ON AIMED AT ANSWERING THOSE QUESTIONS, AWARDING GRANTS TO FOLKS THAT GO INTO DATASETS LIKE I SHOWED YOU CORRELATING MENTAL HEALTH, SOCIAL FACTORS, BEHAVIORAL AND ECONOMIC FACTORS TO TRY TO LOOK AT WHAT WERE THE CAUSES FOR, SAY, INCREASED DEMAND FOR BEHAVIORAL HEALTH VISITS, ARE THEY RELATED TO WORSENING OF THE CASE LOAD IN A GIVEN COUNTY OR MAYBE THEY ARE RELATED TO THE WORSENING ECONOMIC SITUATION, OR TO SPECIFIC MITIGATION MEASURES. WE'D LIKE TO UNDERSTAND WHAT ARE THE RISKS AND BENEFITS OF THE MITIGATION MEASURES IN THE CONTEXT OF THE PANDEMIC, SO THAT WE CAN HELP POLICYMAKERS WITH FULLER PICTURE OF THEIR IMPACT. SO UNDERSTANDING THE ROLE, FOR EXAMPLE, ACTIVE TRACE, CONTACT TRACING EFFORTS MIGHT PLAY BOTH IN MENTAL HEALTH SYMPTOMS AND ALSO DEMAND FOR ACCESS FOR MENTAL HEALTH CARE IS AN EXCELLENT QUESTIONS WE HOPE SOME OF THESE PROJECTS WILL HELP US ANSWER. >> I WANT TO MAKE ONE MORE COMMENT. THAT IS, YOU KNOW, WITH THE ISOLATION AND QUARANTINE AS MITIGATION AND ALSO RESPONSE, SOME EXPERIENCES INCLUDE THAT WHEN CONTACT TRACING AND/OR MONITORING PERSONS ABOUT THEIR SIGNS AND SYMPTOMS, IT SEEMS THAT PEOPLE WITH LOOK FORWARD TO THAT CALL FOR A CHECK-IN BECAUSE THE CALLS MIGHT LAST A LITTLE LONGER THAN ANTICIPATED JUST BECAUSE YOU HAVE THE CHANCE TO INTERACT WITH SOMEONE, AND KIND OF LIKE SHARE YOUR FEELINGS AND WHERE THEY ARE AT WITH THEIR PROCESSES. AND I JUST WANT TRYING TO THINK LIKE HOW THAT INFLUENCE AND IMPACT, TO SHARE, AS PART OF MENTAL HEALTH, NOT TREATMENT BUT JUST TO SUPPORT AND HOW IT ALSO MAY HAVE IMPACTED OUR RESPONDERS IN TERMS OF THE WAY THAT THEY CARRY WHEN PERSONS ARE SUFFERING AND WORK TO WHAT WOULD BE BETTER. THANK YOU VERY MUCH FOR YOUR PRESENTATION. THOSE ARE MY CONTINUES. -- MY COMMENTS. >> THANK YOU. IT'S NOT JUST ABOUT CONTACTING AND TRACING. THEY CAN DO SO MUCH MORE THAN THAT. THANK YOU. >> THANK YOU, RAMONA AND HERMINIA. CAN YOU GO NEXT PLEASE? >> YES, MY QUESTION, HELLO, DR. GORDON, MY QUESTION IS ABOUT -- IT'S A FEW SLIDES BACK TALKING ABOUT TRAUMA AND YOU WERE TALKING ABOUT THE DISASTERS REFERRING TO HURRICANE KATRINA. >> UH-HUH. >> AND PEOPLE THAT REACHED OUT TO PREPARE FOR MENTAL HEALTH CARE, AND THERE WEREN'T A LOT. AND SO MY QUESTION WAS WHAT KIND OF RESEARCH OR HOW DO PEOPLE RECOGNIZE THAT THEY NEED MENTAL HEALTH CARE? , YOU KNOW, I THINK THAT IS THE THING THAT WE STRUGGLE WITH IS THAT A LOT OF TIMES PEOPLE DON'T THINK THEY NEED IT SO THEY DON'T USE IT, RIGHT? AND SO ONE OF THE THINGS THAT WE TALK A LOT ABOUT IS, YOU KNOW, WE'VE BEEN USING THE TERM RESILIENT A LOT, AND I HAVE A LOT OF CONCERNS THAT WE'RE OVERUSING IT AND THAT IT'S BECOMING A BUZZWORD, AND THAT IT'S TAKING AWAY ITS MEANING. AND THAT IT REALLY, YOU KNOW, THE TERM "RESILIENT," WE USE IT BEHIND OUR TRIBAL RECOGNITION LAST YEAR, AND WE KNOW WE'RE RESILIENT. BUT YOU CAN'T JUST USE THAT WORD AND SAY, OH, YOU'RE RESILIENT AND USE IT AS A CHEER. BUT I KIND OF SEE THAT WE ARE DOING THAT IN SOME SENSES WHEN YOU DON'T HAVE THE DATA AND YOU DON'T HAVE THE RESEARCH AND YOU DON'T HAVE ALL THE QUALIFIERS BEHIND IT. AND SO WHEN IT COMES TO MENTAL HEALTH, YOU KNOW, I HEAR THAT A LOT. OH, YOU KNOW, WE'VE BEEN THROUGH THIS BEFORE. WE'VE SURVIVED. WE'VE DONE THIS. YOU KNOW, WE'VE GONE THROUGH THE PANDEMIC. YOU KNOW, AS PEOPLE. AND IT'S TRUE. BUT WE'RE NOT THE SAME PEOPLE. YOU KNOW, WE'VE SUFFERED. AND WE ARE PRONE TO HIGHER RATES OF DISEASE AND, YOU KNOW, WE'RE NOT THE SAME PEOPLE SO, YES, WE HAVE SURVIVED BUT WE'RE NOT THE SAME PEOPLE. AND SO I THINK THAT, YOU KNOW, RESEARCH AROUND ONE RECOGNIZING THAT WE DO NEED MENTAL HEALTH SERVICES AND CARE AND HOW DO WE RECOGNIZE AND HOW DO WE MESSAGE THAT TO PEOPLE EARLY ON WITHOUT THE STIGMA SO THAT THEY GET THAT CARE, AND ALSO UNDERSTANDING BUILDING THAT CAPACITY WITHIN YOUR SYSTEM TO ACCESS THAT CARE. SO THOSE TYPES OF -- YOU KNOW, RESEARCH IN WORKING WITH COMMUNITIES AND TRIBES SO THEY CAN GET THAT MESSAGE OUT THERE BECAUSE I HAVE A LOT OF CONCERNS WITH OUR COMMUNITY BECAUSE WE DON'T TALK ABOUT IT. AND, YOU KNOW, WE JUST SAY WE'RE RESILIENT, AND BUT YOU'VE GOT TO PUT ALL THAT, YOU KNOW, EVERYTHING ELSE BEHIND IT TO REALLY SAY, YEAH, WE ARE, BUT WE'RE NOT THE SAME PEOPLE. >> YEAH, I MEAN YOU MAKE SOME OUTSTANDING POINTS THERE. AND I DON'T HAVE -- I COULDN'T HAVE SAID IT BETTER MYSELF. YOU'RE 100% CORRECT THAT YOU NEED TO NOT JUST -- YOU CAN'T TALK YOUR WAY OUT OF CHALLENGES WITH MENTAL HEALTH. BUT YOU CAN SUPPORT PEOPLE AND RESILIENCE TO ME IS NOT SOMETHING YOU'RE BORN WITH OR YOU HAVE. IT'S SOMETHING THAT YOU LEARN, THAT YOU GROW WITH. YOU KNOW, PRIOR EXPOSURE TO TRAUMA IS BOTH A RISK AND A RESILIENCE FACTOR, IT'S A RISK FACTOR IF IT HIT YOU AND YOU DIDN'T RECOVER SO WELL. IT CAN BE A RESILIENCE FACTOR IF YOU RESPOND TO IT BY GETTING WHAT YOU NEEDED TO GET THROUGH IT. AND FEELING THAT SENSE OF SELF-EFFICACY, I ACHIEVED THIS. TO BE HONEST I DON'T THINK WE HAVE THE RESEARCH TO KNOW HOW THAT WORKS ON A GENERATIONAL SCALE, LIKE YOU'RE TALKING ABOUT, YOU'RE NOT THE SAME PEOPLE THAT WENT THROUGH THE PANDEMIC OF THE PAST, YOUR TRIBES MADE IT THROUGH. YOU CAN TAKE PRIDE THAT YOU BELONGED TO THE GROUP THAT MADE IT THROUGH BUT NOT ALONE. THE QUESTION OF WHEN DO YOU NEED MENTAL HEALTH CARE AND HOW DO WE GET THAT MESSAGE OUT, SO I THINK WE'RE TRYING TO MAKE SURE HEALTH CARE PROVIDERS, COMMUNITY LEADERS, COMMUNITY ORGANIZATIONS, NEWS OUTLETS, MEDIA, KNOW HOW TO RECOGNIZE WHEN A PERSON COULD BENEFIT FROM PROFESSIONAL HELP. WE TRY TO MAKE IT AS SIMPLE AS POSSIBLE. WHEN YOU'RE HAVING TROUBLE CARRYING OUT YOUR ACTIVITIES OF YOUR DAILY LIFE, THAT YOU NEED TO DO, TAKING CARE OF YOUR CHILDREN, GOING TO WORK, COOKING, CLEANING THE HOUSE, GETTING DRESSED, WHEN YOU'RE HAVING TROUBLE DOING BASIC FUNCTIONS YOU SHOULD PROBABLY REACH OUT TO PROFESSIONAL FOR HELP. AND, YOU KNOW, PROFESSIONALS IN DIFFERENT COMMUNITIES MIGHT MEAN DIFFERENT THINGS. MAYBE IT'S A TRIBAL LEADER OR A HEALER, OR, YOU KNOW, MAYBE IT'S A DOCTOR OR A TEACHER, BUT SOMEONE WHO CAN POINT YOU IN THE RIGHT DIRECTION TO GET THE HELP YOU NEED. AND OBVIOUSLY MENTAL HEALTH PROFESSIONALS ARE GOING TO PLAY A BIG ROLE. INDIAN HEALTH SERVICE OR OTHER ORGANIZATIONS GIVING HEALTH CARE IN TRIBAL COMMUNITIES WOULD BE VERY HELPFUL WITH THAT. BUT RECOGNIZING THAT'S THE JOB OF ALL OF US, AND WE'VE BEEN TRYING TO MESSAGE THAT AS BEST WE CAN, OBVIOUSLY WE COULD DO A BETTER JOB, AND FRANKLY WE COULD DO RESEARCH ON HOW TO BEST MESSAGE TO DIFFERENT COMMUNITIES AS WELL. >> WE HAVE A FEW MORE QUESTIONS BEFORE THE NEXT GUEST. >> I'LL TRY TO BE SHORT. >> THANK YOU, LISA. DR. GORDON, THANK YOU FOR YOUR PRESENTATION. BOBBY SAUNKEAH, OKLAHOMA DELEGATE. PERHAPS A HARD QUESTION, THROUGHOUT THIS PANDEMIC PEOPLE RESISTED MASKING A LOT FOR A BUNCH OF REASONS, BUT A LOT IS THEY FEEL LIKE IT'S TRAUMATIC TO THEM OR MAKES THEM ANXIOUS OR NERVOUS OR WHATEVER, AND THEN A LOT OF PARENTS ALSO DON'T WANT THEIR KIDS MASKING IN SCHOOL BECAUSE THEY SAY PERHAPS IT DELAYS THEIR DEVELOPMENT OR PEOPLE CAN'T SEE THEM SMILE, IT'S TRAUMATIC TO THE KIDS AND THAT TYPE OF THING. GENERALLY THERE'S NO EVIDENCE THAT SUPPORTS THOSE KIND OF ISSUES WITH MASKING, ARE THERE STUDIES, DO PEOPLE LOOK AT THAT KIND OF THING TO SAY, OKAY, WE LOOK AT OTHER MITIGATION EFFORTS BUT DO YOU LOOK AT EFFECTS OF SOMETHING LIKE THAT, ARE THOSE REALLY TRUE STATEMENTS THAT WE CAN SAY, IT DOESN'T REALLY DO ANYTHING TO THOSE KIDS, THEY WILL BE FINE, WHATEVER? DO PEOPLE ACTUALLY LOOK AT THAT. >> THANK YOU SO MUCH FOR THIS QUESTION. A REALLY GREAT QUESTION. ONE I'VE BEEN ASKED BY A NUMBER OF PEOPLE INCLUDING SOME SENATORS WHEN THEY CAME TO VISIT THE NIH LAST SUMMER. THE BOTTOM -- THE TRUE ANSWER TO WHAT YOU JUST ASKED IS NO, WE DON'T REALLY HAVE THAT EVIDENCE. IT'S ONE OF THE THINGS WE HOPE TO GET FROM THE DATA THAT I TALKED ABOUT. WE CAN LOOK AT STATES WITH MASKING MANDATES IN SCHOOLS AND STATES WITHOUT, OR LOCALITIES WITH AND WITHOUT, AND LOOK AT, YOU KNOW, EMOTIONAL DEVELOP AM, ANXIETY SYMPTOMS, ITS. THERE ARE GOOD REASONS TO BELIEVE THAT NONE OF THAT IS TRUE. AND THAT, SORRY, THERE REALLY ARE MINIMAL ADVERSE EFFECTS OF MASK WEARING. NOW, FOR SOME INDIVIDUALS, SAY INDIVIDUALS WITH PREVIOUS EXPERIENCES OF SUFFOCATION OR WITH ASTHMA OR SOMETHING LIKE THAT, YES, WEARING A MASK MIGHT BE ANXIETY PROVOKING AND I WOULD RECOMMEND THAT PEOPLE EXPOSE THEMSELVES GRADUALLY IN COMFORTABLE SITUATIONS BEFORE WEARING THEM OUT. THERE'S A BUNCH OF EASY TRICKS ONE CAN USE TO REDUCE ANXIETY AROUND IT BUT WE'RE TALKING ABOUT A VERY, VERY SMALL NUMBER OF PEOPLE HERE WHO WOULD GENUINELY EXPERIENCE INCREASES IN ANXIETY SYMPTOMS. AND CHILDREN ARE AMAZING AT IN THEIR COGNITIVE AND EMOTIONAL DEVELOPMENT CAPACITIES. AND, YES, YOU AND I, WE'RE OLD FOLKS. NO OFFENSE, BOBBY. YOU KNOW, WE MIGHT HAVE TROUBLE RECOGNIZING EMOTION ON THE FACE OF PEOPLE WITH MASKS BECAUSE WE'RE, YOU KNOW, WE DON'T LEARN AS QUICKLY AS OUR KIDS DO AND THEIR KIDS DO. YOUNG KIDS, THEY LEARN REALLY, REALLY QUICKLY. I GUARANTEE YOU THEY KNOW WHEN YOU'RE SMILING. THEY KNOW WHEN YOU'RE ANGRY JUST LIE THE SHAPE OF EYEBROWS OR GLARE OF YOUR EYES. THEY DON'T NEED THAT. WE NEED THE DATA TO PROVE THAT, YES, I AGREE IT WOULD BE HELPFUL TO HAVE BUT THERE'S SO MANY OTHER STUDIES THAT WOULD SUGGEST THAT THIS IS NOT A PROBLEM FOR COGNITIVE OR EMOTIONAL DEVELOPMENT IN CHILDREN AND FOR THE VAST MAJORITY OF AMERICANS MASKS ARE IF ANYTHING GOING TO REDUCE ANXIETY, I'M IN NEW YORK, WHAT I HEAR MOSTLY IS PEOPLE WHO ARE SCARED TO WALK INTO A STORE WHEN PEOPLE AREN'T WEARS MASKS, I HEAR THAT MORE OFTEN THAN THE OPPOSITE, RIGHT? I THINK THERE'S REGIONAL VARIATION AND WE NEED THE DATA BUT ALL OUR EXISTING DATA WOULD SUGGEST THERE SHOULDN'T BE BIG IMPACTS OF WEARING MASKS. THAT SAID, IT WOULD BE USEFUL AND WE HOPE TO GET THAT DATA TO DEMONSTRATE THAT BEYOND THE SHADOW OF A DOUBT. >> THANK YOU, SIR. >> LISA, YOU'RE MUTED. >> YOU'RE MUTED, LISA. >> OH. >> THERE YOU GO. >> WE HAVE A FEW MINUTES LEFT. MAKE IT SHORT PLEASE. >> I JUST WANT TO GIVE SOME IDEAS ON POTENTIAL FUNDING OPPORTUNITIES THAT NIH CAN TAKE ADVANTAGE OF. ONE IS IN MANY, I HOPE YOU JUST GAVE ME PERMISSION TO TALK. >> YES. >> THANK YOU. ONE IS THAT WE'VE SEEN A LOT OF PUBLICITY IN THE MEDIA ABOUT MENTAL HEALTH DUE TO SOME OF THE STUFF COMING OUT GYMNASTS IN THE SUMMER OLYMPICS, IF WE COULD HAVE MORE RESEARCH ON HOW THE GENERAL PUBLIC HEARS THOSE MESSAGES, SPEAKING BACK TO SOME OF THE THINGS THAT MANY SAID AND THINGS THAT PEOPLE HEAR AND HOW WE CAN TAKE ADVANTAGE OF THAT GETTING ACCESS. ALSO, ABOUT THE TIMES OF ACCESS PEOPLE HAVE TO MENTAL HEALTH CARE RESEARCH THAT BUILDS WORKFORCE DEVELOPMENT, LOOKING AT TRADITIONAL PATHWAYS BY TRADITIONAL PEOPLE. SO EVEN THOUGH THERE'S A NATIVE AMERICAN TYPE CURRICULUM, YOU'RE MISSING IMPORTANT PARTS BECAUSE THEY ARE SACRED PARTS, SO THE IMPORTANCE OF THAT IS TRADITIONAL PEOPLE DELIVERING THOSE HEALINGS. LIKE BOBBY WAS TALKING ABOUT RESISTANCE TO MASKS, WHAT IS RESISTANCE TO GETTINGS MENTAL HEALTH CARE, LOOKING AT PROTECTIVE FACTORS AND MULTI-LEVEL FACTORS. FOR EXAMPLE, OUR CHILDREN WHO ARE BEING BULLIED IN SCHOOL DON'T FEEL SAFE AT SCHOOL. THE NUMBER OF SHOOTINGS THAT ALREADY HAPPENED, WE'RE BACK IN SCHOOL A FEW MONTHS AND LOOK AT THE NUMBER. THEY DON'T FEEL SAFE AT HOME BECAUSE THEY EXPERIENCE FAMILY VIOLENCE OR MAYBE DON'T FEEL SAFE IN THEIR OWN NEIGHBORHOOD BECAUSE THEY ARE EXPERIENCING OR LIVE IN VERY TRAUMATIC KINDS OF COMMUNITIES. SO MULTI-LAYER EFFECTS, HOW THAT AFFECTS CHILDREN AND PEOPLE IN GENERAL IN THEIR LET. THANK YOU. THANK YOU, LISA. >> THANK YOU FOR THE INPUT AND THANK YOU FOR YOUR WONDERFUL QUESTIONS AND INVITING ME HERE. I REALLY APPRECIATE IT. >> JOSHUA, ONE FINAL COMMENT THAT I HOPE YOU GUYS DO SOME POLICY, MITIGATION ON, THE VAXED AND UNVAXED, COVID IS HERE TO STAY, AFFECTING DELIVERY SYSTEMS, CATASTROPHIC RESULTS IF WE DON'T NAIL DOWN HOW TO COMMUNICATE TO TOP LEADERS FROM GOVERNORS AND POLICYMAKERS DOWN TO HEALTH CARE DELIVERY AND I HOPE YOU DO TAKE A LOOK AT POLICY MITIGATION FOR VAXEED AND VAXED. >> DAVID. >> THANK YOU ALL. >> ALL RIGHT, DAVID, INTRODUCE THE NEXT GUEST PLEASE. >> ABSOLUTELY. THIS IS YOURS BUT I WILL DO IT FOR YOU. IT'S A PLEASURE TO HAVE OUR NEXT SPEAKER, DR. GARY FERGUSON. WE MET AT THE MEDICINE SUMMIT IN 2019, DIRECTOR OF THE OUTREACH AND ENGAGEMENT FOR THE INSTITUTE FOR RESEARCH AND EDUCATION TO ADVANCE COMMUNITY HEALTH AT WASHINGTON STATE UNIVERSITY, TALKING ABOUT SOME MOVING AWAY FROM TRAUMA-INFORMED TO HEARING-CENTERED CARE IN TRIBAL COMMUNITIES. I'LL TURN IT OVER TO YOU, DR. FERGUSON. >> THANK YOU, DAVID. THANK YOU, LISA, AND MEMBERS OF THE TRIBAL ADVISORY COMMITTEE AND STAFF. I'M HONORED TO PRESENT TODAY. AND SO I WILL SHARE MY SLIDES AS WE GET GOING HERE. I'LL CONFIRM YOU'RE SEEING PRESENTATION MODE. >> YES, THANK YOU. >> OKAY, GREAT. SO, THE TALK TODAY I'M PRESENTING ON IS ABOUT MOVING FROM TRAUMA-INFORMED TO HEALING-CENTERED CARE IN TRIBAL COMMUNITIES, IT'S ABOUT MYSELF AND I SEE SOME VERY FAMILIAR FACES IN THE VIRTUAL ROOM TODAY. HELLO TO MY COLLEAGUES AND FORMER CO-WORKERS. I'VE HAD A CAREER IN POPULATION HEALTH, NATUROPATHIC PHYSICIAN BY TRAINING, MOST OF MY WORK IN ALASKA, STARTED WITH MY WORK IN THE EASTERN ALEUTIAN TRIBES AND FOUND MYSELF IN PUBLIC AND POPULATION HEALTH BECAUSE I REALIZED WE HAD TO ADDRESS ROOTS AND CHALLENGES IN OUR COMMUNITIES, SYSTEMIC, POLICY DRIVEN. AND MY TIME AT THE ALASKA TRIBAL HEALTH CONSORTIUM WAS AN AMAZING EXPERIENCE OF LEARNING AND GROWTH AND ABLE TO CONTRIBUTE TO MANY INITIATIVES RELATED TO WELL-BEING IN OUR ALASKA NATIVE AND AMERICAN INDIAN COMMUNITIES. I HAVE SPENT THE LAST 20 YEARS, HARD TO BELIEVE IT'S BEEN 20 YEARS WORKING IN THIS SPHERE, MY WORK INCLUDED TIME AT THE RURAL ALASKA COMMUNITY ACTION PROGRAM, STATE'S ONLY ACTION AGENCY FOCUSED ON POPULATION HEALTH RELATED TO HOMELESSNESS, EARLY CHILDHOOD EDUCATION, COMMUNITY HEALTH. SO MY VOLUNTEER EFFORTS, CHAIR OF AMERICAN INDIAN CANCER FOUNDATION, SIX YEARS, MATRICULATING OUT OF THAT JOB THIS WINTER, AND WITH THE POWERFUL WORK BEING DONE THERE LEADING THE WAY AROUND ADDRESSING CANCER AND HEALTH DISPARITIES IN OUR NATIVE COMMUNITIES. I ALSO SERVED AS VICE CHAIR OF THE ELLIOTT CORPORATION, ONE OF THE TWELVE REGIONAL FOR-PROFIT CORPORATIONS IN ALASKA. I'VE BEEN AT THE WASHINGTON STATE UNIVERSITY OUTREACH TEAM WHICH WE'RE LOCATED AT THE COLLEGE OF MEDICINE IN WASHINGTON STATE UNIVERSITY, I'VE BEEN HERE A LITTLE OVER A YEAR NOW, JOINED DR. BUCHWALD AND TEAM TO ADDRESS RESEARCH IN COMMUNITIES AND DO COMMUNITY ENGAGEMENT AND OUTREACH, SERVING ON VARIOUS RESEARCH PROJECTS, STIMULATING WORK RELATED TO HEALTH EQUITY ADDRESSING HEALTH DISPARITIES IN OUR NATIVE COMMUNITIES. I SPEAK WITH THAT LENS TODAY. I'LL BE BRINGING SOME IDEAS PUT FORWARD BY OUR OUTREACH TEAM TOWARDS OF END OF MY TALK. MY HOME COMMUNITY IS A FISHING COMMUNITY, I GREW UP ABOUT 800 PEOPLE, SO WE'RE SMALL, AND I LOVE THIS COMMUNITY AND THIS IS DEFINITELY HOME. WE'VE HAD ALEUTIAN-STYLE WEATHER IN THE PACIFIC NORTHWEST THE LAST COUPLE DAYS, THE WINDS AND SQUALLS REMIND ME OF HOME. AND I FEEL LIKE THAT'S A GROUNDING, AND ONE OF MY MENTORS AND FRIENDS, DR. JAMES, TALKS ABOUT KNOWING WHO WE ARE AND WHERE WE COME FROM AS AN IMPORTANT PART OF OUR WELL-BEING AND I BELIEVE THAT THAT'S PART OF OUR ROAD TO WELL-BEING AS NATIVE PEOPLES IS KNOWING WHO WE ARE AND WHERE WE COME FROM, EMBRACING RICH TRADITIONS OF HEALTH AND HEALING, RESILIENCE THAT COMES FROM ANCESTORS SHARED IN THE PAST TALK. ABOUT OUTREACH, WE FOCUS -- THE LAST PROBABLY 25 YEARS OR SO DR. BUCHWALD STARTED THE INSTITUTE AT UNIVERSITY OF WASHINGTON, WE MOVED OVER TO WASHINGTON STATE UNIVERSITY SIX YEARS AGO. WE HAVE CORE AREAS WE FOCUS ON, NATIVE HEALTH, OUR LONGEST-RUNNING PROGRAM, USED TO BE PARTNERSHIPS FROM NATIVE HEALTH, COMMUNITY CENTER RESEARCH TRAINING, OUTREACH, TO IMPROVE HEALTH AND QUALITY FOR AMERICAN INDIAN AND ALASKA NATIVE AND PACIFIC ISLANDER POPULATIONS, AND THE NORTHWEST HERON WORKING ON CLINICAL CARE IN WASHINGTON STATE AND BEYOND AND HAVE SOME INITIATIVES RELATED TO LATINX HEALTH, ALSO RURAL HEALTH INITIATIVES WITHIN THE STATE OF WASHINGTON. NATIVE HEALTH PROGRAMS HAVE MANY PARTNERS, THANKS TO OUR PARTNERS WE'RE ABLE TO DO AMAZING WORK. MAIN RESEARCH CENTERS FOCUS ON ALZHEIMER'S, CARDIOVASCULAR DISEASE, ALCOHOL EDUCATION, RESEARCH. AND NARCH CENTERS. SO WE HAVE DIVERSITY OF RESEARCH BASED ON WHAT COMMUNITY NEEDS ARE, AND WHAT OUR TRIBAL LEADERS ARE SAYING ARE IMPORTANT, GOING AFTER FUNDING THAT HAS DEEP IMPACT AND IS COMMUNITY LED. TODAY I'LL SPEAK TO THREE OF THE PRIORITIES, CHAIRWOMAN SUNDBERG SHARED PRIORITIES. PRIORITY 2 AND PRIORITY 3, USE RESEARCH TO PRESERVE INDIGENOUS KNOWLEDGE, LANGUAGE, CULTURE, FOOD AND NUTRITION SECURITY, AND PRIORITY 6 RESEARCH ON INTERGENERATIONAL TRAUMA, METHODS OF HEALING, TREATMENT, POLICIES, EDUCATION, MENTAL HEALTH AND RESEARCH POLICY DEVELOPMENT IN SYSTEMS THAT NEED TO BE REFLECTED OF INDIGENOUS PRACTICES. I FEEL LIKE THAT STATEMENT IS A STRONG ONE. WE NEED TO ACTUALIZE THAT. AS I SPEAK, I SPEAK FROM THE LENS OF A TRIBAL MEMBER, AS PERSON WHO GREW UP IN A RURAL COMMUNITY, THIS IS A PHOTO FROM OUR GRAVEYARD IN SANDPOINT, ALEUTIAN ISLANDS, SOBERING. MANY GRAVES ARE DUE TO CHRONIC DISEASE, SUBSTANCE ABUSE, AND PREVENTIBLE CAUSES OF DEATH. AND MANY OF THEM RELATED TO HISTORICAL TRAUMA, TRAUMA IN OUR COMMUNITIES, AND OUR COMMUNITIES COMING TOGETHER TO ADDRESS THESE AND IT'S ONE WHERE IDEAS AND THINGS NEED TO BE VALUED ON -- AS FAR AS AS TRIBAL LEADERS WE NEED TO LISTEN TO WHAT THE COMMUNITY NEEDS AND RESPOND TO THOSE COMMUNITY NEEDS WITH WAYS THAT ARE CULTURALLY DRIVEN. AS NATUROPATHIC PHYSICIAN I USE THE PRINCIPLES AND PHILOSOPHY OF NATUROPATHIC MEDICINE THROUGHOUT ALL THAT I DO. ONE OF THE PRIMARY PHILOSOPHIES IS TO IDENTIFY AND TREAT THE CAUSE, AND TODAY'S PRESENTATION WE'RE FOCUSING ON SOME OF THE CAUSES AND I KNOW THE TALK PRIOR WAS STIMULATING, I CAME IN AT THE END TODAY BUT I FEEL YOU'VE ALREADY TALKED ABOUT TRAUMA AND HISTORY. SO I WANT TO MENTION SOME OF THE DATA RELATED TO THIS AND AS WE LOOK AT THE HISTORY OF OUR INDIGENOUS PEOPLES ACROSS THE COUNTRY, BOARDING SCHOOL, MY GRANDMOTHER MARINA GUNDERSON WENT TO BOARDING SCHOOL, TALKING TO SOME PEERS DURING THAT TIME IT WAS A VERY DIFFICULT PLACE TOKING WHERE CULTURE WASN'T WELCOME, TRADITIONAL FOODS WERE NOT WELCOME, AND ASSIMILATION WAS THE FOCUS. SHE WOULD BEAT ME BADLY AT SCRABBLE, INTELLIGENT WOMAN. HOWEVER THE WOUNDING ON CULTURE PERSISTED AND OUR FAMILY CONTINUES TO HEAL FROM SOME CHALLENGES WHERE WE WEREN'T ABLE TO SPEAK OUR LANGUAGE SO THAT TRANSLATED TO MANY OF US GROWING UP WITHOUT KNOWING OUR NATIVE LANGUAGE AND RICH CULTURAL TRADITIONS WERE LOOKED AT IN A WAY THAT QUESTIONED THEM THROUGH THE WESTERN LENS, SO I FEEL LIKE OUR FAMILY, OUR COMMUNITIES ARE HEALING IN IN UNDERSTANDING HISTORY OF HISTORICAL TRAUMA AND HOW THAT'S CONTRIBUTED TO CURRENT STATE OF WELLNESS OR DIS-EASE IS REALLY IMPORTANT. THIS IS A PICTURE OF THE A NEON SIGN OUT HOTEL IN OUR STATE CAPITAL IN JUNEAU IN ALASKA, AND SO THIS LOOKING AT NATIVE PEOPLE AS LESS THAN IN OUR OWN COLONIAL MENTALITY THAT COMES FROM HISTORICAL TRAUMA CONTINUES TO PERSIST AND THIS PERSISTED THROUGH THE '60s AND EARLY '70s AS MANY ELDERS HAVE GONE THROUGH THIS JOURNEY WHERE IT WASN'T SAFE, IT WASN'T OKAY TO BE WHO YOU WERE AS A NATIVE PERSON. AND WHEN YOU LOOK AT THE INTERGENERATIONAL ASPECTS OF TRAUMA AND HOW IT PASSES ON TO OUR NEXT GENERATIONS, THIS IS A PICTURE THAT WAS DONE BY MY COLLEAGUE, DR. ANGELA MICHAUD WHO SPEAKS TO GENERATIONS IMPACTED BY TRAUMA AND RESILIENCE, ALL THE EGGS IN WOMB FORMING OVARIES IN HER MOTHER'S WOMB, WHEN YOUR MOTHER WAS IN YOUR GRANDMOTHER'S WOMB SHE CARRIED THE EGG THAT BECAME YOU. PART OF YOU, YOUR MOTHER AND GRANDMOTHER SHARED THE SAME BIOLOGICAL ENVIRONMENT. IT'S A POWERFUL PICTURE TO LOOK AT AS WE LOOK AT OUR NEXT GENERATIONS MATERNAL CHILD HEALTH IS POWERFUL, IMPACTING FAMILIES FOR GENERATIONS, AND IF WE'RE GOING TO HEAL THE NEXT GENERATIONS WE NEED TO LOOK AT INTERGENERATIONAL TRAUMA. THIS HELPS INFORM US AS WE LOOK AT THE TERRAIN WE'RE WORKING IN, IN A VERY LARGE STUDY, I'M GOING TO COVER HIGHLIGHTS. BASICALLY FOUND THAT ADVERSE CHILDHOOD EXPERIENCES ARE COMMON, AND THEY MEASURE TEN TOTAL ADVERSE CHILD EXPERIENCES, FIVE OF WHICH WERE ABUSE AND NEGLECT, FIVE HOUSEHOLD DYSFUNCTION RELATED. AND MANY OF US AS WE LOOK AT THIS REPRESENTS MANY OF US SITTING IN THE ROOM THAT MANY OF US ALSO HAVE HEALING GOING ON, HEALING OPPORTUNITIES AS WE LOOK AT HOW WE GREW UP AND THINGS THAT CONTRIBUTED TO RESILIENCE AND CHALLENGES. WHAT'S INTERESTING IS THAT ADVERSE EXPERIENCES ARE HIGHLY INTERRELATED, WHEN ONE ADVERSE EXPERIENCE OCCURS, THERE ARE USUALLY OTHERS. 87% CHANCE THEY OCCUR TOGETHER, ONE ADVERSE CHILDHOOD EXPERIENCE AND ANOTHER, AND I'M QUOTING SLIDES THAT ARE PART OF THE ALASKA RESILIENCE INITIATIVE WORKING WITH COLLEAGUES AND ADDRESSING THIS IN ALASKA. THERE'S A DOSE-RESPONSE RELATIONSHIP BETWEEN CHILDHOOD ADVERSITY, THE MORE ACEs YOU HAVE, THE GREATER LIKELIHOOD YOU WILL SUFFER FROM HEALTH PROBLEMS. AND WHEN YOU LOOK AT CHALLENGES, ADVERSE CHILDHOOD EXPERIENCES OF SMOKING, WHEN I LOOK AT YOUTH WHO ARE SMOKING, ESPECIALLY YOUNG PEOPLE, THAT ARE STARTING AT A VERY EARLY AGE I THINK OF TRAUMA INFORMED TRAUMA RESPONSE OF RELATIONSHIP WHERE WE ASK RATHER THAN WHAT'S WRONG, SHAME AND BLAME, WE ASK WHAT HAPPENED AND HOW CAN WE HELP AND I FEEL LIKE THAT'S A IMPORTANT POINT WHEN WE LOOK AT OUR NATIVE COMMUNITIES, MANY HAVE SMOKING RATES, TOBACCO USE RATES THAT ARE ABOVE 50%. SO THE TRAUMA IS ACTING ITS WAY OUT IN POPULATIONS. SO IT'S A WE ADDRESS TOBACCO PREVENTION, LUNG CANCER, WE HAVE TO ADDRESS TRAUMA. PSYCHOSOCIAL ISSUES, IS DATA LOOKING AT ACEs AND SUICIDE ATTEMPTS, FASCINATING TO SEE DIFFERENCE BETWEEN THREE ADVERSE CHILDHOOD EXPERIENCES AND FOUR, PAY ATTENTION TO THAT AS I SHARE ALASKA DATA. LOOK AT CHRONIC DISEASE RELATED TO CARDIOVASCULAR DISEASE, DIABETES, SEVERE OBESITY IS A RISK FACTOR. IF WE'RE NOT TRAUMA RESPONSIVE OR HEALING CENTERED WE'RE MISSING HUGE OPPORTUNITIES. STATES HAVE BEEN COLLECTING DATA THROUGH THE BEHAVIOR RISK FACTOR SURVEILLANCE SYSTEM FOR MANY YEARS, SO THERE'S A WEALTH OF DATA AND ACCESS TO THIS DATA IS REALLY IMPORTANT AS RELATES TO OUTCOMES. AND REDUCTION, WE WANT TO SEE NEXT GENERATIONS HAVE LESS ADVERSITY THAN CURRENT GENERATIONS IF WE'RE DOING OUR JOB RIGHT IN POPULATION HEALTH. CURRENT ALASKA TRENDS ARE SIMILAR TO THE RESEARCH DONE BY THE TEAM, SO HERE'S THE ACE SCORES BASED ON TEN POSSIBLE ACEs, AGAIN 1 IN 4 ALASKANS HAVE FOUR OR MORE ADVERSE CHILDHOOD EXPERIENCE. FOOD SECURITY, NUTRITION SECURITY IS IMPORTANT AND A PRIOR. THERE'S A CONNECTION BETWEEN ADVERSITY AND LOW FOOD SECURITY, INCLUDING USE OF MEDICAID. WE THINK OF CULTURAL STRENGTH AND RESILIENCE, I REALLY APPRECIATE THAT IN THE PAST PRESENTATION, FOCUS ON RESILIENCE, PASSING OF RESILIENCE WHICH IS A REALLY IMPORTANT TO LOOK AT STRENGTHS, HERE'S A PICTURE OF MY HOME REGION, OUR NATIVE DANCE FOR 200 YEARS DUE TO COLONIZATION AND HISTORICAL TRAUMA DIDN'T HAVE OUR DANCE GROUPS. PEOPLE THOUGHT IT WAS DEAD. WE CONNECTED WITH SOME OF OUR TRIBAL MEMBERS THAT ACTUALLY LIVE IN RUSSIA, BEHRING ISLANDS, AND WE FOUND SOME OF OUR DANCES WERE STILL BEING USED AND WE REVITALIZED OUR DANCES, SOME RELATIVES IN SOUTHEAST ALASKA ALSO HAD SOME DANCES THAT THEY REGIFTED BACK TO US AND WE HAVE A REVIVAL WHICH IS REALLY POWERFUL TO SEE THE HUNDREDS NOW OF DANCERS THROUGHOUT THE ALEUTIAN ISLAND REGION AND IN ALASKA MANY COMMUNITIES DUE TO RELIGION AND SOME BELIEF SYSTEMS RELATED TO COLONIZATION, THEY DIDN'T HAVE THEIR DANCE, DIDN'T HAVE THEIR CULTURE, SO THERE TRULY IS A CULTURAL REVIVAL GOING ON I BELIEVE IN INDIAN COUNTRY AND I FEEL THIS IS A HUGE STRENGTH AS WE LOOK AT THE RESEARCH, THIS IS A RESEARCH PROJECT AT THE CENTER FOR ALASKA HEALTH RESEARCH, AND UNIVERSITY OF ALASKA FAIRBANKS, DR. MOHAD AND TEAM LOOKED AT SOBRIETY AND RISK BEHAVIOR, AND FOUND THAT THE MORE CULTURAL ACTIVITIES AND LANGUAGE COMMUNITIES, CULTURAL PROGRAM THAT YOUNG PEOPLE PARTOOK IN THEY HAD LESS RISK BEHAVE SO WE'RE FINDING RESEARCH SHOWING CULTURE IS MEDICINE, THAT OUR YOUNG PEOPLE WHEN EXPOSED TO THESE CULTURE TRADITIONS AND CULTURE CAMPS THROUGHOUT THE STATE, THROUGHOUT THE COUNTRY, ARE ON THE RISE AND I THINK IN THE PACIFIC NORTHWEST WE'VE GOT SOME AMAZING CULTURAL ACTIVITIES THAT ARE BEING REVIVED AND HISTORIC NUMBERS ARE PARTICIPATING, I BELIEVE THAT AS WE LOOK AT THESE WAYS THAT WE'RE BECOMING MORE RESILIENT AND WE'RE HEALING, THAT CULTURE AND CULTURAL ACTIVITIES TRULY ARE MEDICINE. AND WHEN WE LOOK AT SOME OF THE RESEARCH THAT HAS BEEN DONE IN OUR NATIVE NATIONS, THIS IS A PICTURE OF MASLO'S HIERARCHY NEEDS, IT'S BEEN TEN YEARS NOW THAT I WAS REMINDED OR ACTUALLY TAUGHT BY A NATION IN ALBERTA WHEN GIVING A PRESENTATION SHARING THE HIERARCHY, IT WAS A BLACKFOOT NATION MODEL GOING BEYOND THE UNDERSTANDING WHERE MASLOW SAID YOU MOVE TO SELF-ACTUALITYIZATION THAT YOU CAN ACHIEVE HEALTH AND WELL-BEING. BLACKFOOT IS ANOTHER LEVEL, YOUR COMMUNITY CAN BE ACTUALITYIZED, YOUR METHOD TO ACHIEVE CULTURAL PERPETUITY AND SPEAKS TO THE FACT THAT WHEN WE WORK IN NATIVE COMMUNITIES ATTRIBUTING WISDOM TO THE COMMUNITY AND MEDICINE, WHEN IT'S NOT ATTRIBUTED TO NATIVE TRIBES, THIS IS OPPORTUNITY FOR PSYCHOLOGY TEXT BOOKS TOES REFORMATTED, FIRST NATION PERSPECTIVE VERSUS MASLOW. WE HAVE A REVIVAL THIS MEANS THE TIDE IS RETURNING, THERE'S A CULTURE REVIVAL UNDERWAY. IT SPEAKS TO THE MOVEMENT IN THE YOUNG PEOPLE, SO EXCITED ABOUT LANGUAGE AND CULTURE AND THIS BRINGS HEALING AND WELL BEING AND I FEEL LIKE MORE RESEARCH IS POWERFUL, WE CAN HAVE CULTURE CAMP PRESCRIPTION VERSUS ANXIOLYTIC OR ANTI-DEPRESSANT. THAT'S THE FUTURE OF WORK THAT'S CULTURALLY MODELED AND DRIVEN. I MESSAGESSED NEW JOURNEY -- MENTIONED I HAD THE HONOR OF PARTICIPATING IN NEW JOURNEY IN ALASKA, TO JUNEAU, A POWERFUL TIME, FOUR DAYS OF PADDLING, CEREMONY, KILLER WHALES VISITING TWICE CLOSE TO OUR CANOE. THE MEDICINE OF BEING IN NATURE, CULTURE, TRADITIONS IS DEEP MEDICINE THAT'S TRANSFORMATIVE AND MORE RESEARCH IN THIS REALM IS INDICATED. INTERGENERATIONAL CONNECTEDNESS, IN BARROW, WE'RE DISCUSSING TRADITIONAL PLANTS THAT IS EATEN AND USED FOR MEDICINE. WE HAD ALASKAN PLANTS, FOCUS AT THE ALASKAN CONSORTIUM, LEARNING ABOUT FOOD AND ADDRESSING SECURITY BUT ALSO FOR ME THIS IS DOMESTIC AND VIOLENCE PREVENTION. THIS IS PRESENTED AT THE UNIVERSITY OF ALASKA FAIRBANKS, FAMILY, COMMUNITY, LAND AND PLACE, INTERGENERATIONAL AND SPIRITUAL ASPECTS, HOLISTIC, THERE'S A LOT TO DRAW FROM AS WE LOOK AT CULTURALLY BASED WAYS OF WELL-BEING AND HEALING. MORE AND MORE WE NEED TO FOCUS ON THESE AS WE LOOK AT INTERVENTIONS IN INDIGENOUS COMMUNITIES INCLUDING CEREMONY. WHEN I GOT TO PRESENT IN THE PAST, TRIBAL ADVISORY COMMITTEE, DR. MICHELE JOHN PRESENTED ON HER WORK IN CEREMONY AS HEALING AND OUTCOMES THAT WEREN'T ONLY JUST QUALITATIVE, AND EMOTIONAL AND SPIRIT BUT ALSO PHYSICAL THAT THERE WAS REDUCTION IN INFLAMMATORY MARKERS IN THE BODY THAT PERSISTED. SO I FEEL LIKE WHEN YOU THINK OF MEDICINE WE OFTEN THINK OF EFFECTIVENESS OF THAT MEDICINE ON A POPULATION AND WE'VE COME UP WITH AN EVIDENCE BASED APPROACH USING CERTAIN MEDICINES, OR ON A HOLISTIC SIDE BOTANICAL MEDICINES OR WHATEVER, BUT CEREMONY IS ALSO MEDICINE AND HER WORK, MORE OF THAT WORK IN INDIAN COUNTRY TO LOOK AT CEREMONIES AND THESE CULTURAL ACTIVITIES THAT PROMOTE HEALING, NOT ONLY IN QUALITATIVE WAYS BUT ALSO IN WAYS THAT AFFECT THE BODY OVER TIME AND REDUCE OUR DISEASE BURDEN. THAT'S A HUGE OPPORTUNITY FOR US. AND I WANT TO ALSO GIVE A SHOUT OUT TO VALERIE AT WASHINGTON STATE, MUCKLESHOOT, SHE WRITES ABOUT IMPORTANCE OF FOOD SOVEREIGNTY, INHERENT RIGHT OF THE COMMUNITY TO IDENTIFIED THEIR OWN FOOD SYSTEM AND CHOOSE THE FOOD ON OUR TABLE. FOOD SOVEREIGNTY IS AT THE HEART OF WELL-BEING AS WE LOOK AT OUR FOODS AND EFFECT OF CLIMATE ON OUR FOODS AND UNDERSTANDING THAT AND COMING UP WITH STRATEGIES TO MAINTAIN FOOD SYSTEMS AND BE CONNECTED AND SOME RESEARCHERS SAY DON'T FORGET URBAN INDIANS AND THOSE THAT LIVE IN URBAN SETTINGS TO RECONNECT OR RESTORE THEIR CONNECTION TO FOODS. WHEN I WAS AT THE CONSORTIUM I HAD THE HONOR OF WORKING ON A PROJECT CALLED STORE OUTSIDE YOUR DOOR WHICH ALSO INCLUDED ALASKA NATIVE PLANTS AND MEDICINE, THERE'S A NATIVE NUTRITION CONFERENCE THE SIOUX COMMUNITY HAS, THAT WAS OVER 500 PEOPLE, FOCUSING ON TRADITIONAL FOODS, FOOD SOVEREIGNTY, THE PLANT-BASED MEDICINES AND CEREMONIES. AND WHEN YOU LOOK AT SOME IMPACTFUL PROGRAMS, ANOTHER AREA THAT I WORKED IN OVER THE LAST TEN YEARS IS IN ADDICTIONS, ADDRESSING ADDICTIONS AND HOLISTIC STRATEGIES, THIS PROGRAM AT THE NORTHWEST INDIAN TREATMENT CENTER HAS BEEN INFORMED BY TRIBAL MEMBERS ELIZABETH CAMPBELL AND VALERIE SEGREST, AND ELYSE CROHN, AMAZING WORK HEALING HOLISTICALLY WITH ADDICTION, CULTURE, TRADITIONAL FOODS, MAKING THEIR OWN TEAS FOR ANXIETY AND WELL-BEING, THERE'S SO MUCH TO DRAW FROM AS WE LOOK AT OPPORTUNITIES FOR HEALING AND TO REALLY DECOLONIZE HEALTH CARE IN A WAY WE ADDRESS TRIBAL MEMBERS TO HAVE CULTURALLY DRIVEN WAYS ON PAR WITH OUR WESTERN APPROACHES. WE HAVE THE WORK GROUP FUNDED, FOUNDED THIS LAST YEAR, WHERE WE COME TOGETHER TO ADDRESS FOOD SOVEREIGNLY AND CONFERENCES, PAPERS, TO ADVANCE FOOD SOVEREIGNTY, EDUCATION AND RESEARCH. WE'VE GOT MEMBERS FROM ACROSS THE NATION, HEALTH SCIENCES, INTERVENTIONS, FOOD DIRECTION SCIENCE, COMMUNITY DEVELOPMENT, NUTRITION, AND THE GOAL IS HEALTH EQUITY AND THIS IS AN ONGOING WORK GROUP. WE FEEL LIKE THIS WILL DRIVE MEANINGFUL CHANGE IN HEALTH AND FOOD SYSTEMS THROUGHOUT INDIAN COUNTRY. AS I CLOSE MY TALK, I WANT TO MENTION A COUPLE AREAS OF OPPORTUNITIES THAT I'VE BEEN INFORMED THROUGH IREACH THAT COULD BE WAYS THAT COULD BE ACTION STEPS, ONE OF THE THINGS THAT DR. BUCHWALD SHARED WITH ME IS THAT WE HAVE OUR CENTER-TYPE GRANTS, LARGE MULTI-COMPONENT APPLICATIONS WITH 6 WEEKS TO RESPOND, THAT REQUIRE COMMUNITY-BASED PARTICIPATORY RESEARCH AND TRIBAL -- OR TRIBAL ENTITY BUY-IN. WE'RE EXCITED TO APPLY FOR THESE, AND I THINK THEY ARE VERY IMPORTANT TO HAVE ESPECIALLY RESEARCH ORGANIZATIONS OR INSTITUTIONS INDIGENOUS LED, HOWEVER THE SHORT TIME LENGTH CAN JEOPARDIZE RELATIONSHIPS GIVEN HOW SHORT IT IS AND CAN DISINCENTIVIZE NEW OR INNOVATIVE METHODS, AND ALSO KIND OF MAKES THE CURRENT FOLKS WHO ARE DOING THE WORK STAY IN THE WORK WHICH HOW DO WE HAVE NEW PARTNERS, HOW DO WE HAVE NEW RELATIONSHIPS, AND I THINK OF SOME OF THE WORK WHEN I WAS AT AT ANTHC, LACK OF PARTNERS AND/OR TIMELINES, I FEEL LIKE THIS IS AN AREA OF OPPORTUNITY. AND ALSO TO LOOK AT RFAs STRUCTURED TOWARDS STRENGTHS. MANY TRIBAL LEADERS ARE FED UP WITH ALWAYS HAVING TO FOCUS ON DEFICITS. ALWAYS HAVING TO FOCUS ON WHERE THE WORST, WE'RE FOCUSED ON NEGATIVE ASPECTS OF TRAUMA BUT WHAT ABOUT RESILIENCE, STRENGTHS, WE TALK ABOUT APPLIED POSITIVE, WHAT'S WORKING? HOW DO WE HAVE RESEARCH THAT MOVES AWAY FROM THESE DEFICIT-BASED MODELS AND FOCUS ON STRENGTH IN ANOTHER STRATEGY AS WE LOOK AT TRIBAL SOVEREIGNTY AND WESTERN SCIENCE AND NIH PRIORITIES, BRINGING THESE TOGETHER SO THAT TRIBAL SOVEREIGNTY, INDANGEROUS WAYS -- INDIGENOUS WAYS OF HEALING ARE ON PAR WITH WESTERN SCIENCE TO VALUE EQUALLY. AND ANOTHER POINT SOME TEAM MEMBERS BROUGHT UP HOW DO WE USE DATA AND HOW DO WE HAVE ACCESSIBLE FOR RESEARCHERS, WHAT WAS MENTIONED IS INDIAN HEALTH SERVICE AS WEALTH DATA, DIFFICULT TO ACCESS. HOW DO WE HAVE BETTER OVERSIGHT DATA SO WE HAVE ACCESSIBILITY? DR. BALL MENTIONED DATASET THAT HAS A LOT OF YOUTH IN IT, AND WE HAVE A VERY HARD TIME ACCESSING THAT DATA, AND ESPECIALLY SINCE IT DOES HAVE A LOT OF TRIBAL DATA. HOW CAN NIH HELP SUPPORT THESE INITIATIVES SO WE CAN WORK AROUND DATA SOVEREIGNTY AND TRIBAL OVERSIGHT AND HAVE THAT DATA BE MORE READILY AVAILABLE FOR RESEARCHERS. ONE INITIATIVE THAT WE HAVE THAT WE'VE HAD FOR MANY YEARS AT IREACH IS NATIVE INVESTIGATOR PROGRAM, DENICE DILLARD IS ONE OF THE GRADUATES OF THE PROGRAM AND OTHERS WHO ARE DOING AMAZING WORK AROUND THE COUNTRY. THE MORE INDIGENOUS-LED RESEARCH, THE BETTER THE COMMUNITY, SHOULD BE PEOPLE COMING FROM THE COMMUNITY THAT CAN LEAD THE RESEARCH SO, AGAIN, THIS PROGRAM AND OTHERS LIKE IT, THIS IS THE FUTURE AND HOW DO WE TRAIN OUR NATIVE SCIENTISTS IN THIS CASE WE HAVE, YOU KNOW, $250 MILLION IN GRANTS TO THESE INDIVIDUALS. 500+ MANUSCRIPTS ON HEALTH, 18 TENURED, THIS IS THE FUTURE. HOW DO WE HAVE MORE RESOURCES TOWARDS THIS IN SUPPORTING THIS? AND REALLY MAKE SURE THAT AS WE HAVE RESEARCH IN THE COMMUNITY THAT TRULY IT IS NATIVE LED, INDIGENOUS-LED RESEARCH. AS I CLOSE AND OPEN FOR COMMENTS I WANT TO QUOTE DR. BLUMENSTEIN, AMAZING FRIENDS AND MENTOR, JUST HAD HER MOVE TO THE SPIRIT WORLD RECENTLY SO I'M THINKING OF HER AND HER LEGACY. THIS QUOTE SPEAKS TO HER LEGACY. WE'RE FREE TO BE WHO WE ARE, TO CREATE OUR OWN THE LIFE OUT OF THE PAST AND PRESENT. WE ARE OUR ANCESTORS, WHEN WE HEAL OURSELVES, WE ALSO HEAL OUR ANCESTORS, OUR GRANDMOTHERS, GRANDFATHERS, AND OUR CHILDREN. WHEN WE HEAL OURSELVES, WE HEAL MOTHER EARTH. AND OUR FUTURE GENERATIONS ARE COUNTING ON US. I WILL OPEN IT UP FOR COMMENTS AND QUESTIONS. >> AMAZING. FROM THE FIRST TIME I MET YOU, I DON'T KNOW, MY FIRST TIME I WAS AT AN NIH CONFERENCE, I HAD A CHANCE TO LISTEN TO YOU TALK AND HAVE BEEN APPRECIATIVE YOU'RE OUT THERE GOING THIS WORK, GARY. THANK YOU FOR BEING HERE AND TAKING TIME OUT OF YOUR SCHEDULE TO POP IN. ARE THERE ANY QUESTIONS FROM VIEWERS? >> NICE TO SEE YOU, GARY. BEVERLY COOK. I DON'T HAVE A QUESTION. I THINK IT WAS BRILLIANT. AND YOU SAID ELOQUENTLY WHAT WE TALK ABOUT EVERY TIME WE MEET, AND I THINK YOUR LAST TWO OR THREE SLIDES JUST REALLY GAVE VOICE TO EVERYTHING THAT WE'RE LOOKING FOR. EVERYTHING THAT WE'RE SEARCHING FOR, OUT OF THIS RELATIONSHIP WITH NIH AND TRYING TO EXPRESS. I REALLY APPRECIATE IT. I HOPE THEY WERE LISTENING BECAUSE IT REALLY WAS BEAUTIFUL. THANK YOU. >> THANK YOU, BEVERLY. SO GOOD TO SEE YOU. >> I AGREE, BEVERLY. I HOPE THAT THEY DO GET A CHANCE TO HEAR YOUR TALK, GARY, BECAUSE IT DOES LEAN TOWARDS A LOT OF THE WORK THAT IS BEING DONE. I DON'T KNOW WHAT MEASUREMENT TOOLS ARE OUT THERE NOW BUT I CAN TELL YOU ANYTIME WE HAVE ADDED CULTURE TO THERAPIES IT'S MADE A DIFFERENCE, IN THE RELATIONSHIP BUILDING WITH OUR OWN PEOPLE, AND THAT SENSE OF BELONGING TOO HAS BEEN REALLY HELPFUL IN MENTAL HEALTH FROM OUR PERSPECTIVE AND OUR BACKGROUNDS. WE HAVE A QUESTION. MICHELE, HI. >> HI. FIRST I WANT TO THANK YOU FOR YOUR PRESENTATION. IT REALLY MADE AN IMPACT. I FELT LIKE THIS IS WHAT WE'RE STRIVING TOWARDS, HAVING OUR OWN RESEARCHERS WHO ARE REALLY CONNECTED TO WHERE THEY COME FROM AND BRING THIS RICH CONTEXT TO THE WORK. AND SO I DON'T REALLY HAVE A QUESTION BUT JUST THANK YOU. I DID HAVE A COMMENT. I THINK TALKING ABOUT ACEs IS CHALLENGING, BECAUSE HOW DO WE BEGIN TO HAVE THESE CONVERSATIONS IN A WAY BECAUSE THESE ARE DIFFICULT CONVERSATIONS AT THE COMMUNITY LEVEL, WITHOUT RETRAUMATIZING PEOPLE OR WITHOUT BRINGING UP SOME OF THE SHAME AND ALL OF THESE, YOU KNOW, COLONIAL BAGS WE ALL CARRY THAT RESULTED IN THESE EXPERIENCES. AND SO WHAT RESEARCH OPPORTUNITIES ARE THERE TO REALLY LOOK AT HOW DO WE BEGIN TO HAVE THESE DIFFICULT CONVERSATIONS IN A WAY THAT DOESN'T I GUESS LABEL US AGAIN AND I KNOW YOU ADDRESSED THAT AT THE END OF YOUR TALK THAT TRIBAL LEADERS, MANY OF US ARE REALLY EXHAUSTED BY HEARING ABOUT ALL OUR DEFICITS, SO HOW DO WE CHANGE THE CONVERSATION WHEN IT COMES TO ACEs? >> SO, THANK YOU FOR THE COMMENT. AND QUESTION. I THINK YOU'RE BRINGING UP A REALLY IMPORTANT POINT. AS ELDERS ARE SAYING, WE DON'T WANT TO FOCUS ON DEFICITS ANYMORE. WE WANT TO FOCUS ON OUR STRENGTHS. I FEEL LIKE THAT IS LIKE, YOU KNOW, CHIEF BEVERLY COOK, WHEN I VISITED, AMAZING PERHAPS YOU HAVE FOR YOUTHS, RITES OF PASSAGE, MATERNAL CHILD HEALTH INITIATIVES, CIRCLE HEALING, A LOT OF AMAZING BEST PRACTICES DEPLOYED ON THE SAME LEVEL AS OTHER APPROACHES ACTIVE IN COMMUNITIES THAT AREN'T INDIGENOUS. I FEEL LIKE MORE FOCUS ON BRIGHT SPOTS, OF COURSE I THINK THE TERRAIN OF UNDERSTANDING HOW TRAUMA IS INTERGENERATIONAL IS IMPORTANT TO HAVE A CONVERSATION AROUND, AT THE SAME TIME SOME OF OUR WAYS THAT WE HAVE DONE HISTORICALLY TO HELP HEAL AND THE CEREMONIES WE HAVE AND REVITALIZATION OF THOSE IN HOW WE HEAL. SO I THINK IT'S IMPORTANT TO UNDERSTAND IT AND SCIENCE BEHIND IT, AND AT THE SAME TIME TO SHIFT THE FOCUS, TO HAVE IT ONLY BE THE SMALL PART OF THE CONVERSATION, LIKE, FOR EXAMPLE, THERE'S RESILIENCY INITIATIVE HAS A TRAINING, HISTORY AND HOPE, WHICH IS FOCUSED ON UNDERSTANDING HOW TRAUMA IMPACTS GENERATIONS AND ALSO THE HOPE IS LIKE WHAT CAN WE DO ABOUT IT. AT THE BEGINNING THREE-QUARTERS OF TIME WAS SPENT ON TRAUMA, SO PEOPLE LEFT, THAT REALLY WAS A BUZZ KILL, PEOPLE WERE DEPRESSED, WE NEED TO FOCUS ON RESILIENCE AND HOPE AND UNDERSTAND THE FACT I MAY BE AT RISK FOR HEALTH PROBLEMS OR AS I LOOK AT LET'S SAY IT'S CARDIOVASCULAR DISEASE OR SOME OF THE DISEASES THAT ARE ASSOCIATED WITH FOLKS WHO HAVE TRAUMA IN THEIR LIVES, MYRIAD, IF YOU DON'T UNDERSTAND WHAT'S TAKEN PLACE, IT'S THE HEALING, WE NEED TO TALK ABOUT IT IN A WAY THAT'S TOWARDS HEALING. AND DR. BLOOM SAID WE'RE SICK BECAUSE WE DON'T TALK ABOUT IT. WE NEED TO MOVE BEYOND IT. LIKE THE RWANDANS IS SHARED AFTER GENOCIDE TOOK PLACE, YOUR APPROACH TO JUST TALK ABOUT IT IN A ROOM ISN'T WORKING FOR US. WE WANT TO DANCE, WE HAVE CULTURE, CEREMONIES, WE DEAL WITH TRAUMA ALL THE TIME AND WE NEED THE OPPORTUNITY TO DO SO. AND TO BE SUPPORTED RATHER THAN JUST ONLY CERTAIN THINGS SUPPORTED, RIGHT? HOW DO WE HAVE THOSE PROGRAMS FUNDED IN A WAY THAT ARE ON PAR WITH ANY OTHER PROGRAM TO HELP HEAL INDIVIDUALS. I THINK WE HAVE A LOT OF WISDOM WITHIN OUR COMMUNITIES AND COMMUNITY BEST PRACTICES, PRACTICE-BASED EVIDENCE NEEDS TO BE BROUGHT FORWARD TO HAVE CULTURALLY BASED HEALING AND SO YOU BRING UP AN IMPORTANT POINT. HOW DO WE NOT GET LOST IN THE DEFICIT. HOW DO WE NOT GET LOST IN THE TRAUMA. AND I THINK IT IS CHALLENGING WHEN WE STARTS TO TALK ABOUT ADVERSE CHILDHOOD EXPERIENCES. I AGREE, IT'S A CHALLENGE BUT IF WE SHIFT TO RESILIENCE IT CAN CREATE A HUGE OPPORTUNITY. >> GARY, IS THERE ANY KIND OF RESEARCH THAT WE CAN PUSH FORWARD OR MAYBE PROJECTS WE COULD ASK FOR RESEARCH TO HELP SUPPORT THE WORK THAT YOU'RE DOING HELPING TO BUILD UP PEOPLE INSTEAD OF FOCUSING ON THE NEGATIVE? >> WELL, I WOULD SAY LOOKING ACROSS INDIAN COUNTRY, LOOKING AT SOME BEST PRACTICES, AND LOOKING TO THE COMMUNITY, WHAT ARE SOME OF THE BRIGHT SPOTS. THERE IS A WHOLE FIELD OF RESEARCH THAT THERE'S A GROUP, IT'S A NON-PROFIT, THEY DO CAPACITY BUILDING THROUGH THIS LENS OF BRIGHT SPOTS BASED APPROACHES, WHERE YOU FOCUS ON PEOPLE WHO ARE RESILIENT IN THE COMMUNITY, DESPITE THE ODDS. SO THOSE OF US WHO HAVE BEEN RESILIENT WHICH ARE MANY OF US IN THIS VIRTUAL ROOM, RIGHT? I WOULD SAY WHAT ARE THE TOOLS FOR SUCCESS, HOW CAN WE GROW SUCCESS, GROW HEALING, AS WE LOOK AT OUR OWN INDIGENOUS WAYS KNOWING AND HEALING ARE WELCOME WITH THE WESTERN MEDICINE, THERE ARE BRIGHT SPOTS, HOW CAN WE GROW THEM AND COME UP WITH BEST PRACTICES IN HEALING TECHNIQUES THAT ARE THOUSANDS OF YEARS OLD. AND I THINK MANY OF US ESPECIALLY OUR ELDERS, CULTURE GOT BEAT OUT TO THE POINT SOMETIMES THE COLONIAL MENTALITY IS TO BE QUESTIONS, AND THE RICH LEGACY OF HEALING AND BRING THE BEST OF WESTERN SCIENCE IN ALONG WITH IT TO SAY, HOW DO WE UNDERSTAND THIS, HOW DOES IT WORK? HOW CAN WE DEPLOY IN A WAY THAT WORKS FOR POPULATIONS, NOT JUST INDIVIDUALS. THANK YOU. I THINK YOU'RE ON MUTE. >> I AM ON MUTE. CAN'T THANK YOU ENOUGH FOR SPENDING TIME WITH US AND GIVING -- OPENING THIS WORLD TO US BECAUSE WE COME FROM A VERY STATIC, YOU KNOW, I DON'T KNOW VERY MATTER OF FACT SOMETIMES IT FEELS AND YOU PUT A LOT OF CULTURAL LENS TO THE PERSPECTIVE OF RESEARCH AND THE IMPACT OF IT. THE GOOD STUFF IS COMING OUT OF THE WORK YOU'RE DOING. THANK YOU FOR DOING THAT. >> LISA, CAN WE GIVE MINNIE AN OPPORTUNITY TO ASK HER QUESTION? >> I'M SORRY. SORRY, YEAH. >> THAT'S OKAY. I JUST WANTED TO RAISE -- I DON'T KNOW IF IT'S A QUESTION OR COMMENT BECAUSE I'M ALL FOR POSITIVIVITY BUT I WANT TO RAISE THE POINT THAT WHEN IT COMES TO -- THERE'S A SECTOR OF THE POPULATION THAT WE'RE MISSING I THINK. IT'S THE POPULATION THAT IS NOT THE SILENT POPULATION. AND THE POPULATION THAT IS NOT -- THAT IS MORE DIFFICULT TO REACH, AND THE ONES THAT THEY ARE NOT GOING TO GO -- THEY ARE NOT -- WHEN YOU START TALKING ABOUT, YOU KNOW, RESILIENCE AND START TALKING ABOUT ALL THESE POSITIVE STORIES AND EVEN WHEN YOU START TALKING ABOUT CULTURE, BECAUSE THEY MAY BE THE FOSTER CHILDREN THAT HAVE BEEN TAKEN AWAY, THEY MAY BE PEOPLE THAT DON'T HAVE A CONNECTION AND THEY ARE TRYING TO RECONNECT, THAT THEY MAY NOT INSTANTANEOUSLY FEEL LIKE THEY HAVE THAT CONNECTION. SO I THINK THAT WE NEED TO FOCUS ON HAVING THOSE HONEST CONVERSATIONS WITH PEOPLE OF TRAUMA. AND, YOU KNOW, JUST HAVE THOSE HONEST CONVERSATIONS ABOUT TRAUMA AND IMPACT OF TRAUMA AND, YOU KNOW, HOW THAT HAS -- THE IMPACT IT'S HAD ON PEOPLE IN DIFFERENT WAYS. AND SOME PEOPLE LIKE IT WAS SHARED IN THE PREVIOUS PRESENTATION, SOME PEOPLE HAVE -- IT'S BEEN POSITIVE, FOR OTHER PEOPLE IT HAS LED TO ATTEMPTS IN SUICIDE, CATASTROPHIC IMPACTS. EVERYONE HEARS THAT. SO THERE'S -- THEY TAKE A DIFFERENT DIRECTION. I JUST WANT TO SAY THAT THERE'S A ROLE FOR HAVING THOSE TYPES OF HONEST AND FRANK CONVERSATIONS, AND YOU ALWAYS HAVE TO HAVE THAT ELDER IN THE COMMUNITY THAT JUST GIVES IT TO YOU STRAIGHT TOO. AND HAVING THOSE ELDERS AND THOSE PEOPLE IN THE COMMUNITY TOO OF SHARING IN THE BACKGROUND, IN THE RESEARCH AND ALL OF THAT TOO BECAUSE THERE'S ALSO THAT TRUTH OF WHAT CAN HAPPEN BECAUSE SOMETIMES, YOU KNOW, I THINK THAT WE KIND OF SKIP OVER THAT. >> THANK YOU. REALLY POWERFUL COMMENTS, AND I TOTALLY AGREE. IT'S BEEN BEAUTIFUL, IN OUR COMMUNITY, YOU KNOW, WE WERE THE FIRST TO BE COLONIZED IN THE STATE OF ALASKA, THE UNUGA, SOME TRIBAL MEMBERS ARE GENERATION REMOVED, FIVE TO NINE CULTURE CAMPS GOING THROUGHOUT THE REGION, VERY LARGE GEOGRAPHY, AND SO PROFOUND TO SEE FOLKS ATTEND FOR THE FIRST TIME. THE HEALING, JUST THE TEARS THAT COME OUT AS YOU RECONNECT, I FEEL LIKE THAT'S WHAT IT'S ALL ABOUT. AND ALSO UNDERSTANDING THAT, YOU KNOW, MANY OF US ARE DISCONNECTED. IT WAS A POLICY. KILL THE INDIAN, SAVE THE MAN, A GOVERNMENT POLICY THAT PERSISTED. MY MOM HAD A HYSTERECTOMY THAT WAS UNNEEDED, UNNECESSARY, HUGE HUGE TRAVESTIES THAT HAVE TAKEN PLACE. >> THANK YOU, EVERYBODY, FOR PARTICIPATING. THANK YOU, GARY. DAVE, I'LL TURN IT OVER TO YOU, WE'LL SEE YOU NEXT TIME. THANKS. >> TAKE CARE. THANK YOU, EVERYONE. >> THANKS, GARY. I HOPE EVERYBODY AGREES WE'VE HAD A WHOLE LINEUP OF EXTREMELY INFORMATIVE PRESENTATIONS TODAY. I ALSO HOPE THAT YOU GOT OUT OF TODAY'S PRESENTATIONS IS IT'S BECOMING MORE AND MORE CLEAR HOW THE NIH IS RAMPING UP ITS INCREASED ENGAGEMENT AND FOCUSING ON OPPORTUNITIES TO INCLUDE AMERICAN INDIANS AND ALASKA NATIVES IN BIOMEDICAL RESEARCH. TOMORROW WE HAVE ANOTHER EXCELLENT LINEUP OF INFORMATIVE PRESENTATIONS THAT WILL JUST BUILD UPON WHAT WAS TALKED ABOUT TODAY. DURING MY PRESENTATION I'M HOPING I'M ABLE TO CONNECT SOME DOTS BECAUSE THERE'S A WHOLE LOT THAT'S BEING DONE WITHIN THE TRIBAL HEALTH RESEARCH OFFICE IN EQUAL PARTNERSHIP WITH INSTITUTES AND CENTERS AND I HOPE TO GIVE A PICTURE OF HOW THESE ARE COMING TOGETHER TO MEET NEEDS OF WHAT WAS DISCUSSED IN THE LAST PRESENTATION.SO WITH THAT I'M TURN IT OVER TO CHIEF MALERBA TO PROVIDE US WITH A CLOSING BLESSING.