Richard Benson - NIH Health Equity Strategic Planning

October 27, 2021

ID7078

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00:00Uhm? So I have nothing to disclose.
00:05UM, so this morning I'm going to talk
00:08about the NINDS mission related to
00:11HealthEquity and health disparities.
00:14I'm then going to talk about my office
00:17and what we do and then go into talking
00:21about health disparities using stroke,
00:23asmodel racism and unconscious bias.
00:26And then our strategic planning process.
00:28Some RFI information, and then some of our
00:31diversity training programs. And then.
00:33We should have time for some questions
00:35at the end to have a nice discussion,
00:37so the mission of the NINDS is to
00:40seek fundamental knowledge about
00:41the brain and nervous system,
00:43and to use that knowledge to reduce the
00:45burden of neurological disease for all.
00:48And we have highlighted here for all,
00:50because this includes everyone from
00:52every strata and every group of society.
00:55This is, this information was recently
00:58presented at the HealthEquity Symposium
01:00or Headway Symposium that we had.
01:03Last week in our institute director
01:06Dr Korsets UM highlights this for
01:09all peace in this very important
01:12'cause that oftentimes is forgotten,
01:16and we do this,
01:17we we reach our goals by investing in basic,
01:20translational clinical research
01:21and we do that in the extramural
01:24community through funding.
01:25Investigators like yourselves
01:26as well as on the NIH campus.
01:29We identify gaps in research
01:31and public health needs.
01:32We train.
01:34Talented and diverse work researchers
01:37and our next generation of researchers.
01:39We support the development of tools and
01:41resources to enable discoveries and we
01:44like to communicate that information
01:46to our stakeholders and including the
01:48public and then evaluate the efficacy
01:51of the various programs that we have.
01:54The NINDS back in the around 2010
01:56or so created a health disparity
01:59statement at that time based upon
02:01the recommendation from the 1st.
02:04Uhm,
02:04health disparities panel that was
02:07organized at that time and they
02:09came up with this statement that
02:11the NIDS is committed to reducing
02:13the disproportionate burden of
02:15neurological disease borne by
02:17underserved groups in society,
02:18including racial and ethnic
02:20minority rule and socio economically
02:23disadvantaged populations.
02:25By funding a spectrum of research from
02:28basic science through clinical studies
02:30and training the next generation of
02:32health disparities investigators.
02:34My office which was created back in August
02:37of 2019 when I came back to the NIDS,
02:41I was previously at the end.
02:42Yes,
02:42I left and then came back in August of 2019,
02:46leads the coordination and development
02:49of programs and initiatives that
02:51foster national international research
02:53on disparities and inequities
02:54in neurological disease,
02:56and our Jeff are jected.
02:58Our objectives include building sustainable
03:00capacity and lower middle income
03:03countries to conduct and apply research.
03:05Best public health challenges
03:07associated with neurological disorders.
03:09Supporting bilateral partnerships
03:10between the US and middle to high
03:13income countries and research areas
03:15that are of mutual interests and
03:17advancing research on tailored
03:19prevention and treatment strategies
03:21aimed at improving health outcomes and
03:24underserved and understudied populations.
03:25In EU S and this includes racial
03:28and ethnic minority groups.
03:30People who live in rural areas,
03:32sexual gender minority groups
03:34and socio economically.
03:35Disadvantaged populations.
03:36And we do this through investing
03:39in research and training,
03:41and we're currently going through
03:43a process to determine our our
03:46our plans for the next 10 years.
03:48In order to address these this process.
03:52I list here are some of the
03:54major studies that have been
03:55funded over the last ten years
03:57to address disparities in stroke.
03:59Stroke is a major or the the largest
04:02neurological disease that that has
04:04large areas of disparities that
04:06we know about and so stroke can
04:08be used as sort of an example of
04:10the types of disparities that we
04:12see in neurological disorders,
04:14and I highlight here the regards study
04:16because I'm going to briefly present
04:18some data that I'm sure all of you
04:21all are familiar with with regards studies.
04:23But it actually highlights
04:24some of the information, UM?
04:26That I'm talking about today,
04:28or this just so important in terms of
04:30why this HealthEquity is so important.
04:32And so when you look at the
04:34pattern of stroke in the United
04:36States from 1999 to 2018,
04:40I have here listed the age adjusted
04:43stroke mortality per 100,000 and this
04:46data is from some of George Howard data
04:49and this is looking from 1999 to 2017.
04:53We can see that there's been
04:55a decrease in stroke.
04:57Mortality from 1999 to 2017
05:00for white Americans.
05:02For black Americans,
05:04Hispanic Americans, Asian Americans,
05:07and Native Americans.
05:09However,
05:09when we look at the mortality ratio
05:12for these groups comparing to whites,
05:15we see that there has been a sustained
05:18increase and the mortality ratio from
05:201999 to 2017 for blacks and addition.
05:24From this slide,
05:25we can see that there are certain
05:27groups in the United States.
05:28That actually have lower
05:30mortality ratios than whites,
05:32and this is something else that's
05:33not talked about that we need to
05:35look into more in terms of why there
05:37are other groups that have a lower
05:39mortality rate from stroke than
05:42these than whites in this country.
05:46So Doctor Howard actually goes
05:48on to say that in fact,
05:49between 1949 and 1951 the white to
05:52non white and at that time it was
05:55mainly largely black populations
05:56in the United States.
05:58Show print Ality was 1.63 for
06:01men and one and 19.2 for women,
06:04and so he states that in fact
06:06we made little progress.
06:08Reduce racial disparities in
06:09stroke in the last 70 years,
06:12and this is pretty startling to consider.
06:15In addition to the race,
06:17ethnic disparities that just talked about,
06:19we know that there are large regional and
06:22geographic disparities and stroke as well,
06:24and this is something that.
06:27Has to be looked into more and
06:29it's related to some of the other
06:32factors that we're going to talk
06:34about today in terms of why we
06:36make some of the reasons in terms
06:37of why we have these regional
06:39geographic factors as well,
06:41like here in the stroke belt in
06:43the Southeastern United States,
06:44we know that in these areas
06:46you have large populations
06:48of of African Americans.
06:49We also have issues related to
06:53socioeconomic status and distance.
06:55To get to the hospital and.
06:58And other issues or social determinants of
07:00health that we know are very important.
07:02Now you may ask and say, well,
07:04yes, we see that and stroke and
07:06that may be something unique.
07:08But when you look in medicine
07:10and other fields we still see
07:11that there are large disparities.
07:13This really startling report was
07:16published in August of 2020,
07:19and it looked at newborns,
07:22black sand and white,
07:23and they found that versus white.
07:25And they found that black newborns
07:27were more likely to die when
07:29looked after by white doctors,
07:30and the same was not true when.
07:33Some white newborns were looked after by
07:35black doctors and this is really hard.
07:38It's very startling and really hard
07:40to sort of explain why we have this
07:43sort of discordance in terms of
07:45disparities and neonatal outcomes.
07:48Additionally,
07:48there's been work that showed that
07:50there we know that in the United
07:53States in general when we look
07:55at maternal mortality rates that
07:57that we are doing terrible,
07:59we should be doing much better when you
08:01look at the income of the United States.
08:03But for African Americans,
08:04it's really striking in terms
08:06of the high mortality rates for
08:08African American women,
08:09and this is something that's
08:11been overlooked a lot.
08:12And again, how does this?
08:14How do we explain this?
08:15This suggests a more systemic
08:17problem in our health care system.
08:19When we see these large.
08:21Disparities.
08:22We also note that in those areas,
08:26states,
08:26or areas in the country that
08:28actually report on reported on some
08:31of the death rates from COVID-19,
08:33we see that there is a black white
08:35disparity in terms of the the death rates.
08:38We also see disparities when
08:39you look at Native Americans,
08:41which has not been talked about
08:43as much as well as Hispanic
08:44populations in the United States.
08:46So these are just sort of very startling
08:49findings that we see and difficult.
08:51Explain however we know back in
08:552003 since the awhile ago as well,
08:58almost the less than 20 years ago,
09:01the Institute of American,
09:03now known as the National Academies
09:05of Science pubs to report titled
09:08unequal Treatment Confronting Racial
09:10and Ethnic Disparities in health
09:12care and this report concluded that
09:14racial and ethnic disparities in
09:16healthcare do exist and that sources,
09:19including health care systems,
09:21health care providers.
09:23Patience and utilization managers
09:25are contributors and so this is
09:28again startling considering that
09:29most of us that our health care
09:32providers to think that we are
09:34contributing to some of these
09:35disparities that we see out there.
09:37This was the first time that this
09:40was published on such a large scale
09:43and and yet that was in 2003.
09:46We still are lacking in terms of
09:50really addressing these issues.
09:52Back in August of 2020,
09:55Dr Olajide Williams and Doctor Bruce Obvio,
10:00Bali public published an article
10:02titled Stroking Out while Black
10:04the complex role of racism,
10:06and they actually cited
10:08some of the regards data,
10:10stating that the regards study found
10:13that only 40% of the black white
10:15incidents disparities is attributed to
10:18prevalence of traditional risk factors,
10:20and so they conclude that.
10:2260% of the remaining disparities
10:25are related to unclear factors,
10:27and some of these,
10:28some of that 60% could be related
10:31to the levels of racism framework,
10:33which includes structural,
10:35personal, and internalized racism,
10:38and that they figure that they
10:41concluded that the NIH or the NMDS
10:44should focus on funding research
10:47through more than equity lens.
10:50I have here some diagrams just
10:52to sort of highlight those,
10:53the structural, the racism levels
10:58of racism framework we have first.
11:01Intrapersonal racism,
11:02and that's sort of the internalized
11:05racism of an individual.
11:08That's where people internalize
11:10the negative views of themselves.
11:12And because of that,
11:15develop negative behaviors that are.
11:18Have negative outcomes for the individual,
11:21and so that's sort of internalized racism.
11:23And then we have the interpersonal racism,
11:25and that's when one person does
11:28something negative towards someone else.
11:30That's something conscious that someone
11:32does towards someone else that this harmful.
11:35That sort of that interpersonal racism.
11:37We know that that's bad as well,
11:40and we see here.
11:41This is a visual of a lynching in the past,
11:45and you see groups of individuals
11:46standing around looking at this.
11:48I think that this is probably
11:50what happened back with the world
11:53watching the murder of George Floyd.
11:55This is probably similar to that it
11:58was an instance and time where you
12:00had people that actually sat and just
12:02were able to look at a murder and at
12:05that time and I think that was well,
12:07it sort of has or one thing that
12:09sort of has energized or sparked his
12:11renewal to sort of address this.
12:13This idea of ****** you know we have.
12:16But then the more ominous and
12:19more difficult to control.
12:21Form of racism is structural racism
12:23and structural racism is when those
12:26structures that are put in place
12:27so that if no one does anything.
12:30If if a person who is usually receives
12:35the negative end of the racism,
12:37tries to do everything positive
12:39goes to school.
12:40East healthy exercise is that person
12:43still because of the structure
12:45that's in place is impacted by
12:47that structure in a negative way.
12:49Or if no one does, if one person doesn't do.
12:51Anything to against anyone else still,
12:55though, that structure is in place,
12:57and so that that's a little
12:58bit more difficult to address,
13:00and this one example of this is when
13:03we think of the data associating
13:05ZIP codes with mortality.
13:07We can look at the ZIP codes in
13:09the United States and determine the
13:11mortality rates in those neighborhoods.
13:13Also,
13:13this idea of structural racism impacts
13:17people in terms of housing being able
13:20to buy a house in a certain area.
13:21Certain areas not having access to good
13:24health care, not having hospitals,
13:27creating food deserts,
13:28no spaces for people to exercise those
13:31types of things are not the fault of the
13:34individuals that live in those areas.
13:36It's just part of the structure
13:38that's set up and a lot of these
13:41things that we consider race and
13:43race is actually a social construct.
13:45It's not a biological varier variable.
13:48Race is just determined for most
13:50people based upon what they think.
13:52About someone when they look at them and
13:54look at their skin color and determine
13:56your of this race or a different race.
13:59Race is not if a person goes to the
14:02medical doctor or hospital to be seen,
14:04that person's race could be department
14:06the same way as if someone walked into
14:09a bank to apply for housing loan.
14:11It's just basically related to skin
14:14color and that race or that skin color is
14:19actually not a biological variable but up.
14:22Proxy for social determinants of
14:25health and other structural racism
14:27that we have and in structural racism
14:30is one of the social determinants of
14:32health here in the United States.
14:35I like the schematic here because it shows
14:38what is the reality for a lot of people.
14:40And then this concept of equality
14:43equity and then liberation we have
14:45here on the left side of the screen.
14:48Diagram of three gentlemen watching
14:50a baseball game.
14:52See that one person has a great
14:55view standing on multiple multiple
14:57baskets in order to see the game,
15:00and then we see one person
15:01that has one basket.
15:02Is able to see over the fence and then
15:04see the game and then we see the last
15:07individual that's shorter than the other
15:08two and also happens to be standing
15:10in a ditch and can't see anything.
15:13And then next we see the quality
15:15where we say, OK,
15:16let's just give everybody the same.
15:18Thing when you do that,
15:19you don't take into account
15:22those intrinsic differences that
15:24people have that may impact them,
15:26and so we can see just by giving
15:29everyone the same thing that that short
15:32individual still can't see over the fence.
15:34And keep in mind that that short
15:37individual has a very unique perspective
15:39and that can actually offer a lot
15:41if you asked in terms of defects
15:43in the fence or anything about the
15:45ground that person has been able to
15:47see a lot and can actually offer.
15:49A lot of information,
15:50valuable information to the other
15:51two people watching the game,
15:53and so input from that person is very
15:56important. And then we have equity.
15:57And that's when you give everyone
15:59exactly what they need so that everyone
16:01has a chance to the all three of the
16:03individuals have a chance to see the game,
16:05and we can see you have to give one of
16:07the baskets to the middle gentleman
16:10and then give two to the other so
16:13that now they can all see the game.
16:15But then you ask the question,
16:17why is the fence there in the first place?
16:19Do we actually need defense or
16:21is it better to have a fence?
16:23That's that you can see through or some.
16:26Other type of barrier so that everyone can
16:28see and you don't have to deal with those.
16:31And that's sort of the state of liberation.
16:33I like this schematic because it's sort of.
16:35It explains those structures that
16:37are out there that are not under
16:39the control of the individuals.
16:41For the most part.
16:42So now I'm going to sort of pivot and talk
16:45about unconscious bias and conscious bias.
16:48So conscious bias is sort of that.
16:50Interpersonal racism where someone
16:52just has a negative idea against
16:55someone else and they just explicitly
16:58state that and they're aware of it,
17:00and it operates consciously,
17:02such as if someone says I,
17:04I like whites more than Latinos,
17:07that's a very conscious decision or
17:10comment for someone to make, but.
17:13Those things that are more difficult
17:14to see are sort of those unconscious,
17:16unconscious, or implicit biases,
17:18and those are people aren't aware
17:21of these types of biases and
17:24they they operate subconsciously.
17:26For example,
17:26if you're on a bus and and a white
17:29individual sits further away from a
17:32Latino individual but never says anything,
17:35that's more of the implicit
17:36or unconscious bias.
17:38Now all of us have biases and the
17:40issue is that it's important for
17:42us to be aware of our biases,
17:44particularly in health care,
17:45because they can have dramatic impact.
17:48There's something called micro behaviors,
17:50and micro behaviors are sort
17:52of small or fleeting.
17:53Verbal or nonverbal ways that we act or
17:56respond when we interact with others,
17:58and micro behaviors can be
18:00oriented positively, such as, oh,
18:02that's a really great comment.
18:04Oh, that's really novel.
18:05I'm glad you said that, so that's the.
18:08Positive Marco validation or it can be
18:11negative or I can't believe you said
18:13that or everyone knows that or that.
18:15That's sort of common knowledge,
18:17though that's more of a negative
18:20micro aggression.
18:21And so this happens all the time.
18:24This can impact colleagues,
18:26young investigators just coming
18:28into a department,
18:30people from who don't feel a part of
18:32the group for for whatever reason.
18:34And so we have to think about these
18:36types of interactions with our
18:38colleagues as well as with our patients.
18:40Uhm,
18:40that we're interacting with all the time.
18:43And so these micro validations they
18:45can support or they can foster teamwork
18:48and collaboration and they can lead
18:50to a positive work environment if a
18:52person is in a positive work environment,
18:55that person is more apt to to do better
18:58to be more productive and and more
19:00happy about putting in extra time doing work.
19:03And it can lead to in a patient
19:05provider setting it can lead to
19:07adherence to orders or their plans
19:09from the medical provider.
19:11Micro aggressions however can degrade.
19:14Communication and can lead to
19:15non compliance and it can lead
19:18to people feeling stressed,
19:19not wanting to stay in a
19:21particular academic environment.
19:22Wanting to change labs or one just
19:24to leave the institution or leave
19:27academic medicine in general.
19:29So these are things that we have to
19:31be aware of and look at and this is
19:33important because EU S population
19:35is becoming more diverse and so the
19:37odds of intercultural provider,
19:40patient or colleague to colleague
19:43interactions are increasing.
19:44Rapidly, and so if you look
19:47directly in healthcare workers,
19:49ethnic minorities form a
19:50majority of the workforce,
19:52and so in any clinical encounter,
19:54both the clinician and the patient
19:56have to adhere to principles
19:57of civility and respect.
19:59Respectful interactions to each other.
20:02So it's important for all academic
20:05institutions research institutions
20:07to have cultural competency,
20:09and this is the integration and
20:12transformation of knowledge
20:13about individuals and groups.
20:14The people into specific standards,
20:17policies and practices and attitudes
20:20used inappropriate cultural settings
20:21to increase the quality of services,
20:24thereby producing better outcomes.
20:26The ability to think,
20:28feel,
20:28and act in ways that acknowledge and
20:30respect and build up on ethnic socio.
20:33Cultural and linguistic diversity.
20:36And so now I'm going to sort of
20:38talk about what we're doing at
20:40the end I age and an IDs related
20:42to the health disparities.
20:43So I'm going to talk about some
20:45of the things that that we're
20:46specifically doing at the IDs,
20:48and so when my office started back in 2019,
20:51we sort of reviewed the report
20:53that was created by the panel
20:56that was put together and 2011.
20:58We created another working group
21:01of our National Advisory Council.
21:03We created something called the
21:05Hugh or the HealthEquity workgroup,
21:06which is.
21:07A group of volunteers from the
21:12ANINDS staff to work with issues
21:16surrounding health disparities.
21:18We had an RFI that was published
21:20from March 31st July 15th of
21:232021 and we asked people,
21:24could they tell us what they felt were
21:27areas of disparities in neurological
21:29disorders, services or care.
21:31And we wanted to get input from everyone.
21:34All levels of society,
21:35from patients family members.
21:37Caregivers advocacy groups.
21:39UM medical providers researchers.
21:42We wanted input from everyone just to
21:45see what people thought were areas of
21:47health inequities and neurological disorders.
21:50And then we,
21:50the capstone of this process,
21:52was our head.
21:53We workshop that took place in
21:55the end of September and we're
21:57going to have this information
21:59presented to our National Advisory
22:01Council in February and then.
22:03The results will also be published as well.
22:07And so just to talk about our
22:09fire requests for information,
22:12I've mentioned the dates that was published.
22:14We did direct solicitation to various
22:16groups to get this information,
22:18and we received over 141 responses,
22:21which is a lot 'cause some of the
22:24responses were grouped responses as
22:26well responses for organizations.
22:28We asked multiple choice questions,
22:30short answer questions,
22:32and then we did qualitative analysis.
22:35Obviously quantitative,
22:36and we categorize that.
22:38Information in order to come to
22:41analyze the data and the responses,
22:44and this is what we have I have
22:47here on the diagram on your right.
22:49Just the the percentage of responders
22:51that were health care providers,
22:53researchers, patient advocates,
22:54patients and caregivers and we
22:56had a few government officials
22:59that responded as well to RFI.
23:01Most of the responses
23:03came from the northeast.
23:05We had the fewest responses
23:08from the Southwest.
23:09And we did have some international responses,
23:12although we're looking primarily for
23:15health disparities in the United States
23:17and you can see a major gap that we had.
23:20Is that a lot of our information
23:22came from urban and suburban areas,
23:24and we had very few rural responses.
23:26So when we do this in the future,
23:29we're going to have to build
23:30in mechanisms to try to over
23:33sample from rural areas as well.
23:35And this this is unfortunate.
23:36'cause, again,
23:37it's an area of health disparities,
23:38so it is something we have
23:39to think about in the.
23:40Future in terms of when we put
23:43out these requests for information
23:46and we have here the region based
23:49upon the organizational types.
23:51Most of our responses were
23:53from individuals over 61,
23:54but we did receive 39% responses
23:57from organizations as well.
24:00And this slide just shows sort of the,
24:03UM,
24:03the whole list of the various
24:05types of organizations that
24:07we received responses from,
24:09and most of them were related to TBI.
24:12Obviously stroke and pain,
24:13so these were some some of the larger areas.
24:16But then there were other areas
24:19too for some rare diseases
24:21where we received responses.
24:23And as you would imagine in terms
24:25of neurological areas of disparity,
24:27stroke was at the top of the list,
24:29and so we know that this is
24:30a major area of disparities.
24:32But some of the other areas listed here.
24:34You know you may or may not have
24:36thought about these brain injuries.
24:37A major area people felt pain,
24:40dementia, neurodevelopmental disease,
24:44epilepsy, Parkinson's,
24:46spinal cord injury,
24:47seizure and so these are a lot of
24:49other areas of neurological disorders
24:51that are periods of disparities.
24:54And if you look at the vulnerable
24:56populations again when we think of
24:57HealthEquity or health disparities,
24:59people automatically go to race ethnicity.
25:01And I mentioned that race is
25:03a social construct.
25:04But what you can see,
25:06and so this made us feel good in
25:08terms of looking at the RFI data
25:11that most people felt that low
25:13SES or that was sort of one of
25:15the most significant vulnerable
25:17populations to look at.
25:19And so again,
25:21this points to the strong impact of.
25:24Social determinants of health
25:26and how race can be used as a
25:28marker of one of the socio of
25:31social determinants of health.
25:33But then we have geographic disadvantage
25:35on uninsured or underinsured
25:37disabled sexual gender minorities.
25:40This is a large population.
25:41It hasn't been studied that we're
25:43looking more into now and then.
25:46Pediatric elderly and then those
25:48others that we have listed there.
25:50We use this information that we
25:53actually mapped it to the the
25:56National Institute of Minority.
25:58Health and Health Disparities
26:00Institute and I'm HD and their
26:02framework and it falls into these few
26:05categories that we have listed here again.
26:08And so healthcare affordability was a
26:12major determinant that came out from
26:14our RF eye as well as these other
26:17factors that we see listed here.
26:19We asked people to suggest interventions
26:22and so we had really great input in
26:26terms of interventions that people have.
26:29For instance, just having in
26:31terms of health service,
26:33making sure that there's someone
26:35who's Spanish speaking there.
26:37This on staff having someone that
26:39sort of looks like a person from
26:42that community is very important.
26:44We know it's important for increasing
26:47enrollment and clinical trials as well as.
26:51Uh, having a better healthcare
26:53interactions and we know this is an issue.
26:57This was just actually I know.
26:59Doctor Lazar mentioned this is
27:00an issue at the end in terms of
27:03the whole Spanish speaking issue,
27:04but we know that this is important
27:07'cause it does impact.
27:09People in terms of our our health
27:11care system and and research and
27:13so that that was our RFI and so
27:15now I'm going to present data from
27:18our health disparities portfolio.
27:20At the outset I mentioned some of the
27:23studies that the NMDS funded over
27:25the last ten years related to stroke.
27:28And So what we did was we went back
27:29and said OK over the last five years,
27:31we did five years because we actually
27:34wanted to be very rigorous in terms
27:38of this process.
27:39And so we actually created a standard
27:42operating procedure we created and
27:45instituted validity and reliability testing,
27:49and to the process to make sure that
27:51the information that we pulled was accurate.
27:53And so doing all of this,
27:56it required a lot of input from our Q
27:59or HealthEquity volunteers through the NIDS,
28:03and so we were able to do five years.
28:05So we looked at what the NINDS
28:07had funded related to health.
28:09Disparities are health equity
28:11research over the last five years,
28:13and we use the healthy people
28:162030 or 2020 definition, too.
28:20And two is to make our to determine
28:24or categorize what we felt was health
28:27disparities or HealthEquity related.
28:29And we looked at all competing grants,
28:31so these were applications that were
28:33competing. We looked at subprojects.
28:35We looked at supplements and that
28:38were active from January 1st through
28:40December 31st of FY20, 6 to 2020.
28:44And then we also categorized this
28:46to the NIMHD framework and we did
28:49the validity and.
28:51Reliability testing that we talked
28:52about and then we use this information
28:55and we provided this information to
28:58our HealthEquity Strategic Working
29:00Group of the National Advisory Council
29:02and this was also presented at our
29:05Headway Workshop in the mid September.
29:10And so come from during that five year
29:14period we had over 9100 applications
29:18that were that were active and
29:21funded during that time period.
29:24We did an initial screening of that
29:27and was able were able to narrow
29:30that down to 910 applications.
29:32We then went into our coding
29:34specifically based
29:35upon the the healthy penny Healthy
29:38people 2020 definition and some.
29:40Other criteria that we came up
29:42with and in order to make sure that
29:44the applications were specifically
29:46related to health disparities.
29:48And it wasn't just the study that
29:50recruited a lot of diverse populations,
29:52which is not considered a health equity
29:55or health disparities research trial,
29:58but maybe according to the CDC definition,
30:01let me go back for a minute.
30:03We use the NIH research condition
30:06and disease categorization data,
30:08which is a database that the NIH uses.
30:11In order to classify the research project.
30:14And then at last we came up with 58
30:18applications during that five year
30:20period that were related to HealthEquity.
30:22Based on our definition.
30:24And again I just want to give this
30:27preface that these funding numbers that
30:28I'm going to show you next or based
30:31upon our portfolio analysis and they
30:33don't represent the official publicly
30:35reported data that you would get from
30:37off the normal databases we did.
30:40We looked at this differently in
30:41terms of how we analyze this data.
30:44So what you can see from this diagram
30:46is that the the numbers and the
30:48amount of money that was spent by
30:52the NINDS to fund health disparities
30:56project from 2016 to 2020, 2019.
31:00You see that there was A and and again we
31:04mentioned the number of projects that we had.
31:07The 58 projects.
31:10They were funded during 2019.
31:12We Co funded some health disparities
31:15projects with NHLBI and so that's
31:17why there was a bump during that
31:20year with the other projects.
31:24This slide shows the various types
31:26of mechanisms of projects that were
31:28funded during this period of time.
31:30Most of them were our ones or your ones.
31:33However,
31:33we do have some cases and deaths
31:36which are training mechanisms and
31:37then some other mechanisms that
31:39we have listed there as well.
31:41Of our training awards,
31:43we felt that this was a very fruitful
31:46area in terms of how money was
31:48spent during that five year period.
31:51Because we had the most sort of
31:53morality of of areas besides stroke,
31:56there were funded when it comes to
31:57health disparities, we had throat.
31:59We had migraine headache, chronic pain,
32:02hypertension, CNS infections.
32:04So we had a lot of different areas
32:06and we also funded some trainees
32:09and multiple sclerosis and 80 ADR D.
32:12And those areas as well,
32:13and so this was a small percentage of
32:15the funding during that five year period.
32:17But we filled investing in early
32:20investigators.
32:21That's important in terms of
32:23developing the next generation of
32:25health disparities investigators.
32:27But also,
32:28it it sort of added to the plurality
32:31of the types of HealthEquity or health
32:34disparities related neurologic studies
32:36that we have supported at that time.
32:39And so here,
32:40just again showing the types of projects
32:42that were funded during the period of time.
32:45Most were related to stroke,
32:46but then we had some other
32:49areas as well that were funded.
32:51Most of these projects were in
32:54the sort of clinical
32:56space or the T2 space,
32:58and I have here examples of of
32:59some of the types of studies
33:01that fall into this category,
33:03but this is where most of the
33:05most of the research studies fail,
33:07and then the other piece is that most
33:09of them were sort of observation.
33:11ULL studies in a sort of a list.
33:13Here the studies and I'm sure if you
33:16read through this little diagram,
33:18you'll see that I'm sure is a
33:20stroke program stroke programs.
33:22You guys are familiar with these studies,
33:25but what we'd like to do is sort of
33:27move from this sort of observation.
33:29Ull space more to the interventional space.
33:32There are a lot of interventions
33:34that we know that have been
33:36developed and have shown efficacy,
33:38but just sort of scaling up those
33:41interventions and exporting
33:42them to different areas is,
33:44is is where we need to go particularly.
33:46Let's say with blood pressure control,
33:48we know blood pressure control
33:50is so important for stroke,
33:51and now it's a modifiable risk factor.
33:54That we know based on Sprint mind
33:57for some cognitive impairment,
33:59and so we have a lot of good
34:02blood pressure medications.
34:03We have interventions that have
34:05been shown to have efficacy and
34:08addressing blood pressure control,
34:09and so we really just need to
34:12scale this up and and and and
34:14and do interventions in various
34:16communities in order to address this.
34:18So we'd like to move towards that space,
34:20'cause that seems to be a large gap,
34:23and that's what we've heard from.
34:24Some of our work. Uhm, we can see here.
34:28Just sort of mapping this to the
34:31NIMHD healthcare framework that a
34:33lot of the projects sort of focus.
34:36Some of them.
34:37You can see that this is more than 58
34:39and this because some of the projects
34:41sort of overlapped with multiple areas.
34:43But in general most of them sort of looked
34:45at biologic factors for these disparities.
34:48And so again,
34:49we need to move.
34:50We like to have more research and
34:52some of these other spaces as well
34:54beyond just sort of biological.
34:56Factors. And this is again.
35:01Something that we have to work
35:03on only 16 of the 58 applications
35:05actually describe community
35:06engagement strategies and so in
35:09order to address these disparities,
35:11it's very important to engage the community.
35:13It's also important to enroll if
35:16you're thinking of enrolling diverse
35:19populations into clinical trials.
35:21It's important,
35:22and it's imperative for large
35:25academic centers to find a way to
35:27get into diverse communities and.
35:31That type of relationship takes a while
35:33to build up, but it's very important,
35:35and so having some type of Community
35:37Advisory Board there were only
35:39a small number or some type of
35:41naturally occurring group like a
35:43church group or some type of other
35:45Community group working with them.
35:47Community health workers or
35:49working with neighborhood clinics.
35:50So these are areas that we'd
35:52like to see more.
35:53Academic institutions,
35:54including these types of community
35:57engagement strategies and
35:59their research projects.
36:01And so now I'm going to talk about
36:03diversity and diversity training
36:05and why this is important to the
36:07NINDS and so the nid's feels that
36:11diversity is important in the
36:13NIH feels it's important as well,
36:15because recruitment of the best talent at
36:18researchers from all groups is important.
36:20There's no one group that has a
36:23monopoly on intelligence or new ideas,
36:25and so it's important to look
36:27at all groups and to to pull the
36:30best ideas from all groups.
36:32And that requires respecting all groups
36:34and and listening when and and looking
36:36to find people with those unique ideas.
36:39It diversity creates improvement in
36:41the quality of educational training
36:44and environment by listening to the
36:46perspectives and the history and
36:48the background from diverse people
36:50and listen to how information is
36:53as given or taught.
36:55That actually improves the training and the
36:58quality of educational training for everyone.
37:00As well it provides.
37:02Balanced perspectives in terms of
37:04setting research, research priorities,
37:06improves the capacity to recruit
37:08subjects from diverse backgrounds.
37:10In clinical trials,
37:11I mentioned this as well.
37:12There were couple of large clinical
37:15trials I can think of where once they
37:19were able to hire research assistants
37:21who actually looks like people in the
37:24community that they were trying to recruit,
37:26they actually were able to boost
37:28their recruitment numbers and so
37:29that's something important to think
37:31about as well and improve capacity.
37:33To address health disparities.
37:35Now, how does the NIH define diversity?
37:39The NIH?
37:42Defines or just.
37:43The describes individuals from
37:45underrepresented and underlying
37:47underrepresented racial and ethnic groups.
37:50Individuals with disabilities.
37:51Those who are defined as those
37:53with physical or mental impairment.
37:55Individuals with disadvantaged backgrounds
37:56and that could be socially, culturally,
37:59economically, or educationally.
38:01And this applies only through high
38:04school and undergraduate level after that,
38:07then it's more difficult to show
38:09that sort of disadvantaged category.
38:12That's the only, UM,
38:14only reason that someone is
38:17considered diverse.
38:19We have an office at NIDS,
38:21did sort of deals with diversity training.
38:23This is called the Open Office
38:25or the Office of Programs to
38:27enhance neuroscience workforce.
38:28The first thing is led by Doctor
38:30Michelle Jones, London my office.
38:33We do look at diversity training for people,
38:37diversity training and people interested
38:40in HealthEquity or health disparities.
38:42And we also look at training of
38:45everyone related to health disparities.
38:48We think that.
38:49Health disparities training should be
38:51included and graduate and medical school
38:54and probably undergraduate curricula as well.
38:57It's important if people
38:59understand health disparities,
39:01unconscious bias and racism,
39:02and its role and the health care system,
39:05and this is taught on the undergraduate
39:08graduate medical school level.
39:09This will spark the interest of
39:11people who go into these fields,
39:13but also we would be able to get diversity
39:15as well in this field and and come up
39:17with new ideas for addressing these.
39:19Areas and so this office from
39:21my office deals with it some,
39:24but the we have an office that
39:27deals specifically with
39:29workforce diversity as well. I just list.
39:32Here's some of the various programs,
39:35uh, or mechanisms, that the NIH uses
39:39who come to fund research and research
39:43training at various levels. We actually,
39:47and I think you probably know this,
39:50that we have a well represented group of
39:53people that submit our one applications,
39:56but it's very hard to get
39:57underrepresented groups.
39:58We have only 66%, six.
40:01Percent from underrepresented groups
40:03that actually submit our ones.
40:06And we award about 5% to underrepresented
40:10individuals and so at any ideas.
40:13We have an OC, so if there are any.
40:16Uhm, individuals on the call that sort
40:18of fall into the UM underrepresented
40:21group category that we talked about.
40:23If you submit your RO one in
40:26response to this particular no see,
40:28it creates a flag for that particular
40:31application as a high priority.
40:33And when we're looking at applications
40:37that we're considering funding,
40:39we consider this group as sort of a
40:42high priority, high priority group.
40:43In terms of those that we fund.
40:46Uhm as well. There's some other things.
40:49Other funding mechanisms that we
40:51have for diversity that I have
40:52listed here on the slide as well.
40:54I'm going to highlight the faculty
40:57institutional recruitment for sustainable
41:00transformational program or first program.
41:03The awards were actually listed last week,
41:08last Monday and this was a program
41:11that looked for applications of sort
41:14of cohort faculty cohort hiring
41:17where institutions.
41:19Would hire groups of people from
41:22underrepresented backgrounds in same
41:24time with the idea or thought that
41:27if people had a cohort of others
41:29that looked like then that started
41:32in an academic environment at the
41:34same time that we can sustain or
41:37decrease the attrition rate of early
41:40staged faculty members or early stage
41:43investigators and academic institutions,
41:45and so that that's sort of the
41:47idea of that program we also have.
41:50Some other programs to address HealthEquity
41:53and structural racism at the NINDS.
41:56I suggest that you go to the NIDS website
42:00and sort of look at the Unite program.
42:04There's a great website for unite
42:07and also the Common Fund program.
42:10As far as the Common Fund program,
42:12it's a program that has a separate
42:14line item of funding from the NIH,
42:17and they actually fund programs
42:19for up to 10 years,
42:21and they're usually high risk
42:22high reward projects that Dr.
42:24Transformation of new ideas, new approaches.
42:27We have a committee,
42:28and I I'm the anti India's representative
42:30on this committee that's developing
42:33initiative related to HealthEquity,
42:35and it will probably be coming out and.
42:39Next year with funding and and 2023
42:43and so again, just go and look at this,
42:46but it's some of the other things that
42:48the NIH is going to address HealthEquity,
42:51and some of you I'm sure,
42:52saw the Ann and I MHD RFA
42:57on structural racism.
42:58We had some applications that
43:00were submitted to the NINDS,
43:02and those will be reviewed within
43:05the upcoming couple of weeks,
43:07and so we hope that those are successful.
43:10And I'm coming near the end of my talk again,
43:13just mentioning the Unite program.
43:16Go to the website,
43:17you'll see there are things that the
43:20NIH is doing for the NIH employees,
43:22but also for researchers and people
43:25in the extramural environment.
43:26Because it understands that this
43:30structural racism has is there.
43:32And if we don't do anything to address it,
43:35it will continue.
43:36And this impacts lives and
43:38impacts people in the workforce.
43:40And it also impacts the
43:41people working at the NIH,
43:43and so they're working to try to change this.
43:45These programs can be very
43:47important and helpful.
43:48I mentioned this that I myself I
43:51actually participated and benefited
43:53from some of these programs.
43:55Some of the CMI programs when
43:59I was an undergraduate school,
44:00I participated in the mark program,
44:02which actually got me interested in research.
44:04Back when I was a chemistry
44:06major in undergraduate school,
44:07but also it allowed me to
44:09participate in an MD PhD.
44:10MD, PhD program,
44:12which I did at Mary Medical College.
44:15These are some of the faculty
44:17members at that time.
44:19In ninety 1994 we were at some
44:22of the historically HBCU medical
44:24schools in the country.
44:26Dr Calvin Calhoun,
44:28who's actually one of the first African
44:31American neurologists in the United States,
44:34was one of my professors at Harry
44:37Medical College at that time,
44:39that could Patrick Griffith,
44:40who was that?
44:41Morehouse doctor we're at at Howard as well.
44:45I the four of us went to the
44:49American Academy Neurology annual
44:51conference in Washington DC that year.
44:54I actually went into neurology.
44:57This lady went into optomology.
45:00She was interested in Nuro optomology.
45:02Not sure.
45:02I'm trying to find out what feel
45:04that these two individuals went into,
45:06but this is at least 25 to 50%.
45:10Of the people of the four people
45:12from that time that this investment
45:14actually made a big difference.
45:16Though this has provided a platform
45:18for me to be able to continue to
45:22address these issues moving forward,
45:24I think that's and these are the
45:26people in my office who helped me to
45:28do the work. We're working to expand.
45:30We've been very busy recently,
45:32but I couldn't do this without them,
45:35and all the other volunteers
45:37and IDs that have helped me,
45:39so I think that's my last slide
45:40and I'm going to stop sharing.
45:42Now and open the floor up to
45:44questions that people may have.
45:46So I can see everyone again.
45:49Thank you very much Richard for the
45:52illuminating presentation and eye
45:55opening US statistics that you shared.
45:57Any questions or comments from anybody?
46:04I think there are a couple of in the chat.
46:07Yes, they will. Thank you.
46:08Someone can help me with the check.
46:11So Kevin shut that most of our
46:13stroke prevention trials in the
46:15past have enrolled patients with
46:17very mild or no disability,
46:19perhaps because of FP,
46:20and also maybe because of other biases
46:22based on NIH definition of diversity,
46:25should we do more to consider
46:26stroke patients with disability?
46:32That's that's an excellent question.
46:33I do think that, uh,
46:35that is something we do have to
46:37address that 'cause that is an area
46:39that we have not looked at a lot,
46:41and that that's a gap,
46:42and so that is something to consider.
46:43And we just have to sort of
46:45look at the markers of that.
46:47I know that for stroke,
46:49some of the trials,
46:50particularly the embolectomy trials
46:52they looked at people with the
46:55lower ranking scores and based upon
46:58small core and large penumbra.
47:01But there are studies now that
47:02are sort of looking at people
47:04with those higher ranking.
47:05And then I showed skill scores.
47:07But yeah, we need more.
47:08I think it's a.
47:09That's a good point.
47:10It's a it is a gap area and
47:13something we should look at.
47:15Thank
47:15you second question.
47:16This has been an eye opening talk.
47:18Thank you from Adam to Adam and
47:21the 5% funded rate Ferraro ones in
47:23underrepresented groups is very troubling.
47:26The NOSI mechanism and the others
47:27you describe seem like terrific ideas
47:29with these changes and the focus on
47:31career development, what do you think?
47:33Slash hope they are.
47:34One rate will be in five to 10 years.
47:39Great question. UM, we we'd like to see
47:43that the we like to see that we see
47:47good representation of funding rate.
47:51Similar to to what we see for
47:54other categories that we see for
47:56whites and other groups as well.
47:58Proportionately, we like to
48:00see those same proportions.
48:01The difficulty that we have
48:04is that this type of.
48:06Quote unquote race ethnic
48:08distinction is self reported and
48:10it's sometimes difficult to ask.
48:13We can't require people
48:14to give that information,
48:15and so oftentimes we don't know and
48:17and some people may not want to give
48:20that information for various reasons,
48:21and so we actually the open office
48:23had to work very hard and sort
48:26of thing strategically to come
48:27up with the no see in a way of
48:30trying to flag or identify people
48:32who fall into that category,
48:34'cause oftentimes people will just sort of.
48:37Fall through the cracks and so it
48:40it you know the way I presented it,
48:42it seems like you know you think wow
48:44yeah it's a no brainer but actually
48:46it's something that required a lot of
48:48thought to be able to pull that together.
48:54Another question from Elizabeth Perlstein,
48:56does this scope include the deaf community?
49:03Yes, that that would, uh, in terms of the,
49:07UM, individuals with disabilities.
49:09It would include that as well. Yes it will.
49:14Richard, this is Mark Alberts we were working
49:17with some outside consultants to
49:20address some of these issues and they
49:23brought up a very good point and it shows
49:26how simple things can make a difference.
49:28Me like you and a lot of folks on this call.
49:32We're in meeting after meeting day
49:34after day and we're always looking
49:36at data and various patient groups.
49:38And with these consultants said or
49:41suggested as well. When you look at.
49:44Your groups of patients for any
49:47disease for any disorder you know.
49:49Being inpatient, outpatient,
49:50whatever it is, do you breakdown
49:53the data by different groups?
49:55Gender, black,
49:57white socioeconomic and we don't.
50:00We don't routinely look at
50:02the data through that prism.
50:03We look at large groups with large numbers,
50:06and we sort of aggregate the data,
50:08which makes sense at one level.
50:10Instead of looking at subgroups of
50:12patients to really see it through lens.
50:15Of inclusiveness and diversity,
50:19and that was really an eye opening
50:22remark that they shared with us,
50:25and I was wondering if
50:26that resonates with you,
50:27and if NINDS is sort of used
50:29to doing that when you look at
50:32large groups for whatever reason,
50:34or if you're changing,
50:36or if that observation has any impact.
50:41No thanks mark. No, it's a great point.
50:43Actually, I've been working with.
50:45There's a health disparities group
50:47through the American Academy of Neurology
50:49and we're actually looking at the Axon
50:51registry and we're trying to look at that,
50:53which is a registry.
50:55Outpatient data doesn't include stroke
50:57right now, so so most of you were stroke
51:00programs aren't including that information,
51:03but we're looking at that data.
51:04Just sort of see how neurology is
51:07actually practice on an outpatient
51:09basis across the country. And so we.
51:11Tried to look at that and race ethnic data.
51:13We found several things.
51:15One, we found that that we're not good at
51:18collecting race ethnic data and actually
51:20it's only about you know 50% of the
51:23information that it actually captured.
51:24People confused race and ethnicity
51:27they would put in ethnicity for race
51:31and it was usually black white.
51:36And then Asian Hispanic,
51:38which is an ethnicity people get
51:40confused when you you think about that.
51:43And so when you start to look
51:45at the different types of Asian
51:47groups or Hispanic groups,
51:48then it starts to totally fall off.
51:50And so there was a so that
51:53that's a great point.
51:54Part of it is because of EHR
51:56systems and clinical practice.
51:58We don't have good ways of collecting
51:59this data, which is part of it.
52:02The other part.
52:03A lot of times we will group smaller,
52:05smaller.
52:06Ethnic groups NHLBI funded a workshop
52:09where they focused on Asian Americans,
52:13Pacific Islanders,
52:14and Native Hawaiians,
52:17and they talked about if you
52:18put those groups together,
52:20you would think that all of them
52:22do much better or have lower
52:23mortality rates than most people.
52:25But they said it's not true that
52:27you have to look specifically
52:28and disaggregate those groups in
52:30order to really see differences,
52:32and so by lumping people together
52:33you can get false positives or
52:35negatives putting people together.
52:37And we have to do better in
52:39clinical care and also in research
52:41in order to categorize people
52:42and to keep this information.
52:44And if we don't collect this information
52:46then we won't be able to go in and
52:48see that there are disparities
52:49and how medicine is practiced.
52:51And so you actually touched on
52:53a very important point Mark.
52:55We have to do better in terms of
52:57not lumping everybody together
52:58and categorizing people,
52:59but then that that forces us to
53:02deal with the uncomfortability
53:03that people have with asking
53:06race and ethnicity questions.
53:08And not just sort of defining
53:10people based upon what we think
53:12they are based on how they look,
53:13but to actually ask people how do
53:16they define themselves with probably
53:17the most important way to look at it.
53:20That's a great question.
53:21Thank you.
53:23More question in the chat by
53:25Tracy Madsen given ongoing
53:26disparities in stroke mortality,
53:28how does funding for surveillance
53:30studies evaluating ongoing race based
53:32disparities fit into the NMDS mission?
53:36Well, uh, one thing that, uh,
53:38yeah we know that the disparities exist,
53:41UM, so uh, what a doctor khorshed
53:43States and so we've highlighted this in
53:46written multiple times is that we don't
53:49want to continue to admire the problem.
53:52I mean, we know that it's there and so
53:54just continuing to look at the problem just
53:57for the sake of looking at the problem
54:00or defining the problem in new ways.
54:03That's not of interest,
54:04but if it's a matter of.
54:06Looking at a new disparity or looking
54:09surveilling something after an
54:10intervention has been implemented
54:12then that's a different issue.
54:14So if you're doing surveillance
54:16after an intervention,
54:17I think that's important in terms of
54:19looking to see if the numbers change
54:21after the intervention or if it's a
54:23new area that's just being looked at,
54:25then I think that would be important,
54:26but we really would like to move
54:29towards intervening on those problems
54:30that we know that are out there.
54:37I had a question from
54:39being struck neurologist.
54:40Some hypertension is something
54:42we pay close attention to.
54:45You mentioned that despite the
54:47science at there there has been there
54:49have been barriers to implementing
54:52good blood pressure control and
54:54underrepresented communities.
54:56It was wondering if you might
54:57elaborate on what some of these
54:59barriers might be in your experience.
55:01Yeah, so this is a really big area
55:04and it's something that we're working
55:07on and hopefully love to fund more
55:09research in this area as well.
55:12We know that you know,
55:13addressing some of the social determinants
55:15of health are very important,
55:17and insurance status competing needs.
55:21If someone it's an issue of putting
55:26gas in the car to go to work,
55:28paying for daycare, paying for groceries.
55:31You know paying for books,
55:33paying for something for school versus
55:35paying for blood pressure medication
55:38so individuals have competing needs,
55:40and so oftentimes people.
55:41Those that actually have insurance and
55:44know they have high blood pressure
55:45and may need their medication may not
55:47take their medication because they
55:49have other competing needs or they
55:51have to stretch out their medication.
55:53I've often times when it was back working
55:56in the hospital, people would say, well,
55:59I take my medication every other day.
56:01I was getting low and so I started
56:03stretching.
56:03Get out and so they stretch out the peels.
56:05That's part of it.
56:06Mental health is very big.
56:08There are a lot of people who have
56:10mental issues that are not addressed.
56:12Depression is is really big,
56:14and so people don't address that.
56:17And then there are food deserts.
56:18There's a lot of data about the
56:20benefit of fresh fruits and vegetables,
56:23and so you know it.
56:26A lot of people.
56:28Go to McDonald's 'cause it's cheap
56:30and it's in the neighborhood.
56:32I was, uh,
56:33you know,
56:34taking care of a friends child
56:38recently and the kid was eleven
56:40and wanted to go to McDonald's.
56:41I would think to myself,
56:42Oh my goodness, make that.
56:43I have not been to a McDonald's
56:45since I don't know when,
56:46but the kid wanted McDonald's
56:47and so I took him to McDonald's.
56:49But I did in my mind I'm thinking
56:51the whole time I can't believe I'm
56:52taking this kid to McDonald's.
56:54But I mean that that's a meal for
56:56a lot of kids to go to McDonald's
56:58to eat and they don't have to have
57:01little corner bodegas.
57:03So they can't get fresh fruits
57:05and vegetables,
57:05and they're eating out of a cannon
57:07or chips and all of that kind
57:10of stuff has high salty foods,
57:12and so I think those kinds of
57:14things have to be addressed.
57:15And in terms of, you know,
57:18those other social determinants of
57:19health that are out there in order to
57:21get the blood pressure under control.
57:23'cause people when you look at the
57:26knowledge in terms of of of hypertension.
57:28For I don't know we're getting near
57:30the end of time of why it's blacks
57:32and other groups blacks actually.
57:34Have, UM,
57:34just as much knowledge or awareness
57:36of having high blood pressures,
57:39other groups,
57:39but it's all these other factors
57:41that sort of come into play in terms
57:43of getting people under control.
57:45And so we have to address those issues.
57:48You're
57:48helpful, thank you.
57:55Thank you so much. Alright, thank you.
58:01So we are on break for the next half
58:03an hour. Please join us back at
58:05noon for a talk by Doctor Broderick.