The Distinguished Colloquium Speaker Series brings national leaders to the IU School of Public Health-Bloomington throughout the academic year. These events, which are free and open to the public, highlight key topics and contemporary issues in public health.
Dr. Griffin Rodgers
Director
National Institutes of Health
National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)
March 11, 2021
Noon–1:15 p.m.
Description of the video:
Welcome to our March distinguished colloquium with Dr. Griffin Rogers. My name is Brandon Howell, assistant Ddean of operations for the School of Public Health. It's great to see you all again today. We have a great attendance and turn out for today's session. I just wanted to remind everyone a few housekeeping items that we will be recording today's session. And also at the end of the session is a chance for a question and answer moment. So if you do have any questions for Dr. Rogers, please submit those to me in the chat function. Zoom. And at the point will be able to call upon you and you can ask Dr. Rogers your question. So welcome again. It's great to have him. I'm not going to turn it over to Dean of the School of Public Health, Dr. David Allison. Well, thank you, Dr. Howell. I will be brief in my remarks because professor Nana Gletsu Miller I believe is going to do the formal introduction of our highly distinguished speaker. But I'm very excited to have him here today. And I'll briefly say that, you know, there are many people used to say about President the United States and times. Is this to someone you want to have a beer with? There are many people we might like to have a beer with or hang out with. And there are many people who are great scientists. And there are many people who are great administrators and the ability to help others to science. And there are many people were goodwill that have the will to help others stupid science and takeaway for their own research to do that. There are very few people have all of those things. And grief is a good friend and a good administrator and a good scientist and a good person. And he has all of those things. And it is truly a blessing and an honor and a privilege to have him here today. And we'll hear more from him in a moment. So thank you for coming. Well, thank you for embody. Are also another wonderful person is professor not a glitzy Miller. And Professor Glenn Miller is a faculty member, know our school. She is an excellent nutrition scientist and scholar, friend and teacher. And we're also lucky to have her here. She is going to do the formal introduction Professor Glenn Miller, floor doors. Okay. Didn't allison? Good afternoon everyone. My name is Nana. That's similar and I am an Associate Professor in the Department of Applied Health Science here at the IU School of Public Health Bloomington. Today I'm very honored to introduce our March colloquium speaker, Dr. Griffin Rogers. Dr. Griffin Rogers was named Director of the National Institute of Diabetes and Digestive and kidney diseases and IDD K, one of the National Institutes of Health, NIH. On April first, 2007. He had served as the NID case Acting Director since March 2006 and had that and had been the institutes Deputy Director since January 2001. As the director of an ID decay, Dr. Rogers provides scientific leadership and manages a staff of over 600 employees and a budget of 2.3 billion. Dr. Rogers received his undergraduate, graduate and medical degrees from Brown University in Providence, Rhode Island. He performed his residency and chief residency in internal medicine at Barnes Hospital and the John Cochran and VA respectively at Washington University in St. Louis, Missouri. His fellowship training in hematology was an adjoint Program of the NIH with George Washington University. In addition to his medical and research training, he earned an MBA with a focus on the business of medicine science from John Hopkins University in 2005, and a master's in Legal Studies in 2017. As a research investigator, Dr. Rogers is widely recognized for his contributions to the development of the first effective an FDA approved therapy for sickle cell anemia. In addition, he and his collaborators have reported on a modified stem cell transplant regimen that is highly effective in reversing sickle cell disease in adults and is associated with relatively low toxicity. He has been honored for his research with numerous awards including the 990 eight Richard and kinda Rosenthal Rosenthal Foundation Award to the 2000 Arthur as phlegm and award, the legacy of Leadership Award in 2002. A masters, a master ship from the American College of Physicians in 2005. The Herbert C. Nikon's Award in 2018, fellowship in the World College of Physicians London in 2018, among others. Dr. Rogers is a member of the American Society of Hematology, the American Society of Clinical Investigation, the Association of American Physicians, the American Academy of Arts and Sciences, the American Association for the Advancement of Science, and the National Academy of Medicine among others. Now, without further ado, I want to thank you all for being here with us this afternoon. And please join me in giving Dr. Griffin Rogers a warm virtual esp ph. Welcome. Thank you so much, Dr. Miller for that very kind introduction. I really wish my mother were here to here. And I let me start off by thanking Dr. Alison for his kind invitation to give this talk. I know we've gone back and forth over quite a long period of time, but I'm certainly glad, albeit in this virtual environment, that we finally have an opportunity to speak with you today. My topic today will be sickle cell anemia, past, present, and future. Next slide please. Let me start off by people say that what people remember most about talks fall into the category of recency and latency. What ear first and what you hear last. So let me start off my talk. But an interesting fact that you might be able to quote at some point shown on this slide is Dr. verne Mason. He was actually a physician who did his residency at Johns Hopkins University. And in 1922, he was the first to describe their first patient admitted to Johns Hopkins, who we followed over the course of several years during his residency. And he reported this case in the Journal of the American Medical Association in 1922. He entitled that report sickle cell anemia. By describing the characteristic of the red cells as well as the important feature of anemia. When you introduce a term that ultimately becomes a standard designation of a disorder, attaching that name not only is important for enhancing the disease recognition and other people picked it up, but it also enhances the recognition of the author. As far as we can tell, Dr. Mason didn't publish any other papers of note. But he went on after leaving Johns Hopkins to become an outstanding internus at Los Angeles and in fact became a physician to many movie stars. Next law, just click once, including this man. Now I know you guys in the audience are probably quite young and maybe don't recognize this guy, but I'll tell you his name is Howard Hughes. And he was a very famous entrepreneur. Actually headed up an airline that he ultimately soul. And as he later became close to clear that he didn't have many years Latvia was known that Howard Hughes was a recluse. And he really didn't speak with very many people except for as I understand, his physician is personal physician verne Mason. And he asked Dr. Mason, I've accumulated a substantial fortune and I'd like it to go to good use. What do you recommend? If you could click one more time? Dr. Mason suggested that he put that money into the establishment of a medical institution, now known as the Howard Hughes Medical Institution in support of biomedical research. So I'll leave you with this snippet that there is a connection between sickle cell anemia and the Howard Hughes Medical institution. Next slide, please. Other people who are much more familiar to you perhaps who have had a role in sickle cell anemia includes this gentleman, Linus Pauling, who as many of you may be aware, won the Nobel Prize on two separate occasions. First word, description of a hydrogen bond. For example. But in a seminal paper that he published in Science in 1942, he describes sickle cell anemia as a molecular disease, later called the first molecular disease. Because it was the first disease in which the molecular defect was identified. It's a single substitution and the beta six position of the beta globin. And I'll describe for you a little bit more detail. And he was able to provide the idea that it was a molecular disease because Dr. Pauling actually use one of the first prototypes of an electro fruit theoretic device in which you could separate proteins on the basis of their charge. And he was able to show that patients with sickle cell disease there are hemoglobin had a particular electrophoretic mobility, which in the obligate, the parents who are carriers of the disease had a characteristic of their hemoglobin, half of which migrating with the sickle hemoglobin, the other half in the same feels as hemoglobin a or normal hemoglobin. Later showed that this abnormal hemoglobin polymerize quantity oxygenation. And given the fact that the defect was in hematopoietic stem cells, it was argued for quite a while that this would be an ideal disorder where a hematopoietic stem cell base approach might result in curative intent, which I'll hopefully persuade you later and talk. Next slide, please. From a public health relevance. This is the disease that affects millions of people throughout the world, commonly in those ancestry of salt, Sub-Saharan Africa. It's also present in South America, the Caribbean, certainly Central America, and Saudi Arabia, India, whether it's probably the greatest prevalence of the disease, but also in areas in the Mediterranean, such as Italy and Greece. In the US, there are probably a 100 thousand people affect it. It occurs in one in every 500 African American birds and about one in every 36 thousand Hispanic birth. Really associated with major complications that I'll tell you about. The good news is that between 792017, because of many met medical interventions, the average life expectancy increased from 28 years to 43 years. And over that same period of time, individuals younger than five years of age, their life Vacancy are the death rates declined by a 158%. An average individual with sickle cell disease spends about $1 million to allow them to live into their 40s. And of course, there are severe complications, including those associated with COVID-19, that we can now appreciate occurs more frequently in people with sickle cell disease. In fact, the CDC recognizes sickle cell disease as a disease that puts you in a higher category. And therefore, in most states there first in line to get receive vaccinations. Next slide, please. As Dr. Pauling indicated, this is disease in which two parents who are carriers, their offspring have about a 50 percent chance of being a carrier. And about a 25 percent chance of a child born in that to those parents actually having the sickle-cell disease. Most patients with sickle cell, most individuals with sickle cell trait, however, do not have manifest any symptoms. And one has to be very carefully phenotype when to pick some of these out. The reason that this condition is so common, as many of you are probably aware, is that if you are heterozygous, that is, if you have the trait, you, you have a protection against developing serious complications of malaria infections in those areas in the Mediterranean and in, and in Africa, and even in the Middle East and in India. Next slide please. Here's what, how it got its name that was coined by Dr. Mason. If you could click one more time. A normal red cell which has a doughnut characteristic shape. When deoxygenated undergoes in individuals with sickle cell disease, undergoes this unusual shape change, conforming into a cycle of parents. Those cells that are able to get back to the lung and B reaction needed, however, will ultimately maintain or retain a normal biconcave or our disk apparent. Next slide, please. What we know so much more about this disease than any other disease. Arguably, this disease is not only known at a molecular and genetic level, but also even at a subatomic level. What we've learned in the last 30 years is this single base pair mutation. A single amino acid substitution at a looted for two before this veiling for a normal glutamic acid. And the six position of the beta globin chain results from a single nucleotide substitution a T for an a. So imagine this in an individual was heterozygous. You have to base pair differences in a genome of a billion base pairs or more. And that gives rise to a condition associated with the following. At a cellular level that these hemoglobin molecules are tetramers in a normal circumstance, either oxygenated or deoxygenated as shown on the left, continue to remain free and solution inside the red cell. But on the other hand, and individuals with sickle cell disease, because of this, this hydrophobic association of veiling, when these hemoglobin give up their oxygen become deoxygenated. They have this peculiar tendency to self associate and form polymers. Polymer elongation begin to place tangential forces on the red cell membrane, as you can see at the bottom here, so that the shape of the cell begins to form. Or do you see this characteristic sickle shape? But as it turns out, what we've learned in the last 25 or 30 years or so is that it really isn't the shape of the cell, but it's the biophysical content of the and the amount of polymer inside these red cells that changes its overall properties. Next slide, please. The disease is also unfortunately characterized by the fact that this hemoglobin polymer interacts with the red cell membrane in these individuals and it causes the opening of otherwise to dormant channels, potassium chloride, cotransporter channel, and a garden hose channel in which potassium has lost the calcium flows into the cells. And in both of these circumstances, this is associated with dehydration the cell. Now, this actually adds further a problem with this whole concept of polymerization. Because the rate at which the cells polymer, polymers are these nice, hemoglobin molecules polymerize varies with the inverse of the 28th power of the hemoglobin concentration. So anything that would lead to dehydration of the cells could greatly amplify the rate and the extent to which there's polymer in the cell, even at fairly high levels of oxygen. Next, lipids. The other issue that occurs because these individuals get so profoundly anemic inside their bone marrow, the cells, as a red cells are maturing. They don't have the opportunity to be completely mature. In fact, many of them are delivered to the circulation before they're fully mature and on their surface of the membrane, they contain just a few examples. Things like sulfate at glycans and CD36 and alpha for Beta-1 integrin molecules, which can either directly bind to the underlying endothelial cells in the microcirculation. Or they can be joined by substances in the plasma like the rhombus spawned and fiber nekton, which can cause these red cells tenaciously at here to the, to the endothelial cells as illustrated on the next slide. So in the microcirculation, next likely. In the microcirculation you see these cells have to deform almost in a parachute like manner. And they go by in a single file of one by one. And you can see and appreciate in this slide how close they come to the underlying endothelial layer. So these cells that may be enhanced in terms of their speaking, this can result in an obstruction to blood flow at that local level, leading to the subsequent deoxygenation of the cells more retrograde, further polymerization, inability to form, causing much a greater impact. In terms of the rheology of the cells. Next slide, please. And obviously any condition that both qualitatively and quantitatively affect every red blood cell in the body. And because of the need for these cells to reversibly deliver oxygen to the tissue. When one gets these obstructive phenomenon going on, the micro circulation, one can envision that not a single organ or organ system in the body would be spared the ravages of the disease as illustrated on this cartoon, these patients suffer from very severe neurologic complications. I manifestations, chest crisis, hepatobiliary, urate to genital complications, but musculoskeletal prices, which occurs at a unpredictable frequency. In many patients who are severely ill, this condition is really one of the more distressing associations that we see in this condition. And certainly it's something that Dr. Mason describe very adequately or accurately in his JAMA paper in 1922. Next slide, please. So just to summarize what I've said so far, the primary mechanism and this disease that we understood at a molecular level. Click please, is a single substitution for this T for an a which gives rise to this abnormal beta S polypeptide, which went to associate it with a normal alpha polypeptides can lead to polymerization upon deoxygenation and cause microvascular occlusion. And these individuals, if you can click one more time, but it is absolutely clear that, that since they are such a tremendous heterogeneity in this disease now, not everyone has a severity of the disease that is expressed on that, that map or that cartoon I showed you a moment ago. But this disease can be modified by genetic sailor, physiologic, no doubt psychosocial and socioeconomic factors. But what I'd like to just focus on for the moment with respect to looking for an effective therapy is a genetic modifiers. Next slide please. And that's illustrated on this slide. In fact, one of the other first associate it with sickle cell disease was that studies of the restriction length polymorphisms or RFLP peas, or also known as haplotypes, which provided the weighing of the Lasker Prize for y. W Khan and his colleagues was first demonstrated in the late seventies that in old-world Africa, the sickle mutation probably arose in the backdrop of at least three different haplotypes. A Senegalese Bernini in and, and band two. And then subsequently they show that the disease arose to separate time. And the Saudi Arabian indian Peninsula, these all have different mutations in and around that beta S mutation that I've shared with you. And of course, through either migration or slave trade, these, these particular haplotypes and their combinations have become more manifest in the New World. But what we learn from these types of studies was that some of these patients, for example, the ones with the Senegalese and the Saudi Arabian, an Indian haplotypes tended to have a milder disease compared to those. Nian Ban two haplotypes. Next slide please. And we understand now that the reason for that goes back to the fact that there are three steps in terms of hemoglobin switching over time. And these individuals with this Can, the Senegalese about the Saudi Arabian tended to have a persistent expression and what's called Gamma globins shown on this slide. And normal circumstance, the hemoglobin Alpha chains turn on very early in the embryonic life and remain on. But the, the Gamma globin chain gets turned on, gets turned off at about the time of birth. This Alpha 2 Gamma 2 reflects fetal hemoglobin as the name would imply. And what then gets turned on at the time of birth is the definitive beta globin. And in the case of sickle cell disease, beta S global. Next slide please. But those individuals, particularly as such as those in Senegal and Saudi Arabia and India, click one more time. Have not a 100 percent sickle hemoglobin, but they have a high persistent expression of fetal hemoglobin due to separate mutations that have arisen over thousands of years ago. And this fetal or gamma chain doesn't allow for this polymerization process to occur normally. In fact, either a homo tetramer of fetal globin or a hetero dimer, once it enters into this polymer phase, tends to melted away. So actually nature has created a best anti sickling age and if you would. And next slide please. Our, our goal has been to try to figure out a way in people with more that Bernini and the more severe disease to reactivate this fetal hemoglobin. A way to replicate the milder condition seen in these geographic region. Now our studies focused on hydroxyurea and I won't have time to go into all of the details. But it was known that Hydroxyurea, if you click one or two more times, simple molecule interferes with ribonucleotide reductase. And in his previous existence when he was used to treat patients who had a pre leukemic condition, it was shown that there are small but statistically significant increases in fetal hemoglobin in these individuals who receive hydroxyurea compared to their baseline. Next slide, please. And this led us to do studies at the Clinical Center here at the NIH in which patients were hospitalized for three or four months given the dose. And, and followed very carefully the fact that they were hospitalized, they know that they were receiving the drug. We can define what the best dose to achieve this outcome would be. And we could rule out the fact that drug compliance, that is the individual taking the drug was not a variable because we were there and the patients were receiving it in front of our eyes. In this early cohort, the first 10 patients, 70, those 10 patients resulted in an increase in their fetal hemoglobin with the best achieving values as shown on the right side of this slide in the range of ten to 15 percent. And subsequent studies continue to show this that 7580% of patients achieve higher levels. Next slide please. Ultimately, this result when we reported in the New England Journal, was actually picked up by someone who you may recognize his name, as it turns out before, he was a widely known New York Times best seller for things like the tipping point, David and Goliath and several other books. Malcolm Gladwell was actually a staff science writer for, for the Washington Post and he covered are our results and it was covered and others, but this drug offered promise. Next slide, please. And in fact, this ultimately led the NIH and my sister organization and not national Heart, Lung and Blood Institute, to fund a multicenter randomized trial with half patients receiving hydroxyurea and the other half are receiving placebo involving 21 centers, as it turned out in the US and Canada, of about 300 patients randomized. Next slide please. And as it turns out, the study was actually stopped by the DSMB early because it became clear that one group was doing so much better than the other group. After a unmasking the group, it was a hydroxyurea group that showed a benefit from a decrease in the frequency of a painful crisis. Click one more time. My colleague, Alan Schechter and I were asked to write the model, we review the paper, but right, the editorial based upon our early work in this area. Next slide, please. And the results quite simply showed a 50 percent reduction in the frequency of painful crisis, increase in the blood count. Therefore, these patients require less than the way a blood transfusion decrease in the frequency of other complications. But because this study was actually curtailment terms of its went at that time, there was no difference in mortality or incidents stroke that was seen in this group. Next slide, please. And that paper came out in 995. The FBA ultimately approved this drug in 998 as the first treatment, FDA approved treatment for individuals, adults with sickle cell disease. Next slide please. This is how they marketed the drug. This was Bristol-Myers Squibb. Several other generic equivalent drugs have come out subsequently. Next slide please. And if you could click a couple of times subsequently these results were, were reconfirm and then ultimately ended up the drug was then applied for children first and a fairly young age. And then even in infants, baby hug, as you can see here, I'm just showing you some of the subsequent publications. Next slide, please. And as a direct result of this, in 2017, FDA actually extended the approval to include not only adults, which it had been approved for, but also pediatric patients. Because of the greater, even greater efficacy. As I've mentioned, about 75 to 80 percent of unselected adults seem to respond. In kids, this may be closer than 90 percent efficacy on this population. And the effect seems to be durable. Over 17 to 20 years of therapy, these patients still continue to have very high levels of fetal hemoglobin production with low in the way of a side effect profile. Next slide, please. In 2019, the last time we were actually able to, to go to national meetings. The question came up, Well, this is fine in the US in sort of in a, in an area in which there's adequate resources available. But what this same kind of therapy work and Sub-Saharan Africa or in an area that was more resource limited. And in fact, presented at a meeting at our American Society of Hematology meeting in early December. And then the paper was published in January of 2019. This this trial, if you can click again, which basically showed that of the 600 or more kids who were treated, the retention rate was very high over three years. The drug significantly increased fetal hemoglobin and it was associated with the same things that we saw here in the United States, except the additional benefit was that there was a decrease in non malarial infections as well as, as a malarial infections. And it prolong life expectancy greatly seen in the middle here as Dr. Zulu, the first author on this paper during that presentation. Next slide, please. Unfortunately, I won't go into this in great detail, but this simple slide actually result is the result of two postdocs in three years worth of work, which summarizes the molecular basis of how Hydroxyurea works. It works in a way in which it induces the expression of NF-kappa B. Nf-kappa B then turns on a gene SAR, which had previously been known for it being an ER, stress related gene in that it allows for proteins to be shepherded from the ER to the Golgi apparatus. This SAR. Interacts with the membrane associated GTP proteins and ultimately the induction of junk. See June pathway, which is specific for Gamma globin induction. This all occurs through the recognition that not only hydroxyurea shown on the left side, but era C and other drugs as genotoxic stress inducers that, that induces the phosphorylation of the ataxia telangiectasia mutant or the ATM gene, which ultimately results in induction. But again, you summarize a lot of work to very dedicated post-docs. And one, I couldn't leave without at least showing you that we understand how this drug works and can begin to understand the potential mechanisms of why some patients don't respond due to potentially genetic mutations in and around this particular path. Next slide, please. There was a conference held by NIH a number of years ago and it's been repeated that not all people are very comfortable with using the product. There are some at the level of sum, so uncertainty at the level of patients, their family members, providers, hospitals. Some people do hydroxyl. At the same way they view other chemotherapeutic agents and therefore patients aren't offered this opportunity. And this consensus conference really dug deeper into not only those issues, but also ways to counteract that. Next slide, please. Actually could click twice. There we go. Okay, good. Click to the next slide. So I've told you a little bit about the pass. Let me tell you about the present time. And that is, while hydroxyurea is a very effective drug, both in the treatment of adults, children. It isn't cure, isn't a cure for the disease. A cure for the disease was already imagine over 50 years ago. And that paper that came from Dr. Linus Pauling. Because this is a disease that out that it's manifested in changes in the bone marrow stem cells. If one could harvest those stem cells from a normal related sibling who didn't, wasn't affected with sickle cell disease and transplant that into patients that could be potentially a curative intent. However, because patients suffer, those, adult patients suffer many of those complications that I talked about. Using conventional Milo ablative therapy, which includes radiation and chemotherapy, to open up a space for the donor. Stem cells to two in graph and develop is associated with substantial toxicity, both in conditioning as well as graft versus host disease. So this would limit the effectiveness of Milo ablation in that setting. Next slide, please. My colleagues and I developed an alternative approach, which is sort of summarized here in which one is not looking for full Milo ablation, but a state of energy or the induction of tolerance can which one uses a drug at that time known as rapamycin or sirolimus, which really works at a later stage, the T-cell receptor recognition, stage 2, as opposed to the conventional therapy at that time that was using these patients. Cyclists born a next slide, please. In fact, an, a, a, a marrow, a rejection prone model of a mouse model. We compare cyclosporin and to rapamycin with a brief period of immunosuppression using one or more of these and showed, and this mouse, and the mouse model that the mice receiving rapamycin displayed. This idea of tolerance or energy as reflected in the percentage of donor cells out about 33 to 36 weeks. In contrast, the mice who receive cyclists born after the first two weeks, there was really no donor cells that are measurable in their bone marrow. Next slide, please. Let us to develop a protocol, all three h 10, 7, which involve the many alo or, or, or low dose Milo ablation and these individuals Next slide please. This really shows a conditioning regimen. Hydroxyurea was continued through day minus 8 or Excel exchange was given that maintain a sickle hemoglobin concentration in at about 30 percent. Click a few more times. They were given alum to the mat TBI and then after the transplant as this agent sirolimus at a target value. And if you can click to the next slide, we can look at the results of this compared to full Milo ablation in which the period of time in which the neutrophils were below a critical 500. These individuals receiving this, this many alo, or low mile ablation, there was only a period of about two or three weeks of the neutrophil mater being at this level. Next slide please. And then the patients who were treated, you can see that at 12 months we achieve this this degree of mics cameras and with a reflection of their CD three cells being there, lymphoid cells from the recipient. Whereas the donor cells CD 14 positive, 15 positive, we're about 90% in the, from a donor derived associated with this alo or this synergy. One sees that the red blood cell count increased over a year or more. And evidence of anemia or hemolytic anemia improve reflected in a lowering of the reticulocyte count, the bilirubin and the LDH. Next slide please. And the initial results involving ten patients were reported in the New England Journal. We did receive criticism know that it was a small number of patients. They are treated and they were followed for a short period of time. Next slide, please, which led us to follow even more patients. This slide or this publication which came out in 2014, involve 30 patients with a longer period of follow-up came to the same conclusion. Next slide, please. In fact, we're up to almost 60 patients had been transplanted to date. Unfortunately, we had to interrupt what we've done so far because coded as everyone else is. But of these 50, a patient is important to point out that the overall survival is 93%. Or 54 of these 58 patients are still alive. There had been no transplant related mortality. There had been no graft versus host disease. An 88 percent of these patients are dipping. One out of 58 are disease free. And most impressive is that we've been able to stop all immunosuppression and these patients and 92% of the patients. So one of the sort of the, the, the, the goal standard of transplantation is not only to successfully in graph what either bone marrow or kidney or liver, but to try to get patients off of their immunosuppressive therapy. Because in many instances the side effects of the immunosuppression may be just as grave as the underlying disease that you'd hope to cure. Next slide, please. Well, of course I've been sort of giving you numbers and names, but let me show you what a patient's reaction to this is. You can click call first year, which they fall at the Internet, the hospital, my life. Sucker snow can cause devastating, life-threatening problems. Within the last five years, it got worse. I was having pain every day. No longer did I have my brakes or she means they are paying or that spark and select a team. But you still have patchy hours, a few hours. So the pain can last anywhere from an hour to several days to weeks. This excruciating is a husband if you want to provide or your spouse may want to protect it from anything that will harm them. Or day six, so you can't ease the pain. You can't take it away. 200 worst failures in our phones in the world. I do fight the depression and anxiety that goes along with the pain. When you become just so chronically ill, broken down? You're not. Tend to participate. I need a good standing. If any badges when he ran for my chat. Thank you. Next slide, please. And yes, it was a good outcome for the address as shown on this slide. Here, I'm standing with Deidre, my two colleagues, Dr. Teasdale to her left and Dr. O'Shea to to to my right. As long as it together would be dressed. Sister who served as the the donor. Now out I think this picture was taken six years after that successful bone marrow transplant and error. And if you can click one more time. This, this was reported. For those of you who are fans of The Big Bang Theory. You'll recognize Jim parse in there who actually narrated this and follow this patient and three other individuals with other conditions over a period of a few years. If you'd like to, to look at this, it's online. It's called first in human. It's a documentary that was supported by the Discovery Channel. And I had to sort of stand for being the person not good with taking shots. But here's a picture of, of my image of this group. Because it really does take a lot of people to do this kind of research. Next slide please. And the most important thing is that it is okay for a single center. But if you can, if you can export that protocol to other sites and then they show that it works in their setting as well. That's when you really hit a home run. And I'm pleased to say that our results have been replicated. This is not quite up to date. They actually publish more subsequent work, but at the University of Illinois in Chicago, and adult patients at the University of Alberta in Canada, 16 out of 16 children who were treated. And then more recently and Saudi Arabia, 31 out of 34 patients all receiving that same protocol. You can see the 91 to a 100 percent event-free survival. And again, no graft versus host disease. And they're able to take patients off of, of their immunosuppressive therapies. And so this is actually as a physician investigator, things don't really get any better than this. This is so gratifying. Next slide please. But just to be fully transparent, I mentioned with the hydroxyurea the past that it's not a cure for the disease. It's 70 to 90 percent effective, but it's not a cure. Patients still have some symptoms. More occasionally, this particular therapy, while it is a cure, the many transplants, it only works if you have a compatible donor, which to get to that number of 60, we have to screen close to several 100 locations to have a donor who fully match the Not only match what their medical circumstance was such that it was allowed them to move forward with the transplant. So we estimate that probably only 20 to 25 percent of patients, unselected patients would fall into that category. So while it's a cure, it's not applicable to everyone. Then really have a cure that will be applicable to everyone. You would take the patients stem cells, hematopoietic stem cells, modify it in a test tube and then deliver that those modified cells of back to the patient in the form of gene therapy. Next slide, please. And in fact, there was one patient out of France who actually did receive gene therapy in sickle cell disease is reported in 2017.53 years later, the patient continues to do well. As I was telling you, it really does take a village look how many co-authors on this description of a single patient with sickle cell disease. Next slide, please. My colleague, John Teasdale, you saw earlier, was actually featured on 60 minutes because there were involved in a study that uses a form of gene therapy instead of modifying the disease, patients sell directly. This actually adds a different type of hemoglobin to accomplish the same task. And so if you'd like to again, you can search and, and, and see that the current status of that protocol, but again, that's quite effective, had been quite effective as well. Next slide please. But that's sort of an addition. What I was imagining for you and maybe what what Dr. Pauling was a maddening is a way of going directly in to correct that defect, that single nucleic acid defect that one has. Now in the setting of potential gene editing technologies such as CRISPR Cas, we're really on the on the, on the eve of doing this type of work. Next slide, please. And CRISPR cas, I'm sure is familiar to many of you. One would envision sort of going in using particular repair technology to correct that defect that we've described for you before. But our approach is actually, again, this is our collaboration. Going even a step further. Next slide, we're getting towards the end is actually envisioning looking at couples who are at risk of having kids with sickle cell disease and storing the cord blood of those affected infants. And in this context, setup, now, about 15 years ago, a NIH sickle cord blood research program envisioning that at some point in the future, we might have the technology to actually follow up on this. And at the present moment, we are obviously supporting the Basic science application and understand how to improve our effectiveness of this technology. But it really is proceeding quite nicely. And I think the next one is a final slide, which sort of summarizes everything that I've told you so far. I've tried to go over the past, the present, and what the future technology is, the future of going in and in modifying this. And what I've told you so far is that sickle cell disease, even though it's interesting and always try to focus on the sickling of the cell that it really is shown in the centerpiece. It really is the amount of polymer inside the red blood cell upon deoxygenation. But with repeated, repeated bouts of polymerization and depolymerization. There's gradual war and potassium loss leading to the formation of these dead cells as shown at the top. These dead cells tend to have Palmer, even at fairly high levels of oxygenation. And these are the cells that are contributing to the microvascular obstruction leading to chronic progressive organ damage. And acutely to prices that one sees. These cells that have irreversibly membrane damage to them are so-called irreversibly sickle cells. It seems contributes more to the hemolytic characteristic of the disease. But what nature has done now shifting to the left side has done, and now we've been able to replicate with drugs like hydroxyurea is to stimulate inside the cell. Another hemoglobin, which can interfere with this polymerization process in a way that one sees less acute complications and chronic complications. And now we know that this actually leads to an improvement in life expectancy, but it's not a cure. If one can go in and take the stem cells of a relative that matches completely in terms of their HLA antigens. And then in a setting of a non Milo ablative transplant, get those cells in. And a very high percentage of individuals who were so lucky to have a complete match, one can actually cure the disease. And where we are now moving into the future is going in to individuals even early at the time that they're born to get their cord blood and begin to make those changes. Ultimately to get those cells back into individuals to prevent these chronic or organ complications. Next slide please. And I want to just display that my ability to take selfies haven't gotten much better. These are members of the laboratory all involved in this work that I want to go great shout out to and also to the department, the transfusion medicine at the NIH. Next slide is the final slide. And I want to thank you for giving me this opportunity and thank you for your attention. Thank you, Dr. Rogers. We appreciate. Your presentation. Now we will go to the question and answer session for the remainder of this event. And our first question comes from Doctrine and it lets you, Miller, who is an Associate Professor in the Department of Applied Science. Thank you, Brandon. So my question is, I know with you being the director of NID decay, you oversaw many grant applications related to nutrition research. And the office of the director now contains the nutrition has office within the office of Director. So it shows that it's now a cross-cutting area across NIH. And I was wondering if you thought because of that, nutrition will be more thought of as a component of grant applications and in, in, across all research and really should be, we should be trying to train more nutrition researchers. Are we going to be in more demand because of that idea? Yeah. Well, thanks for that excellent question. I think Dr. Miller is referring to the fact that the office of nutrition research, what actually was previously within an IBD, kay, was a few months ago, actually moved over to the office of the director. And I and this follows the result of the recommendation of the Nutrition Research Task Force, which was actually created by Director Collins to search, which we did come out with last year. And a part of that was actually to develop under the auspices of the Office of nutrition research a fairly large old project called precision nutrition, powered by the All of Us effort to really begin to ask critical questions about what people should eat. Could you come up with a precise prescription for a particular person given their genetic makeup, their, their microbiome, and other factors that what would be the most important diet that are heating, eating pattern that they should follow. Well, because of the close coordination that's required for this office of nutrition research, together with the all of us project, which includes a million Americans participating in this result, as well as a common fund funded project, which is within the office of the director. We decided that in order to improve the the status but rather as say as the this area of nutrition research which the visibility which you are just alluding to, that such a move would really be a great thing. So there still remains nutrition research institutes like an ID K At Heart Institute and the Cancer Institute. This more central location for it will not only improve it to build its visibility, but we hope that it will increase the amount of resources going to research in this area, both centrally as well as to the targeted Institute. And then finally, within that strategic plan, we were really calling for the development and the training of new investigators in this feel. And so your hope, what are we going to be seeing a new generation that's our whole. And we hope that resources will be coming with that so that people traditionally trained in nutrition. We'll be guided by developments in artificial intelligence and machine learning technology. Use of, of wearable devices that give us a better assessment of what people's true nutritional intake is over, over days. And so we're very excited about this possibility. Thank you. Thank you, Anna. So far that is the only questions. So I that invite additional questions. Now, the presentation has concluded, so please let me know if you have a question at this point. I'll ask a question if that's okay. Sure. So Dr. Rogers, as I know, you know, we think that the evolution and maintenance of the sickle cell genetic trait comes from malaria resistance such that the direct form provide some protection against malaria. And there's always this, these concerns about gene editing of do we lose something, right? Do we lose some variability that as a population level, we may come to lament. What are your thoughts on the long-term future? I think we all in science believe that gene editing at the germ line level or blastocyst level in humans is coming. Should we be snipping out these genes with CRISPR in humans early on? Or is that a malarial issue? And if so, how do we better protect against that in other ways? What's your what's your future crystal ball? Tell you? Yeah, yeah. Well, embedded in your question, there are really two questions and one is the application of technologies like CRISPR, Cas and gene editing to embryonic cells, which will ultimately sort of exist and all of the cells in the body, a more limited somatic cells such as hematopoietic stem cells. And certainly we favor that approach and that's what we're, we're moving towards. The National Academy of Science. And as you probably are aware, have come up with some, some strong suggestions and recommendations related to embryonic stem cell modifications. Because that's a path that, you know, once you, you move into that area, there are some important ethical considerations that one has two. Look at, you know, one could say that, okay, I do have this genetic disease, but once you're in there, I'd like my child to be six but tall and they have an IQ to 100 and things like that. And we're really not in a position, even if we could do that, that would not, at least in my mind, the epically indicated. And I think there's some strong support for that in the community of scientists in the National Academy and others with respect to whether such a mutation that would have the corrective affecting the underlying disease might offer disadvantages from the reason that it was under such selective evolutionary pressures. It's certainly something to consider. There's a similar condition that we've understood or genetic mutation that we've come to recognize, certainly an IDT k. And that's the APL L1 gene. Apol1, as you probably know, is a gene that has several variants. And it appears at a very high frequency and Old World Africa, well, it turns out that if you were heterozygous or homozygous for one of these variants, you had a great protection against trypanosomiasis or African sleeping sickness. And so that's the good news, the bad news that in the US where there's virtually no malaria, in the case of sickle cell disease or in the case of APOL1, what we find is that is a major contributor in, almost explains all of the disparity that we see among African Americans that are in dialysis centers. This particular, these variants seem to contribute greatly to the development of chronic kidney disease than if you have chronic kidney disease. The inevitable march towards end-stage kidney disease requiring either a dialysis or transplant. Now, is it possible, for example, to to correct that that defect in a way that can prevent that. Or alternatively, you can say, Well you've learned something from it. Maybe, you know, using current technology, we can modify cells destined to become kidney cells to understand what pathway we might be able to target to achieve the same effect. And so a lot of our, our efforts and what we're funding is trying to better understand which particular cell types and which pathways might be potentially targetable as a result of this observation. And I think the same is true with sickle cell disease. In that particular case, we really believe that unless there are occurrences of malaria or some other infectious disease and their pressure manifests itself that in the, in the short-term correction would be more beneficial, go on an individual level than potential societal implications. Thank you. Thank you, Dean House and inspired a follow-up question. Dr. Bucks, you know, Dr. No. Thank you, Brandon. Yes. Thanks for your talk. And just to illustrate the importance of nutrition, going back to that, I wanted to reflect on your thought, thoughts on how dietary, how die can play a role in sickle cell disease. And I can think of a couple of nutrients. Can you comment on, on whether the intake of iron ore or glutamine or any other nutrients that you think of that can be modifying the severity of sickle cell at, right? Well, thanks for that question more general, we're actually one of the, one of the major goals of this nutrition strategic plan writ large is the kind of understand food as medicine. And what are some particular dietary prescriptions that one would have for a variety of diseases. Heart disease, metabolic disease, sickle cell disease. So in a feel of sickle cell disease, I'm most familiar with trace metals like zinc, which in fairly high, which seems to be deficient in patients who have a tendency to develop leg ulcers, for example, in fairly good trials out of Jamaica and other places have shown that supplements with zinc, both orally or topically and actually improve the outcome of these legal leg ulcers. Folic acid, of course, is very important in patients who have any kind of hemolytic conditions. And more recently actually use a glutamine that you alluded to. It has actually now ended up becoming, I believe it was a second FDA approved drug for the therapy because it showed that there was a marginal difference in terms of hospitalization rate in patients receiving glutamine compared to placebo. And I'm sure we're going to learn much more in terms of neither micro nutrients and might a macronutrients. In this setting, following the goals or outline roughly as food, as medicine in the strategic planning. And so I think again, the future, ultimately with good allocation of resources is really gonna be, um, limited. For nutrition, researchers need them based, be a basic scientist, translational people, or people involved in a research team addressing specific disorders. Until suddenly I can take a lot of Congressional interest as well. So that also bodes very well. Cool. Thank you. Thank you. Again. No, the house and they didn't have seven minutes remaining. I know other questions at this time and I know Dr. Rogers has a meeting right after hours, so it will be like to conclude at this time. So Louis, I want to say thank you to everybody who came to participate. I see we have many of our distinguished DVS, a lot deans Alliance members here. Many of our distinguished community partners and alumni like Jill Meisenheimer are here and very grateful for their attendance. I'm thankful to our staff together so well, to Dr. Glenn Miller for her outstanding work. And of course, I'm most thankful to Dr. Griffin Rogers who came and joined us. These as I said, he's a good friend. He's a terrific scientist and Eastern music, an extraordinary leader. We're very lucky to have him. You know, I, I often think about how stressful this pandemic has been for so many of us. And so many of us have needed an appropriately I've said I need a little extra help. I need a little forbearance. And I to itself has recognized that I remember the early days while putting out videos. I was learning how to make videos and trying to say to people it's okay where it together we'll get through. And I saw grip learning how to do his videos in us. See that he was struggling with his camera as much as I was. Neither one of us were born to be cinematographers, I think. But you know, it's interesting at the very same moment that he and the others at the NIH have recognized the need to step up and help and forbearance to those who need extra time. We need and we need a little flexibility. He's also recognized that there are people that need to step up and do extra at that time. And I think of all the people at Johnson and Johnson, and all the people at Pfizer and Moderna, the others, and the FDA and NIH and CDC. And where would we have been, where would we be if they had said this is all too scary, I need to just go home for awhile and take a rest. But instead they said I'm going to double down. I need to work harder. I need to do better. I need to do more. We are so blessed and thankful to have people like Dr. Rogers who not only didn't throw in the towel, but redoubled his efforts and still comes forward as a scientist during these most difficult times and says, I'm not giving up on sickle cell. I'm not giving up on the people who need me. I'm not giving up on you. The, my fellow scientists in the community who want to talk science and my colleagues. And here I have to help grip. I salute you. Really appreciate it. Thanks for your leadership and the great things that you're doing now at the in Bloomington. Really appreciate and thank you for the invitation and your kind remarks. Be well, everyone.
Dr. Michelle Williams
Dean Of Faculty
Harvard T.H. Chan School of Public Health
Angelopoulos Professor In Public Health and International Development, Harvard Kennedy School
February 24, 2021
Noon–1:15 p.m.
Description of the video:
For the School of Public Health. It's my honor and pleasure to welcome you, as well as our distinguished colloquium speaker, Michelle Williams today from the Harvard TH Chan School of Public Health. I would like to now turn it over to Dean Allison. Good morning; actually afternoon and we'll get some opening remarks. Welcome everybody. It is truly a pleasure to be here. Pleasure to see all of you. I see Professor Sailes who I will introduce in a moment. And let me simply say what sectorial elegance, professor sales. Thank you. Welcome is a wonderful word. And it is a word that I'm pleased to offer, not only to all of you, but of course to Dean Williams. It is truly a privilege and an honor to have somebody of Dean Williams’ esteem and caliber here. But more than esteem and caliber, Dean Williams is able to express the word that I emphasized earlier, which is welcome. I've had the privilege of meeting her on a few occasions, but particularly one was in my first meeting as deem as a member of ASPPH, when she hosted a little roundtable and I was seated at the Roundtable she was hosting and her ability to welcome everybody and including me and make me feel relaxed and comfortable and welcome and invited. And to welcome a diversity of views. To welcome people, to express their opinion and to be heard, and to think things through was wonderful. And so she is someone who embraces the word welcome. And we embrace having her here. Dean Williams, Thank you for joining us is truly a privilege and honor to have somebody of your steam and caliber and ability to be welcomed me here. Thank them much, Dean Alison. Now I'd like to turn it over to my other esteemed colleague, Professor Gary Sailes, who I'm equally privileged to work with and know who was inspirational to me. And I suspect many of you in his positivity of spirit, in his commitment from making a positive difference in the world, in the lives of students, in the lives of all of us. Who's truly an honor to have him as part of our school. And it is wonderful to have him today here to introduce our speaker, Professor Sailes. Good morning everyone. My name is Dr. Gary Sailes and I am an Associate Professor in the Department of Kinesiology here at the IU School of Public Health, Bloomington. Today I'm honored to introduce our February colloquium speaker. Michelle Williams. Dean Williams as the dean of faculty at the Harvard TH Chan School of Public Health and Cambridge, Massachusetts. She is also the thanks a lot, professor and public health. International Development, a joint faculty appointment at the Harvard Chan School and Harvard Kennedy School. Dean Williams is an internationally renowned epidemiologists and public health scientist, an award-winning educator and a widely recognized academic leader. Prior to becoming Dean, she was Professor and Chair of the Department of Epidemiology at the Harvard Chan School and program leader of the Population Health and Health Disparities Research Program at Harvard Clinical and Transitional Science Center. Dean Williams previously had a distinguished career at the University of Washington School of Public Health. Scientific work places special emphasis in the areas of reproductive, perinatal, pediatric, and molecular epidemiology. Dean Williams has published over 450 scientific articles. She was elected to the National Academy of Medicine in 2016. Dean Williams has a master's in civil engineering from Tufts University and master's and doctoral degrees in epidemiology from the Harvard TH Chan School. Now, without further ado, I want to thank you all for being here with us this afternoon. And please join me in giving Dean Williams a warm Virtual School of Public Health welcome. Thank you so much. Thank you so much, Professor Sailes. And again, my heartfelt thanks to you, Dean Allison. It's an honor, really an honor and a privilege to be here at least virtually with you all, especially during a time, this time in the history of public health in our country. I appreciate that my remarks today will feel somber. And I ask that you bear with me as I make my remarks. Because I think as I review and talk about my presentation entitled racism as a public health crisis, epidemiologic evidence and narratives to promote social justice. I ask that you think hard as you listen to my remarks about the action part of this title. The way we can take the evidence and the narratives to promote social justice. And so while much of my talk will feel somber and heavy, I want to foreshadow that there are reasons for us to be purposefully optimistic and intentional about how we use public health evidence and stories to promote social justice. So let me start by saying just how delighted I am again to be here. And I can imagine for many of you, particularly the students at IU School of Public Health, did not pick to yourself to be spending your days, months, and even the last year. In the circumstances that we find ourselves, that you would be mostly learning remotely and that you would be entering your field as a professional public health expert during a time of unprecedented challenge. But I do hope that this pandemic has reinforced your reasons, your why you chose the path to engage in advanced learning in public health in the first place. You know, since I became an academic administrator as a department chair nine years ago and as it, as a dean 4.5 years ago, I found myself always saying the following, that public health is everywhere and nowhere all at the same time. What do I mean by that? What I mean by that is the work that we do is vital. And yet all too often, our work goes invisible to the outside world. Think about how we take the cleanliness of our water for granted until there is a contamination crisis. Or how we take our food supply for granted with no thoughts until there is a lettuce recall or a meat recall. And until recently, most of us would hop on a bus or in a plane without wondering what pathogens might be along with us for the ride. Well, that's no longer the case today. Public health isn't just top of mind for our community of students and practitioners like us. In fact, it's front and center in the lives of everyone across the globe. As we all grapple with one of the deadliest pandemics in history. Covid-19 has revealed for so many our vulnerabilities as a society are fragile health care system has been revealed. The disjointed state and federal leadership in public health management has been revealed. Also revealed is our lack of global coordination and the longstanding inequalities that exist and have been hiding in plain sight. Of all the forms of inequality. Injustice in health is the most shocking and the most inhuman because it often results in physical death. Those were the words of Dr. Martin Luther King when he addressed the Medical Committee for Human Rights more than five decades ago, five decades ago. But the health disparities that he spoke of in 1966 are every bit stark and as persistent today as they were 50 years ago. The next slide, please. You don't have to look much further than two pandemics separated by a century. Just over a century ago, the 1918 influenza pandemic was ravishing the United States at the height of Jim Crow. Black people who came down with the disease were largely left to fend for themselves. They were stigmatized for getting sick, even in some instances, blamed for inciting the outbreak. Many were turned away from hospitals and instead had to suffer at home where they could get other faculty members sick. Remember, to respiratory disease. When, when they did go to get medical help, their care was relegated to substandard hospitals. In those times. They often had to enter in a back door and proceed to a basement in order to get treatment. The few healthcare and social systems available to Black Americans at that time were quickly overwhelmed. And as a result, even though fewer Black Americans caught the disease, they were far more likely to die when they did come down with the disease. Heartbreakingly familiar, isn't it? Just think a year ago when COVID-19 first reached the US, that was January last year. It was dubbed the great equalizer. It was dubbed that because all of us in every corner of the country were at risk. But it didn't take months. It was actually quite quickly that it became clear that while the virus might not discriminate, our society, does. That's why week after week, month after month. Communities of color, especially Black Americans, Latinx, and Native Americans, have borne the brunt of this crisis. That has been true across the board, and particularly among health care workers of color who were not only suffering emotionally and physically, but who also have been disproportionately attracted and died from COVID-19. Next slide, please. I'm sure many of you have heard about Dr. Susan Moore, an Indiana physician, whose story has resonated deeply with me and with many across the country. Like so many other nurses and physicians, Dr. Moore had been working around the clock with COVID patients since the start of the pandemic. But in late November she became a patient herself. She was admitted to the hospital where with an oxygen tube hanging from her nose, she summoned the strength to post a video about exactly what was happening to her. What she described was an experience that sadly is all too familiar for Black patients. In a soft, strained voice. Those who watched the video heard her talk about being in severe pain and struggling to breathe. She said the pain was so bad that all she could do was cry. But when she talked to her doctor about her condition, he dismissed her concerns. She said he told her she should probably go home and that he was uncomfortable giving her more narcotics. As she stated, I was crushed. He made me feel like I was a drug addict. And he knew I was a physician. At every turn, Dr. Moore described having to prove that there was something wrong before she would be given help, particularly begging for routine checks and scans. And it wasn't until she finally got those scans and they detected problems that she was believed. Unfortunately, this story isn't new because Dr….it wasn't new even for Dr. Moore. Attacks from an inflammatory disease sent her to the hospital frequently. According to her son Henry, nearly every time she went to the hospital, she had to advocate for herself, fight for something in some way, shape, or form. Just to get baseline proper care. Just to get baseline proper care. As Dr. Moore herself put it, so poignantly, “I put forth and I maintain if I was white, I wouldn't have to go through that.” After Dr. Moore escalated her concern, her complaints, she said she finally started to receive adequate treatment, adequate treatment for her pain, and eventually she was released from the hospital. But about two weeks later, five days before Christmas, her heart stopped beating. Dr. Moore passed away at the age of 52. I talk about what happened to Dr. Moore and the outrage and the reflection that sparked. Not because her story is unique, but precisely because it's not unique. The fact is no matter where you live in the United States, your experience with COVID-19 depends a lot on who you are and what you look like. Next slide, please. And now even your likelihood of getting vaccinated against this horrific condition depends on who you are and what you look like. After a rocky rollout, we're finally seeing vaccinations pick up across the country with four times more shots happening each and every day than a month ago. And we're grateful for the more competent, more proficient, more humane national governments in response to this pandemic. But as some of you may have already experienced firsthand those shots, those vaccinations are still hard to come by. Particularly if you are not white. Without comprehensive, standardized data, it is hard to know just how wide the vaccine disparities really are. But the available data do begin to reveal a disturbing story. Across 23 states, white Americans are being vaccinated at far higher rates than Black Americans. Right where you are in Indiana, more than 2.5 times the rate….Black Americans are less likely—two and a half times less likely—than their white counterparts. A lot of the factors contribute to this, these disparities. But they essentially boil down to two major hurdles that I want to emphasize. And the first of this is access. Distribution plans have varied widely from state to state. And many have failed to make racial equity a central part of their approach. For example, in some places, vaccine information is only available in English. And so many, many communities where English is not the first language spoken are at a disadvantage. And to date, a large share of the vaccine supply has gone to large-scale healthcare systems. And large grocery store and pharmacy chains, which are missing from many Black and Brown and Native American communities. At the same time, clinics within these communities, say the appointments that are available are being snapped up by people who travel from wealthier, segregated white areas of their communities. Meanwhile, people in underserved areas are getting tripped up by the many obstacles. In terms of getting an appointment for a vaccination. Many simply don't have the hours or the Internet access, the broadband access to navigate online registrations or access to reliable in transportation, to get to an appointment at one of the stadiums or major vaccination sites. And sadly, far too many who are fortunate to have a job don't have the flexibility at work to schedule and to make and keep these appointments during business hours. So that's just the first hurdle. Access. Let me now turn to the second hurdle. And that's going to be trust. The good news is that more Americans than ever now say that they will get the COVID-19 vaccine as soon as it becomes available to them. But we do have to reckon with this basic fact that Black and Hispanic Americans remain more wary than white Americans about the safety and efficacy of the vaccine. Despite being disproportionately impacted by the virus. Black and Hispanic Americans are more likely to say they're definitely not getting the vaccine. That they plan to wait and see that trust gap is generations in the making. The medical, the medical establishment and our national public health establishment has a long history of mistreating people of color. From the Tuskegee syphilis study to the Mississippi appendectomies to the under-representation of people of color in clinical research. And the under-representation of people of color in the highest ranks of academic, clinical, medicine and science. And we are months behind. We are months behind on a national public health campaign to answer questions and to address concerns and to address vaccine hesitancy. All of these issues can have a snowball effect. For example, a recent Kaiser Family Foundation poll shows that there's a correlation between people who know someone who has gotten the vaccine and their own willingness to get a vaccine. And that in turn could compound, could accentuate the disparities we're seeing today with COVID transmission, hospitalization, and mortality. Because if we don't vaccinate the population at the highest risks, we're going to keep losing this population at higher rates. From the first reported US case in January 21 into 20, to the millions of vaccine doses given today. Well over 50 million. Covid-19 has been anything but the greatest equalizer in which it's been purported to be. All told. Pacific Islanders, Latinx Americans, Black and Indigenous Americans have all died from COVID-19 at more than double the rate of white Americans. And they continue to shoulder a disproportionate burden of the economic fallout, which itself is a driver to worse health. What we are seeing is a microcosm of what we in public health have long grappled with. And that is, racism is a public health crisis. It is a crisis that manifests in two primary ways. First, there is the toll of individual racism that people of color experience day in and day out. Like being followed around the store, making less money than your co-worker, or having one's health concerns downplayed by a physician. It is well documented that the relentless assault of daily discrimination, everyday discrimination leads to what researchers have called wear and tear on the body, which in turn causes a range of adverse health outcome from premature aging. Accelerated blood pressure from high rates of heart disease to immunodeficiency, culminating in a reduced, reduction, a disparity in life expectancy. Then there's another pervasive form of racism. And that is structural racism. The legalese legacy of colonization, of slavery, of segregation, and discrimination that still has profoundly managed to disadvantage people of color and still cut short their lives to this day. We see one of the starkest examples of structural racism, who loses their limbs in the US. And I want to spend some time and talk about this statement that we see the starkest examples of structural racism in what people have called the epidemic of limb amputations in America. Bear with me as I describe what I mean here. Diabetic amputations are arguably the most preventable surgeries in this country. Amputations are usually a last resort after a wound gets so infected, so gangrenous, it becomes unsalvageable, even life threatening. It's a devastating outcome. But it doesn't happen overnight. And quite frankly, it shouldn't happen at all. We've made great strides in both diabetes prevention and treatment with the right medicine. The right health care interventions, improvements in diet, exercise. People with diabetes can live longer healthier lives. And yet diabetes diabetic amputations are on the rise, primarily in places where people are poor, underserved, underinsured. Today, Black Americans in particular, are losing limbs at three times the rates of non-Black diabetic patients. We in public health spend a lot of time learning how to not connect dots, how to use data science to create the detailed narrative. To help us understand the complex interconnection of biomedical, social, and environmental factors that contribute to adverse outcomes. So let me take a moment and try to connect some dots here for you, for us all. So what are the reasons that we would see triple the rate of amputations among Black Americans, diabetics. The reasons are complex as they are intertwined. There are the multi-generational disparities that lead to the high prevalence and high rates of diabetes in the first place. But there's also the contribution of poverty, the high density of food deserts, and the disproportionate burden of poor preventive care in Black communities. Then there's also the barrier to treatment. The skyrocketing and frankly, outrageous cost of insulin is a part of the narrative that creates the disparities in limb amputation. The pervasive skepticism of doctors, the dearth of specialist in underserved areas, and the health system's failure to screen at-risk patients for vascular disease and other diabetes complications all converge. To undergird, the basic statistics that shows the three times higher likelihood of limb amputations for African-American diabetics. And when diabetes isn't managed, it wreaks havoc on the body. We know this. Sugar rises and courses through the bloodstream. Plaques build in the blood, in the blood vessels, slowing blood flow to organs and two extremities. And without any intervention. Those biological processes lead to blindness, end-stage renal disease or kidney failure, and untreatable infections in the legs or feet. The consequences are tragic. Having a foot or a leg removed isn't just a source of dignity. It can leave a person dependent on others for care. It can leave them unable to work or even exercise. At all of these factors make their diabetes that much more difficult to manage. It puts them at a higher risk for more infections, more amputations, for more cardiovascular events including heart to heart attacks, and even enhances their risk for stroke. And for many, having a limb removed is a death sentence, sadly. And research shows that as many as three quarters of diabetic patients who have a lower limb amputated, three-quarters die within five years. That's three out of every four diabetics who has to have a limb amputated die within five years. Just let that sink in for a minute. A Pro Publica journalist by the name of Lizzy Presser, conducting, conducted recently a harrowing investigation into the epidemic of amputations among Black Americans. Lizzie spent months interviewing patients and shadowing doctors, delivering care in the Mississippi Delta where amputations are sadly, sadly extremely common. And what she found was what she calls the cardinal sin of the American health system. Next slide, please. I think of Lizzie's article and articles since, a lot. And I think a lot about one particular patient that Lizzie met. Her name is Lavinia Stokes. And she's pictured in this slide. Like so many people living in the Delta, she grew up poor and in a food desert without fresh produce and good nutrition. She developed diabetes at a remarkably young age, and her condition went unmanaged for far too long. Years later, after the diagnosis of diabetes, her foot got nicked during a pedicure. A seemingly minor little thing like a nick. Most of us wouldn't think twice about that. But without good blood flow in her legs, that nick became a festering wound that failed to heal. But no one ever performed an angiogram to get a good look at what was happening to her circulation. She never got a vascularization to clear out the arteries perhaps because those procedures aren't covered, they're generally not covered by insurance. Instead, a surgeon elected to remove her second toe. It's unclear whether or not he or she had any other limb-saving options available to them before making that amputation. But in many cases, surgeons don't rely on other options because they're not required to. Put a place marker on that because that's a health system failure point. Moving on with the story though, it didn't that surgery that amputated her second toe didn't address the root cause of the infection and the poor healing because that infection just continue to spread. And, and within weeks, another surgeon, a new surgeon, had to remove her leg up to the knee. That left her dependent on a wheelchair which didn't fit through the doorway of the trailer where she lived with her mother. And you can see that in the photograph. Without any exercise, Lavinia gained almost 50 pounds in two years. Her vascular disease got worse and soon her other leg was imperiled. Just think about the story I've shared with you. And where we started. All from a toe that was nicked. There are thousands, thousands of stories like Lavinia’s. At least two others in her family alone share a similar fate and countless more in her neighborhood. Of course, this is just one example of how structural racism can devastate how structural racism is the reason. That here in Indiana, for example, the average person living in Carmel can expect to live to 83 years while up in Gary, the average person does not see his or her 72nd birthday. It's a gap of a decade. It's why Black children nationwide are more than twice as likely as white children to have asthma. Why Black women are more than three to four times more likely than white women to die from complications in pregnancy or childbirth. These outcomes have nothing to do with biological vulnerability. Instead, they can be traced to centuries of racial oppression in policy choices. From segregation to the gutting of public schools and social programs, to voter suppression, and even to racist housing policies. So let's take a little step backwards and let's talk a bit about one of the most egregious and maybe most significant policies in US history that impacts popul, population health, public health outcomes: redlining. Let's spend some time talking about redlining housing policies. Next slide, please. In the 1930s, the federal government created maps of hundreds of US cities, color-coding neighborhoods. Green for best, blue for still desirable, all the way down to yellow for declining and red for hazardous communities. Imagine Black, and immigrant neighborhoods, despite their vibrancy, were almost always exclusively deemed red or “redlined.” That's where the name comes from. That meant the federal government refused to back loans for these areas. And as a result, that starvation of revenue, of investments….over decades, banks denied residence of these neighborhoods, home loans and credit financially leaving them for dead. Property values logically started to deteriorate and store public housing projects were built. And while wealthy white neighborhoods were dotted by fresh produce vendors, quality schools, green space….Redline communities became sites for federal highways, pollutant dumping sites, an empty concrete lots. In India, in Indianapolis, for example, Black neighborhoods were concentrated along the southern banks of the White River. In the late 19th and early 20th century, the city installed a sewer system that sent waste directly into the water. State law actually mandated industry to be located there and actually required—and I repeat the word—required—required those facilities to dump their chemicals, gasoline, animal entrails right into the river. Unsurprisingly, those same neighborhoods were then redlined. Next slide, please. Fast forward today, you take a look at this map of Indianapolis. It's no coincidence that many of the whitest wealthiest communities in the city, are at the top of the river. Meridian Hills, for example, was graded greed. And today it has the highest property value at county, roughly $326 thousand. And the second-highest median income, roughly $133 thousand. The average life expectancy there is 81 years, more than five years above the average for the entire city. But everything changes when you move down river past where the tributaries and the industrial sites and the sewer overflow points dump pollution into the water. The predominantly Black and Brown community of Riverside has a median income of $23,500 and a life expectancy that hovers around 70 years. A 10-year, a decade difference. Only now more than 80 years after the fact, is there a multi-billion dollar plan that has been put in place to clean up the raw sewage and redevelop areas along the river. And that will likely take decades to complete. But imagine the decades of exposure and the intergenerational impact that was set in place because of redlining. So I share this to underscore the fact that the long-term effects of redlining are heartbreaking examples of a fact that is well documented. The conditions in which we live, work, and play are the primary drivers of our health. And the health disparities that we see so starkly, especially those of us outside of public health who now because of COVID, are looking and trying to understand why the disparities, how the disparities they are seeing that the drivers of health disparities are way upstream from the actual health care system. And more are accounted for by the social determinants of health. They are seeing that the social determinants of health account for 80 to 90 percent of our overall mental and physical health and well-being. They're seeing that for generations, communities of color have faced vast disparities in job opportunities, income opportunities, and inherited that family wealth. They have seen that legally, financially and socially, segregation has deprived communities of color of opportunities to have fresh air, clean water, resources to improve housing. They're less likely to have the housing security, the access to quality schools, healthy foods, and even green spaces. And of course, all of these factors, every single one of these seemingly unrelated, not health-related factors have a significant consequence on our health. All of this doesn't happen by accident. It happens by design. These disparities are the product of four centuries of systemic racism from slavery to segregation, all of which is still entrenched in our public policies to this day. And the health consequences cascade from one generation to the next. There is no starker example than our criminal justice system, which today another key driver of health inequality. And the reality is so visible and gut wrenching in the scourge of police violence that kills Black Americans more than twice the rate of white Americans. Think about it in the last year. How many names we now recognize? George Floyd, Brianna Taylor, Jacob Blake. But they are among countless others whose names don't make headlines. In fact, we don't even know exactly how many because we don't have that data. And deadly encounters with law enforcement are just the beginning. For example, consider the public health connection of our cash bail system. Let me give a little bit of a narrative here. On any given day in America, there are about 0.5 million people sitting in jail who have not been convicted of a crime. Most of these people are simply there because they couldn't post bail. Because in most states you have to pay money out of pocket to go home before your day in court, whether you're innocent or not. We know that racial bias plays a lot, plays a big role in who gets arrested by police and charged with the crime. While research also suggests that it also influences the amount of bail that is set by the court when they do attend to the court. For example, a bail judge may see a defendant of color as more dangerous than a white defendant charged with the same crime. And that set their bail higher. So Black and Latino Americans are not only more likely to be stopped by police arrested and charged, but they're also less likely to be able to go home because they can't afford that bail, which is often higher than their counterpart of a different race. That leaves many with an impossible choice. Wait behind bars until trial, which can take months, or sometimes a year. And in the meantime, potentially losing their job, losing their home or custody of their children. Or they can pay a non-refundable fee to a bail bondsman or enter a plea and give up the right to defend themselves at trial. So essentially, cash bail has created a two-tiered system of justice. One for defendants who have resources and one for those who don't. As Bryan Stevenson put it, it's a system that's better if you're rich and guilty than if you're poor and innocent. Better if you're rich and guilty than if you're poor and innocent. And it explains in part some of the vast disparities we see in incarceration rates. Again, let me give in Indiana example. For example, Blacks in Indiana are about 10 percent of the population. And yet they make up a quarter, nearly a quarter of the jail population, and a third of the prison population. And that only contributes, accentuates health disparities. Millions of people who cycle through our courts, jails and prisons suffer from disproportionately high rates of chronic health conditions. Diseases, substance abuse and mental illness. And incarceration only makes these conditions worse. The conditions behind bars are extremely hard on a person's health. Too often there’s substandard medical care, poor nutrition, and lack of ventilation. There's the risk of physical and psychological trauma that comes from solitary confinement and sexual victimization. And then there's the issue of severe overcrowding, which has many inmates double- and triple-bunking. That reduces their access to drug treatments, their access to meaningful work and educational opportunities. It increases the likelihood of violence and the likelihood of self-harm. And it fuels the spread of infectious diseases. About 4% of incarcerated people in the United States have HIV. Fifteen percent have hepatitis C, and 3% have active tuberculosis. And in the pandemic, prisons and jails have become COVID-19 super-spreaders site as well. Threatening not only the the inmates, but also the lives of those who work to support. A December study from the National Commission on COVID-19 and Criminal Justice found that the infection rates were three times higher among the prison population than the general population. And again, in Indiana, about one in eight state prisoners have been infected. Many inmates have reported they have no way to protect themselves or to keep distance from other inmates and staff. And yet so far, governor Holcomb has refused to prioritize inmates for vaccination. It's a decision that could very well cost more lives. So I share this because the health consequences of being locked up can be dire. And they don't just end upon release from prison. Let me share what I mean by that. Most U.S. prisoners don't get any kind of substantial rehabilitation or life skills training while incarcerated. And when they're released, they often face social stigma, unemployment, housing insecurity and poverty. In fact, it’s estimated that imprisonment cuts a person's annual wages by 52 percent. And all of this takes its toll on health. It's also estimated that every year in prison takes two years of a person's life. A very important public health metric. Next slide, please. And these consequences aren't just limited to those who are incarcerated. Forty years of mass incarceration has had a crippling intergenerational, multi-generational effect on families. Today, more than half of U.S. prisoners have at least one child under the age of 18. That would account for at least 2.7 million children who are missing a parent who is behind bars. It impacts many families. So many families that sesame Street has aired a number of episodes about this topic and have created toolkits for helping children of those incarcerated to cope. Having an incarcerated parent has been shown to have devastating impact on kids. Increasing their chances of dropping out of school, increasing homelessness, increasing foster care parents, and a range of our adverse physical and mental health outcomes that come with these circumstances. Connecting the dots again, all of this. Has guided the economic and social fabric of communities, which in turn undermines the health at a population level. And that's why it's about public health. And that ripples that, that tearing apart, that gutting of the social fabric ripples across the country. According to another analysis, mass incarceration has shortened the average life expectancy in the U.S. by a full half decade, a full five years. You guys, I started out by saying, I knew that this would be a somber lecture. And I know that I have painted a pretty bleak picture of what we're up against. Suffice it to say, the challenges to eliminating health disparities are myriad and dire. They are interconnected and deep. And working to eliminate disparities is going to require the kinds of reckoning that we are on the journey of doing. And it's going to require that we address oppression and discrimination and racism at its fruits. On the next slide, please, I share with you a quote from the writer Ta-Nehisi Coates who so eloquently stated, “An America that asks what it owes its most vulnerable citizen is improved and humane. And America that looks away is ignoring not just the sins of the past, but the sins of the present—and the certain sins of the future.” It's up to every one of us here today to push our country to finally reckon with the sins of discrimination that pervades society in health care and across every facet of our daily lives. It means working towards better health care quality and access, but it also means addressing so many social determinants of health, like improving school quality, improving employment opportunities, expanding access to affordable housing, creating opportunities to build back green spaces in our communities. And to be sure that healthy foods are available and accessible. And that we overall, our criminal justice system from championing effective community policing to eliminating cash bail system as it exists. Now, I don't say all of this to depress you or to overwhelm you. I say it to motivate you. I say it to motivate you because the things that we have to do can be done. The things that we do not have to sit here and say, we can't make the change. The outcomes we're seeing today are by no means preordained. These are opportunities for us to make change and all of us in public health, those of you entering public health as professionals and graduates, soon to be graduates from public health, have a tremendous opportunity to upend the existing paradigm. I often think back to the words of Isabel Wilkerson, and I'm a huge fan of Isabel Wilkerson, the author of Caste, and her earlier book, The Warmth of Other Suns, where she gives us stories of the great migration. Isabel Wilkinson says, you cannot heal what you have not diagnosed and you cannot repair what you do not see. Today millions, millions of eyes are being opened. The past year has been nothing short of a national awakening to the harsh realities of structural racism. In response to this awakening, we have seen an uprising of people across the country who take the streets, take to the streets to declare a one voice that Black lives matter. That march has been in procession for centuries. But we should be encouraged that today the crowds are larger, louder, and far more diverse than ever. And we're starting to see this movement translate to policy. For example, Senator Elizabeth Warren and representatives Barbara Lee and Arianna Presley just reintroduced the Anti-racism in Public Health Act of 2021. The goal of this bill is to raise government awareness about health impacts of COVID-19 and police violence on communities of color and ultimately create anti-racist health policies. And across the country, more than 50 municipalities and at least five states declared racism a public health crisis. That framing matters because it puts the focus on systems and structures at the root of century old health disparities. These are promising developments, but of course they are just the start. The good news is that all of you are in a unique position to help seize this moment and create a movement. Everything your learning and living through today and for the last year will prepare you to turn our public health challenges into public health opportunities. We need collaboration across all sectors. So I encourage you to apply your background no matter where your career takes you. Whether that's to academia, business, or even politics. And let me just pause and say I really, I'm serious about politics. All of you should consider running for office. Can you imagine what our pandemic response would have looked like? With more public health experts in Congress. There are lots of juris doctors, lots of lawyers, but they're very few. And pH's, in fact. When I think about it, I can only think of two members of Congress who are holders of a Masters of Public Health degree. But seriously, wherever your path takes you, all of you are well-suited to help the world respond to the threats we face today and to the ones that we'll face tomorrow. And it gives me a lot of hope, despite how somber my speech has been. It gives me a lot of hope. So I want to thank you for your commitment to the well-being of people around the world. I want to thank you for running towards public health. And most importantly, thank you for your attention this afternoon. I'd be happy to take questions and engage in a conversation. Thank you. Thank you very much. Dean Williams. That was superb and it hit close to home because a lot of the information you had were very familiar with in regards to the Indianapolis area. So thank you for for that. We do have several who have submitted questions and so we'll start that at this time. Dr. Pierre Theodore has the first question. He is a physician and vice president of medical affairs at Johnson and Johnson is also a member new member of our Dean’s Alliance. And I'm not I'm sure most of us are aware Johnson and Johnson received some pretty good news today. So Dr. Theodore, would you mind asking your first question? Thank you. Brandon and Dr. Williams, it can truly be said that you said everything today, so thank you very much for this lecture. I was struck by your comment by Isabel Wilkerson that indeed you cannot heal without a proper diagnosis. In the course of your conversation, you spoke to data analysis. Could you address some of the data analytic tools that exist to help us to tease apart the various drivers of inequality? So we can take in more targeted and specific approached, overcoming inequities. And again, thank you very much for your superb address. Thank you. Thank you, Dr. Theodore, and thank you for your question and your remarks. And let me just say, I've, I've reflected a lot about data analysis and data availability, particularly in times of this pandemic. But my whole career, I'm an epidemiologist. And so since I entered public health in 1986 as a student, I have been particularly fond of and aware and in tune of how powerful data are. I think first and foremost what we are learning, especially because of this pandemic and especially because of the issues in the last four years. What gets measured is important and what's not measured doesn't begin to tell the story of where work needs to be done. And so I've become even much more aware now of just how important it is for all of us to be certain first and foremost, that we have quality available data that is available and transparent. Really accessible for us to be able to assess where there are vulnerabilities and populations at high risk. And it concerns me, for example, that early as we were starting to do the vaccination program implement that, we were finding that 52 percent of the information around the race and ethnicity of people getting vaccinated was missing. And without that information, we're not able to track we're not able to track where the disparities are and where we really need to make programmatic improvements to close those disparities. So I come back to the very fundamental that we have to have a surveillance system in a data collection system that is appropriately situated to capture the information to inform policy and action. Secondly, data analytic tools have been improving remarkably in the 30 years that I've been a professional. We have lots of wonderful techniques. But they’re only useful if we have a diverse population of individuals who ask a diverse array of questions and apply those techniques. I've been particularly enamored with the geospatial analysis that happened because they are powerful. They are most powerful technique for identifying the hyper segregation that exists as a result of red lining, for example. And then allows for that deeper dive to look at the whole array of adverse medical, clinical outcomes, health outcomes, and social outcomes that are place-based and placed base analyses. Just to speak specifically to your question is going to be important going forward. Because if we're really going to go down into the soft tissue of what drives inequity, we’re going to have to go into communities and work to address those social determinants at the root to start to see the upstream health and disease change. So I'm all in favor of having excellent quality data that is as complete as possible, that it be accessible to all who have the ability to analyze and that the analyses be done using all the possible tools and techniques with multi-sector partners who represent diverse stakeholders and diverse people to ask and answer questions that will inform policy, identify vulnerabilities, and address them in real time. I hope I've answered your question. Thank you, Dr. Theodore for your question. Next is Paul I'm sorry, Mr. Mark Morel. And Mark is a senior lecturer in health care management and policy at the O’Neill School of Public and Environmental Affairs. He's also a board member on the Monroe County Board of Health. And he's asked me to read the question for him on his behalf. Dr. Williams, the health disparities you describe seem to be driven largely by economic status. We have good ways to quantify the correlation between health disparities and economic status. But how can we measure and quantify the word racism when doing evidence-based research? How do we separate the pure economic effect from racist attitudes and or practices? For example, if racist structures and attitudes were magically eliminated, i.e., quantified and 0, we would still have health disparities. So how do we quantify racism? Yeah, I think that's a really important question. And I think the fundamental issue here is poverty. The policies that have been in part undergirded by racial injustice intentions not only imperils the health and wellness of Black, Brown, or immigrant populations, but they imperil the health of people who are poor. And so I think while it's, it's important to identify the contributors to poverty and racism is one of them. Poverty drives health disparities. You know, in, in the United States today, there are 2 million people living in poor communities that don't have piped water in their household. That is a function of our failure of our infrastructure that impacts not just Black and Brown and Native American people, but poor white people as well. And so, you know, I think when we think about racism and the way policies drive income out of communities that are Black and Brown. There are large numbers in absolute terms. We even larger numbers of white Americans who are harmed by those similar policies. And so the focus really has to be on poverty, as well as the racially coded history of colonization and segregation on, on the impact of communities. Thank you. And thank you. Mark for your question. Next question. As with Dr. Jackie MacDonald Gibson, she's currently our chair and environmental and occupational health and our school. So Jackie, would you please ask your question? A lot of my research has focused on documenting racial disparities in access to regulated community water service in the South and shown that there are important public health implications, including increased children's to lead; increased rates of gastrointestinal illness. My question is, I have to concerns about doing this kind of research. One is, while I agree it's important to uncover the problem. Like how, how can that be translated into action? I think solving this problem of this size really requires major congressional action. Like a major overhaul to the Safe Drinking Water Act, increased resources to support development of water supplies for underserved communities. How can I, as a researcher, contribute to that, number one? And also as a white researcher sometimes I feel like my like an interloper or a fraud. I mean, this isn't my lived experience. So, you know, what is my my particular role as somebody who hasn't lived this experience? And how can I really make a difference for policy? Yeah. Yeah. Thank you. Thank you for both of those questions. And let me start with the second one. I think I think we all play a role here. We all bring our special skills, techniques and who we are and identity to this conversation. And you as a researcher have a very powerful voice. Although science and the expert voice has been attenuated over the last decade or so. What's, what COVID has done is, has really changed public opinion about the important voice that experts brings to problem-solving. And as a researcher, you have that expert voice that can be brought forward and you are doing it in multiple ways. One, you are educating the next generation in the work that you do at the university. And two, you are asking and answering questions that will bring forward science-based evidence that then has to be brought into the spaces where legislations being written and policy is being promulgated. And so we all play a role. I think, to do more, one could engage in conversations like this to find ways to take your expertise into communities to work with people who are actually solving community-based problems. And three, to continue to find ways to make sure that we open up the pipeline so that we have as diverse student body and a pipeline of people going through the training into the workspace and workforce. Your question about, your first question is one that's really important. And I think about Michigan, right with the Flint water crisis. I think about what's happening right now with our brothers and sisters in Houston. We in the United States have an infrastructure problem. And when you want to put a human face of how that infrastructure problem plays out, the best human face you can put to that is health. And we have as academics and public health have to keep doing what we do. Faithful to the evidence. Be faithful to our skills and our training. But raise our voices, bring our voices out into the public space and make sure that our neighbors, our policymakers are representatives, all have the evidence to guide how and where they spend our precious resources. You know, I think about what happens in communities where I live. The schools have good ventilation systems. But the schools that I grew up in New York and Queens, they don't have those good ventilation systems. The message about opening schools and how safe they are is unequally available to communities. And so the face of, you know, that health inequalities can be as stark as which school in which neighborhood? What's the tax base? What's the revenue available to schools and to school communities that have been able to be resilient in times of a pandemic and ones that aren't resilient. It could be. You asked about water, but I'm expanding it to schools. Whether or not the schools have windows that you can open. Whether the schools have cracked paint that's still lead encrusted. These are all based on policies that were baked in decades before. These kids and teachers are now sitting in these rows. And there are policies that we can now start to work to correct by thinking about when and where and how funds that go into improving infrastructure. And I hope it's coming from this administration that those those funds are as equally available in Newton, Mass as they are in Queens Village, New York where I grew up. Thank you. Thank you, Jackie, for your question. Well, we have three minutes remaining, so I'd like to pass it to Dean David Allison for closing comments. Well, thank you, everybody. Dean Williams, that was truly a superb and moving presentation. It is a, as you say, a sobering reminder of how important our work is and how much work we have to do. I am grateful that we have leaders in the field like you to help guide the way. Beacons of light, we might say. I am grateful to realize that we have helpers and partners like Dr. Theodore who spoke earlier who are helping us advance this mission. I'm grateful to all of you for coming; Dr. Sailes particularly for that wonderful introduction. Thank you, Professor Sailes. I would point out that our school is taken up this charge. We recognize the call that, that you have ably amplified Dean Williams. We have added politics to our portfolio. We have just added one of our own alumnus, as you said, Run, run for office. One of the alumni of our school, the Governor of Kansas, Governor Laura Kelly has just joined our Dean’s Alliance as member of our advisory board. So our advisory board has a sitting governor. It just includes as a 24 hours ago, it's not even publicly announced yet, but I'll announce now. That includes the immediate past president and CEO of the United States Import Export Bank. And so we've recognized the need to interact with these levels and are doing so. Dr. Murray, who was I'm sure, interested in this topic and probably on this call somewhere is leading the charge within our school for a taskforce to address these needs and pulling in some major players from around the country, so Dean Williams, thank you for pointing this out. You've made me realize one more thing that I think we as a field need to move forward on. We often hear the phrase, the idea of health as a basic human right or medical care as a basic human right. And until I heard you speak today, had not thought about something else, which is maybe data as a human right. That we need access to data that Professor Bill Ramos on this call needs on behalf of the people of Indiana. The basic right to know how many drains in swimming pools are safe drains. And he doesn't have that information now because it's not available. And we need to have data on redlining and water. And Jackie MacDonald Gibson needs have access to all those data and all the data that exists that address this should be publicly available. I should I testified before Congress on EPA's proposed rule on transparency, which seemed good, well-intentioned on the surface. But maybe it was not. And it was about data access. May think we need to look at those things and make sure that data is maximally accessible every way as a basic right. Dean Williams, thank you for your perspicacity. Thank you for your courage. Thank you for generously sharing your time and wisdom with us today. Thank you, Dean Allison. Much appreciated. It’s an honor. Excellent. Well, that concludes our Distinguished Colloquium Series for February. Thank you so much for attending. Have a great day.
Dr. Deborah Prothrow-Stith
Dean and Professor of Medicine
for the College of Medicine at Charles R. Drew University of Medicine and Science
January 27, 2021
Noon–1:15 p.m.
Description of the video:
For the next part here I would like to introduce Dean David Allison, who has been our dean for over three years now. It's a pleasure to have him with us and he's going to introduce Dr. Murray, who is then going to introduce Dr. Prothrow-Stith. So, Dean Allison? Thank you, Brandon. Well, it's a pleasure to be here today. And Brandon is correct that Dr. Murray, who might want to adjust her camera a little bit so she looks a little taller. It will be the formal introduction. But in the meantime, I'll just I will introduce Dr. Murray in a moment. But just informally say how grateful I am to have Dr. Prothrow-Stith with us. I've known her for years. She has been a great help to me and many others on many occasions. She has been a source of wisdom and support, and I'm grateful for that. One of the things that I'm most proud of and grateful for the opportunity to be a student here in the School of Public Health at Indiana University Bloomington. And that might seem initially like a slightly odd statement. Aren’t I the dean, aren’t I a professor. Yes, I am the dean. Yes, I’m a professor. But I'm first and foremost a student. And I think all scholars are first and foremost students. We never stop being students. And the great thing about being a student is to be able to learn forever and to be able to have great teachers. And I can imagine no greater teacher than Dr. Prothrow-Stith, and I'm grateful to have her here. And another great teacher is Dean Maresa Murray. Very lucky to have Dean Murray here. And I would like to introduce her now. She is an expert in some of the topics we're discussing. You see behind me the sign that says just science and the scales of justice and indicators of science. And I stole that from a podcast. And I periodically like to use this one because it reminds me that we should just focus on what we know on the basis of science. That it’s just. That science itself must be just in the way that we conduct it, and that science must aim towards justice. And Dr. Prothrow-Stith will discuss that; Dr. Murray has committed her own life and career to the pursuit of justice and well-being among many people, all people, so we’re lucky to have her here. She is a scholar of the highest order. Dr. Murray, the floor is yours. Good morning everyone. My name is Dr. Maresa Murray and I'm a clinical associate professor in the Department of Applied Health Science. I'm also the assistant dean of diversity, inclusion, and organizational climate for our School of Public Health here in Bloomington. Today I am honored to introduce our January colloquium speaker. Dean Deborah Pro I'm sorry, Prothrow-Stith. Dean Prothrow-Stith is dean and professor at the Charles R. Drew University College of Medicine in Los Angeles, California. She advised top-tier healthcare institutions in an area called leadership as a principle at Spencer Stuart, and also served as the Henry Pickering Professor of Public Health Practice. Additionally, she previously served as associate dean of diversity at the Harvard School of Public Health, where she actually created the division of public health practice and secured over $14 million in grant funding for public health programs. While working in inner-city Boston, she broke new ground in in redefining youth violence as a public health issue. She was the forerunner in the development of violence prevention curricula for schools. And one of the main pieces of curricula that she developed is called the Violence Prevention Curriculum for Adolescents. She has either authored or coauthored works such as Deadly Consequences; Murder is no Accident; Sugar and Spice and No Longer Nice; as well as a high school textbook that is very widely used called Health. In addition to those contributions, she has published well over 100 peer-reviewed publications. In 1987, Governor Michael Dukakis appointed her as the commissioner of public health for Massachusetts, where she led a department of over 3500 employees, eight hospitals, and a budget of over $350 million. Dr. Prothrow-Stith is a graduate of the Spelman College, a historically black college and university, and Harvard Medical School. And she's also a diplomat of the American Board Internal Medicine. In 2003, she was elected to the prestigious National Academy of Medicine. She has received ten honorary doctorates. And in 2017, she was named the Woman of the Year for the second district by the LA County Board of Supervisors. So without further ado, I want to thank you all for being here with us this afternoon and please join me in giving Dean Deborah Prothrow-Stith a very warm virtual SPH welcome. Thank you very much, Dr. Murray. I appreciate that introduction and it's a pleasure to be with you. Dr. Howell, thank you for this opportunity. And Dean Allison, I know that your commitment to being a lifelong learner is also shared. And one that, that I too find inspiring in my administrative role at the CDU College of Medicine, being able to remain a student while administering the work. Being a dean does remain a delight for me as well. Thank you for this honor and this opportunity. I am going to share some thoughts about the work to prevent violence in the United States, and I look forward to our opportunity to have Q and A. I'll start with just thinking about with you what it means to call violence a public health problem and why that came to be. I will share a little bit of history, if you will. For a long time. I was reviewing the 30 years of work in public health to look at violence prevention and discussing that in my talks and someone said to me, “Well, it's been about 10 years that you've been saying 30 years.” So now I realize it's about 40 years of work. So there will be a little bit of history in what I am sharing. Part of the realization in the early days of this, especially as we were reaching out to police and bumping heads with criminal justice, was, was just appreciating that what we as a society call upon the criminal justice community to do is really tertiary prevention. If you put on a public health lens or target it—we used to say primary, secondary, tertiary. Now we have universal and selected and targeted. And I really like what you see here, width, which some teenagers in Philadelphia offered us, which was upfront, in the thick, and after the fact. So what we ask criminal justice to do is pretty much after the fact, it's figure out what happened. Figure out who's to blame, execute punishment on behalf of society. And when this public health lens is applied to violence prevention. And when we did early on, we realize that what was really missing was the primary prevention and secondary prevention. So this chart just shows public health’s responsibility in this sort of gold color, which is mostly upfront, even though we do some after the fact, if you will. And criminal justice responsibility and white, which is mostly after the fact, but there is some upfront policing and more and more with community police reemerging as an item and police attention to relationships with the community that involve athletics with teenagers or going into schools in an educational way. There is some, some upfront policing. But all of this sort of came to be when Koop was surgeon general and many of us were beginning to learn what a big problem this issue of violence was for our patients. And I, as a medical student, was doing my third-year rotation in the emergency department when a young man, after my senior resident woke me up at three o'clock in the morning and told me to go put in stitches. A young man and I did. But I was a student. I was a third-year student, so I took a long time. I took about an hour. He had two stitches that are needed with the cut just over his eyebrow and that hour allowed me to talk to him and him to talk to me and he shared what had happened, that he had been to a party and danced with the young man's girlfriend, Another young man's girlfriend. They had gotten into an argument and friends and sort of egg this fight on and they finally got into a fight and he was cut. And then when I was done with the stitches, the senior resident said he was ready to go and he turned to us and said, look, don't go to bed because I'm going to go get this SOB who cut me and he's going to be back in this emergency room in about an hour. You're going to get all the practice you need putting in stitches. And he said it with this, you know, sort of bravado and humorously and we all kind of laughed and he laughed. But almost immediately, I started feeling inadequate and unsure why we had no response to what was a clear risk and how different that was for everything else that I learned to treat in the emergency room or anywhere anywhere else in the healthcare delivery system. I realize that had he made a suicide attempt and said I'm going to go home and take some more pills. And you're going to get all the practice you need cleaning out my stomach. We would have responded very differently. We had a protocol, we would have called the mental health workers, the psychiatric nurse. We might have even kept him against his will in the hospital. So almost immediately with that experience and my finding others in the country who were asking similar questions. We started making the case: You know, this is a, this is a public health problem. And we said it was because of the magnitude of the problem, because of the characteristics of the problem, which was very interesting to learn at that time. Because like most people, I thought that violence in America was all about some stranger bad guy that was coming from some other community and harming people. And I learned that a lot of the violence in the United States, whether we're talking assaults or homicides, has to do with friends and family and people who know each other and getting into an argument. And the more we learn, the more we realize that the after the fact strategies were not sufficient, that we did need to do some upfront around behavior. Well, my contact in the ER, it was another reason we realized almost immediately that whether it was oral surgeons or visiting nurses or dentists or primary care doctors, we were all having contact with both victims and perpetrators. Health care was having contact. And then we made a big assumption then which was late seventies, early eighties. And that was that some of the same things we had been doing for drunk driving, for teenage pregnancy prevention, for lead poisoning—Some of those same strategies, whether it had to do with public policy or changing behavior, ought be applied to this issue of violence prevention. And well, over time, we've learned that in fact, those strategies can help us. And we'll talk a little bit more about that. One of the things that, that really strikes me about our violence in the U.S. and our ability to respond to the problem is that we've had an impact (“we” being public health), and by public health I'm really thinking quite universal. I'm thinking about our interdisciplinary, comprehensive approach, policy-based and practice based approach to problems. But we've had some we've had some success with motor vehicle accidents and that's what you see in the, in the blue line here. Whereas the red line over time and that says from 1950 to 2015, it really is sort of over time. Look at this. We had to make the case that this was a health problem. And you know, what we have done in this country around death from crashes has made a difference. With firearms, we have been less successful. And, you know, the, the, the numbers from gun deaths and the numbers from car crashes are often very similar from place to place, but the amount of money that we spend on prevention and the policy-directed activity on prevention is very different. And I think that's part of the reason we haven't seen the impact on that red line, that we've seen on that on that blue line. Well, what have we learned over the last 30, 40 years of looking at this and encouraging epidemiologists to look at this and getting our public health practitioners in schools and communities to look at this. Well, we've learned some about the risk factors for violence in America. And certainly there are issues of poverty and income inequality. Something shown very clearly to correlate with homicide rates. Whether we're looking at states in the United States or the United States compared to other countries. Access to guns, another very important risk factor. We've learned that alcohol and other drug use; that witnessing violence, probably one of the more robust risk factors is witnessing and victimization and what some would call that cycle of violence. I put biologic or organic here because we know some things about serotonin and other neurotransmitters that don't—those things don't necessarily mean genetic, but certainly represent, I think the body's response to the environment. And just think about a fetal development in a situation where a woman has very high adrenaline rates and cortisol rates. And what that might do to the ability to make serotonin or receptors for serotonin. And so there's some learning that we can do there. One of the factors that I think a lot about is this issue of the culture of violence. And we'll talk some more about that. But let's talk about guns for a minute because that's one of the reasons the United States really stands out compared to other industrialized countries. And that was one of the biggest arguments we were making early on, that this was not some kind of genetic problem that we had in the United States. It was not some kind of inevitable part of our human condition here because other countries didn't have the problem that we had. And it's suggested strongly when we started comparing ourselves to other industrialized countries that we were doing, things that we shouldn't do. Or there were things that we should be doing that we're not doing or some combination, but that we were dealing with a preventable problem. And I I just have to say that I think that's probably one of the most important contributions that public health has made over the last four decades. Looking at this problem is to say it's preventable that there's something we can do about the problem. Because when we look at this issue of guns in America, one of the things that surprised us early on was that there were many more suicide, sometimes twice as many suicides as homicides every year in the United States. And that was really surprising because of what we see in the media and what we learn to fear and what we develop policies around. This this chart comes from the Gun Violence Archive and worth checking, you can from the National Institute of Justice and the Department of Justice get the Uniform Crime Reports. They tend to be 18 months to two years behind. So there are other data sources, but I find it very interesting that we don't appreciate when we talk about gun violence, some similarities that may exist between homicides and suicides, particularly with adolescents. If you think about the role of alcohol or other drugs. If you think about the role of guns, if you think about the role of precipitating instances or peer responsibilities for relationships and how they impact both in the homicide and suicide arena among teenagers. And if you think about adolescent development, all of a sudden, the demographics of homicide, which often are urban, Black and Brown young men in under-resourced communities and families experiencing poverty or suicides which tend to have a different demographic. It, it may be that there’s a lot more similarity from a cultural and risk factor in these two arenas. So gun violence is one of those areas that public health has addressed. And obviously we have come right up against conversations about the Second Amendment. I just put it here so we could read it and understand the problems with interpretation or the challenges. “A well regulated militia being necessary to the security of a free state, the right of the people to keep and bear arms shall not be infringed.” And those interpretations, you know, and, and we won't deal with, but the presence of guns in our homes and in our communities is part of the problem that we're dealing with. When we talk about violence in America. I want to spend a little bit of time on the culture of violence because quite honestly that for me is the risk factor that is most compelling when I think about it. And I say that because if we look at things like the emergence of women and girls in the use of violence. I think about it this way. We've been marketing and promoting violence to boys and young men for centuries. We've been doing the same with girls and young women for probably three, four decades now if you think about our entertainment media and, and the display and use of violence there, I think it really for us….as you start thinking about how to improve and prevent, improve health and prevent violence among adolescence…girls are, in some ways, no different from boys. But in the violence arena, they don't use guns as much as boys yet. And I put YET there very intentionally. So it's the presence of guns, but what it means to have a gun and who uses a gun and how a gun appears culturally. That I think we also have to factor into this. Another aspect of this is that we're often told that it's hurt children who hurt other children. Traditionally girls would hurt themselves when hurt: Run away, become prostitutes, start using drugs. It was a much more internalized expression of that hurt. I think with this marketing of violence to girls, we're getting some of that externalization that we've seen for a long time with boys. And you know, people say, well, what's better? Well, I think where we have to start is at the hurt children side of this equation and figure out how to stop hurting children, but also how to help children heal. And I think as a country and as a culture, this idea of healing through things like forgiveness, if you will, or helping others, or mental health strategies, community-based strategies. This notion of healing is one that we have to promote as we think about violence prevention. Probably one of the most surprising things that caused me to start focusing on this issue of culture was the learning I did about dueling in the United States. Something that I really didn’t know a lot about until I came across Fox Butterfield’s book: “All God’s Children: The Boskett Family.” And in there he documents the homicide rate from dueling in the mid-1800s in Edgefield, South Carolina as about 18 per 100 thousand, which at the time that I was learning, this was about the same rate we were experiencing in urban America in the middle of the late 80s, early 90s epidemic. And I, I thought, oh, what, what is this thing? Well, as it turns out, dueling was a practice in the United States, brought with the European settlements that became quite common. Gentlemen who were in some ways “dissed” or dishonored, had to respond and this placard to the public on the right side of this slide sort of illustrates that it was really an insult. It reads, the object of this placard is to inform the public that General Lee read has declined, giving to me an apology for the insult offered. And it goes on to say that he's bound to give this. And this was the first sort of posting before mediators or seconds started trying to get that apology and prevent a duel, maybe, but certainly organize a duel if one had to happen. Harriet Martineau, and I really appreciate her contribution to this as an author, wrote that “it's understood that in New Orleans, there were fought in 1834, more duels than there are days in the year: 15 in one Sunday morning; that in 1835, there were 102 duels fault in that city between the first of January and the end of April.” And this isn't….and she makes note that duels were organized activities. They were not arguments with an impulsive response to an argument and what might be a homicide. These were scheduled and planned and people went about the business of organizing. In fact, it is believed that ambulances have their history in doctors coming to duels or being asked to come to duels with their carriages to treat injured people or participants in the duel. So it's an interesting reflection on our history. And certainly if you saw Hamilton (if you didn't, it's worth seeing)…but the document on which Lin-Manuel use as the back ground for, for the, for the musical, actually documents that Alexander Hamilton wrote in his diary before his duel and his son was killed in a duel three years before. He was challenged to a duel by Aaron Burr. And the night before he wrote why he shouldn't and duel, which is that he loved his wife and children, that he was in debt and he didn't want to leave them with that debt. That he really didn't have any real ill will towards Erin bar, that it was illegal. So we're talking about lawmakers for, for sure. And that it was condemned by his religion, which was Christianity. Then he wrote why he had to duel and that I found most interesting, the first being a pressing necessity of necessity not to decline the call. And and that's just straight-up peer pressure. That's just, you know, I gotta do it because that's what everybody expects me to do. That it would cost him political support. That's sort of like my posse. You won't hang with me, won't stick with me, won't support me. And then essential to his more utilitarian is just essential to his usefulness. Well, that's a lot like if they're going to beat me up every day, if I don't beat him up, boy, if I don't scare them, if I don't shoot them….Interestingly, this history and the, the migration a bit of the demographics around violence to include girls and women, really makes me understand that it matters what we say to our children. It matters what we say as a culture. It matters how we're entertaining. And certainly the presence of guns or other instruments of violence have a role. But I think we do need to think and, and look clearly and closely at our behaviors and our culture if we want to get ahead of this. Speaking of culture. So recently we have been forced to think about policing in the United States and police as a culture. And I don't think we should do that without understanding a bit of history, particularly as it relates to police and the Black community. This is a placard that was posted in 1851. So before the end of slavery. And during a period where fugitive slaves were coming north. And you might've seen the movie 12 Years a Slave, which was about the recapture of a man, assuming that he was a fugitive. But going north and getting to places like Boston where you could live a free life…or even as far north as Canada, where Harriet Tubman settled…made a huge difference in your life. But in Boston in 1851, this was posted and basically it's a placard that says, Don't talk to the police because the mayor and alderman have enfranchised the police to kidnap and catch fugitive slaves. And they are saying, don't tell any police officer, anything like, Oh, you know, Miss Jones has a new boarder or I saw a new guy at the store. You know, those kinds of tips cause people to say, well, who's the new person and how did he get here? And so, you know, to the point of, I guess if it were social media, then you could imagine now it would be on Twitter or on Facebook saying, don't talk to the police. But what's interesting is 1851 sounds like a long time ago. And in some ways it is. You can imagine that someone’s, you know, great grandparents told somebody's grandparents, told somebody's parents, told somebody don't talk to the police. They are not, you know, they're not here to protect and serve us. And so with that background, I think America really does have to take a look at several aspects of policing. And this is, this is where I become confessional. I have to admit here because when I first started looking at this problem back in the mid-80s and getting the DOJ data from the Uniform Crime Reports, I was aware of what was called justifiable homicide. And when we graphed out the the homicide categories at the bottom…much, much lower than homicide among family or home inside, among friends or stranger violence, much, much lower…but steady, always there, was this this line at the bottom of the chart that was justifiable homicide. The definition was and is the killing of a felon by a police officer or a peace officer in the line of duty, and in the in the commission of a felony. So that that's the part that's in both of these definition. Even if it's a private citizen, it's the killing of a felon during the commission of a felony by a police officer or a private citizen. And, you know, I just assume, hey, you're committing a felony. Well, you know, I'm not going to spend my time trying to prevent that violence. I'm trying to prevent youth violence. The numbers up here at the top of the chart, not appreciating even though as a Black American, I knew many, many, many, many stories of police brutality, of police being unjust, of police arresting a friend's son who called them because he thought somebody was breaking in the house and even though he had his robe and house shoes on, they came to the house and arrested him. You know, I I knew those stories about the police, but but still, I assume that this was in fact what it was. And if we look at these numbers, what was on that prior chart was basically this light blue bar, which is law enforcement officers. But what's also here is this dark blue bar called the private citizens. So what we're looking at is, are from this is 2017 to 2019, but these numbers go back, that steady line goes back and I'm going, what we're looking at here is an endemic problem of homicides by police that we now know. And private citizens that we now know may not be so justifiable. And that's really a reflection of cameras and phones and other ways that people have been documenting this. And whether it's George Floyd or Breonna Taylor or Eric Garner. I mean, we've just been made aware that we have a problem, that all justifiable homicides are not justifiable. They may be labeled that way. But we, as a society have to look at endemic problem and begin to understand what it is that that we have created in our policing and what it is that we want from police, and how it is that we are going to interact with police through public health and other disciplines in order to truly prevent violence. And I'm just going to read that because I think it's really important for us to reflect upon as a culture. “First they came for the socialists and I did not speak out because I was not a socialist. Then they came for the trade unionists and I did not speak out because I was not a trade unionist. Then they came for the Jews and I did not speak out because I was not a Jew. Then they came for me and there was no one left to speak for me.” I think it's a very important way of thinking about what we know in public health is this notion of canaries in the coal mine. And I love that analogy for us as a, as a discipline, as we think about public health as a discipline. Because, you know, when the bird stops singing, when the canary stops singing in the, in the coal mine, then the miners knew something was wrong and they needed to get out, what they didn't do is start saying, Oh, something's wrong with this canary. Maybe this one's got a respiratory problem. Maybe we can get some little ventilators and put them on the canaries, you know, maybe we can, you know, have the canaries spread out. They didn't focus on what's wrong with the canary. They started focusing on what's wrong with the air. And let's get out of here before what's wrong with the air impacts us as well. And I think from a public health perspective, that's really important for us to sort of keep in mind that, that it is right to say, let's help hurt children heal. It is right to say, let's look at juvenile probation and juvenile detention and imprisonment as a way of talking about rehab and second chances. And, you know, let's talk about how to make a, you know, a situation that is clearly full of violence, less violent. That's right, that we should do. But we also need to appreciate what it is about us as a culture that creates this environment. Whether it's the, the injustice of poverty, which in and of itself is violence, whether it's issues of race and racism, whether it's the presence of guns, whether it's what we teach our children and how we're entertained or all of those things conflated. We have to think about these things and we've had some successes. So I'm going to talk a little bit now about what it is we have done and what it is we can do and how we are approaching it. Now as a problem. I think this is an important notion because there were quite a few late 80s, early 90s, very, very public visible shootings that led to the federal assault ban on semi-automatic and automatic firearms assault weapons signed by President Clinton. And it was a big day for those of us in violence prevention and in fact, was one of the first times the police joined with public health, to express support for a piece of legislation like this. And from that perspective, we had a success. But then just after that I'm sorry, let me go next to you. Just after that, we began to have a bit of a backlash. Now, whether this ban was effective in reducing the numbers of those sorts of things by length, homicides, mass shootings in particular, is certainly debatable. Some suggests that it did reduce the number of people per episode, which is what these the heights of these bars represent. So these, each bar represents a mass shooting in the years shown. And the height of the bar represents the number of deaths in that shooting. And as you can see, there is an argument that after the repeal, because that's what happened with the success we had the, the assault weapon ban was repealed or allowed to expire is, is another way Congress would frame it, but they allowed that ten-year ban to expire. And just after that, one can argue that the numbers of people killed in episodes continued to, to rise. We started experiencing a backlash only a couple of years later. And that is when the Dickey Amendment was passed. And that is when the, the Centers for Disease Control had $2.6 million taken out of its budget because there was a line item veto everywhere the word “firearm” appeared. And the backlash was in part because of the ban, but also what was precipitating and continuing, which was the data that was coming out. This particular article looked at the risk of having a gun in your home. There was a comparison of Vancouver and Seattle—Vancouver, British Columbia, and Seattle called a Tale of Two Cities. Public health epidemiologists were getting very involved and, and showing pretty clearly that guns do kill people. And those studies, along with the ban, created a backlash, which was the Dickey Amendment. And it basically stayed at night, passed in 1996. So two years after the assault weapon ban, it stated that none of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention and may be used to advocate or promote gun control. And the implementation of that under the Bush administration became CDC doesn't do firearm data analysis or studies. Not to mention prevention. Despite that, some of the private foundations continue to fund the work. Some of the early heroes—Garen Wintemute, Art Kellermann who's cited in the prior slide—continue their work to a certain extent. But fortunately, we're now getting new data. And this particular study I found helpful in the way that secondhand smoke helped us with smoking prevention legislation. What we learned with this study of three thousand counties in the mainland U.S. so looking at the contiguous states is that generally, strong state firearm policies were associated with lower suicide rates regardless of the state's laws. Strong policies were associated with lower homicide rates and strong interstate policies were also associated with lower homicide rates where home state policies were permissive. And what that means—and the darker the blue, the stronger your firearm policies are—and the darker the red, the weaker they are. And the purple color is in between. But what is shown here is that the strong firearm work in California, for instance, has an impact on the states nearby. So even where home state policies were permissive, it was helpful to have strong interstate policies in the contiguous states. And finally, strengthening state firearm policies may prevent firearm suicide and homicide, with benefits that extend beyond state lines. So we're learning that things we've done, whether it's classroom education or or citywide programs like that in Boston or Minneapolis, or policies around firearms, that there are things we can do and there are ways that we can continue to address this problem. It seems—and we don't know, because we've had lower homicide rates nationally in the last I'd say half a decade, last five years or so we had a plateauing and then lower rates. And you've heard people talk about lower crime rates. But in the last year there appears to be a rise that I think we're going to call, we're going to be called to attend to. So public health people and physicians and visiting nurses across the country are really beginning to act on this issue. I think school shootings brought a lot of teenagers to the table. And what they did in Florida behind the school shooting there that of course made national news is, is noteworthy. And in fact, they were able to get Florida and I emphasize Florida. I'm saying Florida to pass a gun bill; it didn't do everything that one would want. But it did quite a bit and it was just striking that the legislature in Florida tended to this issue and passed a bill which the governor signed. Interestingly, right after the riot at the Capitol. One high school student tweeted, “So the members of congress had to duck under their desk and fear a shooting. I've had to do that six times during my high school years.” So it's interesting what young people can do for us. Pending now, introduced by Representative Karen Bass, is HR 7120. It will I think, be resubmitted in this, the 117th Congress if it hasn't already, but it lowers the criminal intent status such that the conviction of a law enforcement officer for misconduct is a bit more likely. It limits qualified immunity. And that's part of the immunity that has created difficulties in prosecuting law enforcement officers. It authorizes the Department of Justice to get involved at the police department level looking for patterns of discrimination; it creates a registry, one of the major ways that we learn about these these things. One of the contributions that I think was made in the effort around car crashes because it's basically the motor vehicle registry that allows us to understand a lot. You can figure out where car was painted, what kind of paint was used when there's a car crash, but we are still having trouble tracing the gun that was used when there's a homicide. So with the police, this is another way of understanding better what happens and when it happens. A framework to look at racial profiling and the new requirements around training and the use of data and wearing body cameras. So the assault weapon ban—Dianne Feinstein was the submitter of the bill back in ’94 and she's at it again and I think, you know—basically, we did it before; we can do it again. And I think we're in a position to really have those activities, school-based activities, city-based activities double and triple. So that we can just deal with this American problem, both the endemic aspects of it and the periodic epidemic that, that occurs as homicide rates wax and wane in the, in the country. So with that, I will end up and we can go for the Q and A. And thank you again for this for this opportunity. Wonderful. Thank you so much, Dean. We really appreciate that very informative presentation. I'd like to start with the question with Dr. Maresa Murray. And Dr. Murray, would you like to go ahead and I just wanted to announce to everyone: If you do have questions, please please let me know and we can start with that now. So Dr. Murray? Sure. Sure, that was absolutely spectacular, first of all, thank you so much. Such a wealth of information. And I just had a couple of quick ones. One was a comment in one was a question. One of the comments was in reflection on one of your slides where you mentioned that there's a need for healing, which is not often discussed in a public health setting. The idea of a need for healing around how we think of gun violence. And it's reflective of a conversation that was had with one of Dean Allison's—he has an advisory board called…well it’s called the Dean’s Alliance. With the Dean’s Alliance advisory board. Yeah. And her name is Marty Lemert and she is particularly concerned about gun violence. And she and I were talking about the rise of that was obviously happening in the last year of the rise of gun sales and ammunition among white Americans. And at the same time, there was a large increase of gun sales and ammunition buying among middle-class, middle- and upper-class Black Americans. And that was very alarming for people to see, and they were like, “What's going on?” Not necessarily with the white people, but the Black people not being lower class or those who are who people typically expect, but this other group. And so she and I were talking and she said something very reminiscent of what you said. She said Maresa, it seems to me that everyone's running out to buy guns. So I wonder if in the School of Public Health, I wonder if we don't have a gun problem, but maybe we have a trust problem. Because we're trying to “out-gun” each other and protect ourselves. And so maybe, a part of intervention in the School of Public Health could be, how do we build trust with one another? And I thought, “Wow.” So when you mentioned healing, that reminded me of it. Were you going to say something? I didn't want to interrupt you. No, no. Go ahead. I have several thoughts coming to my mind, but…Please share. Well, I think I do think that the issue of trust was one of the things that was eroded at the level of the citizenry and our government. And trust in CDC and science and trust in public service. And so there's a lot of work that has to be done there. And I think, you know, between ethnic groups in the United States, we've been through a period where the worst of us has been fed, you know….the parable about two wolves, it depends on which one you feed, whether you feed the wolf or the lamb or I'm messing it up, but you know what I'm saying, I think. So fear is a strategy of many, and because we are so deficient at healing and at solving problems, I would say we often wind up in a situation where we think the only thing to do is respond violently…if we are ever in that situation that we fear. I tell…I'm going to have a long answer to this one and I apologize. Awesome, so important. I tell the story of the first flight that I had to take after the World Trade Center, after the planes were flown into the World Trade Center. It was by about two weeks after that event that I had been invited six months prior to speak at, I believe it was Columbus, but definitely Ohio. And so I had a flight scheduled from Boston to Ohio and planes were flying again. And I had a conversation with myself and with my husband about flying. And I intellectually got myself on the plane. I thought, okay, you know, everybody's paying attention to security now; if you’re ever, in your whole life, going to fly again, this is the time to fly. You know, unless you're about to give up flying for the rest of your life. You know, it's as safe now as it ever will be again. So I got on the plane, my my mind was fine. I was on the plane literally. And there may four other people on the whole plane. And I—I broke down, I started crying, I started shaking….fear overcame me, and then I had this thought, which was: “OK, President Bush, you're supposed to be ‘the hawk.’ It’s been two weeks; you haven’t bombed anybody. I want these people dead. I want to be able to fly without having this fear and I don't understand why we haven't killed these people.” And then right after that was the thought, “Well, who the heck is this? Ms. Violence Prevention? I want to walk the walk. Like, I don't understand this.” Sure. And what I learned in that lesson, what was my real “a-ha” moment was that I really hadn't, despite our work in high schools to talk about conflict resolution and violence prevention, I hadn't dealt with fear the way it needed to be dealt with. Yes. And I do think that we've got to attend to issues of healing after trauma, of handling fear, of really being very intentional about helping people in situations where they were, or are, afraid. Fantastic. That was wonderful. Thank you. I yield. And that’s across race. It’s black, it’s white, it’s red, it’s yellow. We get afraid like that, there’s a part of us that needs a lot of help. Absolutely. Thank you so much. I'll yield my other question for other people. I think others are standing in line. Thank you, Dr. Murray. Dr. Jon Macy: You're up next, sir. Thanks, Brandon. And that was a really interesting talk. Thank you very much for taking the time to share all that great information with us. So my question is about your comments on culture. And it seems like there's a significant portion of our population who at this moment, are going to value individual rights, freedoms—and in this case, specifically the second amendment—over any public health or benefit that's going to come from gun control laws, regulations, policies, and things like that. And we can talk ‘til we're blue in the face, drive ourselves crazy presenting data on, you know, the jurisdictions with stronger gun control laws have fewer gun deaths and fewer homicides, fewer suicides. But people who really have these strong feelings about individual rights, second amendment, they, they get that but they just don't care. You know, the, the protection of individual rights and freedoms are more important to them than the public health benefit. And so I'm just curious about your thoughts about bridging that gap, if that makes sense. Yeah, no. And I think there are some there are some robust efforts to work in the space of control, not ban. And I think banning assault weapons just makes sense. I mean, you know, you can talk about it, but that aside, there are robust conversations about things we can do to make guns safer, treating them like automobiles. So, you know, there's a risk having automobiles on the street. But we say, if you're going to have one, you've gotta have two white lights in the front and you gotta have two red lights in the back. And those two red lights when you're putting on your brakes to get brighter. And you've gotta have a turn signal and it's gotta be inspected. And, you know, you can't have lead in your gas. I mean, so we have taken that industry which was dangerous and made it less dangerous and so with guns, there are people who are saying, let's use fingerprints as the trigger, so no body but the owner, which would probably help us with the one child a day, you know, that's killed in an unintentional situation with a gun. And, and that is, that is not something we should have to convince a lot of people about. The NRA is now bankrupt. And I think it was the obstacle to a lot of rational conversation about how do we have and keep guns if we decide as Americans that’s what we want, which we clearly have. But, you know, a little finger that, you know is, is much weaker than an adult's fingers should not be able to pull a trigger. So others have said, “Look, these hair triggers shouldn't exist; that the trigger should be something that only an adult can release.” We have irons that when we're ironing are close and we set the iron down, it shuts off. There's an argument for the same with guns. If you take the safety lock off and you were not using that gun, that in X period of time, the safety lock goes back on. So there are some middle of the road and, you know, there are some who would say, you know, if you're going to own a gun, you ought to be able to see, just like you can see….you have to prove you can see to get a driver's license. So I would say one of the things we can do is kinda work in that middle and work in the areas where there is more agreement than not. And, and most of the polls and most of the gun owners actually are very much in that middle. I think the NRA became kind of the voice saying, “You can't do anything because if you do anything, there’s going to be that slippery slope and then all of a sudden they are going to come get our guns.” There have been a couple of organizations actually, I don't remember the names of them, but it's worth googling if that's something you're thinking about. Because they are they are working on that middle area. Thank you. Thank goodness. The next is Dr. Jackie MacDonald Gibson. Dr. McDonald gets in there. Thank you so much for that. Just really, really inspiring talk. And I just wondered if you have any thoughts. I think, you know, so many people really truly believe that they're safer with the gun in their house than without, even though, you know, data show otherwise. Do you have any thoughts about how to really try to reach those people to kind of correct that misperception? I think we have to get back to producing those because there was an abrupt end to the Kellermann and the Wintemute work; Garen Wintemute is still working on issues here in California, but I think we just need to fund that work so that we understand the nuances better. There are good data, but they are old. And what's not in there is how people may or may not have defended themselves. That's a hard measure. So I would suggest that we continue that, but in the meantime—and directly related to being able to do that as well as public policy—is I think working with survivors of homicide. That for me was and it's the work I'm going to get back to doing. When I have “Dean-ing” time relief. I don't know when that’s gonna come. But survivors of homicides and serious episodes of violence—meaning mothers and fathers who have lost children to violence and siblings of those who were murdered—they tend to be, when given a platform, a very, very powerful source in, in influence, source of influence on public perceptions as well as public policy. So Tina Chéry in Boston is an example of a mother whose son was killed. Her son was killed. It's been maybe 25 years now. She started an institute in his name: the Louis D. Brown Institute. And she is active around public policy doing things that public health professionals and epidemiologists really aren't able to do. She has an ear that we don't have and being her partner and being a source of information and helping to create a platform is a strategy that can help with that. So I do think that those who have unfortunately experienced the tragedy of a suicide or a homicide with a gun in their homes may help us with this, may be influencers here. But we do need more data. We, we, we actually do because “A Tale of Two Cities” I think was published in ‘93, that Kellermann study that shows that you are four times more likely to have a suicide in the home and three times more likely to have a homicide knowing somebody. Homicide involving somebody you know, if there's a gun in the home, I think that's early nineties as well. So so we've got So I mean, that the ban that was put on CDC, that $2.6 million in 1996, those were 1996 dollars. So that had a huge impact on on the data and what we know and for all that we can't do in public health, what we can do and what we do well is create that database that will allow somebody like a Tina Chéry or other advocates and other survivors to really make the case publicly. Thank you very much. Thank you for your question. Next is Kourtney Byrd; she is a fourth-year doctoral candidate and associate instructor in the Department of Applied Health Science, Kourtney. And then we have then Dr. McCloskey. Thank you for that introduction and hello. Thank you for your presentation today. And I just want to say wow, I am so inspired, and thank you for your last comment about working with those who have those lived experiences; as well as being a partner with them. My dissertation will explore the relationship between Black, Hispanic, and biracial males who are exposed to community violence and look at their risky health behaviors in Lake County, Indiana, which is a really understudied area. We hear about violence in Chicago, but not necessarily in Indiana, particularly Lake County, which is next door to Chicago. So I’m really, really excited. And I'm just going to ask a few questions. You mentioned about fear and healing and so…my dissertation is going to focus on what are their coping strategies, following some of the research from Dr. Noni Gaylord-Harden which she's very known in the field for coping in Black males who are exposed to violence. And just thinking about, you mentioned fear and as we know, recently…his name was Dante Barksdale, he was recently killed in Baltimore from the Safe Streets. He was a Safe Streets worker with the Baltimore mayor. So, just thinking about this uphill battle that a lot of us will have in doing this work, wanting to partner with communities. How do we remain, I guess, fearless? Because if you're working with communities and you have to go to where they are, if you will…how do you stay true to this work and there is a risk that you also may lose your life and being a part of whether you're a researcher; whether you’re an advocate….I’m just curious do you have any tips? Well, first you've got to stay safe as best you can. And so I would in Boston when we were doing the violence prevention work that caused President Clinton and Janet Reno to come and show this dramatic decline in homicides. We had gone from over one youth homicide a month—of a child 16 or younger with a gun, a month—down to zero. And we had been at zero for a year or so when Clinton and Janet Reno came and all of that, I mean, you know, victory has a lot of handmaidens and so everybody was taking credit. And everybody actually deserved credit in that situation because we didn't say it was this program or that program of this program. We had preachers who were going out on the street corners at one, and two, and three o'clock in the morning. So I let them do that. I didn't. So when I say stay safe, you know, there are people who are, you know, living the experiences, who want to change things. And those are the partners for you. Those are the people who can really help you bring authentic solutions as well as be present in places. And it's not just preachers or teachers or, you know, businesses. People go in those communities and have those conversations with the young people on a regular basis. It's a young people themselves. Because, you know, one of the times we were in the classroom in Boston and I was asking people, well, how did they stay out of fights? What did they do? One kid said, “Look, I play football to stay out of a fight,” and I was like, “Okay, what does that mean?” Because of course I'm thinking that football, that's pretty violent…if you ask me. A public health worker. He said, “Because I leave school after everybody else. And if I run into somebody who's trying to say, ‘Come on, man, let's do this. Do that.’ I can say ‘No man, I'm so tired, I'm coming from practice’ and being tired is a legitimate excuse. They don't call me a coward or wimp if I do that.” So the young people could be huge partners of yours. I call it looking for Roses. In other words, looking for Rosa Parkses—the people who will refuse to give up their seat on the bus and be there and present. And and we need to help by providing that platform and providing the information and being that partner for them. But they're out there and you do need to stay safe. The only other comment I make to you is that it would be interesting if there's someone doing their dissertation on adolescent suicide in the same area, I don't know how you might identify them, but there are some parallels there that I think are worth exploring, especially when it comes to the hurt and the fear and the pain that accompany both of those. Thank you. And the guilt. There's big brothers and big sisters who felt that they should have protected younger brothers and younger sisters from things. Boys who feel they should have protected their mothers from the battleground, and not just boys. So, so there's some similarities in those things that were worth exploring. I know we've run over and there's one more and I'm here, so I'm pleased. But if you need to shut down Dr. Howell just let me know. Well, thank you, Dean. Would 1:30 be OK for you? Yeah. Yeah. That's good. Dr. McCloskey has a question and then we'll end with a final comments with Dean Allison. Okay. Thanks. You're on mute. Sorry. Yeah. Can you hear me now? We overlapped at Harvard. I know! It’s good to see you. Yeah, and it's wonderful to see you in Los Angeles, a great social laboratory in itself iconic city. But you know, I had a question about sort of the idea of regulations and controls, over guns. If we were to sort of try to implement better controls. Isn't it true that….so I studied domestic violence and they're always cases of domestic violence where there had been previous arrests for DV and the guy still had a gun and he killed his wife with that. So what, what do you think about that? About the sort of people get between the cracks? Um, what what what's what's behind the low enforcement rate of registering your gun; taking your gun away if you’ve had felony convictions or domestic violence. I would really encourage a conversation with Garen Wintemute who's been behind some of the LA laws and I forgot the name of the law; maybe it's the Red Flag law. Where families…and it's not just domestic violence situations, but family members can say to the police “I’m concerned about what's happening with person X” and have their gun taken away. That is something that Garen Wintemute has been actively involved in and the DV part of that has really been the precipitant of his thinking about that. Unfortunately, I don't know the details, but I would really encourage a conversation with him and maybe he's a good public health colloquium speaker to think about having. But we know, for instance, with drunk driving and with smoking even that the role of family, children who ask their parents to stop or, you know, wives, but spouses generally you take away the keys. In the case of drunk driving, we know that family can play a huge role in this. And I think that it's it's there at that Garen has gotten a lot of traction with the work that he's been doing. But I would think we'd we'd want to start there because there are, as you mentioned, a lot of cracks to fill. And what we don't have is basic gun control regulation. So so there's some I don't I don't want to call it low-hanging fruit because it's not easy. But, you know, there are some pedestrian stuff that we can do state-by-state and even federally. But after that, and in the case of Garen, because California has some very strong gun laws, he's gotten into some of the granular, more nuanced levels and they're having some success with this notion. And it includes parents who have an adolescent kid who is…..who were concerned about what that kid is about to do or the behavior of that kid. And I think we've got some some possibilities there. Right. You said…I think there have been a couple stories of the mass shooters where parents were concerned about the kids owning guns but couldn't didn't feel they could do anything about it. Right. Exactly. So it's an attempt to address that and back to the homicide/suicide piece. Both seem to have this giving of clues before the event. So we know with suicide, that people may say to others, “Oh, I won't be here for that,” or give some kind of clue. Well, with with the homicide, often it's an escalating event or a kid taking making choices that, that are worrisome if you're a parent or a teacher. And the school shooting in Florida that I showed in the slideshow is one where the kid was known, had been reported, expelled, suspended, that that whole nine yards and nobody ever got up under that hurt. There was a lot of hurt there as well. We've got we've got some opportunities that once we get to exploiting those opportunities that are right in front of us, I think we'll discover others. So hopefully, you know, a decade from now there'll be a much more robust answer to your question. That is good positive note. I want to thank Dr. Murray, Dr. Howell, Amy Oakley for organizing this. I'm pleased to see so many of you and especially so many students on the call. Grateful to have our students express their interest and their enthusiasm and their smarts. So good for you. One of my favorite songs is by a former ambassador of the United States named Greg, Greg Engle. And the song is called “A Simple Prayer.” And some of you may have heard me quote from it before. And in it he says, “Leave this world better than before.” And that is what I think we all aim to do. And yet I often feel myself, how do I do that? The world seems so big and I seem so small. Where's the path? We need a Virgil to show us the path. We need a Lao Tzu to show us the path. I think today we saw our Lao Tzu. And I feel that I have seen some of the path. And I'm grateful to have a guide. Dean Deborah Prothrow-Stith. Thank you. You are a good friend to the world, not just to me. Thank you for your time today. Thank you very much.
Dr. Neil Powe
Professor of Medicine
University of California San Francisco Medicine Service at the Priscilla Chan and Mark Zuckerberg San Francisco General Hospital
The University of California, San Francisco
November 18, 2020
Noon–1:15 p.m.
Dr. Freeman Hrabowski
President
University of Maryland, Baltimore County
Time Magazine: "100 Most Influential People in the World" in 2012
April 21, 2020
Noon–1:15p.m.
Dr. Randy Schekman
2013 Nobel Laureate in Physiology or Medicine
University of California, Berkeley
January 17, 2020
11:30–1:30 p.m.
School of Public Health room
C100 – Mobley Auditorium
School of Public Health-Bloomington
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Bloomington, IN 47405-7109
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