Distinguished Colloquium Speaker Series

Description of the video:

Good afternoon everybody. Welcome. Pleasure to see everyone here. I think there's hardly a seat available. My name is Justin Ten, I'm the Director of Strategic Initiatives and Senior Advisor to the Dean. Momentarily introduce just an overview of the events. We are welcoming our first distinguished colloquium series Speaker of the Year. It's a very special occasion and I'll let the Dean articulate that further detail after an award presentation to our guest speaker that we'll be giving us a delightful lecture followed by Q and A Life without further ado. Welcome and deals closes. So I want to say thank you to Justin, and Tess, and Kate, and everybody else who organized this event did a beautiful job. For those of you with me, you know, we just had a wonderful special lunch where we had a brisket tasting. So we had the New York Jewish brisket flown in and we had the Texas brisket flown in. And we did a compare and contrast. And we had a few other things in addition. But it was a wonderful event and it was a great exchange of ideas in addition to an exchange of brisket. And we had a lot of fun. So I'm really glad I, re, I want to acknowledge everybody for coming and thank you. We have some dignitaries, Distinguished Professor Richard Dekho here. For those of you who are hearing about Ozempic, Wego and lag let and all those things in the literature, you have in part Dr. Mark, to thank as one of the big progenitors of that whole entire domain of research. And we have Dean Bonano from, I think, number one ranked School of Optometry in the United States. We're very close. Welcome everybody. I'm going to present a very special medal to our guests today. Our guest is as you know, President Dr. Victor Zao who was the President of the National Academy of Medicine. He's a very special person. He's very special person in many ways. I'll tell you about that a minute to acknowledge that we want to give him a very special award. And this is called the Dean's Medallion. There's the medallion itself. It's a fictional couple of minutes with Dr. Zao and myself holding it. This is the Founding Dean's Medallion. I am not the founding Dean of the school. I am a Dean of the school. Founding Dean was my predecessor, Dean Muhammad Trap. He's founded as a School of Public health. This was given to a small number of important contributors prior to my coming. Since I've been here, it has been given to one and only one other person. That was Professor Sean Carroll from the Howard Hughes Medical Institute at University of Wisconsin was one of the world's preeminent evolutionary biologists and thinkers and writers about evolutionary thinking. This is only the second person to get it. Very important thing. It acknowledges the bigness of who's here, acknowledges the important contribution they have, the important inspirational power that they have. I think in saying that, I just want to hearken back to 15, 97 when a young man went to the University of Pisa. That young man was named Galileo, Galilee. And shortly after getting there, this was later in the 1600s, Galileo proved that there could be no giants. This is because the cross sectional area of a bone is what gives it its strength. So that increases with the square R square cross sectional area, but the mass of the body increases to the cube. So you've got to keep increasing the cross sectional area more than the total mass in order to have the whole thing stay together and not squish unless you're a whale and you. But we buy the salt. If you're on land, there's a limit. If you get bigger and bigger, you need more and more bone. Like the elephant limbs, not like mouse limbs. At some point, you have to be all bone, that won't work. So there can be no giants. Galileo proved in the early 1600s that there could be no giants, but he was wrong. Because there are giants, perhaps not physically in bone, skeletal muscle, and so on, but in spirit, there are giants. I've had the privilege of meeting many great scientists. I've had the privilege of meeting a few great people. It's really special when you meet someone who's a great scientist. Human being, Dr. President Zu does not only push the field forward and aim to do so by leaps, not by incremental nanometers, but by leaps in regenerative medicine and cardiology, with the aim of making a big difference in the world. The aim of having an impact and taking the risk of falling on one's face, because it's hard, but he hasn't fallen on his face. He's done great research. He's internationally known. And when I mentioned to some of our cardiology community here in Indiana that he was coming, some leading cardiologists wrote back to me. They said he is a giant. That was their word. He is a giant. We have a giant with us, but he's a giant. In science, he looks one way, he looks forward, it's all that way. But as a human being, he looks around at lunch today. He almost never said, I think always, over and over said, what do you think? What do you think? I don't know, What do you think? I have seen him embrace with equal vigor and sincere passion, the ideas and the goals of diversity. Since he's been president of the academy, I have seen him promoting early career people. I have seen him, or, and the mentor with equal comfort say, I learned from you today, you learn from me. Next, we do this together, it's a circle. So we have a circle because we have a Jack. Come on on jacket, please. As spiffy as him. You guys step he say, all right, here we get. Thank you, sir. Thank you. Now I'm going to briefly introduce the person who's going to do the formal introduction of Dr. Zu for his seminar. Then I will have a chance to thank you. Yes, thank you. Okay. The floor will be yours. So the person I want to introduce is now going to do the formal factual based introduction of Dr. and that's Professor came there. She is Professor Carmen Tech who's also a wonderful person and a great scientist. Dr. Tech has herself been very involved in the National Academies. He was very lucky I got to be part of that team, as did Dr. and some others in the room when we were called upon to help with the dietary reference intakes would determine what the energy needs, that is how many calories to eat the entire nation's population. We just did that in the last year. So if you can complain that the USDA tells you you shouldn't eat so much, you can blame Carmen. Man did very rigorous work. Had to be very rigorous, right? A lot of scrutiny and she did it and Roger and the rest of us, hopefully we did a great job. Hopefully we got it right. Man's been so very involved in the academy. Also, someone who looks forward on the science and looks around as a human and around the world science. You look at Carmen's linked in page, it's like, where in the world is Carmen today? She's over here. She's over there. But she's always promoting goodwill. She's always promoting science. She promotes diversity. She is like Galileo, who they call Acaba, the Wrangler. She's not afraid to wrangle, afraid to tell you when she disagrees. But she always disagrees collegially. She always says I have an opinion, I might even disagree with you, but that's okay, we're in this together, let's move forward, and I think that's wonderful and we're so lucky to have her here. Carmen. Alison, it's truly a great pleasure to introduce Dr. Z today. Dr. Victor Zao is President of the National Academy of Medicine and vice chair of the National Research Council. He is Chancellor Emeritus. And James B Duke Distinguished Professor of Medicine at Duke University, and is also Past of Duke Health. Previously, he was Chairman of Medicine at Harvard and Stanford. Dr. has a highly decorated career as a physician, scientist, administrator leader. His pioneering research in cardio vascular regeneration led to the paracrine hypothesis of stem cell action and the strategy of direct cardio reprogramming. His research also laid the foundation for the class of lifesaving drugs known as Ace inhibitors. As inaugural President of the National Academy of Medicine, he leads a strategy of innovation and equity. Under his tenure, the National Academy of Medicine has launched important initiatives, including the global health risk framework, human genome editing initiative, global roadmap for health, longevity and grand challenge in climate change, health and equity. A leader in global health, Dr. Zao launched the Duke Global Health Institute and the Duke National University of Singapore Medical School in Singapore. Where I actually got a chance to spend some time this summer. He serves on the Global Preparedness Monitoring Board, Advisor to the G 20 High Level panel on financing for pandemics. Co chair of the G 20 Scientific Panel on Global Health Security. And he's also an advisor to the G seven Japan Health Taskforce. As one of the world's preeminent health leaders, Dr. Zao advises governments, corporations, at universities, worldwide. His many honors and recognitions include the Gustav Nil Medal from the Swedish Royal College of Medicine, the Distinguished Scientists Award from the American Heart Association, The Ellis Island Medal of Honor, the Poser Prize of the European Academy of Sciences and Arts, and the Henry Friesen International Prize. He has also been awarded 18 honorary doctorates and honorary citizenship. Singapore. Please join me in welcoming Dr. Zao as he presents his lecture titled Science, Medicine, and Society A Brave New World. I was born in China. We tend not to talk too much about our lives, our accomplishment, some of Chinese colleagues will understand. It's really difficult for me to listen to all hyperbole about my career and others. First to you, David. Thank you. It means a lot me to be receiving this medal from you, but also to be the first speaker for the colloquium. Now, as much as I can talk about giants, David, certainly easy is the category of someone who's a major leader and giant in this field among the many things he does. I'm sure you all know about this for me and the Academy. He's been so helpful in so many different ways. For example, he co chairs the Strategic Council of the National Academy of Science, looking at science, integrity and science, shall we say, ethical processes. He's helped me with the National Academy Medicines Strategic Plan, which he's a member and I've learned a lot from him, the word trustworthy science, which I hope you'll expand on this in my talk at some point. I won't dare to get into that space, but also in so many different ways. It's just wonderful to come to Indiana and looking at your vision, mission, goals and values. They're so resonant with everything that we believe in. And you should be very proud of, in fact, having leader like him, as well as being in this great school. Thank you very much for honoring me. Thank you. Comment for all that you do. When I was asked to give this lecture, I gave, I think David or maybe just in three topics. I said, I don't know what to choose. There's so many things we can talk about. It ranges from the future of academic medicine, which I thought about to my research in regeneration cardiology. But I think this one is the one that resonated most with everyone about science, society because it's broad. It certainly hope that provoke some thinking around this area. How important it is now, why this topic? Well, I think we all recognize that we're really reaching a very amazing time, unprecedented progress advance in science. Where we now can think about things that we've never were able to do before. Right? I've been in medicine since 1970s and I can tell you no doubt that when I first started as a career as a cardiologist for heart failure, we had three drugs, right? We had talis, doesn't really work, diuretics and every so often we think about other things like curios or whatever. But of course today the range of Mars is phenomenal. If you look at cancer now we can really think about cure and cancer. Think about genetic accomplishment. Think about how you can actually change genes in human beings and others. It's really quite amazing this unprecedented advances in science is a phenomenon. But with the science advancement obviously has huge implications in health and medicine, and we've seen the benefits of those as well, and therefore the impact of society. We also know that we've seen during Covid 19 which is in fact a great testimony about science, the rapid development of vaccines, diagnostic digital in, I mean it's quite amazing. But at the same time recognize that we have uncovered inequity, we've uncovered a lot of other issues. As we now enter this phase, I thought this would be a really good time to examine where are we in science? I was it infecting medicine? I was affecting all of us in society. In fact, that's the purpose of my talk today. Now in this regard, I'd like to take a step back. I think everything you see here the last century, I think where we have almost double life expectancy of human beings is related to advance in science. If you look at this curve, you can easily see that in 19, about 100 years ago, around here to where we are today, 35 years to now, well over 70 to 80 years of lack of vaccine. I think most of us to breed has to do with the advanced signs in terms of hygiene sanitation, nutrition, vaccination, tobe control, growth safety, improved diagnosis, and of course, new therapies. I'm sure I'm missing a number of things, but the point to make is science has been really good to all of us. To society and also particular health and human beings, pharmacologic technology advancement. We have antibiotics, anti virus, chemotherapy. I talked about heart disease, diabetes, we just mentioned briefly. Mental health robotics, organ transplantation devices, MRI, CT scan, you name it. I think that's in accounts for a lot of major advances. But I also want to point out two major revolution that's happened in the last 50 to 70 years. One is the Biomedical Revolution. This is a borrow from a slide, I think a slide made by Field Shop MIT, which demonstrates therefore, starting with 1953 double helix Watson and Crick, to where we are today. We've gone through several revolutions. Biomedical sciences, molecular biology, then of course, the idea of the genome. And in fact, we're amongst maybe the first national academy to say we should sequence human genome 1988, well before its time when people say we don't have the technology, we don't even know how to interpret information to course completion of the human genome project. Here. In fact, looking at what we are doing now with genomics of course, Home and others. The point I want to emphasize here is the last word called convergence. This came from both national academies and MT, to say the future of science is the convergence of different discipline. Now we used a lot of words like interdiscipline, cross discipline, Multidiscipline convergence simply says, we're going to solve a problem by bringing disciplines together to focus on solution a problem. It's not just collaboration, it's actually totally focused on solving problems in this context. I think the other revolution is Digital revolution, where convergence with biomedical sciences also is happening here about the same time. 1950s, just like the Watson and Craig double helix, the first commercially available computer for simple arithmetic and data handling. See the two I just randomly picked. Microprocessing, world wide web computing, iphone who can live without an falls, right? It's only a little bit over ten years old, maybe 15 to in fact Supercomputer Quantum Computer which has chat about large language models, chat GBT, that's really changing the wheel, things, you can imagine these revolutions are all converging. And I don't think there's a time in history of mankind when science, technology, innovation is really making such precedented advances. Now just take a look at what we have today. And this is just a partial list of technology, augmented reality to Internet of Things, autonomous vehicle automation, nanotechnology, quantum computing, big data analysis, and AI. And the range of AI applications. On the biomedical side, genetic engineering including genome editing, but regenerate disease, immunotherapy, synthetic biology, microbio tissue generation, you name it. Where does this all lead us? But many people who are predicting the future would say this is going to transform healthy medicine. We're going to have much more effective prediction and therefore prevention as well. We will much better understand the complex pattern of biology and diseases using mass amount of data that we've collected. We changed the way how care is delivered, where is delivered and who's delivered by. Of course, we would have seamless continuation of care with digitally connected, monitored continuously, and in fact, without any interruption. Of course, with all the stuff we talk about lunchtime about data, data intelligence, digital health, help you shape personal health decisions. You name it. I would agree that all of this is realized. One can imagine this may well happen. I think what's really bold is Chan Zuckerberg who says, can we prevent, cure, manage? Or by the end of century, I want to see a show of hands. Do we believe we can do that? Does said very broadly, not cure, cure, prevent, or manage. I say that can come pretty close, I'll tell you why. Because between now and then it is 75 years. I look back when I was in training in 1970s, three drugs to use in heart failure. I have no other option, Transplantation was just coming in yet, L Vets but of course drugs that we have now use left and right. Sgo two inhibitor is making huge differences too. Actually I think it's possible that we can prevent, manage, or cure all diseases. Maybe not all majority. I won't be surprised if you live to 75 years from now. Now it is a brave new world. Which is why pick this topic, the brave new world in terms of transformative science and technology that can really do things that you never imagined before Sony. I was just thinking, watching a movie the other day. When people use painful in London, they're going to the red booth and these are painful. I said we use a painful, you have to put a dime in there. Right. Things have changed tremendously. You just don't think about this because you accepted. But as Huts wrote in 32, almost 100 years ago to say that, okay, we may have all this technology we could end up with this Pian world, genetically modified citizens, intelligence based social hierarchy, and of course, scientific developments in reproductive technology, sleep learning, psychological manipulation, and classical conditioning. 100 years ago, 90 years ago, dystopia. Well, guess what? We now have those tools to do what he says there. We have genome editing that we can treat genetically modified citizen. We have reproductive technology, which is really quite advanced in IVF and others. And of course you think about stem cell and others using AI, we can manipulate so many of those issues that are we also facing the other side of the equation, transformation and posit of harm. Let's talk about geno editing first because you know there are several technology but to crisper came in it was more difficult to use. Telling zinc finger crisper editing using guide can delete any genes, replace them. Consequently, you suddenly have a technique that's easy to use and basically can manipulate genes in our own body. If one were to think about using it in germ lines not only fertilized, but now go back to games, you can manipulate this, you can actually transmit and pass on to generations. You begin to change the genes in the population. Cell phenomenal, right? What's hot wrong about this? It's not if we use it for that purpose. And I'll talk a few minutes about the ethical implication. But there's another approach to which is safer. Now already, I think you're going to see within the next few years, therapy is coming into the market. Somatic gene therapy, taking somatic cells, blood cells and genetic modified to treat diseases such as cancer, HIV, diabetes and others. Here we are, amazing. Technology is only one of many bot technologies. I, well we can talk AI for hours about what you can do. I've shown here about AI, we can do as a whole in terms of data transformation solutions generated AI automation and combined machine and people to enhance cognitive productivity. Certainly as you know, the logical thinking working on this issue whereby human performance are going to be enhanced by the use of machine closely connected to actually the brain as well, health care. You can imagine there are many great things you can do because we have so much variation in treatment and decision making and monitoring patients and so and so forth. That in fact AI can do so much more for medicine. I'll come back to that as well. But as I said, the risk and harms on all the technology such said, First of all, when you think about all those genetic technology and start changing the way we perform, et cetera, you can certainly change social norms. How do you look at disabled individual if maybe we don't have any P who's disabled? How do you see if a kids born with impairment, The whole idea of enhancement, in terms of genetic enhancement to create designer babies. That's not unheard of. One day it will be possible is that can be an issue. Forgetting designer babies, even as somatic therapy, you can possibly increase my performance. I could be even better looking taller giant and I could certainly more athletic and others. These are fundamental issues we need to address with regards to these technologies. Of course, weapons, bio terrorism do use research, gain of function research where as you know, there's tremendous debate now with the covid virus where it's been manipulated or not, that you can enhance pathogenesis of viruses and pathogens. Which was done with the idea that we can study better how to prevent it, but it can also have great harm. Of course, the use of synthetic biology, which has been used to create grande organisms and of course three D printing to create of course, all sorts of biologic as well as physical otitis. So on the side of data in AI, you can imagine what we all know about bias and algorithm privacy, security, reliability of your information, the overall potential for misuse and lack of governance. But I think the harms are really where T is talking about, what have you now I, to a point. You can control information access, you can manipulate data or forgery data, right? You can have bellware hacking, inappropriate surveillance of every one of you, and abuse harassment. I think these are the big concerns that we all have in the brave new world. What are we doing about this? Well, there are of course, insufficient efforts in different ways to look at, beginning to look at this issue. There are genomeditingyud say that the Academy was among the first, if not the first, to shine light on this. I still remember one of my council meetings, three scientists, that is Bob Holwell, Lloyds, Mark Fishman from Harvard and Keith Amato came up to me at to counsel and say, we got to think about gene editing. What do we do about this? I went to talk to Rob Cistron, the late president of the National A Science, and we decided what we can do is create a genome initiative To that, we held summits 2015, bringing together some 400 people to discuss this issue. It reminds me of the days of recombinant DNA. When 1970s, this was great concern. And there was a famous cinema conference of scientists coming together and say, what do we do about this? And the conclusion is it should go forward, however, with self governance and with some government regulation. Now, had it not happened, we won't see the advances about technology. See today. Of course, this happened I think in many ways which are under good integrity and governance of the. We created two reports to discuss what we should do about this. But in 2018 when we had the second summit we held in Hong Kong, that was the big surprise news when the Chinese investigator, her cu, came up and to say, I did it. Twins that spawn from this and of course that result outcry that led to us to say what do we do about heritable germline editing? And we basically with many argument moratorium or not, we say the research should go forward but not in application. You could look at how to refine this better in vitro but not in vivo. Because not only do we have not called the technology understood long term effect, but also the cultural, social, many issues that needs to be addressed. We go forward. Petty Hamburg chaired the the WHO framework for governance, which also we inform that governors guidelines on how to go forward with this. Right now there's an understanding, not a moratorium, but certainly a slowdown of journal editing until everything is known to be visited. But somatic therapy on their hands report in the area AI. I'm sure every day now you hear Congress discussion and news media your name about the risk of AI. It's very reasonably so. There are in fact discussion in Congress about how to regulate this. And Senator Bill Cassidy just last week talk a framework of AI in the use of health and medicine, being a physician. Now, there are two lines of work that we've done on this area. One is from the White House Office Science and Technology. There's a AI Bill of Rights which was published in 1022 N Medicine. We launched an AI code of conduct for health care, which will look at the principles, the best practices. We are going forward with the idea of looking at specific areas, of looking at what are the guidelines for medical education. I think this is going to change my education in a big way. Think about years of setting preclinical for two years, clinical rote memory, et cetera, Trying to even problem based learning. I think I is going to really make things very different. The question is how we use it effectively and perhaps free up more time for our clinicians to have more time with their patients and less administrative work. We'll see that's what we're working on right now. That leads me to a broader discussion. I've given you examples of extremes where in fact says it can create dystopia society. But overall, there are many issues of emerging technology which affects health and society. I wrote this paper with Len Balad was my special assistant, and myself sit address and talk about the Src issue, about the implications in this regard, not only those major harms, but many issues of inequity that we see every day that emerging technology can really, I think, uncover. Some people benefit from it and others will have not the opportunity to benefit. They are cost affordability, I'll talk about that. Access, ethical issues we mentioned briefly of privacy ownership training workforce is prejudice, lack of consideration of social issues. Let me spend a few minutes talk about this. I think what we're seeing in the whole are health and society is the increasing have, not the inequity which is reflected what I saw emerging technology, but overall this slide shows you see rising costs de despair, declining life expectancy in this country. Misinformation, mistrust many social health inequities. All you have to do is look at this slide. Here on this slide, look at life expectancy first. Looking at country and United States, you can see the last two years we've actually had a downturn of life expectancy. Where across the world, comparable countries are seeing continuing increase that reflects a lot of issues in our country. Secondly, if you look at life, it's almost like zip codes matters. As you all know, 15 years of difference in a single city with two different Zip codes, Those who are more social, economically impaired, marginalized, those who are much wealthier, and of course, life expectancy and household income. You can see the income determines greatly life expectancy and of course the level of education. What I'm saying is, while we're discussing and think about science and technology, I think it is reflective of what's going on fundamentally in our country, covid to me shown a big bright light on this issue. While we have amazing vaccines, diagnostic viral, anti virals and warp speed and making deals survivable the vaccines. Yet we know that there are many people who didn't have access to it. Problem with rollout delivery, particularly in marginalized communities in this country, hospital, pharmacy, shortage of workforce, et cetera. And globally you can see in low income countries, the vaccine nationalism has resulted in vaccine not getting to these poor countries and hence lots of pub access and death. I think this is really an issue of equity, excess and trust. Vaccine has to see as well. Let's talk about the cost of prescription in United States. This is one of my favorite topics. You look at how much we spend this country than any other country in terms of cost of drugs. It's astounding in many ways. We are subsidizing everybody else by willing to pay the cost that's demanded of our country. Per capita spending in the last 15 years grew by 70% which is high, 30% comparable countries as you can see here, one in four adults think the cost of drugs is unaffordable. I think that's a low number because they don't have to pay for it. Your insurance pay for it. Medicare pay for it. Had you pay for it. You say it's way too high no matter how you look at it. One in three says they really can't take their medicine because they can't afford to buy them. I think it's unacceptable in my opinion. But here's some numbers. Medicare part D ten drugs that come for a quarter of drug spending in 2021. Eliquis limit it around total 5 billion to $12,000,000 a year. It's huge. If you look at the gene therapies, they're curative one time, 3.5 million, 3 million per dose. Who can afford it if your insurance doesn't cover it? To me, we're not solving a population problem. We are providing opportunities for those who can afford. Take a more preventive approach. Hepatitis C, the drug they've reduced the cost of regional was 95,000 to 25,000 even then where if you take the drug you can imagine you could be cured. Hepatitis, downstream, cirrhosis, liver cancer, transplantation, all that stuff. Safe savings and costs and lives. Yet only 33, 34% have been cleared of the virus. Millions have not been treated because insurance company would not be hesitant to pay for it. Finally, the drugs we talked about, they're expensive. People can't afford it right, and now there's a shortage. We have a fundamental problem. I want to take a minute to say, how do we get there? How does this country, which is so amazing, I'm an immigrant, came as a student from Asia, Given me all that opportunity, this country say, how do we get there? Well, these are four things I can think about. This is why I call society first of all, where we are today so successfully in innovation is based on the vision of NFL Bush, which I'll talk about in a few minutes. Who is in fact a chief scientist and science advisor to Harry Truman. Second, because of his work and others, this country believes that market driven economy, everything we talk about being more equus socialism. Let's let the market take care of self. Well, market has done very well for the country, but for some, not for all. Therefore, innovation is also driven by the market opportunity. The government policies, very good ones have also been enablers of this. Finally, as our health care payment system, Naf. Bush in 1945, when he became the Chief Scientist Science Officer of the nation, was asked to say what's in the future. He wrote this really important paper report called Science and This Frontier. He was absolutely right that we need a new national vision for ation, research enterprise. Government needs to invest science. Therefore, this result to establish of natural science foundation, a greater support for NIH and so much more money as we have today pumping into science from federal government. All good basic research, curiosity driven research, the engine of innovation. His feeling is the government's role is to force innovation, but we also believe translation should be done by private sector. That is, we government can do that we handle off the private sector. Therefore, market should drive the pace and scope of translation that's thinking. Hence the idea of market driven research and eco, innovation of health should function within a complement the current privatized and decentralized health system. That's what we have today. We didn't go far enough to think about the social arts, but more in the research part to drive innovation. Now I would say to you, US is the most in the native country. Partner you can argue about China. We have been phenomenally successful. Everybody looking at us to say how can we do what US does. It's been successful, and I'm not being critical of it. However, it's left many people behind. And that's one of the problems we need to address. Marketplace is not prioritized. Social good innovations are driven by market demand and the price is what the market can bear the emphasis on market driven use. In spite, research will interest private sector to say there is in fact profits to be made. We can commercialize this and we can also a patent that can protect us. But that really creates a misaligned incentive from social good point of view. Not that it is not good for social good, but there's all this issue about system skill towards revenue. Rich ailments encourage companies to look at high reward strategies. There's an adequate consideration of what we really need, what the market thinks. Can actually bear this. Then the private sector, of course, really think about innovation committee level public policy and others. Now, our government has done so well in enabling this economy. But I would argue that it also has its own issues that need to get better. For example, if you look at our framework, whether it's FDA or whatever regulatory framework, it really tends to optimize fairness and opportunity for investors and deliver developers the prioritize when it comes to ethics, it thinks about safety, autonomy, not necessarily equity, right? It's a drug safe, so they come to a market. Fda does a great job protecting people's safety, but really never thinks about because it doesn't have a job of deciding what to charge individuals what the cost is. Patent practices enable people to have monopolies. If you look at Hat Life 20 years, if you look at the top 12 grossing drugs, they may extend it to about 30 years of had life. It's very difficult for you to come in to compete. And of course, the intellectual property system comes frequently because of the monopoly of collaboration. The other thing that does not do well, how many billions of dollars? I 40 some billion dollar a year. And if you include NSF, you name it, but we get no conditions including this money. The word conditionality that say, if I look at the biotechnology industry, the things that come out came from N. I support research. The data is very clear on this. What do we get in return as a public who support this research? Nothing. The argument is that the economy is now better for the country and therefore that's our return is if I were the king of the hill, I'll say for every product that comes out from N I research, you ought to at least give us back a percent. All drug pricing, the same issue, right, for all the stuff that came out from our support. Why can't we negotiate better price? Consequently, the Bids Act, which is really important and in many ways have enabled research to be intellectual transfer, commercialized, getting to the market, get. People have missed this idea of conditionality and I'll come back to talk about this payment system doesn't help either. I think all of you have insurance so you don't have to worry about. You may have some Co pay. You know, the other day I had to co pay of about $100 I complained. And I think about this, I went out to a meal with my wife just like that at night, right? So we have a very warp way of looking at things of what we should be paying for this. But what happens is, yeah, insurance company will pay for it, but guess what? It gets back to you. The premium Medicare will pay for it. Guess what? It gets back to you. The taxpayers, don't you think you're getting a freebie? You are paying for it, but our system enables high prices. Of course, until recently, starting this year, we now can talk about maybe negotiating ten of the largest trucks that's going to take place to 2026. And many people worry that if we change administration, being political, this may all be overturned. Again, It's so difficult to do the right thing in my opinion. Just VA can negotiate prices. Why can Medicare negotiate prices? The question, what is the value of government investment research? Well, I'm a big fan of Mariana Mas Caro. If you're not, read about work, take your name down. Read about this. She's written pot work. She's now the chair of the Economic Council WHO she argues that. Think about wealth creation. People don't think about government as wealth creators, they just facilitate wealth creation. I would say if you look at sta, we create lots of wealth. Internet supported by DOT Google research algorithm supported by NSF tells when they started struggling, we gave $465 million with no condition, well, it's good for economy for sure, but the public getting its returned. I think what she's arguing, we need to move towards a mission driven approach versus market driven approach to allow the public sector to play a role in strategy, long term social oriented investment. I always talk about this, and I think David has heard me talk about this. Our country does not have a real science strategy. It is market driven strategy where people who put their money into quantum computer you name it, is all related to the fact there's a market there. At some point when the government can only do so many things, we need a much broader look. I chaired the Biomedical Science Council for Singapore, where they have three pillars to report to the Prime Minister. They have five year strategies. Swear five years areas, we're going to put more money into look at human potential and health. We don't really have the, by the way, the word word wealth creator. Lot of you think investors are wealth creators. Companies are wealth creators and banks are wealth creators. Mariana wealth extractors. Wealth creators are people like you who create, in fact, great ideas to enable to move forward in wealth. I think we need to develop mission based, national approach. And to do that we have to begin to address incentives of market regulation and Fen systems. It focus on population and social good human centered design and development and reward wealth creation instead. And consider ethical principles like equity, fairness and coherence versus prioritized values such as opportunity, profit, and safety. When I'm going to talk about the rest of my talk to say how do we start thinking this way, Mission driven, equity based innovation and economy. I think we need to follow, number one, we need to believe the principles of equity and social good as we move towards innovation and economy. We need government policy that enable this to happen, particularly in return investment to public the conditionality I talked about. We need innovation that's equitable at every single step. Think about is innovation achieving equity. We need all everyone to come together, to collaborate, to cooperate, and to create a government structure. That's a big order. I've been thinking a lot about this and of course, it's the beginning of some thinking about how we can move forward. As I mentioned, David is involved with our strategic plan and we're now doing 2024 to the next five years. This one reflects the last five years which end this year 2023. About three goals treated plan one of goals is articulate the importance of science, technology, and innovation. The question about transforming health and medicine a new platform. But also down here addressing what we just talked about social, ethical workforce implications of this chain. I've written a paper in journal Medicine for Governance of Emerging Technology, creating a new framework. Of course, also our work in terms of what we've done as I'll show you the next few slides. To do this, we actually created a committee called Committee on Emerging Science Innovation, Innovation, Tech Innovation Cost. This is in fact a committee that we put together. I want to put a quote on the work done. Martian says, emerging technology involved a complex mix of applications, risk benefits, uncertainties, stakeholders, a public concern. As a result, no single entity is capable fully governing. It's not CDC, not FDA, NIH, whatever. What we need is to bring together multifaceted tools to look at how to govern collectively. Together, this committee is supposed to look at what are the emerging developments? What are the factors that shape translation? What are the potential societal risk? And how do we create a framework going forward? It's co chair by George Daley from Harvard to Boot from UCSF. And the first co chair of the behavior science was the Land Nelson who then went on to become the Deputy Director of the Office Science, Technology Whitehouse, and all the Charitable. We started 2020 in January and we brought together for more than 2.5 years to look at this issue. The committee members made up many people that you already know, previous commissioner, FDA peoples, but also academia, industry, investors, bio ethics, law, policy, engineering, social sciences. Our question begin to say how do you approach this issue? We did 34k studies picking on things that we thought would be really instructive to look at how these technologies are developed and how they affect health and society. We took new technology. Imagine from transcranial neal technology to forward looking visionary component. Look at what we talked about, AI and brain interface, Te, health regenerate medicine and also genomeditate. Using those studies, we begin to look at what are the different pieces of the ecosystem that these technologies touch? And how to create a governance structure that can think through all those issues and a set of principle values, governance for this technology. What we did in this first round is to create a heat back that looks at a technology and put it through the steps of development and the current governance structure, which in fact has the FDA, Medicare, Medicaid, and others. Look at how technology will walk through this to get to where it is. Secondly, we also look at a life cycle approach. That is, when you look at technology, you look at startup, you look at repurposing. We look at life cycle to say, if you have a technology to go through this life cycle, what are the things you need to pay attention to? For example, early research. You may think about how to design clinical trials and how can you make sure that it's done right to later about to come into the market? How do you covered by insurance to laws and regulations. And overall, we create a strong framework of heat map that you can pipe in play and look at technology and see what are the lines, red lights that you need to address. Well, ahead of time to start, think about this. At this point, we thought, okay, how do we move this forward? Well, it became to us that at the end of the day, what we're trying to do, no matter who we're putting together, is really trying to address the issue of equity. Everything that we talk about begins with equity. It's a fundamental concept. The report I just released last month, about three weeks ago, focus on equity innovation. Here I read a few quotes. The implication of health technology extends beyond individual concern. So it comes to collective social values and needs. The US ecosystem for emerging science technology, innovation and health mess is dynamic and diverse, but does not prioritize alignment with equity. Therefore, innovation to address equity is a vital champion imperative for 21st century science medicine technology. Our report, this is a report it's called chaired by Keith You. Keith Yamamoto. Keith You as a famous social science princi Keith Amato, a molecular scientist and a very active person in the policy of science. We just released this report commissioned by us and done together with National Academy of Science, Engineering Medicine. We had 19 members, two fellows, looking at the range of possibilities and the expertise. But particularly, they were asked to say, create a report that there was a framework aligning science, technology innovation with equity. And look at approaches to technology life cycle to translate equity into governance ecosystem. And third, to recommend actions to look at coordinated governance of innovation. Question first, why equity innovation? Well, I think it's a foundation to build research enterprise that's for the greater good. Equity helps everyone and not just a few. Second, equity and diversity will give you even better. Three, science, because of the objectivity, the diversity of opinions, experiences that were or excellence in science. Third, if you engage people and they begin to understand this, you can build more trust in science and technology. Fourth, actually is economically beneficial when you look at the few people can benefit from some of the treatments versus the broader population can benefit. Let's not forget the downstream savings of hospitalization, disease treatment. It's actually economically beneficial. There should be equal innovation. To begin with, we look at innovation life cycle, starting with an idea. Getting funding to developing and researching that technology or scientific area. To licensing investment scale up to looking at regulatory approval to costs and coverage to oppose market. That's the entire ecosystem. Our argument would be you apply a lens. Equity at every single step of this equal system. That's how you can achieve equitable innovation. The imperatives are one, got to broaden the participation and responsibility to empower much larger group of stakeholders. Then a few scientists find them. I got a great investment, I got great discovery. I pitched to investors to see there's a market there. I think that align incentives to encourage equity, determine how inequities can take and actually impact society and how do you mitigate them. Create guidelines for equitable ends and shape sharpening oversight evaluation along these pathways. Let me give you some examples. Here's the steps in the innovation. And if you have an idea, maybe we should ask the question, how would this benefit not only few, but to the greater good in training of your trainees? That question should be asked, not that we don't believe in investigator initiated heroic research, but that also be how would it actually mean to society in equity. That also means that now, and I just asking you about diversity, why not asked the same question? Not that it will be fully judged by this, but it's one requisite when you apply to look at panels, to review, to say, have you addressed equity, this amazing technology, how would you address in the future? Also support communities which are affected in looking at design this research when you get to beyond the idea to design design with affected committees, not just a few people who are scientists. But having people feeling design Uns, ethical issues, IP license start up. When you begin to look at the use of performance, you want a whole range of intended uses and context. You need to look at whether in fact this committees agree with the performance to looking at metrics, to look at purchasing, use, and coverage, decision making in the technology. To in fact ultimately do post market analysis to see whether in fact the technology is intended use or whether inequities at risk. How can we mid cost adjustment? That's why some of the reports are thinking along the entire ecosystem. But every time you think about this, you pin an equity lens. Maybe you can begin to change the way which now products are getting into the market. And of course, it will require a cultural change altogether. The report has six recommendations. National leadership, we need to galvanize them to align innovation with equity. We need to create a culture of innovation that cops equity as a concept that happens to universities, that happens in companies, et cetera. We align innovation with benefits that's equitable. We make sure that we empower diverse communities to participate in innovation system. We have now proposed a new science called equity science. Implementation science. We're working very hard to say what's equity science? What are the metrics, what are the measurements, what are the ways of the future you apply science to issue of equity. Finally, context specific guidance because different areas, different technology can be different. It can be one size fits all. It should be context specific guidance on the framework as well. Where do we start first? Well, in terms of national vision, we need national leadership as we have. As I mentioned to you from very first day, we've engaged White House OSTP in, including Alondra Nelson and others. We've been continued discussion with them. So the idea we already have rent report is for them to begin to create a cross sectoral equity and biomedical innovation task force to say how to move forward. What I'm thinking, there are things which are well beyond the executive branch and the things with the legislative changes. Is it within I say now on your grant application should include considered equity. Is it within the journals prerogative to say when we look at integrity and others? Have you considered equity in your research design? These are totally, to me, changes that can be. Can you bring together government agencies, CDC, FDA, to think along this way? Or As I've been studying, the Belmont report. How did Belmont report, which is human subject protection to a concept. Of the deed to now norm from Tuskegee people say, oh, now we really need to be sure they'll protect human subjects. Like here, a conversation occurred and studies were done. The Commission was done to look at what needs to be done. In this case, Congress embraced it and then told s to implement. We're thinking through how we can take some equity thinking and eventually moving into norms as practice in research and commercialization. The idea would be leave, as I mentioned, requirements. We should design funding, approval publication, targeted funding, market incentives, best practice to recognize value, sustained input from broad range of and development of equity science. That's what we're working on now. We recognize this is a big, big area and I'm not naive to say just because world it can happen, we need to get together many people in this ecosystem to say this is important for us to work together. Academia to R and D to government, to patent office, you name it. You know, for example, we interviewed at officers universities during this study and asked them, do you ever asked the question when someone comes as the Stanford Chief Patent Officer said no, our job is to push it out and get profits. University, I actually believe, and I think we're going to launch, We are you to say, hey president, don't you think it's a good thing that you have your patent officer ask that question and then make a decision on who you want to license to, to have a commitment to equity. That's the kind of thing we think we can begin to change as we move forward. And Mastercoin says innovation is now come, a massive collection of efforts, not a small group of people valley the biggest problem together. To solve that, we need to create a culture of equity. And we need to have mission driven organizations like yours and others. So this is my checklist. I feel that in the future want to think about innovation. This is my checklist. Is it mission driven? Is related to mission? Second, are we addressing unmet medical needs? Or is it too, just because there's a bigger market, doesn't really have improvement of outcomes. This is relevant to a broad, diverse population communities. But we still recognize there are specific diseases, genetic disease, and others that needs also special look at equity is accessible, affordable, and distributed fairly. We certainly don't want to perpetuate the justice disparities and look for ways to correct them. I think this should be, in my opinion, a check list for researchers and technology in the future. Hopefully, that we'll get this adopted. I'm going to end by saying how do we move all those concepts forward? First of all, we do need public private stakeholders. We need to get everybody agreed on this, to move from this recommendation to implementation to line incentive, but across all sectors to have the right regulatory oversight pathways as a starting point. As STP, think about creating a aspect. There's going to be a lot more work and this is where Academy is particular good at because we started member T, then we went on this. So it's been about four years of journey. We're going to come back and to create a collaborative is bringing the initial committee and the report committee select members together to look at what are the actionable things that we learn from both T and S studies. And then begin to look at each sector and work with each sector. For those who are motivated, coalition, willing, if you will, to start making changes in sector, I use the university sectors best example because I think we're going to get good traction because every university believes that we should think about these issues. Perhaps starting point and looking at how students do their training, how do the research, how do you look at licensing can start changing university. It little bit like Belmont Report where you can say, suddenly it becomes a norm because the Belmont report in terms of human subject approval, did not apply to non government support research because government can only do that much. Right? But what happens is, guess what, is a standard? You can't get a drug approval if you can get some human subject approval, even though they're not mandated by the Belmont report. I think this is the way to start bringing people together. And then finally, to have a shared vision of governance. How do you get all the pieces together? Saline and B. And I wrote this paper about what do we need for governance? We need both hard and soft governance. Some laws will have been passed and others are voluntary guidance standards. We need to be cross sectoral. There's no single agency that can have a complete jurisdiction. How do you do that? Maybe it's a standalone group of people. We have to have a dynamic approach across sectors because we're not only do with one sector, equity has embedded to path, here's where we are. If you look at what's happening, science and ethics, this slide tells you everything, right? Sens moving so fast, we can't even keep up with asking these questions. And of course in our world we frequently face the Colenrich dilemma early in development product. We don't really know what's going to happen a AI. How do we actually make policy, as some of you argue inhibit innovation? You may get it wrong. People are therefore more reluctant to act late in development, but it's too late. So how do we get it right is the question. I think it's going to take years to explore this together Going forward in my slide, I think what we need in the broader fashion besides innovation, is the mission driven equity based innovation ecosystem part where the government has to play a large role in thinking about its investment. How do you actually convert to social good, where innovation should be problem oriented and non profit? We need a package of all these regulatory policies, measures to make it work and have a nation that looks across national vision altogether. What does that mean for you? My last line, my second, last slide. I think we no longer, can we be scientists, simply say, I do the science. Hey, I'm a scientist, I do the science. This is what the rest of society should do. I think we need to have a shared vision of what we can do in the innovation ecosystem. We should teach students when they enter a laboratory or medical nursing school, public health school. To think along those areas, we have to develop really important scientific evidence. We need together help us evaluate and oversight. We embed equity as transparency principles and encourage equitable decision making and oversight responsibility. And of course, as I'm beating David, talk about this trustworthy signs. I didn't get into this today because there's not enough time nor my expert, but he certainly has not lot about this. We have responsibility, we have to advance opportunity with responsibilities. No longer can we just simply say we develop without considering the social implications. In conclusion, innovation has been phenomenal if you see where we are in public life expectancy. But also along with it has exacerbated inequities and create disparities. We need to start thinking about new ways of addressing this issue, about a mission driven based innovation ecosystem. Coy, Thank you very much. The first time I've given this talk, I've given the different pieces. But when I thought about putting all together, this is the first time I've actually put it together in this fashion. Thank you. Let me to on you, you very much. So we've got about 15 minutes for Q and A. Dr. Lanzo, thank you for a great talk. I really appreciated. I want to go back to your first question. I think it was cure prevent. It seems to me the I was trying to think, do I want to put my hand up? Yes, I think that's right. But thing that kept me from that, I want to see the word effectively in front of me, age because I think that there will always be other diseases that come up. And I think just myself, I had two parents that moved toward cognitive decline, and one, my dad died pretty early. And one, my mother has continued to live nursing home stroke, et cetera. If you look at the numbers, it looks like my mother has gone through effectively matched, but it's actually much, much worse situation. I mentioned that and see if you had our thoughts about that. I just want to say really quickly, thank you for hitting on diversity in equity so heavily. And I just wonder if one thing we could do that's relatively simple is change the way that we review. I do a lot of section shares and a lot of grants, but the way that we look at score from an environment, I know NIH has talked about getting rid of that, but that won't help either. I think we need to flip that. So places like my colleagues at Hawaii and Puerto Rico who actually have those rich populations and understanding of equity can be rewarded for that in having potential be funded. So thank you. Thank you both. Great questions on the first one, no question, effective is a part. Those are not my words, but Chan Zuckerberg words about can we manage? I say also equity. We can manage diseases, but not everybody gets managed either. We can manage things, but they may not be effective. So you're quite right. So this will be a clear modifier of the statement. Want to achieve that, Perhaps what we want to, that's our vision of trying to get there on the other one. Absolutely. I think this is why I keep emphasizing that they are within the powers of, in fact, our agencies to make some of these changes. I say the good news is that you probably agree with me. I've been around for a long time. You've around for a little shorter, but still long enough to see the change now in the attitude of NIH and others. I think that it won't surprise me if we put more and more change to the series and please be a strong voice in making those changes. Thank you, Dr. Such a, I guess where the question lunch over here. Thank you for this lovely presentation. Throughout the presentation, I kept thinking about Hela cells and I kept thinking about the consumer. And you, I think, did a really great job of saying we should care about the consumer, we should care about the community on your figure of all who needs to be involved. You presented the community, the affected communities is what that circle said. But you also presented at the beginning about uptake of science and medicine and mistrust because of these ethical issues that have happened in the United States and around the world. I think about equity, but in the form of the consumer. And how do you change minds of the consumer? We can legislate and we can, we can create policies for scientists and titans can't do that for the consumer. And I'm wondering what your thoughts are to rebuild trust among communities who just don't trust us. I think the days in which scientists says trust us is over to saying, well, we know the information. If I can only explain it to him or her, they'll get it. We certainly learned that unless you understand, people can simply believe that. You can say, I can teach you these things, right? It brings to the issue of behavioral sciences. How do you understand how people learn, perceive, accept, or develop back to ultimately trust? These are very difficult issues. We've done, a number of studies came on this issue. Thank you. Vaccine as example, first and foremost says that scientists have to know much better ways of communicating than the way we've been doing. All right, it's not grafts and data, it's listening and narrative to talk to people. But secondly is that it's really important to trust to people that you listen to them. First, what are their concerns? What are the issues? Do you understand how to address their concerns and whether your information gets to that point is starting point. Third is we certainly are not the best, most trusted voices. Although I think if you look at the national surveys are still quite good, right? But I think what you have to actually think about community leaders and voices, if you're going to access community who are the leaders and voices that they trust, and how do you work with them to get the messages across? In fact, they support your message. That's key. We all know about religious organizations, community places, et cetera to work through those things. I think finally, the way that you look at your communication tools, social media influences things like we have to really learn how to use it effectively. It's a lot more complex in the way we used to believe. If I stood up in front of a town hall of 500 people and I say to you, look at this data, don't you think you ought to do this? Those days are gone. I think that you really have to do a very Now the good news is that we have had quite a bit of effort at National Academy with relations with other members. Members of academy and minority members have actually done a lot of work on videos and messages to the community to talk about science. Greek is one of our members, have actually created a whole new initiative to look at how to create trust. Maybe David, you can say more words about your point of view, but no question is central to what we do. Think that trust is central, the ideal world. Trust is earned and it's earned by being trustworthy. Said not by saying trust us, not by wearing a white coat, by whatever personal characteristics you have. Not by your great storyteller, all of those things can help communicate messages. But in the end, especially for the long game, we need to show that we're trustworthy and we need to have trustworthy science. There's even evidence that when we say things with greater certainty in the short run, we may be more likely to convince someone to take an action that we wish them to take. I absolutely know this is good for you. Do it, and I'm a scientist and you should trust me. That helps in the short run. In the long run, what builds trust is to say, I'm a scientist and this is the process we use for science. And I have some uncertainty, and I know this, but I don't know that I may lose the battle today because someone else with more certainty will come in and say, I know that Dr. Oz is of the world. I know, I'll say maybe. But in the long run, I think we may win the war, even if we lose the battle. And too few of our fellows, I think in academic science are willing to lose a battle to win the war. Left Duke, a good friend from be Lord says science self calibrating part. The problem is a people don't understand the process of science call truth and non truth. Science is continuing to evolve and that's what they was saying. I think one of our effort has to be explaining to the public, certainly hopefully in the education K 12, the scientific process is. And how you can get better with better tools, how do you establish facts? But I'm not sure the word truth is easy to define. Again, thank you for an amazing talk. So thinking about this issue of trust and mistrust. And not to have you comment on anything politically. But we see that some of this is politically driven and there's lots of political viewpoints that led into science. And affect what the public trust about science, how do we communicate that, and how do we fix that problem? When you're talking about we need legislation and we need the government involved. But then I see a lot of senators making reproductive health decisions based on accurate. How do we fix that? You want to run for President of the United States? I don't know the answer, quite frankly, we're all exploring this. Maybe some of you have better thoughts than I do. But I think the starting point on the other side, as we've learned, talking to Congress and others, is understanding where the starting point is. I go to Congress, can sit down with Senator and say, here's Senator to do this, he's going to say it doesn't fit my agenda. You do have to understand what's a win for them. Where are they going from? I'll start with the following, and you may challenge this. I'll start with the idea that people who go public offices have the right intention, at least at the beginning. They want to do good. I don't get paid too much. Yes. Maybe you call yourself someone from Congress, but it's not an easy job. But I think they're very much drawn in by party politics and power over time. I do think understanding what actually helps them accomplishing goals, really important sometimes maybe right place. Second is narratives. Everybody will tell you. If you go to Washington, storytelling is lot more compelling storytelling of a patient from Bloomington who suffered, this is more compelling. Other bar graph. Now that's not to say graph is not important. Congress have staffers who study all the stuff too. It's not as if the ignoring the data, but I think what gets them going is this whole idea of how am I doing with my agenda. How am I doing to get people elect me? Say I'm doing good for them. And so understanding that can go a much longer way. But I agree with you. The environment is not that conducive for Reedy reason decision sometimes between the parties. I'm not sure I know the answer. We still try. I go to congress. We still try. You do the best. It is about 04:00 Time for one more shall. Why not? Dr. Mark, you still have a question. Oh yes. Right. It's a great lecture and very provocative and visionary, as big as Bush's vision in the '40s. The question I have is the implementation side of this. Every revolution requires funding. When you step back and look at what has happened through the covid period and wonder how has that changed, how we use our financial resources, what constitutes national defense? When the total budget is ten times bigger than what the NIH is receiving, the CDC is receiving only a fraction of that. So how do you stop what we've been doing to provide the space to do what you're proposing to do? There's no simple answer, right? You know that because we've been living through this the last few years. Just take Covid, you heard about bio very active in G. 27. People came together and then now the fatigue is gone. Right? You know what needs to be done and people are not doing it because of the short term issues within their own countries. You name it, right? It's very difficult. It does take strong leadership and I like leadership with a critical mass. I'm not going to political. I just simply say that the last two years it has been much better for us in terms of equity went to address some of the issues, right? Infrastructure dollars, you name it. That's strong leadership. That's comforting to here. Yeah, that's comforting to here. It is true. If you think about the, what it's called the great deal, you know, great new deal, right? I think in some ways, if there's a way to really explain what it's doing. Things that we have not done for a long time, things that we're trying to do. I think it could be transformative. Absolute. I don't know why it's not connecting from a communication point of view. People still don't think it because they go to the grocery store. It's more expensive, the gas is more expensive, the mortgage is not more expensive. So that's bad economy, right? This is a long term look at how we can change our society. It's very troublesome and this can all change in a few years. If it's done properly, it's what I would define as national offense. Why should we only play defense? Correct. Great. And I hasten to say this is not a political statement. I'm just making the observation it's tough to make changes. I guess one last thing I'll say is, the government serves the people. We elect the people to Washington and to your capital. That's the best we can say, is democracy allows us to say what kind of people do we want there and why. We just need to make sure that we exercise abilities. Thank you.