 Good afternoon. As we wait for more of the participants to join, I'd like to welcome everyone to the 10th webinar of the Engineering Rising to the Challenge Initiative from Purdue Engineering. My name is Arvind Raman. I'm the Executive Associate Dean here in the college. And now this initiative started in May 2020 in response to the National Academy of Engineering's call to action for engineers to tackle some of the challenges of the COVID-19 crisis. And now our initiative also looks to the longer term future to really rethink and re-engineer the very systems that our modern society has come to depend on so that they might be more resilient to such shocks in the future while yet serving society better. Part of the initiative involves webinars where distinguished panelists unpack some of these challenges and provide us a glimpse into what the future might look like. Today's panel is about engineering health access, an issue that has really come to the fore, especially in light of pandemic, in terms of who gets access to what technology. And it is my honor to introduce the moderator for today's webinar, Professor Jacqueline Linnis, who is the Martha E. Gross Assistant Professor of Biomedical Engineering at Purdue University. Her work emphasizes the application of fundamental microfluidic principles and biological assays to develop point of care diagnostics and wearable devices for low resource settings in the US and globally. Research in her lab focuses on advances in paper microfluidics, molecular biosensors, and human centered instrumentation designed to enable sensitive, robust and rapid diagnostics for informed health care decision making. Dr. Linnis' extensive experience in translational research includes co-founding and managing early stage user feedback for three startup companies and leading health related quality of life assessments with engineers without borders in Bolivia, in rural Bolivia. She has co-developed mobile diagnostics wearable devices and airborne pathogen inactivation tools and water purification technologies as well with users all over the world in the US, Nicaragua, Kenya, Zambia, and Haiti. She applies these experiences in her teaching of undergraduate engineering capstone design courses, graduate level point of care diagnostics, and international workshops on human centered design and medical device translation. Over to you Jackie. Thank you. Thank you for that introduction. I'm very excited to be here with some fantastic panelists and talk to everyone about our engineering health access and how we can do better moving forward. What we've learned from the COVID-19 pandemic, where the opportunities are, and where the challenges are, how are we going to make sure that moving forward we're providing access to the people who need it and not continuing to overlook those individuals. So I'm going to share just a few slides that introduce our topic and our panelists. I'm going to start by introducing each speaker will have about three to five minutes. So I'll introduce each speaker and then the challenge. Each speaker will have three to five minutes to discuss their work and their contacts. Some of them have slides. Some of them I will be posting resources available to our attendees. And then I get to ask them questions. A few of you have already sent some questions ahead of time so thank you. And then the audience will continue to ask questions for the last 30 minutes of this. So our first speaker is Sanjay Malkani. He is an alumni of the Purdue Industrial Engineering and has an MBA from Northwestern University. He is incredibly busy and is currently the head of Lab Solutions at Lumira Diagnostics. He's also the founder and director of Jean Pace Laboratories, the director of Omega Laboratories and the director of Versa Holdings, Inc. These are all different ranges of diagnostics from point of care to centralized laboratory settings. And his previous roles include the global president of toxicology division of Lear Inc. And he helped in that sale to Abbott Laboratories in 2017, as well as leadership positions in point of care diagnostics and diabetes at Roche Diagnostics. He brings expertise in a global in vitro diagnostic strategy. And as I mentioned, on the point of care side from biologics to laboratory services, all the way to health information solutions. Our second panelist, Dr Natalia Rodriguez has a PhD in biomedical engineering, as well as a master's in public health, and she's an assistant professor here at Purdue University in the Department of Public Health, and it has a courtesy with my school where I'm at in the Weldon School of Biomedical Engineering. Her research focuses on the design of health technologies and tailored implementation strategies to address health disparities in underserved communities. Some examples of this are using community-based participatory approaches and multi-level determinants of health for mechanisms of uptake and adoption of innovative technologies that empower community health workers, strengthen health systems, and improve health outcomes for vulnerable populations. And she is going to be bringing a lot of that engagement of underserved and vulnerable populations in the development of diagnostics and talking about these aspects. Dr Zachary Haas is an assistant professor in both the schools of nursing and industrial engineering at Purdue University, as well as a core faculty member of the Registry Center for Healthcare Engineering, and he has a PhD in statistics and then did his postdoctoral training in health services research. His research is around evaluating policies, programs, and interventions that impact health systems and that serve vulnerable populations and older adult populations. So these applications are in long-term care, home and community-based services, adult protective services, and oral health, and he'll be talking about addressing implementation of innovations and understanding whether they're working or not working in the real world. Finally, we have Dr Sarah Wehe, who is the co-director of the Indiana Clinical and Translational Sciences Institute. She's an investigator at the Registry Institute, division chief of Children's Health Services Research and Pediatrics. She herself is a pediatrician and has a master's in public health, and she's also the associate dean of community and translational research at Indiana University School of Medicine. Her research focuses on health equity issues among children, adolescents, and young adults in order to improve health among vulnerable populations. Examples of this work include engaging community stakeholders and leveraging existing data, identifying mechanisms and opportunities for interventions, and working with patients and community to guide her research questions, study designs, and disseminations of findings. And she will be working in her co-director of the CTSI Institute, where she's asked me to post a number of different resources and opportunities available. Questions to consider as we go along this discussion include what advances have been made, have made these innovations possible? What is it about the current last year that has really changed things? How can we leverage future innovations to change and reach populations with limited health access? And how can we design engineering solutions to reach underserved patients from the start of the process? Lastly, where are the new opportunities and where do we go from here? And I'm going to ask the audience to help hold me accountable and make sure that these questions get asked. In case I don't ask them in my portion of the discussion section, please feel free to bring them up again in the audience participation portion. We have a number of innovations that have occurred in the last year. This time last year there was a huge outpouring and a desire to help. People were building and innovating and engineering and creating all these incredible solutions to help with the pandemic in its emergence. This is an example of some ventilators and masks and face shields that were made here at Purdue University. I dusted off my sewing skills and worked on creating masks, as did many, many other people, to the point that they were being given away to other individuals in the community. And there was just a lot of engagement and a lot of goodwill. Nowadays, we're probably a little more tired and ready to be done, but there's a lot that has happened in this last year. Now, we have these innovations. We have mass vaccination and we have testing sites that you can come to. And those have gone in some cases well, in some cases not as well. Here are two examples of news articles where they didn't go as well. There was a lack of access to the people that actually were the most in need and the most at risk from some of these mass vaccination sites. There were losses in distribution and you can see all these cars lined up. They actually ran out of vaccine because they didn't have enough. And so on the logistics side, there have been challenges and also on the development side. So, there is still an abundance of health inequity. We at Purdue University can go to the COGRAC or to our gym and get COVID-19 testing. It takes about two minutes and we are one of these dark blue dots on here in this map of the United States, but there are other parts in the state and in the country where it can take three hours to even get a test from using traditional methods. So, how is it that this has changed? There are point of care tests, there are home-based tests that are now available and I'm going to leave it to our first speaker to tell you a bit more because Sanjay has a wealth of information on that. But in the next few minutes and hour or so, we are going to talk about engineering that health access. And so I'm very happy to turn this over to our first speaker, Sanjay, who's going to give us that overview and talk about what we can be doing, where the opportunities are and how we can make this change. Thank you. And Jackie, can you hear me okay? Yes. Great, thanks. Sometimes I struggle with Zoom, but hey, thanks everyone for attending and thank you for inviting me. It's awesome to be a part of this panel and to really come back and get to participate at Purdue. I left Purdue with that kind of engineer's mentality that was taught to me to change the world or teach others how to do it. And to be honest, I was never a really good engineer. I'm at least hope for those of you in the crowd in the audience that would say you can leverage an engineering background into a successful career. You know, I went into sales from Purdue and then into marketing and then into general management and then into entrepreneurship and really continuing in general management so I kind of keep day job and night jobs now. But I am at a Gates funded company called Lumira diagnostics where we've distributed point of care meters all over the world to resource poor environments. And at the other end of the spectrum, I'm running a laboratory at least on the board and founder of a laboratory where I am today downtown Indianapolis called Jean Pace and we're a we're a covert laboratory where a molecular panel laboratory and will probably be the first in the world to launch a finger stick toxicology tests that actually tells you how much drug you have on board versus allows you to cheat through urine testing so so we're trying to innovate down here as well. And, and it's just through the grace of being a Purdue engineer and having that kind of mentality of one step at a time and thinking about changing the world that a lot of this stuff has been helpful for me. What I wanted to talk to you all about was really around that innovation side, and that opportunity side because I am not as a specialist and in any sense of imagination and any of these markets and really around testing but I think I want to acknowledge that the the global pandemic and the impact of that has been horrible for humanity and, and we remember and suffer and empathize with the loss. So I lost my father in the midst of all this and it was quite painful. At the same time, I think we've seen time, you know, in time again here examples of how from the ashes, something better can emerge and in this case time has been compressed. I want to cover three or four trends with you today briefly just to kick off the idea that first of all, from a diagnostic testing standpoint, there is incredible relevance right now to the COVID pandemic pharma has always been relevant, and at the table. The diagnostics has largely been irrelevant or unless you're in the hospital and I think one of the amazing things that you would think about whether you're working in industry teaching others or a student is how many of us a year ago knew or cared what an antigen or PCR or antibody test was now we talk about these things even brand names of tests, as if their names of drugs and I think overall, that's a real positive thing because in resource poor environments. You can't start the medical treatment without a diagnostic I think the second thing around relevance of this whole idea of resource poor is we found the developed economies were actually underserved, you know for a moment in time there which was pretty scary. And then what lingers in your mind as you think about India and Brazil is that we can't leave behind our global neighbors, and it's our accountability to bring them along so just awareness of what underserved really means when you feel it when you feel that threat, I think you can better empathize with what's going on around the world. You know, I think that I think the second thing I want to talk to you about is in your shoes and in our shoes in diagnostics and health care today. The capital cycle is so productive and it should lead to so much innovation I think right now I'll give you an example. And it goes to relevance as well in Germany right now, the government is funding and paying for home testing, and that's to the tune of 500 million tests per month at the point of care level. And the government is also reimbursing all the PCR testing at a lab level that comes behind it so the government is the primary payer for the pandemic in that regard. And so I don't realize that right now in America between cares one cares to, and the new Education Act. There's, there's 40 billion reserved for testing, an additional 10 billion for K through eight or K through 12 still to be determined testing which has already been allocated by the way and appropriated and 3.7 billion available for impact community healthcare and testing primarily this is testing I'm talking about so over $50 billion of capital out there. There's 20 separately available for reshoring of diagnostics and of health care, and there's all kinds of barter and DoD and government sanction programs to invest in innovation so now is the time capital is as available as ever, both non diluting capital from the government, and that number multiply it by 10. There is so much venture and private equity capital out there that we ought to be able to connect good innovation to to capital right so that's that's a really exciting time right so we learn and you know around awareness and relevance and we have capital now to back it up I think the third thing that's happened. In the last year is the innovation cycle right being in diagnostics for 25 years. You could count on three years from the time you thought you had something working till the time you might get it to market through FDA, you know maybe a year C but then you have toxicity testing stuff like that. It's remarkable right now and it leads to access and it leads to equity and it leads to to you know serving the community is that is that innovation cycle lab, you know lab to bedside is, you know, sometimes weeks to months, you can count on it maybe now at this point in history being six to nine months if you're just starting, and if you if you have a dedicated team. And really, by the time you get to a trial, you know and you enter into the EU a process or the CE process, you know you count on 60 days and you'll have a pretty good sense of being to market, if not sooner if you're kind of in a high impact area, such as lab pooling today with the FDA and preparing for schools, but but what I would say is the result of relevance and capital and the innovation cycle and I want to make sure this dawns on all of us. There used to be four to six companies at the table that really ran the decisions and diagnostics you had to compete with these four very large companies. And in fact, if you were a threat to them they would just buy you and you know good for the innovator maybe but not necessarily you know into market. What you've seen in the last year is hundreds of companies started out of universities and small laboratories, get to market and get to scale. If you have an idea and I'm looking at Jackie on my screen and I believe in what she's doing, don't give up, find a way to get funded, find a way to get dedicated resource and get out there because now is the one time in history. And I think it forever also changes in our lifetime, the innovation cycle shrinking. I'd say, you know kind of the finally final thing I wanted to talk about and I think you know the other speakers have so much more knowledge in this area is the final trend and macro I'm seeing is that as a result of relevance capital innovation cycle is just this business model evolution that's come along with the products and services. So, right now there's probably more diagnostics around the world being delivered in home by the numbers, you know, billion units just delivered a bid just delivered to the UK home testing a billion tests, by far in community care. So, so it's there's really this idea that if we can reach you at home, we should be able to reach you in your village we should be able to reach you where you live with diagnostics. And I think that's really exciting and developed economies. That means that the tele the telehealth infrastructure the delivery infrastructure, the test regulation infrastructure which has been really hard to solve all got moved 10 years earlier. So, I just want you to think about you know as you have an option to move forward here as speakers as as educators as students. You know just just what these macro trends do, in terms of innovation opportunity and access, because the road has now been paved to forever change healthcare. It is easier to get that funding, there's a short development cycle, and you actually can think about getting to home now that path has been paved and I think for years to come, you know the personal loss I've faced and many others in this in this in this global pandemic. And it'll be worth something for humanity, because the opportunities to enrich others lives are there and that's really a big macro learning for me and if we can be helpful at Lumira, or at Jean pace or any of these companies I'm affiliated with or the university. I know we'll find a way to do it so thanks so much and I appreciate the time. Thank you. That was wonderful. We are. There's, there's just so much opportunity and I'm happy that we have the chance to talk about what we can do rising from the ashes is a perfect description. So, Dr. Rodriguez Natalia would you give us a little intro into some of your work and and how we can do this and get communities to reach the right people from the start. Absolutely. Thank you, Dr. Linus I'm going to share my screen I do have some slides to share. Everybody see this okay. Perfect thank you. So thank you for inviting me I'm really thrilled to be here anytime that I can have conversations at the intersection of public health and engineering I'm like in my happy place so thank you for having me. I'm Natalia Rodriguez I'm an assistant professor in the Department of Public Health at Purdue University, and I also have a courtesy appointment here in Weldon. I'm a medical engineer by training I worked for many years in health technology development in the lab and through a couple of startups as well and specifically rapid diagnostic tests. Also had some unique opportunities to work for national and global health systems to understand the policy side of technology uptake. So I really wanted to be able to see the opportunities decide which technologies to adopt and why. And I found all of that quite fascinating, but never in any of those areas of work. Did I ever speak to an intended end user of any of those technologies. Not once did I visit those communities that would theoretically be benefiting from these technologies to really understand the context in which they would be used. I have a huge issue and a huge gap in my own training and my own understanding of health technology implementation and uptake. And what I have realized over time is that I wasn't alone in that. And as a field as as health technology developers. I've done enough to meaningfully understand the people in the context on the other side of the technologies. So I became really interested in that and decided, you know, to go back to school I studied public health and learned a lot about community based research. And that was a huge mind shift for me and that's how I ended up in public health. So I'll tell you about today is is almost entirely community based and I'm very fortunate to be able to still collaborate closely with biomedical engineers like Dr. Linus, and to serve a sort of a bridge between these two fields. So my research focuses on human centered design of health technologies, as well as community based approaches to design the implementation strategies that need to go along with those technologies to really ensure their uptake and their impact. So I'll tell you one about one of our largest projects just to share an example of the full process. This work is addressing cervical cancer disparities among Hispanic communities in Lake County Indiana. This is building on work I started during my PhD designing a rapid test for human papilloma virus or HPV the virus that causes cervical cancer. And Lake County has the highest rates of cervical cancer in the state. It also has the largest Hispanic population in the state and that community faces pretty significant cervical cancer disparities to its other groups in the area. So this here is a map of Indiana showing cervical cancer deaths, death rates by county and this bright red county in the corner that's Lake County in border Chicago. And so we are engaging all kinds of stakeholders in this community, all kinds of organizations to understand exactly how we need to design this rapid HPV test to make it usable acceptable. And so it actually meets the specific needs of this community. So we're engaging all of these different organizations doctors nurses community health workers, cultural and religious based leaders policymakers. And just trying to understand what the implementation of that test should look like who should administer it, where should it be administered, how might the health behaviors of the community. The change or be affected as a result of introducing this test, and what type of education needs to go along with its introduction to maximize its health impact. I'll answer all those questions and design of a resulting intervention of which the technology is then just one part. So this is a prototype of that rapid HPV test that we're working on very early prototype and currently under development but this is just one piece of a much larger and a much more complex puzzle, if you will. And we're learning a lot about what its implementation should involve in other communities that I've worked in and we're trying to bring some of that work here to Indiana. We learned that this process really needs to involve and start and be rooted in a community health worker or some other trusted source of information that can engage and outreach to vulnerable communities. We need to equip those people with the right informational materials so that they can educate those communities. And this also possibly needs to be accompanied by additional tools and additional innovations like patient self sampling, which is just one example for for patients who cannot or will not access healthcare facilities for for diagnostic testing. So I think I have one minute left but I will quickly share just echoing much of what Sanjay said earlier. More recently with COVID-19, all of a sudden this idea of how best to introduce rapid testing and who should do it and where we should do it and how it would change health behaviors all of a sudden these questions became super important this past year and on everyone's mind with the pandemic. So our other major project right now, more recently has been working with a homeless population here in Lafayette. This community experienced some pretty horrific challenges this past year with a pandemic I'm sure you can all imagine how difficult it is to keep everyone safe in a congregate shelter setting with people who already suffer from very poor health, have low health literacy and on top of everything. Shelters had to wait a couple of days, sometimes more to get test results back during the height of the pandemic and you already had, you know, countless exposures at that point in the shelter so it was just really, really difficult so we hired community health workers. They are based full time in the homeless shelter here in Lafayette. They provide COVID education, this is one of our community health workers Becca does a daily public service announcement at lunchtime talks about COVID talks about the vaccines. They also work to navigate homeless individuals to resources like their stimulus checks and insurance and their vaccine appointments. And we more recently have trained them to conduct COVID rapid testing at the shelter so we were able to obtain a clear waiver to do the testing on site. We are running these Abbott by next now antigen tests and that you know work in 15 minutes. These are three community health workers being trained on that. And that has been really effective and we're now, you know, trying to understand the impact of doing this kind of rapid testing on site in this type of shelter setting. How does that change behaviors what is the benefit of having community health workers administer this, along with the educational interventions they're providing, you know what impact does all of that have on the uptake of this technology. So very similar questions to our other project very similar methodologies but just a different disease in a different context. And I just wanted to mention we were able to quickly get this community based work off the ground with resources from the Indiana CTSI and I know Dr we he will be speaking about that a little later so I'll end there but I look forward to the discussion and the Q&A. Thank you. Thank you so much that it's really I'm always impressed I know we work together but I'm always impressed by the the actual engagement and when technologies hit the ground and and how much impact you're able to have for your work so thank you for sharing and I hope that we are able to leverage all of that good work as we develop new technologies and new innovations. But for now, I want to ask Dr has if you can tell us a bit more about how to know if these innovations are good and if they're working, because a lot of stuff works in my lab and then you know you get it out into the real world and and there's a whole different story to be told. So, could you give us a bit of an overview of assessment of innovations in the real world. Absolutely thank you Dr. Linus. So I'm a statistician in training and split between the School of Nursing and industrial engineering. And so my viewpoint tends to be maybe not so much a single thing although I'll work sometimes on a single say like a diagnostic test but we're often I'll be tasked with evaluating say a system change or a new program or a change in policy, although a lot of the principles are still the same. And I really like what Dr. Rodriguez had to say about, you know, dealing with the end user at the beginning of the design. And that carries all the way through to the evaluation as well. And so I spent a lot of my time thinking about, you know, how can we assess the impact of what it is that the innovation is trying to accomplish. You know, when we say it's good what do we mean by good what are the outcomes. In particular, what are the things that we can measure and how close can we get to that idea of good. And what kind of models can we use what things we need to control for what are confounding factors or lurking variables. And then a big one out in the real world is, what is your comparison group. And so in the beginning when you're developing something. It's a lot easier to run an experiment and get some good causal evidence. Once you get towards the end and you're implementing it, especially if people believe that something's good. Legislators aren't going to be too keen on saying, well, this is really good and our constituents want it. Therefore, let's deny it to half the people for a while and see if it works. No, it's not popular. And so with those evaluations, it's necessary to spend a lot of time thinking about how close can we get to causality. You know, what are some different creative ways we can create groups. I know a lot of different methods quasi experimental design and things like that and new things being developed in causal inference. But then around data collection, you know, where where can we get data how can we collect it or the processes. A lot of times, I'll end up seeing administrative data which is awesome because it's collected anyway, but it's not so great because it doesn't exactly know what you want or there's always these hidden things and how things are collected. But those are just things that I spent a lot of thinking about and then my perspective is also tends to be a part of large collaborative projects. So there's, it's usually someone else's great innovation and I'm interested in helping to figure out if it works. There's a lot of different stakeholders. And one of the things that I first thought when I heard the term community engaged research is I thought of, well that means you're in a community and you're engaging with with the citizens. And those citizens might be maybe the end users of something. And, and I think it's a little broader than that such want to mention some different individuals or groups that made up the community for an evaluation that I've been a part of. And the first one, it is often the end users. So maybe caregivers or consumers, the individuals are being impacted by the system change or what's being done. Other times it's the government itself. And they sometimes have an interest in regulating something or a budgetary interest. And if, if this innovation actually proves to be cost savings, you know, the idea that amounts prevention is worth a pound of cure, then that innovation suddenly becomes very, very popular with the government and then it has a much better chance. Other times it can be a private company like a software vendor. There was one time where the innovation was actually a module built in that the software could use, making itself more appealing to simultaneously help the service agency self assess themselves and, and show whether or not their services, namely an adult productive services was having an impact, which is something they really hadn't been able to do. And so it was kind of aligning both parties and building research into the equation. Another great one is community health coalitions. And these are groups of citizens who have gotten together, often at, at say a county level or city level, who are working on a problem already, and they know who the players are locally. They're motivated they're interested. And if you have a solution that's going to help them accomplish what they want to accomplish. They can help you do the research part they can connect you with resources with subjects with with whose permission to do what. So that can be really great as well. Another project, it was really key to engage with with hospital leadership. And so we were trying to get different health entities in a city to cooperate better on patient care transition, and having the hospital on board, and particularly the hospital leadership on board was key to getting everyone else on board. Sometimes it could be an entire industry so there was one time we were looking at a law change policy change that was going to impact the entire industry and reimbursement. And our job was to evaluate the policy and make recommendations on where it was working where it wasn't working. And one of the really helpful perspectives was how did the industry react to what we were proposing was what we were proposing going to be something they would accept or something they were going to fight all the way through, because really to be implemented and had to be accepted also the government and to the industry, and, and seeing both of them as partners rather as adversaries was was really important. And so, you know, it's dependent where you work in the pipeline sometimes you wonder well I already know I have theory that it works. You know it's good the numbers are good. It works well my lab testing why, why would I worry about evaluating it out in the real world. It's one of the things that I care about once it gets to that point. And so most of it. All researchers are caring about at some point is you know does it the innovation do what we say it does doesn't accomplish that one thing that primary task. But we can also think more broadly of what is the impact of this innovation. Are there time savings to that the healthcare workers. Is it going to make their life better or their financial implications is it going to save insurers money are they going to now want to pay for that thing that you've got, because it's going to save them money in the long run. Does it improve health outcomes is going to be popular with with consumers doesn't improve accessibility to care doesn't improve quality of life. You know, sometimes we spend a lot of time on can we prolong life a little bit, but it's also important to think about that that extra life is it is it good is it a good life. Our consumers happy with it and this gets a little bit into the qualitative aspect and that's often a good part of a design. Is it easy to use. Does it fit into the workflow. Is it trustworthy do do consumers trust it and that's a big part of access that sometimes gets overlooked. Do people not access a thing because they can't or because they don't think it's worth it. And that you know you see that a lot around vaccines in the current time. And is it isn't meeting a clear need. You know, sometimes we, we come up with an idea that's that's good and you meet something on paper but once it gets out there is it doing the job. Then also doesn't have policy implications. So, should a law changes the result of what we're seeing would a law change law change make the innovation more effective. Who should know about this innovation, what do they need to know about it can we make sure we're asking those questions and innovation. And then the last one I think about is is it sustainable. And so we do a lot of things around coven right now. And that's good. And then the question becomes how does that translate into similar crisis or similar applications or maybe even entirely different applications. How does it carry forward. And then as we're looking at things in the real world and seeing how it works doesn't need to be tweaked in order to be effective. The last thing we want us to spend years and years on an idea to see it get out there and then fail because it was just slightly wrong. And if we can figure out what that is and tweak it, then it becomes much more effective. So that's a little bit about my perspective looking forward to the discussion. I'll turn it back to you, Dr. Lids. Thank you. This is a great perspective and I, I think getting all the key stakeholders involved is really critical. You know, have gone from my little lab world view and expanded to the users and coven made me realize that we need to expand to the manufacturers that are going to make our devices, because we did not think about that when we were getting PhDs in making these technologies and even engaging the people to make them useful. But there's a whole range of stakeholders that need to be thought through. And as Sanjay said, the policymaking has changed quite a bit. And so that process is something that we as not the first ones getting things out of the lab didn't end up having to deal with but it is something that is ongoing and can shift backwards very quickly. So that's that's whole. All the stakeholders is really critical and I'm very much interested in how you do these assessments in the messy real world that it is. So before we get to that, I want to go to our last panelist, Dr. Sarah we heat and hear a bit more about how does one, how does one engage in this and how what are opportunities available to those who are interested. Thanks so much for the invitation to join you guys today. I am excited to share with you some of the resources from the Indiana clinical and translational sciences Institute for the Indiana CTSI for short to address the how of engineering health access. The CTSI's mission is to bring together Indiana's brightest minds to solve the state's most pressing health challenges. It's a partnership between Indiana University Purdue University, and Notre Dame, as well as leaders in life sciences across the state, including with healthcare systems governmental and state agencies, industry and community based organizations. Hello, it's co director with me, and there are deputy directors and navigators at each of our partner campuses so here at Purdue, George Wataka is the deputy director and Tommy source is the navigator. Okay, so what resources do we have to offer funding is generally our most popular offerings so I'm going to start there. I think Jackie's going to put a link in the chat to our website that has more of what we have to offer but I wanted to highlight a couple of things that I thought were most relevant to today's session. So first there's an open call for Community University partnership grants called the trailblazer award and the trailblazer planning award. The trailblazer award is a $25,000 grant for research projects and the planning award is the $5,000 award for developing a new partnership. So I encourage you to check those out applications are due on June 1. In addition, we have what we call project development teams or PDT's and these are one stop shops for funding and grant review. There's eight across the state, and you can go to any of them and membership includes from well funded scientists with diverse backgrounds biostatisticians regulatory support bioethics support. You can get rolling deadlines and meet weekly to monthly so you can get in at any point that you have a proposal that's ready. And you can come with a concept idea to a specific games page to a fully developed grant application for pilot funding or a grant application that you plan to submit to an funding entity for sort of a pre review by a mock study section. And that's a free service I should add which is really great. If you have the luxury of that time for review before submission which I generally don't. Finally, we have our new think tank teams, these are also one stop shops that focused on drug and device development for the purpose of SBIR or STTR applications and also commercialization. We're very excited to have just launched these in the last month or so, and includes members with experience and drug and device development, entrepreneurs regulatory expertise, business plan expertise representatives from the commercialization office from whatever, you know parent institution, the investigator is coming from, and really just helps along that that process, similar to the PDT's but for drug and device development. In addition, we have a variety of community engagement resources. Our community health partnerships program is for the arm of the CTSI that sort of assists with identifying community partners or university partners for community agencies. We have a pretty robust network of over 800 partners statewide. And we have free consultation. So please reach out to us if you have a need. In addition, we help manage the statewide chronic disease coalitions on behalf of the Department of Health and in partnership with the IU Simon Cancer Center. And these are wonderful existing partnerships and networks that we have in certain practices areas. So we have what we call Research Jam, which is our patient engagement core that Natalia was referencing I think a little bit earlier and this is our human centered design research service that basically pulls together stakeholders that meet a study inclusion criteria to really design solutions to research barriers and assists with communication strategies for things like research recruitment and retention patient centered outcomes measures, as well as dissemination of findings to a non academic audience. And in our most recent we know all these are five year awards so just in the last couple of years, we've initiated more work ourselves like beyond sort of providing research infrastructure to actually working toward impact ourselves. And is another layer of infrastructure in and of itself, and that includes some community impact tubs work with specific communities across the state and network of stakeholders around social determinants of health and one thing in particular that I wanted to highlight which was our Indiana partnership so we have a partnership between the Indiana CTSI and Indiana Family and Social Services Administration. And this partnership is called well being informed by science and evidence in Indiana. And essentially the state comes to CTSI is the front door for access to expertise across the state to respond to specific task orders that they would like to be addressed. And that would be sort of a policy or program evaluation or review the literature and serve recommendations on existing best practices. And despite the contract just being signed in May of 2020 we started in March, couple months before, which I think is a reflection of the trust between the two agencies that was already in existence on the coven evidence based rapid response team. And in real time we're responding to questions are over 90 in January alone. And we've engaged in network of library scientists as well as experts in a variety of areas, not just health but also in engineering and in ethics and education and, you know, public policy and so on. So we've done things on elder care, mental health and addiction and currently relating to snapper food stamps and food deserts and uptake in those services during the pandemic. So I'll stop there but I look forward to questions and more discussion. Thank you those are excellent and I tried to keep up and thanks to Stephanie for reposting to everybody since I sent it to the panelists and Aaron for the think take link as well. If I missed anything, please feel free to add them into the chat. We can get them back out to attendees as well. So that is the overview of what everybody does and how they're thinking about this. And now, we get a chance to ask questions, I get a chance to ask questions first but please post yours in the chat, and we can include those as well. I have so many questions. I think I'm, I'm going to start with Zach about the real world health innovation evaluations because that is very far from from my side of things and and I work in a very controlled environment, living in the lab and making things like work when they're working, but knowing that they do have to step out into the real world and then knowing that beyond that they have to get into the real world in a whole system that may leverage them or not, depending on things that are far beyond my control. So, how do you even start in these real world evaluations. So once, once you have a general idea of what is your looking at you know if it's a policy or a system change or a program change. I think one of the most helpful things and those evaluations that have gone the best is when we have a partner who lives in the real world so to speak. And it could be someone who runs a group in the government it could be that community coalition, it could be the director of the service agency, but it's someone who has some authority. It's been there long enough to kind of to know people, and so to broker connections to order access to data whatever it is they may have to allocate resources. Without that, it's really really tough. And unless of course you have have a grant that provides lots of money and you can can pay for all of those things but having that champion is really helpful. The next problem is, you know, getting to the data that you need, and does it exist already. And sometimes it does, at least in some form, and are there ways to augment it. Sometimes qualitative interviews can be really helpful part of the process. Nailing down the right questions and having those other perspectives from, I'd like to say that project champion from the other side so to speak. From their perspective that the people that they know who know the different aspects of the problem that can broker meetings and you can ask questions and figure out what it is that people care about, or what the different questions ought to be. Once the data is nailed down the next hardest part is coming up with some way to show the effect. Is there another group that is didn't quite get this intervention you know is there some kind of regression discontinuity that you can do where people only got it under certain situations. Is there some way to do some propensity match sampling. I think those are probably the toughest problems but the key has always been having a partner, someone who who can champion things from the other side. On that partner note, Natalia, how you you moved much of your research from Miami to Indiana. How do you develop those new partnerships. Who do you reach out to how do you gain the trust of the communities that you want to work with. And, and how does one leverage that for developing these new technologies. That's a great question and no one likes the answer because they take time and a lot of effort to build meaningful partnerships that are that are truly like mutually beneficial. So I think a lot of the timing was really ideal. Well, ideal or not, but I moved here and then six months later everything shut down because of the pandemic and so reaching out to people and meeting people and building those partnerships was really for that reason, but then also this opportunity kind of fell in my lap with this homeless population here where here was a community that was five minutes from Purdue so vulnerable so in need and really needed expertise and an intervention design, like immediately I think that was kind of just the timing and and all of that but in general, I think and I've had other faculty reach out to me about how do I engage this particular organization that I really want to work with. And honestly you just call you call or you show up and you start that conversation and you find out what's important to them and what questions they're trying to answer. And where you can be of use to them, and you look for the areas of common interest and start there. And if you're not someone who can pick up a phone and call or you have no idea what organization or what type of organization you would best partner with. I think the CTSI Community Health Partnership is a great place to start. And I'll mention, you know, this this homeless organization for example we already kind of knew what we wanted to work on we had very concrete goals and objectives and questions we wanted to answer so we went for kind of the big trailblazer that we mentioned. But there are small planning grants that are just 5000 bucks which are super helpful to just engage an organization to start off with and say like hey I'd like to plan, or meet a couple times and see if there's common ground here if there are ways we can help each other out. And here are my interests and here's where I where I think I can be helpful to your organization. And when you can throw money at that, it's usually very helpful because you need to compensate people for their time. So, I think those planning grants are really helpful and it gives you an opportunity to explore, and it's low pressure and if it doesn't work out there's no harm done and it was just $5000. So I would really take advantage of those of those opportunities and also just the expertise at Community Health Partnerships of like I want a clinic that works, particularly with women in this county or whatever I think they're probably the best place to start to help you find those partners. So that's my general two cents on that. That's definitely the advice that I've seen that's really useful and the keeping in mind like it has to be beneficial to your partner and you're not just wasting their time. And that's something we balance on the student side to like where we want students to learn about design and we want them to reach out to partners and we want them to build something that's useful, knowing that just like things that come out of my lab it may take years for it to be really beneficial. So having that support and compensating people from their time is really, really helpful. If I can just quickly add that's the importance of doing it at the beginning, because if you already have a thing you made, and you show up at the door and say I want to talk to you about this thing I made that's less interesting to a partner then if you have an idea or just a general question and you engage them from the beginning so that's super important to Thank you, but that's a good, good, very good point. So we already have an audience question. Thank you, Luke. And I was going to wait but it's actually one that I had as well for Sanjay which is all the rules have changed for getting diagnostics out. How do we know if they're going to stick around. If they don't stick around what do we do. And, and have they only changed temporarily from the business perspective, or is it something that has really shifted. And how do we leverage that. Yeah, so this is a great, a great question and there's a couple, there's a couple ways to respond to this and I think just raw unfiltered honesty and saying, I actually don't know is a good place to start but I'll give you in my opinion right with with this with diagnostics being so accessible and in our daily walk and I'm talking about obviously the part of the economy where you know we're privileged you know because there are still in recognition to the work that you see you see every day that it's there's not equity here, but that you know the working population and the home population that has access is now so used and becoming so used to getting what they need in a more convenient way that I think it's going to be hard from a policy maker level to hold back innovation now and also be honest with you, it may not be in very large diagnostic companies favor to have low regulatory bars, because that invites a lot of you know well funded but small competition. I would say, here's how you know that we have some time under this window and why I think it's important so the context of the overall answer is, it probably won't go all the way back to how it was, because we will all demand something different as a population now, but it most certainly won't stay with where it is today. Right, so the smart diagnostic companies are already beginning their 510k trials. So that's an important thing about the regulators a they're more accessible than ever. So this is the time when you're planning non COVID diagnostics to be on the CDC calls the town halls on Mondays the FDA town halls on Wednesdays, and to get your questions asked, because you can now we used to have to go through a consultant submitted pre ID spend $50,000 it kept small guys out. Now the CDC will respond to your question, literally within 48 hours, the FDA will respond to your question. If you're lucky, they'll talk to you about it on the town hall. This is a time saver and a money saver for everybody. The second thing is, as Tim Stenzel said, I don't know a couple months ago we don't see this order going away soon. Zika is still open, just so you guys know original SARS is still open five years later right. So there will be this opportunity and this strategy to tie what you're doing to COVID. And remember COVID has had just dramatically negative impacts on mental health so mental health diagnostics mental health resolutions healthcare can be tied to COVID. Think about missed medical visits and the importance of doing more medical screening and testing at home, because of COVID you know I can tell you right now unfortunately another outbreak is coming. Worst time ever for the J&J stoppage, you know creates a lot of negative pickup for vaccine. So what I would say, you can almost bet that we're all gearing up and diagnostics for a second wave unfortunately. And in the midst of that then home diagnostics home visits become something you attach to COVID so so the first thing is get your questions answered now for free while that window is open. Secondly, in your strategy to bring diagnostics out attach it to COVID. And the third thing is understand that, you know, there are we've talked about HPV today we've taught in cervical cancer we've talked about, you know that there's obviously hidden diagnostic issues with mental health which with hcv screening with Pepsi. You know, I mean there's there's just so much to talk about that we can rethink and frame in light of pandemic and light of learnings that will help. But I think generally the FDA works for us right they work under HHS which is appointed so I think you'll see political pressure to bringing diagnostics and making them more accessible, because this time scale this this innovation has been largely good for everybody. Look it's never going to be perfect it'll always be frustrating it's never going to be like it is now you know 90 days to nine months. But we have some time to think about how to attach things to the learnings and the relevance of COVID. And I think this window stays open for a while. But look, if you're making a you know a diabetes marker right now, you're in the standard 510k in fact you may be de emphasized for a while right. There's a lot of stuff that the FDA doesn't have bandwidth for and that has to be addressed and they're trying to address that because they admit that on the calls. But I would say it will go back to being pretty rigorous, but I don't envision it will go back to being the FDA and the regulators be as inaccessible as they were before. Thank you. That's, that's very encouraging for those of us who are on the very early ends of making our devices and also a little scary because now we have to be further ahead and everybody has moved very quickly forward and so on our you know in academia when we're expecting to not have to compete with industry, where we very clearly will get scooped by companies that have the resources to put behind it. We can we can really start thinking about other new problems. One perspective on academia and then I'll shut up I can talk a lot here unfortunately is. You know Jackie, one of the things that as you and I have even talked that the issue we have with academia is trying to recruit a postdoc or a temporary or someone to work on something under the university auspices which is important for the university and for the learning. But in addition to that things generally don't get funded for commercialization unless there's a dedicated initiative behind it and I think to the extent that the university can set up a way to have full time employees and postdocs working together, it would really help innovation move out from university and into market because it's so hard that that time for recruitment and people moving on and completing their work. It's so hard to replace people if they're kind of transient. Yes, and our big mandate is training new workforce development so creating creating widgets is a excellent side effect of my lab, but creating new PhDs and graduates and from the program is is really at the core. Yeah, that's something I have definitely struggled with this is how do we get technologies, even postdocs. They are also trainees they're learning new things and I used my postdoc to get into global health and diagnostics and I'm looking for people to do that but if you want technologies to move quickly and industry does it like there's a mandate and you're making a thing. So I know there are initiatives at Purdue that are helping translate technologies out the door and building community spaces to help get them up and running and I'd love to see more of that as a applied technology person for sure. So as as companies are doing that Sarah maybe you can talk about engaging the policymakers and engaging those users and where on the like how do we really hit these underserved populations that we're targeting. Clearly we can't just do it from the lab because Natalia has been really good about explaining that that's not how that works. But, yeah, how do we, how do we do this. Yeah, I mean I'm not sure I'm going to say anything that hasn't already been said today but I'll go out of shot. I do think that we need to come at it from like to the areas to really be getting the full picture here I mean the benefit of community engagement is that it adds relevance, you know it adds sustainability and if you don't do that from the beginning and sort of recognize that both the community and the translational researcher whoever that is or a team of translational researchers are both bringing expertise and they're both bringing data elements to that equation and it can only happen in sort of this engagement platform. And others have mentioned like starting by listening and understanding where that win win is and sort of, you know, starting with giving back is is really critical. As well as identifying, you know that potential partner that has that shared vision. And that's where I feel like we've been. We're just so lucky. I'm sure most of you recognize this but with the family and social services administration now and, you know, the focus that they have on evidence, evidence and you know science and wanting to work with the University. I mean, it's been actually amazing to me at how quickly that has involved as a partnership because of, I give all the credit to FSA. You know, there's been so many, you know task orders and sort of activity that it's just been like building the plane as we're flying it. And so getting from both sides, we are hoping that, you know, this will be a bidirectional partnership, I would say and up until now it is generally started with like a question or me that I have I try and be patient and listen and learn where that sort of, you know, opportunity is a bidirectional benefit but it up until this point has generally started sort of on the academic side I would say this is an example of where it, you know, I think is being driven by the state's needs which is, you know, phenomenal and and I've never seen so many researchers get so excited to, I mean they're getting paid for their time but essentially drop other funded work to like, you know, prioritize this on behalf of the state, you know, to get, you know, a timely and high quality deliverable. You know, it's like a drug, you know this huge incentive, especially I think for researchers who, you know, it takes sometimes a decade or more right for our fight for our research to get into into practice if we're lucky. And to be able to, you know, have this responsive opportunity to offer our expertise on behalf of the state and they're taking that, you know, and translating into programs and policy is is great. And that's translated into more grassroots engagement as well thankfully they're leaning on us and in some cases to leverage our community network and our trusted relationships to be able to be responsive I mean I think we've seen with the COVID pandemic. So operation work speed that you can't just snap their fingers and develop like you know hundreds of community partnerships. And yet, what we knew was going to happen and what has happened is these terrible health inequities, you know that have resulted, you know, because of the structural barriers and structural racism and structural everything that's sort of, you know, working against the most vulnerable, we have to actively work against that to be able to level the playing ground here. Right. And where there is not those existed trusted relationships, it's going to fall down. So, the fact that, you know, in this space and entrepreneurship, you know with the state, you know we can partner with folks who have those trusted relationships, you are able to respond more quickly you are able to get sort of that critically needed insight and expertise from the community in informing, you know, things that doesn't always happen so quickly. But we have been fortunate. In this case that, you know, some of that infrastructure was in place on which to sort of build because as we all know there's, you know, centuries of wrongdoing and challenges that, you know, we're working to break down and it's more than vaccine hesitancy, I think, you know, that's the other pep, and I'm going to be quiet because I can also say I got your rolling bottle it out for who can talk more about, you know, what we found is this actually because of our, some of our trusted relationships, like for the AstraZeneca trial, for example. They gave us three months to fill, you know, their target recruitment numbers with certain demographic breakdowns. We had sign up within 24 hours that met those requirements, you know, from our network. But what we saw was this drop off in enrollment numbers that sort of pointed to, we don't even know yet we're in the process of trying to figure that out but I suspect, you know, asking them to drive down to the clinical research center, pay for parking up front before they get reimbursed. I mean, of course, they're getting paid for their time, but it's just like all these assumptions and barriers that are sort of baked in to not make it easy, you know, we are not coming to them, we're expecting them to come. I mean, some of those things are perhaps not changeable, you know, with the vaccine trial, it needs to be under very controlled conditions. But we need to be aware of those barriers and like really, in my opinion, go out of our way to make sure that we have an, you know, an even playing ground here for folks to participate and engage, because it's not all about, there are trust issues, you know, there's that too, but it's certainly more than that. I can add to that too Jackie, building off of what Sarah was saying, I think there's also now a growing commitment to community engagement reflected in major federal initiatives, including CTSA programs but also minority health and disparities funding and there's this new NIH RADX up, you know, rapid acceleration of diagnostics for underserved populations. These types of initiatives create opportunities for that and mandate that and I think that we're seeing that, like, exponentially increasing over time so now is really an exciting time I think for engineering in public health because it's no longer enough to say I'm going to make a thing, I think you need to now demonstrate that commitment to engaging people in that process so I'm hopeful that this will continue to gain momentum. I'm with you. One of the questions that was sent ahead of time. Sarah, you did a great job answering most of this but it made me think, what are the barriers like parking like, you know, these these things that we're not considering when we're asking people to come, you know, get a vaccine drive over here to get a test like transportation is obviously one of them. But yeah, things like that you have. I mean, in my opinion, when I just took a recruit, we're trying to work on optimizing our recruitment services as part of the CTSA but because there's a lot of resources available that they're not as coordinated as perhaps they could be and so we're in the process of surveying investigators on like how we can do better. So I actually took it as a user. And, and when I was responding to that one of the things that wasn't sort of one of the list of things but I think it's really important is essentially how we communicate value of these research projects to the community. So that's starting with engagement and sort of having these conversations before you're recruiting right so you understand what's resonating with folks I mean, a story about how I got first and I was in a community, I wasn't like didn't think this is what I was going to do in terms of going in, I was interested in health equity issues but not necessarily going this route until I was doing this, this project with adolescent teens and we were tracking their locations and all the risk behaviors that they do, which, you know, a lot of folks back then as long years ago said it was not possible. But we did find some foundation funding and in doing that, found out that, oh yeah flyers don't work that say you know the traditional IRB, you know approved, you know blah blah blah blah blah blah. You know but we were giving teens a cell phone for many months to use with unlimited, you know, texting and all these things. Maybe you should highlight that, you know, after talking to them, you know, because 100% of people, like agreed to participate when we approached them in the clinic and explained all the ins and outs, but we had zero calls when we were trying to recruit from the community. After we had partnered with the teens themselves to try and understand what it was that was appealing to them and communicated, communicated that like we rebranded the whole project, it was called Pearl Girls, that dates the study right there. Anyway, so my point is is that I don't think we communicate well in general, unfortunately we get inadequate training on that I don't think we have the resources to spend on that oftentimes it's not recognized as the need. And it goes to the engagement piece. But then I think also just listening to an asking the question like what is it that you would need, you know what what appeals to you about this project and, and what do you see is like, perhaps the problems. I think part of the issue is like expecting us to know, because we're not walking in their shoes oftentimes right. You got to ask the question, you got to engage the population and understand from their perspective. I mean that's sort of a non answering answer sorry Jackie, but yes it is transportation is childcare it is that we're oftentimes not paying enough it is that we're expecting them to sort of accommodate sort of, you know our controlled environment. And perhaps we're not communicating best but I think the bottom line is, you know, asking and listening to the answer. Before you do that before you have an IRB, but then you have to recruit people to. Oh, great question. Well, yes. We do work with a lot of a lot of investigators in advance with research jam that that human centered design, you know, approach to get some ideas, I mean that is really the value of pilot studies in like probably the number one critique in the study is based on its recruitment plan. You know inadequacies. And, you know, the silver bullet for that is, you know, pilot feasibility data and experience right so I think from one of the many sort of funding opportunities to see CSI or otherwise you know sort of doing it on a small scale is really critical. Did you want to jump in. Yeah, just one of the barriers, going along with your question with older adults in particular is, does it require them to learn or use technology. So, you know if you're recruiting through the internet and it's an older adult population, you're only going to reach a very specific segment of the older adult population. I just want to toss that out there. I think that's an excellent point. I think that's very well taken as we're developing these new technologies that then require new skill sets but not everybody has or wants to develop. So, we are in our audience portion and we have already questions which is fantastic. I'm going to ask, as a biomedical engineering student at Purdue. Do you have ways to get involved in health equity through engineering lens on or off campus. I can throw out the Center for Health Equity and Innovation, which is actually out of the pharmacy school. A few of us are involved in from the faculty side of things. And we are in process of trying to develop things like a health equity certificate type program so that we can collect there's many courses out there and it's just a question of figuring out where they all are and what they what they bring together. If anybody else on campus wants to highlight some more. I know I have a biomedical engineering student who's actually working with Natalia doing public health side of things and the community engaged research to have a much more applied work that they're doing so anybody else wants to jump into I'll add that. I think Jackie and I are in particular are interested in creating these opportunities for interdisciplinary work where engineers can can work in health equity topics but I think in any biomedical engineering by definition you're working on some kind of health related topic health equity will more than we like relate so I think what's important is to understand and ask your professors ask your PIs. Who would ultimately benefit from this thing we're making or from this topic that we are working on in this class, and you kind of do the legwork reach out to three, four people that fit that stakeholder group, whether it's doctors whether it's patients. If you need help doing that I think again CTS is a great resource or please reach out to me. You know there's always someone who's willing to talk to you. And so reaching out to people who will ultimately benefit from the thing you're working on is a really great way to understand where the equity issues may be, and how to bring that light into your work so so I just wanted to say that because you need formal projects rooted in health equity to bring a health equity lens to your work. I would just mentioned to you there's oftentimes various student internship opportunities through the CTS I so I would encourage folks to reach out to community partnerships if you're interested in something that's more of like immersive experience but like one of the kind of statewide you know they're in you know West Lafayette as well and I don't know specifically like how the biomedical engineering you know lens could be applied but I think if you sort of approach it with some creativity and openness that there probably will be ample opportunities there so. You can bring your interest and your desire for health equity to, as Natalia said to whatever it is you're doing. I mean that that can expand what the current lab is working on if they're working on a technology that's not necessarily targeted. In that way, bringing that up as a priority and making sure that the technologies are able to reach the broadest population possible is really going to be critical and thinking about okay who does this not serve. We have this great new device for home health care that doesn't actually work for the age of the population at home. And honestly you're going to bring new ideas to your research and your courses and we professors think about a lot of things but we don't think about everything necessarily. Please come feel empowered to to bring those aspects to everything you do. Another question from Carsten is, and I'm going to read it out this pandemic has given rise to groups disregarding the advice of highly educated professionals within stem. What can be done to mitigate the bureaucracy preventing underrepresented communities from obtaining help. What's the best way to get through to individuals who are not who don't necessarily have the education or the understanding. Regarding adoption of emerging technologies so. For example, vaccines lockdowns hygiene mask the use. How do we reach out to everybody. And, and help them to understand it sounds like Sarah you mentioned a lot about communication challenges and fixing those. Yeah, I mean. I hear what you're saying but I think there are reasons underlying that that go beyond differences in education or understanding to. I guess I, yeah, this is sort of hard to unpack without sort of like, I think, fully engaging and understanding. I mean, I think there's a lot of, I mean, fake news and sort of understanding like competing, you know, theories and information that's out there. I'm not so sure. I would challenge at least whether there's like a uniform just disregard for the educated in the science. I think it's just like a lot of distortion and clouds in sort of in the way. And so I think starting with the conversation and with some trust building activities and understanding where somebody is coming from and understand, you know, and from that may emerge. A deeper understanding of why somebody may not be engaging in a particular activity whether it's not knowing or thinking that it's not a true risk. But then I think the other aspect of it is like channeling those messages through trusted venues. I think a lot of our messaging is coming from a sender if you will that is, that is not trusted. And then from our perspective like, I mean, the CDC what the CDC says, you know, what the, you know, this New England Journal of Medicine article says is like, you know, is not to be challenged but that is not the case, you know that those are not really the trusted folks people. And so I was sort of wanting to ask Natalia maybe I'll pitch this to you to, I mean, I think the value of community health workers in particular faith community I could go on and on like you know there's specifically about thinking about those types of folks as intermediaries and ambassadors, if you will, to sort of carry some of these messages forward and understanding, you know, from those they serve, you know, what what the correct messages may be is oftentimes a very efficient and effective way to go. Then Natalia has way more experience though this arena so I'm going to pass it over to you. Yeah, no, I think that's a great point and I think community health workers. It's a buzzword for just someone who's a member of those communities that can be that link to health system to the social service system and like Sarah was saying provide that two way street of information like here's all the resources available to you and how to access them and how to navigate them, but also communicate back to the health system this is the needs and the beliefs and the issues of this population. So I can talk about community health workers all day long but I will say this, this issue of, you know, I'm reading the question again about people not understanding or not having the education, you know, I would also push back on that because the, like the best way to help individuals who don't possess the education is to educate them and so I think providing also through community health workers, you can do that you can empower communities you can provide that information. I think also for particularly for communities that have been historically underserved or actively disenfranchised by our health system or other systems. It's especially important to do that. And I really dislike, you know, we hear this all the time now in the media about vaccine hesitancy and lack of education and I really dislike those terms because I think they place a lot of blame on the individual as opposed to the system that has really built this mistrust and has actively, you know, cost a lot of harm to to those links with with people so so yeah I think community health workers like this is a hill I will die on they are the answer to so many things that from engineering and health technology design to to policy implementation I think all of it is really dependent on having trusted sources of information in both directions. I'd add a couple things from from a regulated industry perspective so to have some experience in the drug testing or toxicology industry having, you know, built and run and sold tab at the world leader in that space and I would say, what's different about Kobe and this is really important to understand, you actually don't need an emergency use authorization for a lot of testing. You do if you want to do testing that is free of liability, and I want to make that clear, right so. If you're doing surveillance testing, you technically don't need any way. If you're a high complexity lab, you can always operate under an LDT and we do a gene phase for certain tests not covert of course. And the reason that everybody is pursuing any way is not only for that mark of quality and approval, but to allow the manufacturer to operate without liability. The same as for vaccines part of project warp speed was removing the liability constraint from the vaccine manufacturers. So I want to I mean I'm just I would just make this clear so part of the answer here is when employers are held accountable for the policies they're implementing at work. You will see a lot more information that is probably skewed towards being conservative with this virus than being liberal with the virus meaning it's not just free and fancy. When you've got people working, you know two feet apart in a manufacturing facility and they get sick today nobody gets sued. The minute that liability comes back, I think you would find the information resolves discreetly around the science, right. And I just want to make that distinction, you know politics very county to county state by state. When there's liability on the line you will find best practices really begin to organize. I think also we have to be mindful and I want to reemphasize, you know Jean Pace labs is down here in an impact community in downtown Indianapolis, I don't really know how to test this community. And if I'll get paid, I want to do it, but I will tell you this they know nothing about this virus, and that is a shame the number one thing we could do is educate the communities that need to have a job every day of their life. And when they go to work, you know if they're not feeling well, they can't go to work and many people here in the middle of Marion County. Don't even understand the basic things about that they have free access to testing and free access to vaccines, nor do they have transportation nor do they have the digital tools to sign up on and on and on. So it's not really that they're debating policy. It's that they have the lack of the fundamental access to education. And we want to be part of the solution we located down here to do it, we can't get a clear answer, we got doctors willing to give vaccines and we got tests, all kinds of capacity for this community. I don't know who to partner with to do that. And that's part of the issue to you know when people in the state don't know how to help, because there's no clear infrastructure but but I would say, remember that we all operate free of accountability and liability for now. When accountability comes primarily to the people paying taxes the employers, you will find the information organizes pretty quickly around mitigating risk. That is an excellent point and I think that yeah where you're getting the information from it needs to be from trusted sources, and you're likely to get it if the people who are giving you the job well employing you you're helping them. If they actually care, if you get sick, they're going to start paying more attention. And to, to Natalia's point the, the trusted sources. I learned about community health workers through global health projects like you come in from across the world and you're like hey we have this thing for you. Nobody's going to nobody wants that. Why should they want it down the street from me, if they don't know me either. Of course we should be using trusted community members who are leaders to do this and so yes I'm following you up your hill Natalia. And then, Zach you, you had been unmuted at some point and did you want to add to that and this was just going to kind of highlight the point that's been made a couple times is, you know, I, we would like it to be a simple straightforward solution you do the one thing and everything's good but it's a complex problem and you know there's different populations as Sarah was talking about who are motivated by different things coming at it from a different place. And so what may be the lever for one population is not going to be the lever for another population. And so just being careful to figure out what the need is for a particular group is going to be the best way to find a solution for that particular group. And within that group it's going to change person to person within one family you may have very different reasons. One maybe because they are not the head of the family one maybe because they don't care one maybe because they have wrong information they don't quite have enough information they can't get there. There's, there's a lot of ways that this is a complicated messy problem. So we are about out of time though. And I'm really glad we had this panel, I think Sanjay that we will be able to connect you to CTS I and to the many different communities that are so that we can, we can really get the people with the technologies to the people that would benefit from them. Thank you to all of our guests for joining us and sticking around for this panel. Thank you to our panelists. Thank you to Dr Ramon and Stephanie for coordinating and making this happen. This has been a wonderful conversation. Thank you all for joining us for a discussion on engineering health access.