 Super. So this is something that we're presenting to you for your information, and thoughtful comment, but there are no specific questions in that that we have at this point. So this is a meeting that's, as Eric mentioned, that we held in early January at the National Academy of Sciences. We actually had a very nice sort of impromptu partnership with Adam Berger, who leads the genomics roundtable there, and very much appreciate his help. That led to this, and we've reported to you previously on our genomic medicine meetings. There's a working group of council that's focused on this. And a few years ago, no, sorry, maybe a year ago or so, began to see increasing numbers of reports from various countries on sort of genomic strategies for healthcare in their systems. The first came out from the U.K., and actually this one's in January of 2012. The European Science Foundation came out with one on personalized medicine for the European system. There was an approach published from Italy. Another somewhat recently from Canada, Genome Canada, funded a number of programs that are moving genomics into clinical care. And it occurred to us that, you know, gee, maybe we should have such a strategy in the U.S. We actually held a meeting in May of last year to try to address that with various agencies, and there's still a number of things being followed up from that. But that was preparatory to really trying to get a number of these countries in the same room to ask, you know, what are the things that you're doing, how can we share, how can we build on what's going on, et cetera. So we sent out invitations, basically said, you know, we're having this meeting January 7th and 8th, and we can't pay your way here. But if you can get here, we can at least put you up and, you know, have a wonderful conference room at the IOM. And we also arranged for them to go and see the genome exhibit at the Smithsonian, which was a very positive experience, I think, both for them and the Smithsonian, and many thanks to events and others for arranging that. We were also very pleased to see we had 50 international leaders from 25 countries with a really nice representation of people sort of outside the Eurozone and the U.S. kind of Anglo axis, which was very interesting and unusual to us. These are the countries that were represented. We all gathered with about 40 genomic leaders from the U.S., including many members of our Genomic Medicine Working Group and NHGRI staff, and spent two days talking about this. And our objectives were much like they were the first time we gathered U.S. centers in genomic medicine to identify areas of active translation and implementation, sort of determine what common barriers might be and how we might overcome them, frame a policy agenda to the degree that we could, highlight nations with unique capabilities. So are there certain things that are going on because, for instance, there's an electronic medical record or those are biobankers, or the other thing, and then potentially discuss some opportunities for international collaborations? What we found was really quite surprising. I think certainly the many of the Americans were kind of thrown back on their heels. Aravinda said he was just floored by the number of things that are going on in some very relatively small and to us out of the way places. Not the U.K., obviously Genomics England announced its plans to sequence 100,000 whole genomes and link them to the medical record in the National Health Service. But in Belgium, there's a medical genomics initiative that's creating a national framework for clinical exome sequencing. In Singapore, they're beginning with a pilot test of sequencing a single gene to test for disease diagnosis in stromal corneal dystrophies, and I'll talk a bit more about this in a moment. In Estonia, there's a plan to sequence 5,000 individuals developing an Estonian chip and offer it to everybody, age 35 to 65 in the country and link it to their medical records. In Thailand, there's a pharmacogenomics card that identifies risk for the top 10 drugs causing Stevens-Johnson syndrome or toxic epidermal necrolysis, which I'll describe in a moment, as well as doing clinical exomes and genomes. Israel is finding a way to push family history data when a case of disease, typically breast cancer, but others as well, when that's diagnosed, finding a way to push that information to their first degree relatives in a confidential and privacy-protected manner to the degree that that's possible so that that information is then available for treating that person's siblings or children, et cetera. In Sri Lanka, there's carrier screening going on for thalassemia and modifier genes. There's a high prevalence of thalassemia in this country, and they hope to convert it to a chronic manageable illness. Luxembourg has a program for early diagnosis and stratification of Parkinson's disease based on genomics. Japan is implementing a three-component, actually multi-component genomic medicine project, including prediction of drug response, efficacy, and cost-effectiveness studies. And there's a genomic medicine alliance that I'll describe for you briefly that's attempting to bridge developed and developing more low-income countries. It actually has over a hundred members in various, some very out-of-the-way places, at least again to us, combining, for instance, eight national ethnic genetic databases from various places like Kuwait and Saudi Arabia and Serbia, et cetera, and economic evaluations going on in Croatia, Serbia, Greece. So we were quite surprised to see all of this. Just to show you a few of them in a little bit more detail, the stromal corneal dystrophies we learned are almost all, or if not exclusively, the ones that have been identified to date. Our genetic conditions, they're caused by misfolding or other abnormalities in proteins that then end up being deposited probably everywhere, but in the cornea, they lead to opacities and blindness. TGF beta-1 is a well-known risk for this, for a particular type of this, and I've forgotten which one, but there are a number of other genes as well. And what they did in Singapore was to identify this problem, identify it as something that they saw fairly frequently, and also as something where they had a willing group of clinicians who said, you know, we want to be able to do something about this, we want to try, you know, identify it preemptively and treat it. We also wanted to identify family members who may be at risk. And so they took it as a sort of a pilot example of something that they could move forward on. So looking at the clinical utility of this for disease diagnosis, treatment selection, and screening of family members, interestingly, this may not be evident on clinical exam, and yet if you're at risk, you shouldn't have certain things done to your corners, such as corneas, such as LASIK, or other such things. So important information to have, this was from Patrick Tan with a Duke collaboration with National University of Singapore. And they identified all the difficulties that we're identifying in our newborn sequencing program and a variety of other things, legal and licensing agreements across institutions and ministries that are complex, reimbursement options for genetic assays that cross medical centers, a general lack of genetic counselors and advisors, a common problem that we've come across here, and official policies on patient consent, incidental findings and aggregation of genetic genomic data. Doesn't this sound familiar? So wouldn't it be nice to learn from the efforts of their Polaris effort, as the pilot effort as they've described. They have this in the field now and they're hoping to expand to, I believe, about 50 genes in the near future. So that was Singapore in Estonia, a program approved by the Estonian Government Research and Development Council just in this past December involves healthcare, educating healthcare professionals, patients, and developing their eHealth electronic health decision support systems. Research and development, as I mentioned, sequencing 5,000 individuals and developing this chip and collaborating internationally. And then some hopes for commercialization in business agreements and IPR, this is from Andres Metzpalu. And so their pilot project is to sequence 5,000 individuals. They estimate that they'll get the SNV actually, the frequency down to about 0.1 percent, minor allele frequency. They would then propose or they're going to develop an Estonian chip of about a million SNVs. And then pilot that with 50,000 gene donors from the Estonian Biobank. The Estonian Biobank has been going on for a number of years now. And they're planning to do that during one year and link it to the primary care provider. Their eHealth database which is extremely well developed, one of the best in Europe, in fact, and decision support software. That's the pilot. Then the main project is actually to offer it to everyone in the country age 35 to 65. They estimate about 75 to 80 percent will accept and they project them. They'll have nearly or roughly 500,000 people in the database who have electronic medical record information, genotype samples, and longitudinal prescription data that can then be both mined for research as well as used in clinical care. As Andres points out, the system could be used as an additional instrument for physicians in diagnosing, treating, and preventing disease. And he refers to this actually as evidence-generating medicine, which is a little bit different from other ways of looking at it. But I think also the term has come into the U.S. as learning healthcare systems or that where one is able to use lessons learned from ongoing clinical care to improve that care in a research format. That's Estonia. Lastly, the Stevens-Johnson syndrome that I mentioned, Thailand has one of the highest, maybe not the highest, incidences of this disease, which they they have referred to and anyone who's ever seen it would refer to as a fate worse than death. Basically, after taking drugs to which an individual patient is sensitive, they proceed to sort of slough their entire skin surface, including internally, the GI tract, the respiratory tract, the corneas, and it's just a horrible disease. They have identified and show here that the prevalence of this, sorry, the incidence of this, hopefully people don't get it twice. But at any rate, these are the accounts that they have seen and in each of these places where there's an arrow, there are genomic markers have been found and utilized as predictive tools by their group. So basically, you can test for these markers and a number of them have been identified through genome-wide association studies and in other ways. And then preemptively, if you're concerned enough about it, avoid having those people get those drugs. So the first of these that was identified, to my knowledge at least, is carbamazepine and the HLAB-1502 variant. And you can see that that has the highest prevalence in this area where Thailand is and then it decreases as you get further and further away from that area. These slides are a courtesy of Boston Chandra Tita from Ramathbodi Hospital. And what they are doing now, in a pilot program, soon to be expanded if it works out well, is basically a pharmacogenetics card. So it's an ID card, essentially, that has the name, you know, first name and family name, the outcome of a pharmacogenetic assay that is run on every patient in this particular hospital. The date, obviously, the pharmacogenetic interpretation and that interpretation in this person is that they have a high risk of Stevens-Johnson from carbamazepine, according to the most recent available information. On the back of the card, then, is sort of the recommendation of clinical action. They have a high risk and if they take that particular drug, if you need more information, ways to contact that laboratory and the signature of the molecular pharmacist. So this is something that really, I think, captured people's attention and said, you know, this is a wonderful, wonderful idea to deal with a dreaded condition. And in fact, they have done some very nice cost-effectiveness analyses. Shown here is an economic evaluation for severe adverse drug reactions, pointing out that the cost-effectiveness ratio for universal screening in that country, where obviously the incidence is much higher and the minor allele frequencies are higher, at about 222,000 Thai Baht, which is about $7,000 per quality adjusted life year, gained for patients with epilepsy about half, a little more than half of that for patients with neuropathic pain. That is considerably below many of the interventions that currently are approved and used in the United States in terms of cost per quality adjusted life year. And interestingly, and I thought what was compelling here is that they only need to test 343 patients to prevent one case, which is really amazing. On the patients who are scheduled to get this drug, it would be much lower in a setting obviously where the incidence is lower. But again, this was something that I think really captured people's imagination. So having looked over a variety of these things, there was agreement that the products should include a base structure, a white paper, that sort of thing. We would like to continue international collaboration and communication through a variety of working groups and a steering group. We recognize that the leadership must be multinational and we're looking for leaders and volunteers. We had five breakout groups, which were the five working groups that you saw there minus the communications group. We realized communications was something we needed to add. And I've just shown here some of the top ideas from there's an IT Bioinformatics group that wanted to define key elements to be stored in the medical record, identify robust solutions. They were very interested in a global resource for actionable variants, which could build on our ClinGen resource that we're developing here within the U.S., an education group that wanted to propose defining workforce needs, developing tools that could be shared, including region-specific teaching materials. This links very closely to the work that we're doing with our inter-society coordinating committee here in the U.S. and there was great interest in trying to expand that beyond just the U.S. The evidence generation group, we had initially thought that they would propose large-scale collaborative evidence generation project, however that might look. And what they said actually was that there seemed to be enough going on that we probably want to first stop and kind of take an inventory of those catalog existing projects. Not a simple task when you consider the world, luckily there is a project funded by the European Commission, the EuroBio Forum, personalized medicine observatory, which is something that we might be able to build on. They are basically cataloging these kinds of projects in Europe, so might there be a way to then expand that to look beyond Europe and include others. We'd like to identify poolable or extendable projects and develop systems to capture evidence through the systems of routine clinical care so that hopefully it's not adding on too much more burden and get so much more generalizable population. In pharmacogenomics, Alan Shuldiner stood up and said, you know, we should try to basically address global eradication of Stevens-Johnson toxic epidural necrolysis, which would be a challenging thing to do, but wouldn't that be cool if we were able to do it? And I think there was a lot of enthusiasm for at least exploring how that might be done, at least in places where it's highly prevalent. And the pharmacogenomics card, again, was something that was quite attractive, I think, to many people. In the policy arena, obviously we need to share efforts in consent and results reporting and also, I think, a strong endorsement for studying economics and cost-effectiveness. I should mention that there were several groups that we were aware of and that we became aware of doing work like this. One of them is the Genoic Medicine Alliance, which is organized by George Petrinos from the University of Patras in Greece. And what he has done is basically managed to pull together a whole huge number of both developing and developed countries to encourage multidisciplinary collaborative research, facilitate introduction of pharmacogenetics, propose guidelines and recommendations, and develop and coordinate educational activities, all things that all of us are interested in doing. This is their website shown here. And one of the things that I think impressed us was that in some of these smaller countries, they had a certain nibbleness and flexibility to be able to move forward that we were quite envious of. And we're a little bit concerned that should you bring in some of the larger and more pondersome groups, you may remember in the 60s that the Bambi meets Godzilla film where basically you sort of end up with ruining the very thing that you are most enamored with. So we need to figure out how best to do that that would not really inhibit their ability to do the things that they've done so well. So our next steps were to distribute a meeting summary, an executive summary that's just been done over the weekend, establish a steering group and working groups, engage and leverage related groups, and we recognize the Global Alliance for Global Health is a group that's working particularly in the data sharing realm. We had hope to have representatives from that group at the meeting, but that didn't work out and we're hoping to make contact with them. We have tried in terms of how we might be able to work together going forward. The International Rare Disease Consortium is another group that's been suggested and the European Personalized Medicine Alliance, I think it is, is another, but there are obviously several others. We would draft a white paper, or circulate it to the group and hopefully submit it very much like we did with our first Genomic Medicine meeting. We'll share this information with other NIH institutes and centers and encourage their participation as we're encouraging their involvement in many of the Genomic Medicine things we're doing. And then the Genomic Medicine Working Group now feels a bit like we have a tiger by the tail or maybe a couple of tigers following the great success of the efforts in professional education. We have the Inter-Society Coordinating Committee that is keeping us very busy. We also have a number of collaborations from our May meeting with the federal agencies with the interactions with the FDA and with CMS and others. And now we have this group and so we're going to sort of regroup and try to ask ourselves what our priorities should and could be and where we might go from here. Before we have another meeting that gives us another tiger. So any thoughts that you would have on that would be most welcome. I think Howard, maybe since you were at the meeting I'll give you an opportunity to comment and then open it. Thanks, Jerry. It was a great meeting. I think there was not only was there a lot of evidence that things were going on across the world but there was very clear desire to try to have a United Nations of Genomic Medicine except more effective than the one in New York. And really trying to not reinvent things and the beauty is a lot of these things will be led by other countries as well as us. Not just the U.S. as its thing and other people are welcome to tag along. And so I think that was it was pretty clear that people were going after this in a very in the same spirit. Really not that different than a lot of the genomic things over the past while the HAP map, the SNP consortium, all these other things in the past where people just wanted to get things done. And so I think that was exciting. The other piece is that a lot of these things would not require a lot of money. There would be some amount of coordination and there would be obviously some stat, in a GRI staff time but it's people weren't didn't come to the meeting looking for money. They looked for it for collegiality, camaraderie, but more importantly really working together to solve these problems. So I think that part was was great. There the number of problems are immense and I think I think if you know we just can't take it all on but if we take on something like eradicating Stephen Johnson syndrome. Right now, there is still polio in several countries in the world. It's increased in Pakistan over the last years but the concept of eradicating polio caused countries to get serious and go after it. And so just the concept of eradicating an adverse drug reaction that's genetically driven will cost people to think about it differently than they do right now. It's just all it's part of the price of doing business whereas it could be wait a minute that's a preventable disease and let's solve it. And so I think we can change the language with this kind of a group. And often it might need the rest of the world helping remind us what to do in order to help change us. And we always bring an outside consultant to tell your bosses what you've been telling them for years. And this might be a similar situation with other countries helping us see straight. Great, thanks. Yes, sir. Terry, has there been an attempt to engage the World Health Organization? They've been very interested in tracking. I can remember the late great Roger Williams was actually on the Swiss air flight. Meeting when it went down in the middle of the Atlantic and trying to track people that have all the various mutations one to identify an indexed case. And I wonder if they might be in a unique position to help organize this worldwide instead of a very western Judeo-Christian look of the leadership. Yeah, no, that's a good point. Actually, Roger's efforts in the MedPed program which we're identifying of familial hypercholesterolemia heterozygotis were incredibly effective in finding cases. But I agree that would be one group we haven't reached out to them yet. All right, hold on there, Jane. I'm mindful of the need to keep council caffeinated in the fact that the cafeteria closes. They say 3.30 but sometimes they're doing that. So why don't we take a 15 minute break, be back here no later than 3.10 and we'll resume with the H3 Africa report.