 Okay. Thanks, everyone. I think we're ready to resume with the open session. We're going to start today with a presentation of one of the working groups of Council. There are four working groups of Council, and we use them for a variety of purposes. One of their requirements is to make periodic reports to the full Council. So today we're going to hear from the Genomics and Society Working Group of Council. And the presenter is Dr. Malia Fullerton. She is the Chair of the Working Group, as I mentioned before. She's Associate Professor of Bioethics and Humanities at the University of Washington. She trained in population genetics and then transitioned to research on ethical questions involved in biobanking and clinical genetic testing. Malia is a co-investigator on the CSER and Emerge Research Projects that are ongoing at UW. Malia, there she is on the screen. You hear us okay? Yep, I can. So why don't you go ahead with your presentation? All right. Thank you so much, Rudy. And good afternoon, everyone. I apologize for not being there in person. Let me get my slides up. Yes. Thank you. It is my great honor and privilege to be presenting on behalf of the Genomics and Society Working Group that I currently chair. And I hope you're spending a few minutes today talking to you about some of the topics that we have been discussing over the last year and a half since my predecessor, Steve Jaffee, gave a presentation to counsel. So just as a reminder to folks of what the mission of the Genomics and Society Working Group is, and sorry, I'm just going to see if I can move my, there we go. It's to provide the National Advisory Council for Human Genome Research Advice on short and long-term planning and priority setting with regard to genomics and society activities at NHGRI, particularly as they relate to the ethical, legal, and social implications research program. The Working Group, which meets, has met virtually the entire time that I have been involved. I think it used to meet in person once a year. We meet in the fall and we meet in the spring and then we have a longer two-day meeting, typically in the spring. We provide input to program about LC research priorities, discuss with NHGRI staff the appropriate, thinking about the appropriate balance between investigator-initiated and program-initiated research, and advise and counsel on the best use of limited budgetary and staff resources. That's the overall mission of the Working Group. We have wide-ranging and, I think, very helpful discussions. For the purposes of my presentation today, however, I'm mostly just going to focus on one area where we've been having extensive discussions. Sorry, let me see if I can, there we go. Basically LC research priorities, and so I'm going to be spending some time describing to you about some of the recent research priorities that we have been discussing as part of a Working Group. Less, I think, by way of giving formal recommendations to counsel is more to kind of give a sense of the kinds of topics and concerns that have been rising to the surface. Here is just a brief description of the current Working Group members. I serve as chair, two members of the advisory council, including Kyle Brothers, who's there in the room with you, as well as Lisa Parker, who are also members of the GSWG. In addition, we have Shiniko Kaliar, Marcia Mipi, Gabe Lazaro-Munoz, Holly Pie, and we are very fortunate to have just invited three new members to the Working Group, just literally days ago, including Stephanie Russo Carroll at the University of Arizona, Beth Terini at Children's National, and Jan Wojcik from Johns Hopkins University. So we have a wide range of ethical, scientific, legal, and social science expertise that advise the group. It's a really wonderful group. I'm very happy to be working with them. So the last time the Working Group reported out to counsel was a while ago. It was in May of 2021. When my predecessor, as I mentioned, Steve Jaffee from the University of Pennsylvania was giving our report and at the end of his presentation, he ended with sort of three primary kind of summary points that really GSWG has been focused on thinking about challenges at the intersection of science and society, particularly as they had arisen in the context of the pandemic. And then, of course, the conversations abroad, national and indeed international conversations about racial justice that occurred in the wake of the murder of George Floyd, that the Genoese community has more work to do in its reckoning with the legacy of race and racism and that the LC community is in particular well positioned to assist the broader Genoese community in identifying and addressing these challenges as they touch upon genomics. And I wanted to sort of begin there at the beginning of my presentation because I would say that much of what we have been now talking about in the intervening period with the GSWG is trying to think about ways to assist and ensure I in thinking more concretely and operationalizing some of these goals of reckoning with the legacies of race and racism and broader concerns of health equity and social justice. So I will briefly touch on five emerging LC research priorities that we have been discussing and indeed have come up again and again as we have discussed various research programs that are either already supported by the NHGRI or that are moving into kind of future research support. Those include an emphasis on and thinking critically about social determinants of health and their inclusion in genomic research, broader and more in consistent attention to health equity as an outcome of genomic research, structural factors and social justice, thinking about gene and environment interaction research, which of course was the topic of a major meeting earlier last year as well as then thinking about genomic applications beyond health care. So I'm just going to briefly kind of talk about each of these areas in turn. So the first LC research priority that we've spent, I think each of our meetings since May 2021 talking about to some degree or another is thinking concretely about the role of LC research in the context of thinking about social determinants of health, social determinants of health, of course, is a sort of term of art, which describes measures of social, broader, social and cultural factors that may come into the measurement of genomic interactions and genomic effects with disease, but invariably involve the measurement of non-genomic factors. Inclusion of social determinants of health, which I think are broadly recognized as being extremely important to thinking about the ways in which biomedical risk factors lead to adverse health outcomes. Inclusion of SDOH in genomic research is clearly first and foremost a scientific issue and thinking about how to do that well and with methodological rigor. It's a scientific question, but there are related normative and ethical questions and ethical, legal and social implications that can be brought to bear. So in the course of our discussions, we have spent some time thinking about the ways in which not only must social determinants of health routinely be brought into genomic research, particularly research involving the interrelationship of genetics with common complex diseases. It must involve understanding from the LC perspective, it must involve understanding how and why studies of common complex traits need to be avoiding a tendency towards genomic determinism, where we understand that genes and non-genetic factors clearly are in a multifactorial way, contributing to disease outcomes and how best to design research studies to prevent an appearance of or misunderstandings with regard to genomic determinism. They necessarily and ideally would involve ongoing and extensive community interaction and engagement, not least because communities that are affected by particular adverse health outcomes are in many ways the best position to understand which social determinants are likely to be of the highest relevant relevance to particular health outcomes and will also be extremely well positioned to understand how information about the joint effects of genomics and social determinants can be brought to bear with particular health interventions and public health strategies. And it will also we have talked about involved developing sustained partnerships with researchers who have spent most of their professional lives, probably not caring about or actually having any direct experience thinking about the role of genomics in health outcomes, but have extensive experience in measuring social factors, social determinants in a population context, and those will involve, as we have talked about in the context of our working group, bringing other people in. Heart and parcel of the social determinants of health is thinking critically about the ways in which populations are understood and described, categorized and measured, and we have discussed in the working group the forthcoming National Academies Report on population descriptors, which we imagine will identify related methods and challenges that can be considered and interacted with in the context of the ethical, legal and social implications research program. So that's the first LC research priority that we spent quite a bit of time talking about in the working group. The second research priority that we have spent time talking about and really kind of grappling with our concerns with regard to health equity. Unfortunately, and I think probably everyone there would acknowledge many of the questions that have and continue to be asked about the role of genomics research in the context of population health and population health equity, many of those questions that we can ask today and concerns that have been raised, particularly in the last two years, are similar to those that were asked decades ago. It's like, what is the proper role of genomics information and genomics knowledge in the context of intervening on these large scale population health disparities that are pervasive, that are a huge concern, both to our nation as well as internationally. And action is clearly needed now to ensure that the genomic studies that we are doing and that the NHGRI supporting generate knowledge that it's going to benefit all patients and communities, including patients from diverse, underrepresented, medically underserved backgrounds. While a big part of the health equity conversation and one that I think has received a great deal of emphasis and importance appropriately so there at the NHGRI is enhanced workforce diversity. While that is important, the Genomics and Society Working Group has acknowledged that genomics cannot rely solely on people from underrepresented groups to be the ones that kind of bear the weight of figuring out how to break down research and translational barriers. This needs to be a concerted effort across the board. There are many ways in which these kinds of concerns can be addressed. One idea which has come up in the context of our working group is thinking about the ways in which more explicitly criteria could be brought into the program review process that would encourage investigators to explicitly address the potential for particular lines of investigation to tackle, extant and worrisome health disparities and to be explicit about the ways that health equity can be advanced as an outcome of particular programs of research. And so this is one area in which I think the Genomics and Society Working Group has has had some thoughts in this regard about review criteria as being important. It could be a matter of ELSI scholarship to kind of think more explicitly about what those criteria might be, how and when they would be applied, how we would measure whether the expectations or the kind of promises at the beginning of the research process, whether the outcomes match the expectations at the beginning of research and how to do that well in ways that will responsibly advance health equity. A third research priority, ELSI research priority that received a fair amount of discussion and conversation in our working group, has been the ELSI research priority of focusing on structural factors and social justice. Racism, structural racism and discrimination is a pervasive and important concern across all forms of biomedical research, including genomic research, and these concerns about structural factors and structural racism continue to be important challenges, both for the genomics community as a whole, as well as for ELSI researchers. In response, the ELSI research program have reorganized their kind of research areas to not only include genomic medicine and thinking critically about the ways in which genomic research studies are organized and disseminated, but also to include new areas, including social cultural, attention to social cultural values, as well as thinking about the correct pursuit of and implementation of genomics at the institutional and system level. This could be addressed in a number of ways, but what we have acknowledged in the context of our discussion is not only is sort of reorganizing the portfolio to highlight better the fact that research in these areas would be welcome and indeed is encouraged, but really the genomic society program and the ELSI research portfolio needs to be doing more and exactly how to do this, I think, is an open question. Maybe we can have some discussion about this to attract scholars from fields who explicitly study structural inequities and have this particular normative, ethical focus, not so much on beneficence, not so much on sort of autonomy and sort of things that were kind of bread and butter of ethical enquiries, such as informed consent, but actually thinking beyond to more kind of population level concerns and thinking about the concerns of justice and how we can best ensure that that that genomics research is not inadvertently underwriting or supporting racist points of view, that there can be no difficulty about research, programs of research and inadvertently being taken to underwriter or support that there are primarily deterministic genomic underpinnings for differences across social categories, such as race and ethnicity. So but there are people who do this for a living. There are people who have not traditionally been in the ELSI portfolio and we could do a better job of bringing them into our research and encouraging them to apply for grants and to become involved with our genomic investigations. Along these lines of fourth ELSI research priority, Genome is of which I think is more concretizes some of these ideas is thinking about extending the genomic research into more of a consideration of gene environment interaction. There was a very successful meeting held jointly with NIHS last year thinking about this and one of the outcomes we spent some time talking about it with the Genomics and Society working group, realizing that a lot of what we have focused on in the past are individual risks and benefits and making sure that we're not harming people as we're inviting them into the research process and and hopefully that they are participation and research will ultimately result in individual benefits. But environmental sciences, it's trying to do something slightly different, is much more usually focused on the community level. And as we move in invariably more into gene environment research and genomics moves more into the population health arena, we have recognized that the ELSI program will also need to be thinking about population level ELSI and learn from the practices that have been successfully pursued already in environmental studies, recognizing that groups that have previously been harmed, minoritized or abused in research are just as concerned, if not more concerned about harms to groups as to individuals. The ELSI program can help both in reorienting normative research beyond individual to population level research research ethics questions, but can also help guide the robust inclusion of community members as researchers. This could and probably indeed will have to involve new funding models, which will help to bring community members in as full research partners into the research process, involving them at the earliest stages of study design, implementation, as well as dissemination, because research that is conducted either in a health care setting or in a population setting. Ultimately, we want the fruits of that research to be sort of taken up and used by communities to benefit them. We're going to need to have community who are involved in that process directly involved in helping us to figure out how to do that well. And ELSI researchers who have some bona fides, I guess, with regard to doing work and working closely with community might be very well positioned to help with some of that work. Finally, a last research priority that we have spent some time talking about in the in the working group is thinking about the role of ELSI scholarship in the context of genomics projects beyond health focused applications and some of the ones that we have spent a little bit of time talking about are socio genomics, directed consumer genetic testing forensic applications. It is appropriate. We have argued indeed essential for the ELSI research community to engage with these non health applications simultaneously, although some of the in particular applications of genomic research to social and behavioral outcomes have been particularly have generated a lot of concern. We have also the discussion has focused on taking care not to let easy villains distract us from broader structural concerns that we argue should probably be the primary focus. ELSI can work and should work and support the rest of the genomics community in combating such misinformation. So that is what I wanted to share with you today. That is just a kind of a very high level overview of the kinds of topics that we've been focusing on in our working group. Folks there at program can can also provide their own comments about the ways in which our deliberations have been helpful in terms of decision making for the purposes of council. I think the three conclusions that I would like to leave you with is that just as was emphasized by Dr. Jaffee a couple of years ago, we continue to feel that ELSI research has an important role to play in guiding efforts to address ongoing important need to be addressed and ameliorated structural inequities and genomics research and genomic medicine. Priority needs to be given increasingly to population level analysis. This is true of genomics, but it's also going to be true of the ELSI research program, including sustained attention to responsible incorporation of social determinants of health, working to involve and include community in research at all levels and explicit consideration of health equity as a defined outcome of genomic research programs and that part of this work of necessity will probably involve broadening ELSI expertise to include new perspectives that have not necessarily usually been involved in genomics and society work funded through the Institute, but easily could be and indeed it would be very value added to have those folks as part of our research teams. So that is what I had to share with you today. Thank you so much for your attention. I'm very happy to answer any questions that you might have. I will stop sharing my slides. Thank you. Questions for Malia, Steve. Hi, Malia. Thanks so much for that presentation. You presented a number of possibilities and I think it would be useful to think about some sort of prioritization if possible to think about what can be actionable, perhaps. Obviously, one of the things that you mentioned was getting people who are experts in areas of research related to social determinants, health and equity into the genomic space. I could see that as something that possibly could be done a little bit more easily by having some specific workshops or some other types of activities. But have you given some thought about what types of things can can really be done quickly and effectively, obviously, money's a question. But I'll leave that to Eric and his pocketbook. Thank you. Yes, thank you so much, Steve. I really appreciate that question. I think it's an important one because I do think we realize that these research priorities are quite broad. The idea of a workshop is an interesting one, and I think that certainly could begin a conversation where we could be attempting to bring in people who are working more traditionally in health disparities research and social epidemiology and sociology, political science, for example, a workshop of that kind would be helpful. However, I would say in the context of our conversations, what we regard as being most helpful would be thinking about ways to either design calls for standalone investigator initiated projects or perhaps to be thinking in a more concerted fashion in the ways in which LC scholars have been embedded into other research programs of ways to encourage research, which would deliberately bring in people as co-investigators and would call for expertise, other particularly population science and public health expertise that is not typically been top of mind. I mean, we've had some success, I think, in bringing in folks with more implementation science interests, but of course, implementation science is very much focused on trying to get genomics applications into the health care environment. But as we move into more of a public health space, we'll need similar kinds of expertise that are I don't think those folks would fall in the implementation science bucket. And that's a little bit of what I think that in the portfolio is trying to be signaled by the focus on structural factors and institution level, system level impacts is a great question. Thank you. I'm not sure I'm not sure we have a specific recommendation, but that's my top of my response. Yeah. OK, I see Nancy Cox and then Tim and then Peter. Thanks, Malia. That was a really well organized presentation from your group. And I really appreciated hearing the the ways you're thinking about the future here. I think one of the one of the concerns is as we move to involving community more in our science, we had to face a bit of burnout in the community members that have served broadly in our activities in the Medical Center at Vanderbilt and making sure to diversify that community component. And enlarge it really to handle the number of people who now want to do studios with community members to do activities that include community members. And so I think it would be great to see a focus from your group in kind of best practices for creating larger community board activities. So it's not to burden people who who are willing to represent and and advocate for their communities. I think, you know, including appropriate payment and so forth is one thing, but it's just it's also really just figuring out how to make these committees and memberships large enough to basically serve all the needs of of an institution that wants to bring community members to the table. So it's a it's a complicated thing to make sure that we that we hit the right note. And I think your committee, your group is is in a good position to develop best practices around this. Thank you for those comments, Nancy. I couldn't agree more. I think that we definitely need to be kind of re I would argue, possibly going out in a limb here, but I will turn to Lisa and Kyle and others that we need to be kind of rethinking the ways in which we engage with communities. And this is part of the call of really thinking about community members, not just as advisory entities that we go to on an ad hoc basis and even with compensation for a limited amount of time, but actually more long a model, which has been pursued successfully by colleagues and other disciplines of if not community based participatory research, certainly community well, community engaged research, where you have community members coming into the research process at the earliest stages and letting you know what their health care and broader public health priorities are. It's it feels uncomfortable to us in genomics because it basically gives over some of the direction of our research programs to community partners. But in my experience, with that level of participation and buy in, you have people who continue to be willing to show up and continue to participate because they see directly how the research might benefit their groups. It is a complicated issue. It's one we can certainly spend more time talking about in the working group. Tim Reddy. Thank you so much for the presentation. I was wondering, you mentioned collaborations with NIH, NEHS briefly, and it seems like a lot of the areas that we're talking about here might align very closely with investigators over there. Have you thought or do you have some ideas on what you see as the opportunity or the path forward there and how to work with them or leverage those skills? Yeah, thank you for that. I am the chair of an advisory group. I do know that the NHGRI and the NEHS, you know, hosted a fabulous workshop that Dave Kaufman was very heavily involved in. I actually had a chance to participate. It was sort of, it was very eye-opening for us on the genomics side, because, for example, things that are sort of bread and butter for us in genomics, LC community, such as return of research results, just take on a completely different tenor when you're doing research in an environmental science context with communities who are concerned about community digmatization, but at the same time are anxious to receive any kind of information. There's been a fascinating conversation about about benefit and actionability and how to think about that. And the ways that we think about actionability in genomic research are very different from how they're thought about in environmental sciences. So I think there's tremendous work to be done. I believe that there is some in that workshop was a harbinger of future collaborations. I hope that will be the case because I think that there is very important information that genomics could provide about what I will describe as sort of pockets of vulnerability in a community health context and it's going to involve an entirely different skill set, I think, in some ways for genomic investigators. So I don't I'm not the right person to ask. I don't quite know what the future plans are, but I think I think it would be wonderful if the two institutes could figure out ways to to partner to support research programs. Yeah, that sounds fascinating. It seems like some great opportunities. Yeah, thank you. Linda, did you want to follow on that point or a new question? Hi, Malia. That was a very nice presentation. I really enjoyed it. I wanted to ask about the all of us project because I know one of the one of the real goals of that project has been to engage more underrepresented populations. So my question is, have any new insights or cautions been derived so far from all of us to your knowledge? Well, I think it's an interesting question. Thank you for that, Land. Great to see you. And all of us, all of this research program, in part because it's out of the office of the director, as opposed to, you know, a genome focused project, although it has a huge genomics component, has not been a major topic for us in the Genomics and Society working group. I think that they are very interested in LC questions. They have, of course, been doing some very extensive work with interacting with tribal communities, for example. There are people there in the room sitting around the table that I know probably know more about that than I do. I think that the the program has been spectacularly successful in bringing in people into population based research, including genomic research that have not traditionally participated. And so from that point of view, I think it can count as a success. Where this becomes interesting and how it relates to some of the points that I made about health equity is I think it remains an open question. The project is in a very early stage, of course, but it remains an open question about whether the degree to which the inclusiveness of that project is going to result in population health outcomes that are going to benefit the communities that have been brought into that research process. That has been the promise. That is certainly the hope. I think it's too early to tell at this point. But I do know that the project has made very good use of community partners throughout their governance process, and they also have a very open way of making people aware of the kinds of research that's being done. So they are prioritizing transparency. I think they're still working out the issues with indigenous communities and involvement in that project. That's my understanding. I appreciate any update from anyone who knows more. But I think I'm not sure that totally answers your question. It hasn't been a major topic for us, but it's certainly something we could talk about more in the future. Peter Robinson. Thank you, Molly. That was a great talk. One of the things I'm wondering about is so the issues you rose were our common to essentially the entire biomedical research enterprise. And so if there's a genomics project about a specific organ, typically that would not be funded by this Institute, but if there's something that's specifically genomics, it would. And so I'm wondering of the issues that you discussed. Did you identify some that are specific to genomics and not just general medical LC issues? All right. Thank you for that. That's a very interesting piece of feedback. I do think that all of the topics that I briefly alluded to in my presentation today are all we are always thinking about them and they are always inflected in the context of genomics research projects. So, for example, a lot of our discussion about social determinants of health arose initially both from concerns about sort of a structural racism and structural determinants, but also because one research program funded by the NHGRI, the Electronic Medical Records and Genomics Research Program, at least in its in its early information about stage four, had suggested that social determinants of health were going to be included with other risk factors in the in the context of the genomic informed research assessment. And so we had questions about how that was going to be done, whether it was being done, what what what kinds of social determinants would make sense to include in the context of a genomics informed research report that includes polygenic risk scores, for example. So so there's one example. Some of the questions about sort of population descriptors, thinking about race and racial categories as social entities in the context of genomic investigations, which are primarily focused on, of course, genetic ancestry and the ways in which people can mistakenly attribute biological outcomes to social categories of race. This is a particular concern for the genomics research community, which is part of the reason that the population descriptors work of the national academies is so essential and important. So so there's another example. I think the gene environment example is is already kind of self-evident. So I take your point that these are broader concerns that are not simply concerns of genomic research, but every single one of those topics that I refer to involve particular ethical questions around the pursuit of genomic knowledge. And so I do think that they are directly relevant and pertinent to the work of the Institute. Hal Dietz. Thank you, Molly. I found that to be a very informed and inspiring discussion. The one of the underlying themes, though, seem to be determinants of disease rather than social, structural or environmental determinants of good outcomes in disadvantaged populations and vulnerable populations who by many accounts should be having poor outcomes. Is there enough emphasis on looking to these disadvantaged communities as a source of inspiration and solutions, rather than as simply as a source of a population to be studied for their unfortunate circumstance? Yeah, thank you for that. I think that's such a wonderful point. I do not know enough about particular programs of research. I mean, I certainly believe that resiliency as a population phenomenon is crucial, and this is another reason why, in my experience, and we've talked a little bit about this in the genomics and society working group, when community members are involved from the earliest stages of research, they begin asking the same kinds of questions that you ask, which is, why are you focusing on what's wrong with my community and why don't you focus on what we're doing well, what's going well, the people who, despite something like April one risk factor for kidney disease, seem to be doing fine, for example, those kinds of concerns and questions about a more positive valence are the ones that communities, I think, definitely are in favor of. And I think it's a great question. And I apologize if I sort of went the way that I think we usually do, which is thinking about genetic determinants of disease as opposed to genetic determinants of health. But I do think it's an important question. I'm not completely sure of particular programs. I'm not sure that we discussed any directly in the working group. Others there in the room might know better about the possibility there. I think certainly there's potential to to ask and answer those kinds of questions, particularly when we're thinking about gene environment research and gene environment interactions. But yes, thank you. It's a very important point. Thank you. Laura Beirut. So thank you for the wonderful talk and just this discussion, I think, is showing just how how much interest there is and how salient it is. Nancy Cox and I just returned from this World Congress on psychiatric genetics and it has a large international group with it. And what I was really struck with is how many companies are jumping into the field of genomics and returning results. You know, one of your colleagues on the working group, Gabriel, was presenting there and talking about pre-embryo selection for psychiatric illnesses. You know, I met someone from Brazil who's starting up their company to give genetic results for educational attainment. And so what I'm seeing is just the businesses and companies are really racing very quickly and faster than we are moving regarding, I think, the ethical issues. And I kind of don't know what to do about that, but I'd love to hear your thoughts. Yes, well, I'm so glad that Gabe was there. I mean, he's been doing very important work in this area. Yes, I think commercial players in this space. I mean, it's of course very complicated, right? Because I mean, we all would like the fruits of genomic research to be where appropriate, responsibly translated, and that is going to involve public-private partnerships, for example. And but the kind of premature, for lack of better words, sort of uptake of some of these technologies and suspect applications like the use of polygenic risk scores in the context of embryo screening are very worrisome. There are investigators, including Gabe, who are already funded to do this kind of work. These are issues that we have begun to talk about in the Genomics and Society workgroup, and they are areas where I think it would be appropriate for LC scholarship to be encouraged probably more with a legal regulatory valence, because of course, a lot of these applications are able to move forward so rapidly, basically in the absence of any kind of regulatory oversight. So and I may be going a little too far. So apologies to people who know better. But I do think I do think that these are areas and questions that are of interest to us, rapid commercialization, and then the ways in which commercial partners work with public data, public reference data to advance their commercial goals is another very interesting area. We have not spent as much time, at least during my tenure with the Genomics and Society workgroup, talking about these these concerns. But I agree that it's something that we could spend more time in our work thinking about. I don't see other hands, but I'm going to invite Lisa Parker and Kyle Brothers as members of the working group, if you have any other comments. You know, I think Malia summarized, I mean, all of all of our work and conversations, very succinctly into five themes. I think you hit the highlights. I think the final theme that you mentioned of moving beyond what we have thought of as the strict disease and health space to look at other uses of genomic research findings or genomics and the commercialization the direct consumer does begin to get at this final suggestion that we need to be mindful of the promise and the perils of premature public-private collaborations or of private entrepreneurial advantage taking of early results and educational attainment, for example, where that falls in terms of being a health factor. I mean, obviously, well, it's a much broader discussion, but I do think that that fifth theme is something that touches on what what Laura was raising. Kyle, I'm just going to respond briefly to House comment. I think it there is a need to focus on positive outcomes and that works really well with methodologies that you can flip the other way. So Geos is great because you can look at protective factors, but a lot of this work looking at environmental factors, outcomes of various sorts that are related to health or maybe other dimensions of wellness. There's so much track record working on diseases that there's a lot still conceptual work, design work, design development of measures that still need to be done to do the kind of work that you're talking about how. So it is work that needs to be done. But in some ways, we're still at the ground floor of doing such such work. And there really needs to be a lot of fundamental work done to get there. Yeah. Thank you. Thank you, Lisa. Thank you, Kyle. Yeah. All right, Malia. Malia, thank you for really beautifully organized and well delivered presentation and thanks for sticking around to answer all the questions. Yes, of course, it was my pleasure. Thank you so much again, everyone, for your attention and I good luck with the rest of your meeting. OK, thank you.