Transcript

SHELLI AVENEVOLI: Good afternoon, everyone. Welcome to the NIMH Innovation Speaker Series. We’re gonna wait just a minute as people join the webinar.

Good afternoon, everyone. We’re just watching the numbers, waiting just a few more seconds for people to join the meeting. We’re excited to have you here today. It looks like numbers are slowing down. So, I just want to welcome everyone to the NIMH Directors Innovation Speaker Series, and we’re welcoming Dr. Anna Wexler today. She’ll present on Beyond the Lab: Navigating Ethical Challenges of Emerging Neurotechnology. I think we have some initial points to make.

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Back to you, Dr. Avenevoli.

SHELLI AVENEVOLI: Thanks so much. So again, welcome to those just joining. We’re really excited today to have Dr. Anna Wexler with us to present our Innovation Speaker Series. Again, the title of her talk is Beyond the Lab: Navigating Ethical Challenges of Emerging Neurotechnology.

Dr. Anna Wexler is an Assistant Professor of Medical Ethics at the University of Pennsylvania Perelman School of Medicine, where she studies the ethical, legal and social issues surrounding emerging health technology, with a particular focus on neuroscience applications. Dr. Wexler is the recipient of a 2018 NIH Director’s Early Independence Award and a senior fellow at the Leonard Davis Institute for Health Economics. She received her Ph.D. from MIT in the history, anthropology, science, technology, and society program, where her dissertation was on the do‑it‑yourself brain stimulation movement.

Her essays have been published in outlets such as the New York Times, the Washington Post, Boston Globe, Slate, and STAT. And prior to her Ph.D., Dr. Wexler worked as a documentary filmmaker and science writer. She co‑directed and co‑produced the featured documentary film called Unorthodox.

So today we’re actually going to hear a pre‑recorded preparation from Dr. Wexler. She is recovering from some health issues; so, she wanted to pre‑record that for us. However, we’re very fortunate that she’s also here today. So, she will be here to answer your questions. So don’t forget to put those in the Q&A function below during the talk.

Thank you, and welcome.

(Video presentation)

ANNA WEXLER: Good afternoon, everyone. I’m very pleased to be here today. I’m gonna be recording this talk in advance, but I will be present for the live Q&A. So, I’m going to go ahead and share my screen.

Okay. So, my talk today is called Beyond the Lab: Navigating Ethical Challenges of Emerging Neurotechnology. So, what do I mean when I say, “beyond the lab”? Well, when most people think about science and medicine, they conceive of them as being conducted inside the laboratory or activities that stay within the boundaries of a hospital or clinic, and I think a lot of people have this sort of idealized conception of when and how advances in basic science in the laboratory should move beyond the laboratory and translate to treatments and therapeutics.

So, you’re probably familiar with some version of this flow chart. This one is specifically about the pathway for medical devices, but in principle there’s a similar pathway for drugs and biologics, where you have discovery and ideation, invention and prototyping, pre‑clinical and clinical testing, regulatory decision, like FDA approval, product launch, and post‑market monitoring.

In this version of this flow chart, it’s only at this stage, at the product launch, that scientific advances funded by institutes like the NIMH, for example, move outside the lab and reach the general public. But that’s not always how it works in the real world. So, science and translational medicine do not always proceed in a sort of neat linear fashion. So much of my research actually has focused on better understanding the places where information and technologies move beyond the lab really in unexpected ways; so where this idealized pathway of translation is disrupted in some fashion and specifically where the public has access to either information, products or technologies in ways that the researchers doing this work and the funders funding this work really did not intend and maybe even had not foreseen. And let me give you some examples.

So basic science and clinical research results are traditionally published in academic journals, which are really geared towards other scientists, scientists writing to an audience of their peers, but because of the internet, the public now has much easier and much earlier access to the results of research.

So, information about science flows a bit more freely than it used to. And so, this has led to the rise of do‑it‑yourself medicine and citizen science, where lay individuals are reading about experimental treatments and therapies, and in some cases‑‑ in some cases where it’s possible to do so, they are self‑administering treatments before those treatments have been properly vetted and approved. And in other cases, companies are taking the products and technologies of science, even those that are really just still in development, and they’re marketing them directly to consumers for wellness purposes in ways that circumvent FDA authority.

So, essentially, they’re not proceeding with medical device approval, but they’re taking the same technologies, not making any medical claims, and making them available directly to consumers without the need for physician direction or physician prescription. And finally, in other cases, even once a product or therapy does obtain FDA approval and the product is out there in the world, has been launched, it can be co‑opted in ways not intended by scientists or original developers of the technology, such as in alternative medical uses of biotechnology.

So, my research, I would say over the last several years, has examined different kinds of do‑it‑yourself medicine, direct‑to‑consumer products, and alternative therapies and the ethical issues that they raise, but I really spent most of my time thinking about these developments in the context of neurotechnology and mental health. So today I’m gonna be talking to you not just about do‑it‑yourself medicine and science as a whole, but specifically about do‑it‑yourself brain stimulation. And while I’ve done work in direct‑to‑consumer products writ large, today I’m gonna be talking specifically about direct‑to‑consumer neurotechnology. And while I’ve written about other kinds of alternative medicine and the ethics of alternative medicine, today I’m gonna be talking specifically about alternative neurotherapy.

Before I go forward, I just wanted to say a really quick word about why I think it’s important to attend to uses beyond the lab, beyond this traditional pathway, especially as the work that NIMH funds and the work that mainstream or traditional investigators do is very much focused on this pathway. And that’s because, as we saw with the COVID vaccine, just focusing on the development of the vaccine or any kind of therapeutic or any kind of treatment without attending to these larger social issues at play regarding public acceptance, public understanding of science, how the public interacts with these technologies, that can be detrimental, I think, in the end.

I think that means that we’re missing a piece of the puzzle here, right? So even when we get to the stage of product launch, as we saw with the COVID vaccine, that doesn’t mean that the public will accept it or in the future accept a given treatment or therapeutic. So, the public is getting information in all kinds of ways and interacting with different technologies and the healthcare system in certain ways, and I think it’s really important for us to attend now, right, and not later to all the ways that the public might be utilizing devices and interacting with devices and techniques for mental health.

So, I’m gonna be covering these three areas today that you saw in that flow chart, the do‑it‑yourself brain stimulation, direct‑to‑consumer neurotechnology and alternative neurotherapies. My research has approached these phenomena from a sociological perspective. So, I use interviews, case studies and content analyses to better map and understand these phenomena, as well as the ethical and policy issues that they raise.

And so, my talk today, rather than diving into one specific study, I’m gonna stay fairly high‑level. So I’m gonna draw on some of the research that I’ve conducted, some of the research that my colleagues have conducted to give you a quick picture, first of what’s actually happening in each of these areas, what these phenomena consist of, what they are, and then I’m gonna talk about some of the ethical issues that they raise and what initial steps, if any, have been taken to address some of these issues.

So, starting with do‑it‑yourself brain stimulation, what is this, what is this phenomenon, what is this movement? Well, it all started about 15 years ago when scientists began to experiment with this technique called transcranial direct current stimulation, or tDCS, and this is a basic schematic here of a tDCS device. You can see there’s a stimulator which is basically inside there. It’s just a battery, sometimes even a nine‑volt battery, with wires or leads, and at the end of each lead is an electrode; and when those electrodes are attached to the scalp and the stimulator’s turned on, current is thought to flow through the brain.

So tDCS is an experimental technology, an experimental technique. It has not yet been FDA‑approved for any indication, and it differs from some more well‑known neuromodulation or brain stimulation techniques. So, for example, many people are familiar with DBS, deep brain stimulation, which is invasive, it’s implanted. You know, it requires surgery to plant it deep in the brain. By contrast, tDCS is non‑invasive; so, it sits outside the skull. And tDCS is different from another more famous non‑invasive technique called ECT, electroconvulsive therapy, an approved treatment for treatment‑resistant depression. Obviously, DBS also is FDA‑approved, has been FDA‑approved for a while for neurodegenerative diseases. DBS and ECT are approved therapies, but ECT sends a very large amount ‑‑ provides a very large amount of current. So, it’s effectively causing a seizure, where the amount of current provided in tDCS is very low. It may not even be enough to make a single neuron fire.

So tDCS has been researched for many years now, and I’ll show you a graph in a minute of its popularity, but it really divides into two kinds of research. So, research on clinical populations to see if it has any effect for improving these clinical indications, as you can see here, but researchers also use it in healthy populations to see if it can have a cognitive enhancement effect, to see if it can improve things like motor skills, memory, creativity, problem‑solving, and a number of other cognitive functions. And so early research and I’d say ongoing research has indicated promise for both of these indications, both for clinical effects and for its use for cognitive enhancement in healthy populations.

I will say that research has been ‑‑ you know, a lot of these studies have been criticized for their small sample sizes. So, there is a debate about the efficacy of tDCS in the literature, but for the purposes of the home use of tDCS, it’s a bit less relevant, but I think it’s important to mention.

So tDCS really took off in the literature, if you look at this ‑‑ so this is a graph of the number of academic journal publications about tDCS by year, roughly in the last 20 years, and you can see it really started to take off around 2010, 2011. That’s when the curve really ‑‑ 2012, that’s when the curve really starts to go up. It is interesting to note the slight potential decline in the last few years from its peak in 2021. So, this is actually ‑‑ I should say this is from a title search of PubMed, a title search for either the term tDCS or transcranial direct current stimulation. So tDCS, this technique, this technology starts to take off around this time, and that also is exactly when we see the rise of do‑it‑yourself tDCS.

So essentially what’s happening is that individuals are reading what scientists are writing about tDCS, seeing its potential effects for cognitive enhancement and for treating certain clinical indications, and because the device is relatively easy to make or build ‑‑ as I showed you before from that schematic, it’s essentially just a device with two wires ‑‑ they’re actually building the device at home. And so, we start to see people on YouTube posting about themselves using tDCS; there’s a Reddit form that comes up dedicated just to the home use of tDCS and blogs and websites, all dedicated to this home use of do‑it‑yourself brain stimulation.

And so, in the early days of this movement, individuals created their own devices. So, they would share these circuit diagrams, share with each other which parts to buy. As you can see here, this is back when Radio Shack existed. They would tell each other which parts to buy, and people would go out and make these devices, and they would share the instructions on how to do this on these online forums. And the movement grew, and it evolved. If you didn’t want to make your own device anymore, people began selling out of their home garages and basements devices and these device kits.

So, you can sort of buy an off‑the‑shelf device kit that just has the very basic batteries, wires and electrodes, and these range in price from about $40 to maybe $90. So, it is not hugely expensive to purchase one. And in the next wave, what we saw was people began to market these sort of slicker ‑‑ more well‑funded companies coming in and marketing these much slicker wearable tDCS devices. So, you can see these look a little bit different. You put them on; you don’t have to have any knowledge of where to put the electrodes. You just put them on your head, and they connect right to your iPhone and deliver a little level of current to your brain. And these are early versions of the wearable tDCS devices.

The rise of this movement really caused a lot of controversy, particularly amongst scientists who were not too pleased about individuals using these devices at home. So, this is an editorial from Nature where several scientists wrote here, “Unorthodox technologies and applications must not be allowed to distort the long‑term validation of tDCS.” And in the media, they issued many warnings over electrical brain stimulation.

So, researchers cautioned the public about the human risks of self‑administered brain stimulation, warnings over experimental brain foods, and there wasn’t a huge amount of data on the safety. And I’ll get to that in a minute, but, essentially, scientists were afraid of two things. One was that this home‑use community, these do‑it‑yourselfers would effectively ruin it. They were trying to see tDCS as this very scientific technique, trying to ‑‑ ultimately, the hope was that it would obtain FDA approval in some fashion. They didn’t want these DIY‑ers to ruin it for the community. And with regard to safety in the laboratory, maybe occasionally it would cause a skin burn or some skin irritation, a very light burn, but they were warning individuals about these adverse events that could arise but also about the unknowns. There’s a lot of unknowns about stimulating one’s brain.

So, this was a media warning, and then we also saw international societies ‑‑ this was from the International Federation of Clinical Neurophysiology warning against the use of do‑it‑yourself devices and methods unless they have shown both efficacy and safety. So professional societies were taking official stances, issuing position papers against the home use of tDCS. And ethicists also really got into this conversation, and they issued a lot of calls to regulate these devices, you know, essentially that we need more regulation about these home‑use devices. And some people argued that existing regulations do not encompass these devices, these home‑use electrical stimulation devices, and that effectively we need to create new laws just to regulate these devices.

And so, this was ‑‑ I would say this conversation was happening maybe eight years ago, around then, and at the time, nobody had actually studied who these people were who were using them, what they were using it for, what sorts of devices they were using, what their practices were, where they were learning about how to use do‑it‑yourself tDCS. So, at the time, I did a number of studies from a sociological perspective that tried to answer those questions ‑‑ who these people are and what are we doing and how could that inform how we think about ethics, how we think about policies. And so, I conducted a number of studies. One was an interview study, another a digital ethnography where I spent a lot of time looking at the online forums, and I also did a survey of users of seven different consumer tDCS devices. So, I’ll just share with you very quickly ‑‑ again, this is just a quick overview of my work, not in‑depth on any specific study. I’ll share with you a bit about what I found.

So, the typical user was a wealthy, highly educated, politically liberal, 40‑something male, living in North America ‑‑ mostly the phenomenon within North America ‑‑ who reported being an early adopter of technology and frequently reading articles about science. Individuals reported using tDCS either for treatment ‑‑ the most common indications were depression and anxiety ‑‑ or for enhancement. Focus and concentration were the two main indications there. And I would say even these findings were very interesting, because early work ‑‑ or at least there was an assumption that these individuals were these 20‑year‑old males on Reddit trying to hack their brains, which was not untrue.

There was that population using these devices, but actually this larger study that I conducted found that a lot of people ‑‑ even though these devices are mostly marketed for focus and concentration and for enhancement, not for medical indications ‑‑ and I’ll get into that in a moment ‑‑ my work found that actually a good portion of these people ‑‑ I think it was something like 40% of the individuals surveyed were actually using these devices for clinical indications, despite that not being their marketed use case, and there was an older population as well than people had expected.

Few individuals reported physical harm; so, we weren’t seeing a lot of adverse events, but what I did find was that some individuals ‑‑ a very small user population stimulated more frequently and for a longer length of time than scientists did, which could potentially ‑‑ the effects of that were unknown, right? So, if scientists were stimulating for two 20‑minute sessions a week, these individuals were stimulating ‑‑ some had stimulated over a hundred sessions and were just going much longer and more frequently. Again, a small portion of users, but that raised some very specific safety concerns. And then finally, what I found was that users are using scientific papers to inform their stimulation practices. So, they were really turning to scientific research and looking at scientific papers to understand where to put the electrodes, how to use them. So really engaging with scientific literature.

And so, what are some of the ethical and regulatory implications of this work? What’s the sociological study of these users? Well, I think first ‑‑ and this is what I argued in some of my work on these papers ‑‑ it’s important to recognize that home users are utilizing tDCS both for treatment and enhancement. As I mentioned, this is not just these 20‑year‑olds on Reddit trying to hack their brains, but also there’s a significant group of people using this who are frustrated with the lack of efficacy of existing treatments for their mental health conditions and they’re turning to these devices at home and self‑treating themselves. I think it’s important for scientists to be aware that this unintended second audience is utilizing published scientific research.

So scientists ‑‑ again, when you’re publishing an article ‑‑ and as an ethicist, when I’m publishing an article in ethics journals, I have this imagined audience of people whose reading my work, but for scientists in this case, there was this whole other group of people who was really poring over their publications, and I think that merited extra care and attention to language. I argued that regulation ‑‑ or at least the regulation that was being proposed at the time would not be effective, as it would only encompass a small subset of devices. Many of these devices were making enhancement claims. Many were not even making any claims at all, and people were still using them and finding them. And I should say that to make new regulation may not be effective, not existing regulation.

As I mentioned, home users look to scientists for guidance. So, it’s worthwhile to consider engaging with users. And this was a really interesting finding. So, these were people who have an affinity towards science. So, these were not your anti‑vaxxers, not your tinfoil hat alternative folks who don’t trust science, don’t trust the scientific enterprise. This was the opposite. These were people who were really into science but just frustrated at the pace that these therapies and treatments were trickling down to them. So, if they saw something happening in scientific literature, something they could do at home, they did it. They were very interested in doing it and administering it themselves.

So, I think the implication of that is very interesting, right, because it points to the fact that these individuals might be open to some engagement from scientists. And so, in part due to the work that I did, in part due to suggestions that others had made, there was this very interesting letter published in Annals of Neurology. It was authored by four neuroscientists and signed by several dozen others, and it was an open letter to users of tDCS, of transcranial direct current stimulation. And the letter took a very interesting approach, which I really liked. So rather than saying “Hey, users, stop doing this. What you’re doing is stupid and you should just stop,” this letter realized that that wouldn’t work, because these individuals were actually quite smart and relatively well‑informed.

And so, this letter said, “Look, here’s what we know about the effects of tDCS, here’s what we don’t know, and these are the things that you should consider when you’re thinking about stimulating at home.” So, it was more of this open engagement approach, which I think is actually the approach that’s needed for something like do‑it‑yourself brain stimulation. My study of this had actually ‑‑ looking back, I wish I’d studied the impact of the letter. So, I can’t speak to the sort of impact that it had, because my studies, as I’ll show you in a moment, moved on to direct‑to‑consumer neurotechnology, but I think this was just a very interesting move and a very interesting approach. I should say also it’s been several years since there was a lot of attention to this movement. It hasn’t gone away, but it hasn’t expanded. It’s really remained a subculture that’s still very much in existence.

Okay. So, moving on to the next ‑‑ so that’s a little bit about brain stimulation, and moving on to the next topic I wanted to talk to you about today, which is direct‑to‑consumer neurotechnology. And I think you can see, based on my initial interest in do‑it‑yourself brain stimulation and how that movement went from home‑grown devices to devices marketed directly to consumers, it’s very easy to see my interest in direct‑to‑consumer ‑‑ how my interest in direct‑to‑consumer neurotechnology came about.

But what is direct‑to‑consumer neurotechnology? This is how my colleague, Peter Reiner, and I defined it in a recent paper. So, it’s the set of products, devices and software that are marketed to modulate or manipulate brain function that are sold directly to consumers. So, bypassing the physician, no physician prescription is needed, and they appeal to the fruits of the brain and cognitive sciences. And this piece is really key, because you could go into a new age store and find some crystals or special bracelets that might be marketed to improve your focus, but these products really are drawing from scientific advances, from the scientific literature, from advances in science.

And so, we talk about three different classes of technology that we see being in this realm of direct‑to‑consumer neurotechnology. Neurostimulation devices, which I’ve just told you about; neuro‑recording devices, so these are devices that use technology like electroencephalography, EEG, to record activity from the brain; and we also did include brain training software in our definition, because they do meet the definition that we set out for direct‑to‑consumer neurotechnology. So, I’ll just go through really briefly each of these categories, really focusing more attention on the EEG and just talk about some of the ethical issues that these devices raise. I’ve already told you about the history ‑‑ the emergence of direct‑to‑consumer brain stimulation devices, but I’ll just say they’re still on the market. I’ll talk about the regulation of them in a minute, but we have this sort of next generation of these devices today and you can see some of the ways that they’re marketed. This is the Fielding energy patch, marketed for energy and focus, and this is a device that apparently appeared on Shark Tank somewhat recently for improving focus, attention, memory, and productivity.

So, I’ve already talked about the stimulation devices; so, I’ll probably spend most of most time here just on the recording devices. Many of these devices use EEG, electroencephalography, which is a very old technology, about a hundred years old. It’s used widely in brain science research. It’s also part of standard medical care, used to monitor sleep and also used in epilepsy. But in the early 2000s we saw the first consumer EEG devices come to market. They only had one or two electrodes, compared to the many more electrodes you saw in the earlier diagram, and it was really unclear if they were actually reliably measuring brain signals. And we had early applications of consumer EEG devices that focused on object control. So, you could, in theory, use the device to wiggle cat ears, do basic control of a video game, control a toy helicopter, but these never really took hold in the mainstream. They really remained novelty items, probably because the signal wasn’t all that reliable.

So, in the mid‑2010s we see a shift and consumer EEG devices begin to be marketed for wellness. As you can see here, this company is marketing their headset for mental fitness. Others marketed their device or are still marketing their devices for relaxation and focus, and the marketing images indicated that these devices could be used equally both for older adults and for children. This is all despite the fact, as I’ll get to in a moment, that there’s actually been little evidence that these devices actually do improve wellness. And so today we have the next generation of EEG devices that are being developed for applications such as control, wellness and focus, and you can see these have a bit of a sleeker look.

It’s worth noting that other kinds of brain recording devices using technology other than EEG are being developed. This one here is the Cardinal Flow. It’s being developed ‑‑ it’s actually being used in research settings now, but the company has stated that it wants the device to be used for consumers. It uses a technology called EFNEER, which at the moment involves a big helmet and it’s actually tethered; so, there’s wire at the end. We have Meta, who are developing a wrist‑worn wearable that uses EMG, electromyography, to measure signals from motor neurons to enable different kinds of control. Just by using finger movements, it’ll pick up on your intended ‑‑ or your actual finger movements that you’ll be making. And we have companies like Apple, who hasn’t been very public about what their plans are for neurotechnology, but they did file a patent back in July that indicated that they might be trying to incorporate EEG into their Air pods.

And of course, the man who has brought the idea of direct‑to‑consumer neurotechnology to the general public, we have Elon Musk, who cofounded a brain‑computer interface company called Neuralink. And Neuralink is starting out by working on medical applications of its brain‑computer interface product, but Elon Musk has been very clear that he wants to see the Neuralink product be used in the wider population, after it goes ‑‑ starting with medical and then moving to the wider population.

So those are different kinds of recording devices that have been on the market, and sort of looking to the future, may be on the market in the future. And I’m not gonna spend much time on apps for mental health and brain training, other than to say that there’s been a massive, massive proliferation of these apps that really bypass the physician. Some are marketed for wellness purposes, some are marketed for medical indications, probably illegally, and there’s many, many brain training apps out there. The market is flooded with hundreds, probably thousands of these applications.

So, what are some of the ethical issues related to direct‑to‑consumer neurotechnology? Well, in the U.S. consumer neurotechnology falls into a gray zone. So, in short, the FDA exercises enforcement discretion. So basically, it looks the other way for all low‑risk devices marketed for general wellness. FTC could potentially take action and they have taken action against several companies in the brain training software space, most notably Lumosity several years back. And the Consumer Product Safety Commission can take action to prevent consumers from unreasonable risk of injury from a consumer product, but they have not taken action either. So, it’s a bit of a gray zone here, and at the moment, neither the FDA, FTC or Consumer Product Safety Commission has actually taken ‑‑ at least publicly, has taken regulatory action against any of the neurostimulation or neuro‑recording devices. Another major ethical issue that I’ve written about quite a bit is misleading claims in this space. So, companies’ claims have largely outpaced science. So, my colleague, Robert Thiebald, and I wrote a paper a few years ago called “Mind‑Reading or Misleading,” where we looked at claims made by consumer EEG companies and found that the scientific evidence to support their claims of wellness was fake.

And then we have an issue that’s garnered a lot of attention, I’d say in the last year or two, which is related to privacy of brain data collected from consumer devices. So, one view on this topic ‑‑ and there’s different views ‑‑ is this one. With advances in neural engineering, brain imaging, and pervasive neurotechnology, the mind might no longer be such an unassailable portrait. So, this view, which is also represented in my colleague Nita Farahany’s book, “The Battle for Your Brain,” is that these technologies, these consumer neurotechnologies ‑‑ and again, I spent a bit of extra time on the recording technologies ‑‑ may reveal very personal information about the brain. And because these devices may not be considered medical devices, that information might not be protected by HIPAA, and therefore, we might need another source of laws or legislation to protect our brain privacy or our mental privacy.

And there’s been a lot of move towards ‑‑ a lot of activity really even just in recent months. This is an article from the New York Times back in April, reporting on the Colorado law that extends privacy rights to neural data collected by technology companies. A similar law just passed in California, and this was really on the heels of advocacy efforts led by the Neural Rights Foundation, cofounded by neuroscientist Rafael Yuste at Columbia University, who also ‑‑ Rafael and the foundation actually got an amendment passed in Chile just to protect the privacy of brain data. But I should say that there’s some debate within the world of neuro‑ethics, those of us who study ethical issues in neuroscience, about whether this is the right approach, about whether new rights are needed to protect brain data.

And so, in my view and in the views of some of my neuro‑ethicist colleagues, we see protection of neural data as part of a larger data privacy challenge. Personally, it’s not that I’m not concerned about data being collected from these devices, but that I’m much more concerned about all the data that’s being collected about me now, from my email, from my browser history, from my Apple watch, from my phone. Taken together, all of that can reveal very, very personal information about me, and I’m not sure that EEG will ever ‑‑ data collected from EEG will ever be as revealing as all the information that’s being collected about me. So, again, not that I’m unconcerned; it’s just that I’m more concerned at the moment about what can be revealed and the lack of protections, I should say, for all this other kind of data. So those are not all the ethical issues with direct‑to‑consumer neurotechnology, but just some of the ones that have ‑‑ again, this is sort of a high‑level overview talk, just some of the ones that have gotten more attention recently.

Now, coming to the last phenomena that I wanted to cover, alternative neurotherapies. So, I just thought I’d share with you very quickly how I became interested in alternative therapies. This area has gotten, I would say, less attention, but I think it’s actually probably one of the most important areas. So, when I was studying home users of tDCS, transcranial direct current stimulation, what I found so fascinating was how you could have multiple uses and users of the same technology, people interpreting and using the same exact technology in different ways.

So, you have researchers using tDCS in the laboratory, applying tDCS to subjects for the primary purpose of research, and they exist in this very controlled and regulated environment. So, every time a researcher wants to do a study, they have to submit a very detailed protocol in advance to the IRB; there’s institutional oversight, but you have at‑home users using tDCS at home and sometimes they actually use the same exact technology applying tDCS to themselves. The primary purpose, whether they’re using it for enhancement or for treatment, they’re trying to improve themselves in some way, and they’re in their basements or their bedrooms. So, it’s a very uncontrolled environment.

So, I was really fascinated by this, by these sorts of different uses. And then sort of as time went on, there was a third party that was in the mix that drew my attention, that I found completely fascinating, and this was alternative medicine providers. So, they’re actually using tDCS in the clinic. Again, this is not an approved treatment, but they’re still using it in the clinic, applying tDCS to patients or clients. The primary purpose is clinical treatment. Actually, as I’ll show you in a moment, they’re using it both for treatment and enhancement, but they’re treating patients, and they exist in a semi‑controlled environment. So, there’s some state regulations, but they’re not as strict. They’re not typically in institutional settings, there’s not this strict kind of oversight. And so, this sparked my interest. I began to see people using this in the clinic and this sparked my interest in looking at how these alternative medicine providers were using all kinds of neuroscience therapies and devices. So, I just wanted to share with you just a few of them.

So, what are alternative neurotherapies? What are we calling alternative therapies? And this is taken from a paper that my lab wrote a few years ago. So, some of the key characteristics. The use is not considered to be standard of care by mainstream medicine. Treatment is not typically reimbursed via health insurance. The scientific evidence supporting use is not typically robust, rigorous, or conflict‑free. The provider training typically varies quite a bit, and they’re often self‑described by the providers as an alternative to mainstream medicine. This is how the providers describe them. And we consider a number of different technologies to be within this realm of alternative therapies, and I’m gonna share with you a few of them.

So, the first is SPECT diagnostics. So, in traditional healthcare settings, SPECT imaging is used to evaluate neurological disease, but there are over a dozen clinics in the U.S. Some of you may have heard about them, Thaymen Clinics offering SPECT scans for neuropsychiatric diagnostic and evaluation purposes, even though it’s not recommended for any of these purposes, but we have clinics out there marketing the sort of diagnostics that’s not supported by mainstream medicine. We have brain stimulation techniques. I mentioned that many different clinics had individuals administering tDCS to different users. Here’s just some screenshots of some of them. In addition, there’s also other alternative uses of brain stimulation techniques.

So TMS, transcranial magnetic stimulation, is FDA‑approved for a number of indications, a number of mental health disorders, but there are individuals marketing it for all kinds of off‑label indications. This is one screenshot from a provider’s website. So, you can see, “Not only can we treat depression, migraines and OCD, but we also treat autism, Asperger’s, TBI, bipolar, mild cerebral palsy.” These are not indications that are supported by a good amount of evidence.

And so, we actually did a study in my lab where we actually looked at the off‑label indications that providers were marketing TMS for. This is the off‑label indications from about a hundred different clinics, and we found that while some of the off‑label indications did have supporting evidence ‑‑ and I believe that actually some of these may have garnered FDA approval since we did the study, but some of the indications did have evidence supporting their use, but some of them, such as the use of TMS for autism or MCI, had less evidence supporting their use. So, brain stimulation is another area that we see alternative neurotherapies.

And finally, the last one, which I’ve really been endlessly fascinated by, is neurofeedback. The idea with neurofeedback is that if you have access to your brainwave activity, if you could see the real‑time output of your brainwave activity that’s being recorded through EEG, maybe you can detect some abnormal rhythms and maybe you could then modulate or adjust your rhythms in real‑time and then improve some aspect of your behavior. It’s a very ‑‑ it’s really widely provided, but it’s very controversial. So, it’s marketed for the treatment of both clinical indications and non‑clinical indications, and I’ll show you what I mean by that in a moment. There’s probably about ‑‑ I think we calculated this based on membership in professional societies, but there’s over 15,000 providers offering neurofeedback globally, and there haven’t been that many great studies of neurofeedback.

The best studies that have been done are in the realm of EEG neurofeedback for ADHD, and the results have indicated that it’s not any better than a placebo. It is a controversial technique that’s not recommended by any physician or society. This is sort of what the marketing applications ‑‑ this is what some of the websites of these providers look like: “Train your brain to heal itself; pain‑free natural alternative to medications and other therapies; think of it as exercise for your brain; taste the freedom of a thriving mind.”

I see I’m getting closer to time here, so I’m just gonna run through these last bits. So, what are some of the ethical issues in this space? Truthful representation of evidence‑based; again, we saw that with direct‑to‑consumer neurotechnology. We did a study looking at all the claims, all the advertising claims made by neurofeedback providers on several hundred different websites. We found anxiety, ADD, depression. They’re marketing neurofeedback for all these indications and there’s really not robust evidence supporting their claims. They are also marketing neurofeedback for enhancement, and we found that almost all websites advertise neurofeedback for at least one non‑clinical indication; non‑clinical indication being mostly cognitive enhancement, mood and wellness, or even improve your general performance or athleticism. So misleading claims are a major issue in this space.

Provider competency and scope of practice, another major issue both in the neurofeedback space and in the off‑label TMS space. So, in the neurofeedback space, we found that very few providers had the training, had the relevant degrees or training. Very few had psychology degrees or M.D.s, and many of them have these short certificate courses, as you can see here, in neurofeedback, but they don’t really provide much training in dealing with the clinical indications. With off‑label TMS, it’s actually usually M.D.s who are administering the TMS, but there was one M.D. who was on the website that I just showed you who’s trained as a pediatric oncologist but is administering off‑label TMS for things like PTSD. So, scope of practice, I would say, and competency is certainly a concern in this space.

Other potential harms ‑‑ the risk of physical harm is relatively low from all the different therapies I just mentioned. They’re not completely absent, but relatively low. Considerable out‑of‑pocket financial costs for these treatments. These are not typically covered by insurance, and as ethicists we talk about something called opportunity cost, which is the cost of choosing a non‑empirically supported treatment instead of a validated one. And I should say that many of the technologies of these alternative neurotherapies are marketed to individuals who are fairly vulnerable, and a good proportion of them, as we saw in the studies that we did, are actually being marketed to parents to treat their kids with ADD or autism.

Okay. Getting closer to time, so I want to wrap up, but this is sort of ‑‑ I’ve taken you on a journey through three different ways, three different social phenomena related to this idea of moving beyond the lab. And so do‑it‑yourself brain stimulation, another way of conceiving this or conceptualizing this is, I think of it as primarily an issue related to information.

So, each of these phenomena raises slightly different ethical issues, require slightly different regulatory or policy approaches. So, it’s very hard to regulate information, right? So, I think the approach here, as I mentioned earlier, is really related to better engagement with users. With direct‑to‑consumer neurotechnology, when we think about policy or we think about regulation, this is really related to the sale of products. So, this is where regulation ‑‑ depending on what it’s regulating, but this is where it potentially could be effective. These services, the alternative neurotherapies are much trickier to regulate. Regulation would have to come at a state level, but probably also engaging with these communities would be beneficial.

So, I wanted to bring you back, just to close with this diagram that I started with. So this talk today was about specific instances of all these different phenomena in the realm of neurotechnology, but I just wanted to say that these phenomena are ‑‑ they’re not just neurotechnology, not just brain stimulation, do‑it‑yourself brain stimulation, but these phenomena are ‑‑ we’re seeing do‑it‑yourself medicine and science in other areas, like thecal transplants, hormone replacement therapy, do‑it‑yourself diabetes. With direct‑to‑consumer products, it’s not just neurotechnology that we’re seeing, but we’re seeing all sorts of different prescription products and laboratory tests offered directly to consumers.

So, the same with alternative medical uses. These alternative medical uses really thrive in areas where there’s non‑invasive medical devices, because there’s less restrictions on who can prescribe. There’s much stricter restrictions about prescribing pharmaceuticals; there’s virtually no analogous restrictions on using medical devices in a clinical setting. So, this is just all to say that we delved into very specific examples in the realm of neurotechnology, but these are phenomena that we see in other areas. These are specific instances that I talked about today of a much larger social phenomenon.

And so just to conclude, I think there’s really been this fundamental shift in the way that the public is accessing and using medical and scientific information and products, especially in the realm of neurotechnology. Funders, researchers, clinicians, policymakers, and professional medical societies, I think, should have a much greater awareness of these developing social phenomena. And I think these phenomena have traditionally been dismissed as not worthy of scholarly attention, things we don’t need to study because they’re outside the pathway. I personally think that’s the wrong approach. I think we really need to better attend to how the public is interacting with these technologies and devices beyond the lab.

And with that, I will conclude. Okay, and I wanted to thank NIH for funding. So, with that, I’m happy to take any questions. And thank you very much.

SHELLI AVENEVOLI: Thank you so much, Anna. That was a really great talk, very interesting and provoking. I see you’ve been answering some questions in the chat. So let me ask you if there are any of them you might want to answer out loud that you thought might have general appeal. Otherwise, we can go to a couple more that are in the chat, although you’re typing answers and speaking too.

ANNA WEXLER: Yeah, this is actually kind of ‑‑ this is the first time I’ve done a recorded talk and I’ve been able to respond in the chat. So, it was pretty fun. I will just say there were several questions about demographic information with regard to tDCS, and so I put the link to the papers in there. Because I was trying to cover a number of different topics in this talk, I wasn’t able to dive in‑depth into any one study or especially any of the methods in these studies. So, I would just encourage you ‑‑ if you’re interested in diving further, the research is there and some of the links to the papers are in the chat.

SHELLI AVENEVOLI: Great, thanks.

I’m noting a question that just came in about whether there are side effects of the do‑it‑yourself neurotechnology use.

ANNA WEXLER: Yeah. So, there are side effects, and there were a few questions about that. So, I just responded to a different one in the chat about side effects of neurotechnology. So, in short, there were side effects. I think we would probably characterize them as minor. I mean, there were things like headache, tingling. One of the things that I remembered we had some difficulty characterizing, because this was an open‑ended question, was when people reported something like burning. Is it a burning sensation? Do you actually have a severe skin burn? Is it just redness that you’re interpreting as burning? Obviously if it’s burning, it’s concerning, but we had a hard time ‑‑ it was very interesting just from a data collection perspective trying to understand the severity.

So, we did, I believe, code ‑‑ when participants mentioned a very serious burn, we did code those, but that was maybe only a handful of cases. I mean, overall, this was not a technology that’s sending people ‑‑ that’s causing very serious adverse events. That’s not to be dismissive of the lesser potential side effects that were there, but when you’re thinking about it in contrast to things like supplements that people are taking and are ending up ‑‑ that are sort of marketed widely and that they are ending up in the emergency room, there’s a lot of data on this. This is not technology that rises to that level of risk, in my opinion.

SHELLI AVENEVOLI: Thank you. Noting only two minutes left, I was just curious about your perspective of ‑‑ basically the thesis running through is that we should be mindful of what we’re doing as it’s interpreted and used by the public. What could NIMH be doing differently to address that?

ANNA WEXLER: I think one is attending to this. So, I know there is ethics funding from NIMH, but making that more explicit to investigators to sort of encourage them to think about the downstream implications of their work, especially since we have seen a lot of unexpected and unintended uses especially in the area of mental health. So, encouraging investigators to consider things, potentially even explicitly, in their applications, and I know that ethics components are now required for a subset of grant applications.

So, one could think about requiring them for additional applications, right? Even just having investigators start to anticipate and think, “What could be happening with this technology that I’m developing down the line?” Because it’s often hard to think about those things. I mean, I know. I write grants. You are focused on getting your grant out, and science has to be good, and the methods have to be strong. So, you’re often not thinking or anticipating what’s going to happen down the line, but any mechanism to get people to spark awareness of that and spark thinking, I think, would be tremendously beneficial.

SHELLI AVENEVOLI: Fantastic. So, I think we should end here, just because of time. And thank you again for sharing your perspective and your time with us today, and we really appreciate it.

ANNA WEXLER: Thank you. Thank you for having me.

SHELLI AVENEVOLI: Thanks, everyone, for joining. See you at the next one.

Transcript

JOSHUA GORDON: Hello, everyone, and welcome to the NIMH Director’s Innovation Speaker Series. I’m Joshua Gordon, Director of the National Institute of Mental Health. It’s my pleasure to welcome you to today’s talk and discussion, which I think you will find fascinating.

Before we get started, I just want to go over a few logistical details. As you see, hopefully, at the bottom of your Zoom screen, you’ll see a Q&A box or a Q&A button. If you should have technical problems or if you want to ask a question of the speaker, please use the Q&A function. Do not use the chat function if you see it, just the Q&A. You can enter questions into the Q&A at any time during the talk, and at the end of the talk, I’ll moderate a discussion based upon those questions with our speaker today.

Just in case you don’t see it, you can enable closed captioning on the Zoom, and there’s also an ASL interpreter. Just make sure you find that person on your video feed and pin that person so you can see the ASL interpreter.

The other notice is that this, as are all Innovation Speaker Series lectures, will be recorded and made available on the NIMH.gov website within a few weeks. If you enjoyed today’s program and would like to make sure that your friends and relatives and countrymen who might have been unable to attend directly would like to see it, please let them know. Or if you want to see it again, you’ll be able to do so in a few weeks.

With that, it’s really my pleasure to welcome Daniel Dawes, Senior Vice President for Global Health and the Founding Dean of the School of Global Health at Meharry Medical College, to give today’s Innovation Speaker Series lecture. Dr. Dawes is a jurist doctor, but a doctor nonetheless, is a widely respected healthcare and public health leader, health policy expert, educator, and researcher, who serves, of course, as I mentioned, as the Founding Dean of the School of Global Health and Senior Vice President of Global Health at Meharry Medical College in Nashville, Tennessee. Before this, he had served as Executive Director of the Satcher Health Leadership Institute and a Professor of Health Law, Policy, and Management at Morehouse School of Medicine.

He is the author of two groundbreaking health policy books, 150 Years of Obamacare, and The Political Determinants of Health, both published by Johns Hopkins University Press. Among his many achievements, Daniel was an instrumental figure in developing and negotiating the Mental Health Parity Act, the Genetic Information Non-Discrimination Act, the Americans with Disability Act amendments, and the Affordable Care Act’s health equity-focused provisions.

These and other landmark federal policies have changed the game for healthcare and mental health care in the United States. And they are built off his many years as a principal investigator on numerous grants in the area of health equity, including establishing the nation’s first health equity tracker, founding the Health Equity Leadership and Exchange Network, and being a principal investigator of the HHS National COVID-19 Resiliency Network. Professor Dawes is an elected member of the National Academy of Medicine, an elected fellow of the New York Academy of Medicine. He serves as an advisor to the White House COVID-19 Health Equity Task Force, an appointed member of the CDC’s Advisory Committee to the Director, where he co-chairs the CDC’s health equity work, and the NIH’s National Advisory Council for Nursing Research. Professor Dawes, welcome. Thank you for joining us today, and the floor is yours.

DANIEL DAWES: Well, thank you so much, Dr. Gordon. It is a true honor to be with you and to be with all of you today, especially during Black History Month as we celebrate this important month, and we talk about an issue that is near and dear to my heart, one that is impacting our fight to advance health equity in the United States and beyond, and of course, I speak about mental health equity.

So, I’m going to pull up my slides, see if we can get that up here, and begin. You know, when we think about the hierarchy of chronic disease value in America, for too long, mental illness has been relegated to the lower end of that hierarchy, and when you couple this with the hierarchy of human value in this country, you can begin to see and understand the striking inequities in mental health and substance use disorders.

Now, I know for many of us who have been in the trenches advocating for mental health reforms, it has been a frustrating endeavor trying to overcome the stigma, discrimination, and unfair barriers to advance mental health, and develop the kind of strong partnerships needed to move the needle of mental health equity to a meaningful degree in the right direction.

So, I want to commend all of you on your 75th anniversary at NIMH, and of course to you, Dr. Gordon, for leading from the front, not the sidelines on this important issue. The work that you all have been doing has been instrumental in our success in changing minds, and advancing the lines over the last 75 years, relative to mental health equity in America. Dr. Satcher, renowned leader in his own right, someone who I’m honored to call a dear friend and mentor, about 25 years ago said it best, when he issued his Surgeon General Report on mental health, there can be no health without mental health. And we know that there can be no health equity without mental health equity.

Diseases of the brain absolutely impact our systemic health, which is impacted by the wider set of forces and systems shaping the conditions of daily life. So, I want to take a moment now for all of us to look at how this has played out for some people by watching a short video which examines the political drivers of mental health.

VIDEO: To best grasp the political determinants of health, let’s examine another hypothetical example that combines experiences of real people in urban and rural communities. Over time, we’ve gotten to know and appreciate Jessica, a young woman raised in a low-income housing environment, a community often overlooked and neglected by elected officials.

For example, her living situations have often been dictated by predatory landlords. Their political pull in her district has allowed these landlords to trample tenant rights that would have prevented substandard housing situations. Jessica’s personal salvation can be found in her three children, Wilson, 17, Francine, 11, and Jasmine, who has just celebrated her second birthday. In every way, they are fiercely committed to each other, just as Jessica has worked so hard to maintain.

There are, however, overwhelming obstacles for each of them, and Jessica has had to navigate the choppy waters of her worst nightmare, a contemplated suicide attempt by her child. Pressures can mount at any age and influence the way we see the world. It’s so tough when these thoughts overwhelm teenagers. It’s even worse when they threaten our younger children.

How do political determinants of health affect our emotional well-being? Francine wants to attend her school’s suicide prevention support group, though she is younger than most of its participants. Because funding has been drastically cut this year, fewer administrative personnel are available to maintain after-school programs. Her only option is an all-ages group that meets on Tuesday afternoons. Francine knows that her mom does everything she can to provide for her family, but their lives have always been financially strained.

Jessica’s minimum-wage job at the neighborhood convenience store doesn’t provide the necessities her family needs. As a result, Francine has only two wardrobe choices to wear to school. Kids in her class have noticed the redundancy, prompting many of them to ridicule her on a daily basis. With the state’s free meal program significantly slashed, Francine starts most days with no breakfast and is embarrassed by the meager lunches from mom Passover. And budget cuts have displaced the number of school counselors from three last spring to one this fall.

With virtually no attention being provided to Francine’s mental health, her feelings of loneliness and isolation have increased. Each day is an emotional obstacle course that she can barely navigate. Since she was nine years old, Brianna has been abusing multiple forms of alcohol. In fourth grade, due to production costs and labor competition overseas, her parents lost their jobs at the shirt manufacturing plant.

Witnessing her father’s heavy drinking as he rotated in and out of jobs, Brianna echoed his behavior. It’s taken her these past two years to realize that she’s likely an alcoholic. Jose is the senior and most prominent member of the support group. As an only child raised by two mothers, most of his life has been filled with affection and loving doses of attention.

Recently, however, new state laws have made Jose feel like having two moms has made him an outcast. Frustration with his mothers has grown at the same rate as the national spotlight has expanded on the subject. The more newsworthy these stories became, the less often his friends wanted to get together. Though initially difficult to manage, Jose has learned to better handle these pressures and admits to finding the support group a healthy release overall. But where is Viola?

No one has seen her at school the past two days. Was her fear of her family’s reduced housing choice voucher finally realized, forcing them to relocate to another city? Or were her family’s disputes and instabilities too much for Viola to bear? It’s Byron, the school’s favorite algebra teacher and moderator of the support group, who inspires the kids’ discussion.

To do so today, he’s brought Danny to the conversation. As everybody knows, Danny is a professional baseball player and former student within these hallways. When his sister was caught in the crossfire of a gun battle between neighborhood rival gangs, Danny started experiencing depression at age 15. Given his school’s location and lack of prominence within the city, Danny received little social or psychological support. His baseball coach, however, could personally relate to Danny’s difficulties and provided the guidance he needed to focus on both school and athletics.

Danny steered his life back on track and excelled at his most personal pursuits to win the attention of colleges around the country. Majoring in American History, Danny realized that his college scholarship was a product of more than 60 years of federal acts and laws enabling kids of all backgrounds to pursue academic and professional success. It’s never easy to measure how political determinants sway our personal health, especially on an emotional level, but being aware of their influence can serve to improve our well-being. What does this mean for all of us? What can we do to improve and mend our community’s most damaged systems?

DANIEL DAWES: Well, there’s certainly a lot that we can do, and as we think of how to proceed on this quest to advance health equity, we need to understand that the road to health equity must be intentionally paved with the determinants of health, because the inequalities seen and experienced in our society were not by accident.

Thomas Piketty, a world-renowned economist, has recently concluded in his work that inequality did not simply emerge from economic reality, from technological change, or the organization of production, nor from inherent disparities in individual talent, ability, or effort. Rather, he argues, inequality is determined through struggles that take place in the political sphere.

Now, this raises an important point. If the resources and advantages attained through the political sphere are not equally distributed among population groups, then it shouldn’t surprise any of us that health outcomes and premature deaths are not equally experienced among certain population groups. Recent research has actually concluded that downstream interventions, which focus on change at the individual level, are more likely to increase health inequality than are upstream interventions, which focus on the social change or policy change.

Many of you have seen these statistics in one form or another. I’d love for you to just let them wash over you for a moment. Many of these have been published in the over 7,000 peer-reviewed journal articles that are published each year, looking at health inequalities in America.

Now, these under-resourced groups have struggled to live in a society that has erected barrier after barrier to weaken their bodies and hasten their deaths, leading to the striking inequities in health status, in healthcare, and life expectancy that we see across the board. Now, how have these arrived? Well, we all know that they have an economic burden on the United States. If the mental and the behavioral health system became more equitable in America, how many lives and how many dollars could be saved moving forward?

Well, in a study that I conducted with the Robert Graham Center at the American Academy of Family Physicians and the Eugene Farley Center for Health Policy at the University of Colorado, we analyzed the data and attempted to answer those questions. From our limited data sets, what we found was that almost 117,000 lives could have been saved from 2016 to 2020, and almost $278 billion linked to those lives could have been saved.

And to clarify this, these lives are considered deaths in excess of premature deaths, meaning that these are beyond what we already expected the number of premature deaths to be for a given population group in America. Understanding then that this number operates from a baseline of an already larger number of deaths for the United States, it is critical that these deaths are looked at with a magnifying glass to uncover the real reasons, not only for their deaths, but for prevention moving forward.

As scientists and researchers, we are used to acknowledging limitations to a study, but this same acknowledgement needs to be applied in real life, especially when we’re dealing with real people, not made-up figures in literature. Our research acknowledged some more limitations embedded within the data that we used, which did not account for the entire population. These included individuals who are incarcerated, those who are nursing home residents, residents of assisted living facilities, the unhoused, active military, and those who are institutionalized in psychiatric facilities.

In summation, a total of about 5.8 million people, by our estimates, had been excluded from the national sampling pools in these federal surveys. So, we went back to crunch some more numbers, only to discover that our initial figures worsened by a whole lot, with $23 billion in excess cost burden among the unhoused alone, and a range of about $40 to $69 billion of excess cost burden among those who are incarcerated. We also found an additional $63 to $92 billion could have been saved among these population groups. With each death and each group that is overlooked or excluded, the cost grows even more astronomical.

So, this begs another question. What if we became equitable and provided adequate treatment for these populations? What would our future look like then? From this report, we know what the costs are, we know what it would lead to in terms of the future, how much would be saved each year if that were to happen.

So, what’s driving these results? Well, many of us have seen the recent headlines highlighting the everyday impact of the political determinants of health, the effects of which can be observed in many areas of health and healthcare, including young children growing up without mothers, owing to high maternal mortality rates, poor and minoritized families being funneled into substandard housing by inequitable systems, and people with depression, anxiety, PTSD, bipolar disorder, drug or alcohol use disorder, or ADHD reporting over twice the odds of accessing transportation.

We have seen over the last several years the struggle to advance health equity in America and the levers of politics and policy that have been used at all levels and by all branches of government, which have affected the health outcomes of every population group in one way or another. Political determinants of health are evidenced in the data. Research has shown us that high obesity rates, maternal mortality, infant mortality, gun violence, depression, opioid addiction, substance use disorders, diabetes, heart disease, cancer, HIV AIDS, and many other health problems can be firmly linked back to policy action or inaction.

On your screen, we’ve highlighted a few of those that are directly correlated to mental health. An increase in voter restriction barriers correlated with a 25% higher probability of not having health insurance. Living further from roadways was significantly associated with decreases in depression and anxiety symptoms among older adults and mediated partially by loneliness and air pollution.

Structurally racist redlining policies from the 1930s were associated with decreased current behavioral health clinician availability in redlined communities. Black infant deaths in the United States Voting Rights Act exposed counties decreased by an average of 11.4 additional deaths beyond the decrease experienced by unexposed counties between the pre-VRA period and the post-VRA period. Of course, the list goes on.

In the United States, our community’s health is not an organic outcome. It is not a coincidence that certain groups of people in our community experience higher premature death rates than others. And it’s not a fluke that certain groups of people experience poverty for generations locked out from attaining the American dream.

Our system or systems have not always valued each group equally or realized the long-term implications that policies have on the health of its people. Why is this happening? Well, today we recognize that a variety of forces collectively impact our health and they determine the quality and the extent of our lives on this earth, including the social, environmental, economic, behavioral health, healthcare, and genetic factors. And of course, we know key among these determinants, it is argued, are the social determinants of health, the structural conditions in which all of us are born into, we live in, and we die in, that affect all aspects of our health and well-being.

Well, of course, from research, we know that they do play an outsized role in these human-made preexisting inequities, but underlying each one is a political determinant that we can no longer ignore. You see, too often we’ve been stopping at the social drivers of inequities, failing to look back and just dig down a little bit deeper to see the depths of the problem and understand its root causes and distribution.

And as a result, we have been missing the link between the social and the environmental and other determinants of health with their policy roots. For every social determinant of health, there was a preceding legislative, regulatory, ordinance, legal, or other policy decision that resulted in the structural conditions that we all find ourselves in today.

So, how did we actually get here? How did we get to these striking inequities in health status and health care? How is it that inequality gets under our skins, leading to accelerated aging or biological weathering, as Dr. Arlene Geronimus has taught us? Or how is it that it leads to the earlier onset of chronic diseases in these groups, as Dr. Williams, David Williams, Dr. Lisa Cooper, and others have highlighted in their work?

Well, we all know that the impact of slavery and colonialism has been associated with contemporary mortality, poverty, heart disease, intergenerational trauma, infant and maternal mortality, etc. And so, as we’re thinking about the structural conditions that generate higher mental illness and substance use disorders, as we think about the healthcare cognitive assessment tools, we need to think about how they came to be in the first place. So, I’m going to look back at big P policy and little p policy, both governmental and non-governmental policy, and I’m going to start 400 years ago.

I won’t start at 1619, although I do believe that is a fair starting point, but I’m going to start at 1641, because this was the time when the health equity champions, if you will, tried in vain to abolish slavery. But the commercial interests, recognizing that these abolitionists were gaining headway in their advocacy to abolish their business model said, wait a second, we’ve got to do whatever we can to preserve the status quo, to sustain our business model of slavery.

And so, in 1641, the commercial interests worked with the policymakers, starting in Massachusetts, developing their first and landmark legislation to authorize slavery or to at least legalize slavery, the body of liberties law. That body of liberties law was then used by Connecticut, New York, Maryland, and the other colonies, again, to justify enslaving other human beings. Well, as if that weren’t enough, when the health equity champions pushed back and said, wait a second, upon reading this law, we believe that it is silent. It did not mean to include the offspring of these black enslaved individuals.

And the commercial interests went back to work with the policymakers a few years after that to amend the law to ensure the inclusion of the offspring of these black enslaved folks. Around the same time as that was being developed, policymakers then went even further, designing policies that would directly impact not only black enslaved individuals, but indigenous population groups across the country. They developed laws that prohibited these individuals from being able to raise their own food.

We know that food, food security, access to nutritious foods is a critical social determinant of health. They also continue to develop, pass, implement, and enforce policies that would prohibit these groups from earning their own money. We know employment is a critical determinant of health. They also passed additional policies that prohibited folks from being educated, from being able to learn to read and write.

Again, we know that education is a critical social determinant of health. Beyond that, we know that there were also, depending on the jurisdiction that you live, laws that were developed to prohibit black and indigenous groups from being able to move around freely, right?

They were required to walk at night with a pass or with lanterns, depending on the jurisdiction. They were prohibited from congregating in large numbers, et cetera. We know that these laws were recycled from one generation to the next, from the 1600s into the 1700s and into the 1800s when Jim Crow reared its ugly head with a vengeance.

We saw the proliferation of laws at local, state, and federal levels, again, designed to make it very difficult for these minoritized groups from being able to realize their full health potential and address their social determinants of health needs. From the time of slavery, epigenetic research has shown a direct link to intergenerational trauma. From the Jim Crow era, we’ve seen a direct link to aggressive breast cancer prevalence among African American women who tend to have the most deadly form of breast cancer, triple negative breast cancer.

We’ve also seen how creative racists can be in our society. There was an attempt after the 1800s, as we got into the early 1900s, when the health equity and civil rights champions said, wait a second, these explicitly racist policies that are denying one or two or three groups of people access to social and economic benefits, they’re unconstitutional. They violate our equal protection clause, oh, Supreme Court.

Well, at that point, the Supreme Court could no longer ignore the truth and, quite frankly, stopped to pretend that there was explicitly racist policies and said, fine, you’re right, you cannot implement policies or pass policies that are explicitly racist. Well, what did they do? Instead, they pivoted to what we call facially neutral policies, policies that are on their face. They don’t exclude a group, but they were designed in such a way that they would have the same effect.

The Social Security Act is one such law, a law that included provisions that would prevent those in agricultural and in the domestic workforce from being able to pay into Social Security. These were largely operating against women, African Americans, and immigrant population groups at the time. In fact, 78% of African Americans fell into one of those two buckets and were prevented from being able to realize the benefit of that law.

Dr. Perrin was one of the architects of that, and he was also the architect of the syphilis study in Tuskegee, as well as the Guatemalan prisoner syphilis experiment that occurred. You can imagine why that was developed in such a way to ensure that once it was implemented, it would exclude these groups.

We also saw, after World War I, the Homeowners’ Loan Corporation Act under the Franklin D. Roosevelt administration designed and implemented to again target certain communities from being able to realize the economic benefits of policy. In this case, the country needed to be stimulated. The FDR administration said, what can we do to stimulate the economy?

Well, they recognized that there was a great need to understand which communities, which neighborhoods were having issues with their mortgages. They went out into 200 cities, in the neighborhoods of these cities, working in tandem with local and state policymakers to grade these neighborhoods from an A, B, C, or D, and then to align them with a certain color.

Of course, your A communities were your affluent communities, your B communities were your middle-class white communities, your C communities were your, quote-unquote, undesirable immigrant communities, and your D communities were your largely African American, or in some cases, Asian American communities, and they were deemed hazardous communities.

Well, interestingly, once these reports were aggregated and sent back to the federal government, they used those reports to create additional policies, right? Policies that would then determine who would get access to VA and FHA home mortgage loans.

Well, after that, we also saw other facially neutral policies, the Housing Act, the Housing Act, which displaced over half a million Black and Brown members of their communities across the United States, where these homes were taken from them, the properties were raised, and then they were sold very cheaply to real estate developers, who then created housing for more affluent communities. We saw the 41,000-mile interstate highway developed under the Eisenhower administration.

Many of you who work in very lower socioeconomic status communities have noticed these highways that cut right through these communities, and again, what has research shown, that there is a direct link to higher rates of depression, anxiety, diabetes, asthma, owing to these infrastructure.

But the one thing we need to think about as we are moving forward and we’re looking at the structural conditions is to think about how they came to be in the first place. How did these railroads, these highways, these infrastructures, the factories, and so forth, come to be in the first place? If you connect the dots, you will see there was a direct link to a policy decision. Moving forward, for the sake of time, we know that today, many of these communities, same communities, struggle with a poverty tax that has essentially been laid on them through the form of higher payments for auto insurance, home mortgage loans, lower property appraisals.

We’ve also seen this idea of food, pharmacy, and hospital deserts, making it very difficult for these communities, these neighborhoods, to access resources to improve health or maintain their health. Where the big P policy had been driving a lot of these now over the past several decades, we’ve now seen little p policy, these commercial interests, saying, well, my goodness, if the government isn’t going to invest in these communities, why would we ever take a risk on this? This would be a poor return on our investment, they have argued, that we wonder why the structural conditions are what they are.

Lastly, let me move us into another existential threat that we are facing here in the United States and across the world, this idea of climate change and what it’s causing through climate gentrification, where ironically, many black and brown and poor white communities were pushed further inland, owing to these racist covenants, and preventing them from owning property closer to the seashore.

Now, as the sea levels are rising, we see many of these communities that have been on the higher elevated lands being pushed out of their homes, displacing them, and it does have a lot of health impacts currently as well as in the future. Well, all told, we can see the impact that these political determinants of health have on lower socioeconomic status communities as well as communities of color.

Professor Michael Marmot, who has been a pioneer of the social determinants of health, has stated that life expectancy as a measure of health tells us a great deal about how we are doing as a society. But, he argues, the inequalities in health tell us even more about a society. Where you live absolutely matters.

And as you can see, the neighborhoods that were redlined, that were starved of resources by laws and policy are now today the very communities that have the lowest life expectancies and the worst health outcomes. Notice the 20 plus year differences in life expectancy. Notice the generations that are lost depending on where you live. Well, we know that policy is a driving force for many of the health inequities that we have seen or experienced ourselves. But it can also be a driving force for achieving health equity because only policy can fix what policy created or has broken in the first place.

So, permit me to take us back one more time in the past because as William Faulkner, the great Southern writer, has stated, the past is never dead. It’s not even past. Well, throughout our history, you can see the constant struggle, a tug of war, if you will, between those advancing the political determinants of health inequities and those who have been trying to counter the negative effects of policies by leveraging the political determinants of health. Going back in time, and I’m going to start at 1789 because I know I’ve had several folks who have said, well, Daniel, it’s not fair.

You started at 1641. We weren’t even a constitutional republic then. That’s not a fair starting point. Fine, I say, let’s start at 1789. At this time, you had the abolitionists, you had mental health reformers, you had advocates for homeless populations and others coming together trying to strategize about how best to get the federal government to provide for the general welfare of the least among us.

Well, if you think we’re having a very contentious debate over health equity, over advancing healthcare access, advancing health equity for vulnerable and marginalized population groups, it seems to me from the record that it was equally contentious. At that time, as they were strategized, they thought about who they could approach as a major policy influencer to push that agenda forward.

They landed on, of course, Benjamin Franklin. Although Benjamin Franklin had been a lifelong slave owner, as he grew older and as he came closer to his deathbed, he recognized what an evil institution it was, and he wanted to lend his name to the cause.

These groups got together and said, Benjamin, would you please sign this petition that we have created calling for the federal government to stop the separation of children from their mothers, to stop the breakup of these enslaved families, to abolish slavery once and for all? Would you join us, Benjamin, in getting the federal government to provide necessities for these population groups, food and clothing, shelter that they so desperately need? Would you join us, Benjamin, in helping us to get the federal government to provide educational opportunities, true employment opportunities, as well as health services to these vulnerable population groups?

Well, he said, yes, I’ll do it. Signs the petition, it gets to Congress, and my gosh, it stirs up this heated debate. The House, the Senate said, how dare you, Benjamin? How dare you, health equity champions, bring up this issue when you know that we’re just getting settled as a government?

Now is not the time to be talking about these issues. Isn’t that a refrain that we have heard over the last 230 plus years of our constitutional republic? Now is not the time to be addressing health inequalities in America. Well, the Senate said, we’re not even going to dignify Benjamin Franklin’s petition with an answer.

But the House said, wait a second, we can’t let Benjamin get away with this. We’re going to address it. And in bullet-by-bullet form, they actually, by the records, decided to push back on his arguments, essentially raising a confederalism argument, stating that it is not the responsibility of the federal government to provide for the general welfare of these folks.

The constitution doesn’t allow us to do that. We are not to be the great almoner for these various population groups. And so, they stated that the states which are closer to these people, remember, black and slave folks, people with mental illness, substance use disorders, homeless individuals, the states are closest to those folks. Therefore, they know what’s in their best interest.

They are the ones who need to tackle those issues. Hmm. Well, unfortunately, by the time that response was sent to Benjamin Franklin, he had died three weeks later. And that was the first time in US history that the light of health equity had dimmed in terms of advancing of equity focused policies in America.

It would take us 75 years later, during 1863, during a major war, the Civil War, for health equity champions to get together again and say, wait a second, we are going to be winning the Civil War. We are going to have all of these newly freed people and poor whites and other population groups that will be displaced as a result of the Civil War. What are we going to do to provide health services to them, to provide these necessities that human beings need to not only survive, but thrive in society?

And so, they started working on the Freedmen’s Bureau Act, America’s first and most comprehensive health policy, most reticulated health policy and health reform policy addressing the social determinants of health needs of these population groups, primarily African American and poor whites. Through that law, they argued for everything that those back in the late 1700s have been arguing.

But there was one provision that was so contentious that even President Lincoln couldn’t get his supporters to embrace. And that was the provision to provide health services to newly freed people. And so, President Lincoln, in the spirit of compromise, said, listen, strike that provision, pass the rest of the bill, get it to my desk, and I will sign it into law. And that’s exactly what they did. They started, they ended negotiation, they got it, he signs it.

What happens four weeks later? He’s assassinated. And his supporters, not wanting to squander the opportunity, the crisis presented, said, wait a second, we believe that upon rereading the statute, that it does authorize us to provide health services in addition to all of these other things that were called out in the bill.

And so, they went about recruiting clinicians from the North into the South and Midwest. They started building sanitariums, hospitals, and clinics throughout the South and Midwest to provide health services. But as this program was being implemented, what happens? As we have seen time and time again, racism doesn’t sleep in this country and hate has never taken a break in our country, unfortunately.

And that’s exactly what happened. After seven years, the opponents of ill will, as Dr. Martin Luther King called them, were successful in dismantling America’s first major health reform law intended to address these inequities. It would then take us 150 years later under the Obama administration to create another more comprehensive and reticulated health reform law that included 62 health equity-focused provisions to tackle these inequities.

Unfortunately, we have seen, as I mentioned, the tug of war with opportunities for folks, opponents, if you will, of health equity to come in and prevent the implementation of the majority of those provisions.

I’ve been talking a lot about the executive and the legislative branches of government, but we all know there’s been this other sleepy branch of government that has been wreaking havoc and undermining our efforts to advance health equity. Throughout the Supreme Court’s tenure, they, of course, refused to acknowledge, as I mentioned, that there were structural and institutional forms of discrimination until the early 1900s when the Civil Rights Movement was taking off.

But in recent dicta, we have seen in recent case law that they continue to recycle this language, that vestiges of past segregation by state decree do remain in our society. Past wrongs committed by the state and in its name are a stubborn fact of history, and stubborn facts of history linger and persist. But, they argue, though we cannot escape our history, neither must we overstate its consequences in fixing legal responsibilities.

Think about what that means for a moment. This declaration from the highest court in the land is alarming for at least three reasons that I could come up with, and I’m sure many of you could come up with many, many more.

First, the court fails to take into account the evidence from a broad spectrum of research in public health, in nursing, in medicine, in psychology, sociology, social work, etc., demonstrating the lasting impact that these vestiges of slavery, segregation, and subsequent unjustified discrimination have on population groups. Second, it has a rippling effect, setting a precedent for other policies commissioned by the other bodies in our government. And third, the court has been arbitrarily determining the point at which these vestiges of legally sanctioned discrimination cease to significantly impact certain communities, essentially arguing that after a certain amount of time, it doesn’t matter anymore.

Get over it, they argue, but here’s why we cannot get over it, and why as health equity scholars, researchers, and champions, we must connect the social determinants of health to their policy roots in the United States.

The Supreme Court would rather view inequities as products of what we call private choices or products of the social determinants, so they do not have constitutional implications or legally enforceable remedies. Health equity champions who continue to make the case that inequities are solely socially derived and fail to show the policy or the political connection will only bolster the Supreme Court’s viewpoint, thus weakening any legal protections to check these structural and institutional forms of discrimination, as well as, of course, denying legal remedies to those who have been impacted by health inequities.

So let me, in the last few minutes that I have left, talk about how we can leverage the political determinants of health. We’ve seen how the hierarchy of human value has evolved over time, and how inequities were structured or concretized in our policies or processes over the last several hundred years.

But fortunately, here’s the good news, before folks leave this talk today thinking, my gosh, this is such a depressing time, it really isn’t, because we have witnessed the incredible impact that equity-focused policies, such as the Civil Rights Act, the Voting Rights Act, and others had immediately following their passage or implementation and enforcement.

In one study that was published in 2006 by Dr. Nancy Krieger and her colleagues, where they examined the effect of the 1960s civil rights laws on infant mortality rates, they found that the concurrence of the timing, the abruptness of the rate changes following 1964, the sharp decline in infant death from infant conditions that are treatable in hospital settings, and the contrast with minimal changes among whites suggests the Civil Rights Act was the cause of these trends.

They estimated that between 1965 and 2002, approximately 38,600 Black infant deaths were prevented by implementation of Title VI of the Civil Rights Act alone. And other scholars have immediately found, following the passage of the Voting Rights Act, Medicare and Medicaid legislation, the Fair Housing Act, we saw declines in premature deaths of racial and ethnic minorities in the U.S. across the board.

But then what happens? We started to see an increase in premature deaths among these groups in the early 1980s, and then a widening of the life expectancy gaps between population groups after attempts were made to limit implementation of these egalitarian or equity-focused policies, like the Community Mental Health Systems Act that President Carter and his wife had struggled, the most comprehensive health reform law at the time, as a result.

Now, in our country, the principal roots of current and historical health inequities are found in the political determinants of health, which inequitably distribute social, healthcare, and other determinants, and they’ve created the structural barriers to equity for population groups who lacked power and privilege. All political determinants affect every single one of us because they encompass the systematic process of structuring relationships, distributing resources, and administering power. However, there are stark differences in how negatively or how positively they affect certain individuals and communities.

Let’s take a look at this. Let’s look at how we can leverage this, right? Whenever I’m analyzing a health outcome, whether it’s a mental health outcome or not, whether it’s an inequitable health outcome or not, I think about them in terms of how they came to be in the first place. What was the policy that created it or has been perpetuating or exacerbating it over time? How did the policy or political action or inaction structure relationships in the community? How have health-protective and health-sustaining resources been distributed in the community? How has power been administered in the community throughout their tenure? Once that analysis is done, I then create an action plan based on the political determinants of health framework. Here you can see the tri-part definition.

Of course, many of these health policies are cross-cutting. They’re not just in one bucket, but they can be cross-cutting underpinning on, of course, your analysis. This was my best attempt looking at the evidence from a political science, legal, public health, and historical lens to think about the levers that have been pushed and pulled over time to advance or hinder health equity.

The idea here, in a nutshell, is that once a perceived health inequity is identified, you have to conduct your due diligence to ascertain whether the health outcome is systemic, avoidable, and unjust, as Dr. Paula Braveman has instructed us. How far can you venture to understand whether it is an institutional or structural barrier that created or has been perpetuating that inequity? What is the policy change desired, and can you demonstrate the value of investing in change? Why is that?

Because in the United States, health equity champions have to understand the disquieting and harsh truth that the political determinants of health inequities have rarely, rarely been addressed unless their reduction or elimination served other purposes. You see, the success of any advocacy effort has depended on how palatable they are to commercial interests and whether there is an investment value to the government.

I want to use as an example to really bring this home what happened in the 1940s. As many of you are aware, we were going through the Second World War. During the 1940s, there was a great recognition, after trying for 150 years in this country, of getting comprehensive mental health reform passed.

Finally, the country was on its knees from a mental health crisis. Here, you had the military generals, admirals, coming together with the business leaders, recognizing that, my gosh, we have a problem. At the time, 20% of young people were unfit to serve in the military, and 40% ended up leaving prematurely, according to Dr. Felix, who was head of the Division of Mental Hygiene in the 1940s at the Public Health Service.

At that time, they also brought in others, General Hershey, who came in, and others, who found that 50% of their hospital beds were being occupied by people with mental illness. All of a sudden now, we had a problem. Even though mental health equity champions have been arguing, we’ve always had a problem, but we waited until it got exacerbated to the point where it was in crisis mode, and we now were reacting.

Well, at that point, after mental health champions learned that the moral argument was insufficient and had been insufficient for 150 years, they tied their arguments to an economic and a national security argument, arguing that, how in the world, if you do not invest, oh, federal government in our young people, how in the world can you expect them to outcompete our global competitors? How in the world can you expect them to defend our nation from external threats?

Finally, Congress wakes up, the federal government wakes up, and we got the first piecemeal bill that actually led to the establishment of the National Institute on Mental Health passed, the National Mental Health Act in 1946. That helped us to finally move the needle in the right direction because we leveraged the economic and national security arguments.

Now, as I close, where do we go from here? For many folks, we are in a very serious time in our nation’s history. Ken Burns, the documentarian, has stated that we’re in the fourth period of a very dark period in U.S. history. I don’t push back on that. I actually agree that it is a very dark time.

However, I’m also optimistic because by my count and the way that we slice and dice history from an equity lens, we are in the fourth period of a remarkable period for health equity. The first period, as you heard me mention, occurred during President Lincoln’s tenure, where he created the first policy to address the social determinants of health needs and provide health care to newly freed Black and poor white people.

The second one opened about 100 years after that, where health equity champions recognized that Dr. Martin Luther King Jr. was right. Of all the forms of inequality, injustice in health is most shocking and inhuman. Two years into that movement, folks started working on policies to desegregate our hospitals, leading, of course, to Medicare, Medicaid legislation, the Civil Rights Act, and others to address the overt forms of discrimination.

The second one opened up after that, where we had an opportunity to address the more subtle forms of discrimination in our society. Then today, we are in the current moment, which for the first time, the U.S. government has been harnessing the powerful levers with a whole of government approach to advancing health equity and addressing the upstream determinants of health inequities. Yes, every time we’ve had these awakenings, we’ve had terrible backlash and retrenchment. We are undergoing some of that too today.

We see that before our very eyes, but it is up to us to keep pushing forward, pushing for mental health equity and not to give up because we are even closer to realizing this vision than any other generation before. As Dr. David Satcher has reminded me, especially now, he argues, we need mental health leaders, scholars, researchers who care enough, know enough, have the courage to do enough, and who will persevere until the job is done.

First, you have to care about these communities, but as you have heard today, caring is simply not enough. You have to know enough. You have to avail yourselves of the knowledge of the political determinants of health. As you’ve also heard, this movement to advance health equity is not for the faint of heart. You have to have tremendous courage to do enough and persevere until the job is done. I hope that we have such leaders today.

I want to thank you all again for the privilege of your time. Thank you all so very much for the incredible work that you have been doing, which has been enabling us to continue to drive policy in the right direction.

JOSHUA GORDON: Thank you very much, Professor Dawes, for that wonderful and inspiring talk. We have just a couple of minutes left, so I want to ask a question that’s a bit of a hybrid of many. We have a bunch of questions in here, and I want to give you a chance to describe.

You talked about your optimism, but also how multiple things have accumulated over the years, multiple chances at equity leaving us in our current state. What is the role of further policy changes versus other societal efforts, for example, philanthropy, religious organizations, et cetera, in helping advance the cause of health equity at the current point in time?

DANIEL DAWES: Oh, my gosh. Dr. Gordon, that is such a powerful question. I love it because you have hit on something as I was listening to your question, thinking about how there were times when you had philanthropy not aligning with the role or the efforts by our policymakers at all levels. It does take a whole approach to this, right? A whole of government, philanthropy.

This is why I do applaud the work that folks like Grant Makers in Health have made when they worked with David Satcher when he was Surgeon General, and he was pushing this mental health report and trying to get folks to come together and address them 25 years ago. It took philanthropy. It took government to build awareness, to raise awareness. I do think there are folks who are nervous because they hear the word political.

It is not partisan. We’re not talking about partisan, but we do have to accept, and we have to understand that policy impacts all of life, quite frankly. There are forces out there that have been working to maintain the status quo, one, to create these inequities, and then, of course, to maintain those. It is going to take all of us at all levels to really harness the power of transdisciplinary collaboration to move the needle even further. I think it is a whole approach and an alignment between philanthropy, between government, between the private sector, and, of course, other systems.

JOSHUA GORDON: All right. I can’t resist one more, although I know that means we’ll go over a couple minutes in time. I hope you can answer this one. How might the average American do something to support this work? What can be done in any workplace, for example, to improve health equity? Are there types of policies you would recommend folks take a second look at? What can we do?

DANIEL DAWES: Oh, my gosh. Well, I think it doesn’t matter what level you are or what comfort level you might have. There’s something we all can do at the interpersonal, the institutional, the structural level. I want to argue that voting – I didn’t get a touch up on voting too much today – but simply going out and voting. Of course, fighting those forces that are trying to prevent groups from being able to exercise their constitutional right to vote is an act that could help us tremendously.

Voting can mean the difference between life and death for our communities, as we are now seeing. As the research is coming out through legal epidemiology research, we can connect those dots better than ever before. And so, if we do not appreciate, we do not build awareness to how voting, the implications of voting on our health and how long we will live on this earth, my goodness, guess what? Then folks will continue to not understand why it is serious and be apathetic.

I think I have noticed in the communities that I’ve worked with around the country, in the South, in the Midwest, and beyond, whenever we’ve connected those dots for community members, not even academic audiences, they say, ah, my gosh, I didn’t know that before, and I didn’t realize that this highway that cut through my community when I was a little girl was actually created by an act of law. I said, yes, ding, ding, ding, ding. This is why voting matters, and this is why there are always opportunities for folks to continue to undermine the vote. But voting, voting, voting is so critical, especially in this election.

JOSHUA GORDON: Well, thank you very much for a wonderful talk. I’ll just add that there are a whole bunch of comments in the Q&As saying what a wonderful, insightful, inspiring talk it was. So, thank you so much.

Thank you to everyone who attended. And again, if you want to share this with your friends, family, and others, just send them to our website in a few weeks’ time where you’ll be able to see a recording. Sorry we didn’t get to many other questions. I tried to merge a few of them in these two questions I was able to ask. Bye-bye for now. Thanks for coming.

DANIEL DAWES: Thanks, everyone.

Overview

During this lecture, Daniel E. Dawes, J.D. , will explore the crucial link between mental health and systemic health through the lens of equity and discuss how we can learn from and repair past issues to achieve mental health equity moving forward. As David Satcher, M.D., Ph.D., the 16th Surgeon General of the United States, concluded, “there is no health without mental health .” And there is no health equity without mental health equity.