Thanks for attending our session. We'll try to keep it as engaging as possible over the next hour and a half that we have your attention. If you do need to leave, we understand. We'll just understand that you have many things that draw your attention, and you'll be still very interested in following up with us after this session. So our talk is called Translating Between the Social and Political Determinants of Health. And our goal is to try to help you all see what is the place of social factors in mental health, not so much in terms of how they affect mental health, because you all presumably have plenty of understanding of that, but what does that mean when it comes to connecting the dots between that and public policy, and then eventually what happens with our patients and us as care providers. So I have a couple of folks joining me for this session. You'll hear from me a little bit, and then Eric here is going to go next and talk about some of his thoughts on this subject, and then Devika will be the third person in. I'm going to give you a brief spiel about who we are, and they will elaborate on their own experiences. So what I do right now is I work as a health policy advisor for the US Senate Committee on Health, Education, Labor, and Pensions. And so part of my objective here is to help you all see, number one, how does one get to that point to have that voice? And then two, if you do have the ability to be in that position, what can you do as far as taking social determinants and applying them to policy, and how you all as a voice are part of that kind of chain. Eric has also worked in Congress, and he does a lot of other interesting things. He's worked on the House side, and he'll tell you more about that too. And then Dr. Bouchon here, she has been an acting Surgeon General for the wonderful state of California. So she will be sharing a lot more about what it means to do policy in a meaningful way on a state and local level. So these are our learning objectives. I've sort of covered them already. And these are my disclosures. I don't really have any financial disclosures. I have a bunch of different roles besides working for Congress. I do some participation in APA councils and a couple of boards and executive committees. I'm also a child psychiatrist. So we're going to start with our first polling question. So if you all haven't used this platform before, I'm going to put up a QR code in a minute. You can also go to the website and join that way. You can also text that number with that code to join. And once you do that, it should work for the remainder of this session. If you like QR codes, here's a QR code. You can scan it. You don't need an app. If you want to, you can get the app. But you can also just use the website. So this is an open question. Feel free to answer with what comes to mind. This is mostly just table setting. So we're all sort of thinking in the same headspace. And we'll keep it running for a couple of minutes so everyone has time. I don't believe this is limited. So if you have many ideas, feel free to share them. So we'll call time here. I'm not going to close the poll. If you keep answering, that's fine too. I think this is really quite interesting. Seeing what you all are sharing as your priorities is important to us because it makes us think about if we do this this year, if we do this next year, how do we sort of laser focus on some of these issues versus others? So what you all have suggested about housing, about income, about a support system, if we look at the landscape of the social determinants of health, here's one way to look at them. This is my attempt at trying to organize them into buckets. The reason I'm putting this up there is because clearly there's a lot that goes into a person's health and well-being, and especially their mental health. We're not necessarily going to have time to touch upon every single one of these. But we'll be picking and choosing among a couple of them later in the session. So it's very much reflective of your ideas. But I think it's interesting that you all are focusing on the housing and income elements because we'll think about that both in this session and how we do future teaching opportunities. So show of hands again, how many of you all are psychiatrists? That's actually pretty great. Having some non-psychiatrists in the room is excellent. I think if you're comfortable sharing, would you mind telling us what your profession is? Yes. I'm a licensed psychiatrist in New Orleans. Wonderful. And I'm also the CEO of an organization in New Orleans in New York that renders the under-services and interviews. Wonderful. And my intention is to talk to you about that. Thank you for coming in. Thank you for sharing what you do. The reason I'm asking you that is because I've said the psychiatrist sees it all, but it's really applicable to anyone who works in the mental health space. One of the things that we know is we've always paid a lot of attention to what goes on in the background of a person's life. It's not just what we sometimes see on Zoom is this part of the individual. But there's a lot more going on, whether it's kids, education, telework, if the roof of your home is not functioning, if you're having water issues, whatever else. And one of the things that has changed over the past three, four years of the pandemic is that we've gotten a little bit narrow in seeing things, maybe not in the person's totality of what's going on with them. But on the other hand, when you are doing sessions in unusual places, like one of my patients decided to Zoom me from the Home Depot where she was getting lights for her birthday party. So that's an interesting change in how we see what happens in the patient's life outside of the lens of diagnostics and treatment. So again, kind of going into those social determinants of income, housing, security, all those other things that you all shared about. The reason that's important is because Eric is going to share why us being able to have that view helps us define policy better. So Eric, go ahead. Hi, everyone. Let me just make this a little higher. So as Mandar said, my name is Eric Rofla-Yuan. I'm a general adult psychiatrist, but I was trained as a public and community psychiatrist. Happy to be here with you all. So I, like Mandar, worked in Congress and lived in Washington, DC, where I was senior staff in the House of Representatives, working with Congressman Tony Cardenas from Los Angeles and the Energy and Commerce Committee, which has jurisdiction over all of the health-related bills and agencies. And then I recently moved back to San Diego, where I most recently was a senior policy advisor for the county, overseeing the Health and Human Services agencies, with a budget of approximately $3 billion for San Diego County's 3.2 million residents. California's second largest county. And then I am at UCSD, although they don't pay me. So here's some of that stuff. But I think some of the things that I really want to highlight today are going to come as we talk about some of these questions. So something that I am really fascinated by, because as we've gotten increasingly comfortable with the terminology of social determinants of health, and these start to infuse into medical records or into textbooks, but where do these come from? And importantly, we need to know that in order where do these come from? And importantly, we need to know that as clinicians, of how we might be able to exert some impact or changes to them. And you all identified how important they are. It's really nice to see in the initial poll question, income, housing, social support. These are not something that we can prescribe from the pharmacy. So is the question open? OK. So text in, what is behind positive or negative impacts? And I guess clarifying a little bit this, where do these come from? What causes these social determinants of health to have a positive or negative effect on your patient's health outcomes? Okay, so we are getting some big focus on policy, racism, and structural racism, some about the kind of politics and money, importantly looking at, you know, who's funding what is very important. Okay, yes. Okay, the next slide we have another question. Do you think of health and political terms? So we'll kind of see what the split is in the audience here. And so for folks who just came in, if you text the 37607 up there with the instructions, you'll be able to participate in it. And please do so, it makes it more interesting, I think, for everybody. I guess we don't have an N on this graph, but apparently everyone who's texted in says yes. So that is one of the key points of this talk, so it looks like we are all there together. But that actually, you know, when I do a number of academic talks, and I think something that is really kind of slow to infuse into the academic medicine, or kind of just the profession of medicine and of psychiatry, is how important politics and policy are in the health of our patients, and how so much of what their health outcomes are is not about what we do in the clinic, or exam room, or in the hospital room with them, but what happens outside of that. So to emphasize that, we have a video which I'm going to play. To best grasp the political determinants of health, let's examine a hypothetical example that combines experiences of real people in urban and rural communities. Imagine a 19 year old woman, we'll call her Jessica. After enduring several miscarriages, she barely survives giving birth to an infant nine weeks early, the baby weighing only three pounds. Her son is placed in the neonatal intensive care unit, the blood from his umbilical cord revealing over 200 toxins. Where did the system fail Jessica and her baby? How and why did these results occur? Three years earlier, Jessica had left her parents house. Access to treatment for her dad's substance use disorder had been eliminated when policymakers closed three of the city's public community health centers to save money. Contending with his wife's lack of education, neither of Jessica's parents could secure a job with a livable wage, prompting serious and substantial mental health conditions. Jessica moved to a low-income neighborhood in the city. She never knew of the extent of how the appalling conditions of her neighborhood were politically determined. For example, determined to keep housing segregation in place, politicians expended very few resources to build sidewalks, parks, or recreational facilities. Health care providers refused to operate in Jessica's community due to poor reimbursement rates for Medicaid. Because they resisted creating bus routes, lawmakers dissuaded grocery stores from operating in the community, preventing residents access to fresh fruit, vegetables, and meat. Simultaneously, policymakers altered zoning laws to permit development of a dump site and a chemical plant, switching the community's water source from a clean river 10 miles away to a nearby polluted river to save money. This water was used to drink, bathe, and wash clothes. It also irrigated the lawn at Jessica's apartment building, adding to the list of pollutants and environmental hazards in her neighborhood. And because her district lacked established tenant rights, her landlord had no interest in improving unhealthy housing practices. Jessica found work as a cashier at the corner convenience store, a job with no employee benefits, including health or disability insurance. Because policymakers rejected proposals to increase minimum wage to a livable income, Jessica often substituted her employers' free snacks policy as a meal, never realizing the effect that high-fat, high-sodium food would eventually have on her or her baby's health. With local politicians striking down an effort to ban smoking in convenience stores, Jessica was constantly subjected to a barrage of secondhand smoke. And when she discovered she was pregnant, no attempt at receiving health insurance coverage was successful. Her non-ACA-compliant plan denied her maternity coverage because they viewed her pregnancy as a pre-existing condition. Medicaid, the government's health insurance program for low-income families, denied her coverage for not being poor enough. After finding a ride to the free clinic, Jessica waited more than half a day to be seen by a second-rate physician, a doctor who was condescending and offensive. Realizing she could not afford to take more days off from work, she never went back. At 31 weeks, a neighbor drove Jessica to a hospital ER 20 miles away. Seeing that Jessica was experiencing excessive swelling in her face and ankles, as well as seizures, the emergency team decided to deliver her premature son immediately. Due to complications, her newborn son was sent to the neonatal intensive care unit. Once his organs were deemed mature enough, he was taken off the machines and sent home with severe cognitive defects. And in their apartment, Jessica and the baby were exposed to mildew and cockroaches, causing her son to develop respiratory problems. The landlord refused to remedy the poor conditions, telling her to move if she didn't like it there. Jessica struggled to find early childhood care and access to schools with educational assistance, healthy food options, and other resources needed to thrive. Because their school and community lacked the resources to enable Jessica's son to even barely reach his potential, he dropped out of school after entering eighth grade, just as his grandmother had done, repeating what is surely the ongoing rule of poverty. Jessica's story shows the compounding effect of political determinants over personal responsibility. No matter how reliably Jessica tried to act, structural, institutional, intrapersonal, and interpersonal obstacles stood in her way. Political determinants were pulling strings that prevented Jessica and her family from achieving optimal health and their full potential. What does this mean for all of us? What can we do to improve and mend our community's most damaged systems? To best grasp the political... So thank you, everyone, for watching that video with us. I think it's pretty heavy, actually, when you think about all of that, but I think does a fairly good job of, in just a few minutes, showing what its tagline was, that these are not something that the individual person, that the patient, has much control over, but really are pulling all of the strings behind the scene. And so sometimes I hear the phrase, well, as physicians, we do medicine, that's not political, that's what someone else does. But really, I have a slide up here to demonstrate that health has always been political, so I'll go through a couple of examples. So the first example we had of a nationalized health service in this country was in 1798, with the Act for Relief of Sick and Disabled Seamen. So basically, this was when most of the states and commerce was on the eastern seaboard, and sailors were getting sick, and this was worsening the economic outlook of this new country. And so the United States government, at the time, passed this legislation, which was signed into law, which created a nationalized health service for these sailors. So this really demonstrates that since the very beginning of this country, that the government has interceded when it has thought that it was in the financial interest, but it does have the power to do so. In 1883, 20 years after abolition, the Supreme Court struck down anti-discrimination provisions of the Civil Rights Act of 1875, arguing enough time had passed, so it's about 18, between 18-20 years, to overcome the effects of slavery. And so in this 18-year period, an actual full federal agency had been set up, the Freedmen's Bureau, which was a federal agency designed to help reintegrate newly freed black families and workers into society, into the economy. It also provided support with housing and with health services. It was only funded for about a year and a half, and then it was basically unfunded, and then in about a number of years after, all of those provisions were reversed. And so when we think about, well, we have health disparities and we, you know, we intensively study these health disparities in our university today, like, very clear answers of how and why those started, and what could have been done differently. Some of you may know that in 1946, the National Mental Health Act, this was a large piece of legislation which created the entity we know today as SAMHSA and the NIMH. So this was the start of federal investments into mental health in this country. And the reason for this was that this was around the World War II era, and the military had submitted a report to Congress basically saying, too many individuals were not able to enlist because of mental health reasons, and this was hurting the security of the nation. And so this prompted Congress to act, and so now we have these agencies which, you know, we more or less somewhat take for granted today that they have always existed, but this was not always the case. And so you can see here just easy, easy, easy pictures of how politics and policy affect the way that we practice today, and the way that we think about our field. So the political engagement cycle really has these three parts that are undergirded by advocacy. And so one, we have the voter and voting, and so this puts in place the government and sometimes directly puts in place policies. But you also need individuals in government who will enact those policies. And then of course you need the policies themselves. And so all of these three, you know, it's like this fancy diagram up here, it basically says these are all interrelated, they all affect each other, and they are all influenced by advocacy. And so that is one thing that as physicians we can do, and whether you know we turn that advocacy, we think of ourselves activists, or we turn that as education, and we think about ourselves as educating people who make these decisions, the policymakers, or we think about this as kind of the direct work we do in the communities that we live and work in. These are all forms of advocacy. So, and then advocacy is an important piece for achieving health equity. And so really, as some of you kind of really noted in one of the earlier questions, money is at a, money is what makes things go round in politics. And so you either have money, and that's called fundraising, or you have people, and that's called organizing. But advocacy has been essential for all of the health equity advances that we've had in this country today. So, survey of the audience, which parts of this political cycle of health have you been involved in? And so again, if you text that up there, you'll be able to select the numbers or the letters here. So as this goes in, you know, some folks don't, so the American Medical Association in the last few years recognized voting as a determinant of health. And part of this is that increasing number of studies have identified that people who exercise the right to vote have better health outcomes. And so there are many reasons for this, but one of the reasons is that when policymakers decide what decisions they're going to do, especially elected officials, they do it in a way that's responsive to their constituents, because they're in the business of getting re-elected. And by attending to the needs of their communities, and often that includes things in these social determinants of health arena, whether it's housing or income or health insurance, this has the downstream effect of improving the health of people that live in those communities. So really exciting to see that we have very few to none that are in E, and hopefully this kind of thought exercise helps us all think about the different ways that we can be involved. So we'll talk a little bit now about kind of a very specific way that I was involved in. So as you can see here, there's kind of a more targeted version of the political and social determinants of health slide that Mandar showed us at the beginning. But I think this is a useful slide in thinking really about when you look at one of these boxes, you can directly see how that worsens the health of patients that we work with. And so I specifically want to talk about that little box in the bottom right corner, criminalization, and we'll do a little policy case study specifically around 988. So before the late 1960s and early 1970s, so I love telling this story because when I first learned it, this was like amazing for me. I was like, how do you do that? It kind of blew my mind. So before the 1960s and 1970s in most places, if you had a broken leg or a heart attack or were hit by a car on the highway and you were in a car accident on the highway and needed medical attention, someone, because there were no cell phones, someone called the local emergency number, which was different in every city, every county, every state, for the police. And if you were lucky, the police were able to respond and they would go and they would put you, they would go to wherever you had your, you know, your heart attack and they would put you in the back of their police car and they drive you to a hospital. And their hospitals by and large do not have designated emergency rooms yet. And so you would get to the hospital and you would get yourself in and hopefully they would evaluate you and admit you. You know, this is not a great system. And the other folks that sometimes responded were funeral home staff or directors who had hearses, which were another way to transport people in medical emergencies. But clearly this is not a great system. And when we think about it, this is how patients who have psychiatric emergencies by and large are responded to today by police in the back of police cars, whether they go to jail, whether they go to an emergency room, whether they're in handcuffs or not in handcuffs, traumatizing all the same. And so a piece that happened here, going back to that kind of political engagement of health slide, was advocacy. And so there was a National Academy of Sciences report, there was grassroots advocacy, there was physician involvement looking at how we needed to develop a better way to respond to these emergencies. Because people in the United States, if they were in a car accident and needed a health emergency health intervention, they had a better likelihood of surviving if they had had that injury on the battlefield in World War II or in the Korean War. Because they had a system to deal with that and we did not have one here in the United States. And so yes, so here's a slide. Sorry, as I go front and back it kind of gets louder, so let me know if it's hard to hear. So kind of walking us through that piece. The health outcome was identified. Physician leaders worked with researchers and a wide range of stakeholders and communities in that voter section. Congress there, the government, responded to the advocacy by passing legislation to address the issue. And so that culminated the 1973 EMS Systems Acts, which has provided the groundwork for the ambulances, EMTs, paramedics, emergency rooms that we rely on today in some ways take for granted. And so a piece in here that I just wanted to bring up because some folks identified racism as one of the issues in the social determinants of health question. If you were in a black neighborhood and you needed emergency medical assistance and you had to call police, there's a good chance that police would not show up. And so an amazing story here in the black community in Pittsburgh, working with researchers and ICU doctors from the University of Pittsburgh actually developed a system to have people with first aid and professionalized training to respond to people who had those emergency needs in the field. And this was really the first time that we had this in the United States where there was someone with professional training with the right equipment designated to respond to those emergencies. And so fast forward to the present day. And so an article where I wrote about this, and so we are now on this exciting precipice of we are developing this for psychiatric emergencies in the United States. And so who knows what, who's heard of 988? Okay, good. Because a year ago I gave a similar talk and there's not that many hands, and a year before that there was zero hands. And so 988 launched nationwide in all 50 states and five American territories abroad, in all tribal areas, as a new 24-7, easy to access, easy to remember number for mental health emergencies. And so who has told a patient so far about 988? Okay. And then in the interest of time, we'll just kind of slide through some of these questions. So just a quick, because I still get lots of questions about what 988 is. So what can you call 988 for? Any kind of mental health distress. It also includes if someone feels like they're struggling with a substance use disorder or like an addiction, and it can be for them or their family. It doesn't have to be the only, the person who needs the help has to directly call. And when you call 988, there is a trained crisis counselor that sits in one of the more than 250 crisis centers around the country who answers that call and provides support. And the call response times have been pretty good. The national average is about 30 seconds before someone gets connected. And so how do you reach 988? So you can call from any landline or cell phone. You can also directly text. This has been especially important for young people. About 90% of the folks who text into 988 are under the age of 24. You can also access online at 988lifeline.org or 988.gov. And 988 is free. The only kind of asterisk to this is if you have a phone plan that charges per minutes or protects, 988 is not exempt from that, but there are no charges for the 988 services itself. And so as Mandar mentioned, when I was in DC, so I had a number of roles. One of them was staff director for the Bipartisan 988 and Crisis Services Congressional Task Force. And so in that, did work to make sure that 988 was actually implemented because as we, many people put up money as an important piece. If something is important, we need to put money to it, otherwise it doesn't happen. And so the way Congress works is this kind of funny thing where they can pass a law, but then there's a second piece called appropriations, basically where Congress sets up the budget, and those are a separate process. And so some states have it like this, some states have it different. But so it was a really amazing experience as a physician to use that kind of clinical expertise of like this is what it's like to work with patients who are in this, like as in a, you know, working in the emergency room, working in a crisis setting, working in a crisis residential program, working with patients in an outpatient setting who are experiencing this and not having anything else to tell them, but call 911 and police will be there to help you. You know, it's like not a great solution, not a great answer, often not a real answer and something to do that will let your patient know that you don't know how they actually feel about police or, you know, I remember times where I, so I've worked in clinics that serve a lot of low income or people who are homeless and their interactions with police had been very negative and police were not a safe place for them. And so having a resource that was not police, I thought was very important and also attached to this, having people that could respond beyond just the phone who were able to actually provide support similar to how we have EMTs and ambulances and medics that provide, you know, support rather than police as it used to be. We needed this for our patients who are having psychiatric emergencies as well. So seeing that we're here in California, I'm very excited to say that California also passed what I think is one of the best laws in the nation in terms of 988. So we're seeing these expand across the United States now, about five states have passed the law and many more have it in progress. So the California bill is named after Miles Hall who lived in Walnut Creek, which is just across the bay from here. His mom called 911 to have them help get him to the hospital and instead police showed up and shot him within 30 seconds of their arrival. And so after this, she, you know, did a lot of advocacy about this and excited to say that now the California, the bill is named after him. So it does three important things, sustained funding for 988, so that that number is always accessible and will continue to be accessible for people in California. Implementation requirements for all California's 58 counties for those mobile crisis teams. And importantly requires insurance to cover services because we're seeing a thing now here where insurance companies were not on the hook for this. It was something police did or maybe no one did. And so now insurance companies, you know, sometimes say, well, we don't pay for this. This isn't medically necessary. Did you submit a prior authorization for this, you know, mobile crisis team? And that's not a realistic thing that you can do in an emergency setting. And so importantly, the bill has insurance mandates in there as well. So shifting to the end of the 988 talk, I just wanted to invite you all to the APA's new Social Determinants of Mental Health Caucus. We are having our first meeting on Tuesday from 1.30 to 2.30. It's at the San Francisco Marriott Marquis across the street. Little disclaimer. So I am the current chair of the caucus. So really hope to see you all there. But as we continue this discussion of the importance of the social determinants of health and the political and policy decisions that underlie all of this determinants, I'm excited to work with everyone to see how we can get APA members more involved in that, both inside of the organization as well as in the communities that we live and work in. So switching over to Mandar. All right. Are you guys all policy-ed out or still in it for a little bit longer? All right. I see a little bit of enthusiasm, but I have some plants in the audience who I told them three months ago, come and cheer me on. But yeah, going back to where we started, I'm gonna try to connect the dots a little bit between our frame of the discussion, what Eric has talked to us about, and sort of how we're gonna work and sort of how the expression is how the sausage gets made. I don't eat sausage, but either way. So I'm gonna focus on safety and security and health services, these two kind of sectors, and specifically about the kind of traumatic exposures that people have that contribute to good mental health or poor mental health. What is their sort of resilience to deal with these type of insults? And how do we help that resilience building? And as well as the access to care question and making sure that when you tell someone to access care, that it's actually accessible in terms of affordability. So I think you all are familiar with this, but I wanted to draw your attention to these statistics because this is a survey that Kaiser Family Foundation does. I think it's every two years. So this is sort of the research nonprofit arm of Kaiser Permanente. And one of the things that stuck out to me is when you look at how many Americans have had someone who has been threatened with a firearm or has been a witness to a firearm injury. It's a lot, right? It's a lot right now. Secondly, the one that troubles me is when you look at how many have had healthcare providers talk to them about their firearms or any sort of exposure to firearms, shockingly few, right? So that's still a big sort of information gap and intervention gap that still exists in our system. And we as healthcare providers have the ability to close that gap. The left side of this is focused on some of the impacts on minority communities and how that's different and significantly much, that the burden is much higher in minority communities for firearms violence. So I was trying to find an image not of Tucker Carlson because he's no longer at Fox News. Not a political statement, he's just not at Fox News anymore. I forget who this guy is, but I think this is an image that we have seen many, many times, whether it's on CNN, on Fox, or any other sort of media network. We have a new incident of firearm violence pretty much every week, right? The reason I'm bringing this up is because I'm gonna take you into a very small window of time when there was sort of quick congressional action on something to do with firearm violence. Mental health for good and for bad got included in that intervention. And what I'm talking about is this bill that Congress passed last year in the summer, which was called the Bipartisan Safer Communities Act. So I'll take you back into a little bit of how this particular timeline played out, but I'm also gonna tell you about why this is a relevant story. So I'm gonna share a little bit about myself. So I've grown up in different parts of the US and also outside of the US. In certain places, not in America, there's really no presence of firearm violence in any sort of significant way, at least for kids, right? So you don't think about this when you're growing up. You don't have that impact, and your providers aren't spending time thinking about it. Then during my medical training, I trained in Florida where people love their firearms. It's, you know, stand your ground state. And when you're interacting with your patients, unless you know how to speak that language, you're not gonna get any information from them. They're not gonna take you seriously, and that opportunity is lost. I've trained in Georgia, but the training was less important while I was studying for my Step 2 CS exam. The night before, my downstairs neighbor was shot and killed. So you get that experience. You see the chalk outline walking up to your Step 2. That gives you a different sort of understanding of firearm violence. I've trained in Pennsylvania, where you can go from the Capitol to the VA, and in that drive, as you're driving through, I think this was in 2016, on the west side, like near Harrisburg, you see all of the Clinton posters. And then as you drive, they get shorter, shorter, shorter. And then as you get to Lebanon, the Trump posters get bigger, bigger, bigger. So Pennsylvania is one of those states where you have both sides of that story. You know, you have the left and the right. You have people that are 100% about protecting their Second Amendment rights, and there are those that are 100% about tamping down on those because they're worried about their kids. So as a provider, when you're interacting with this full range of people, you have to be able to kind of speak to both stories and understand both stories, and still try to arrive at something that makes a difference. I then trained in Baltimore, where 75% of the kids that presented to our ER had seen or experienced a firearm incident, right? So that's another story. It's a different community. It's much more minoritized populations. So all of that is to say that when I had the opportunity to take all of that information and be part of the discussion in Congress, when we were writing and trying to pass this law, the inciting incident was the shooting in Texas, right? We know about the Uvalde School. We know that 20-odd kids and some of the teachers were shot and killed, right? And what happened was, there was this 20, 30 years worth of public pressure that finally got to Congress, right? And then the question was, how do we get to something that can pass? So this was right around Memorial Day, almost exactly a year ago, that we were reacting to this. And we knew that Congress was gonna go out of session on July 4th. So we have four weeks to turn around something from idea to passing legislation. So how do we do that? So essentially, we picked 10 people that were willing to walk across the aisle and cast a vote in favor. And then we had a dual track meeting system where the members of Congress were doing their own sort of conference calls where they were talking about everything from conspiracy theories to turtle soup to all kinds of sort of socializing talk. And then you had the staff talk, which is us, where we were getting into the nitty gritty of, this is what we can and cannot do. So we ended up picking five to 10 big sort of pieces of intervention. We did, on the firearms front, we were able to include banning of straw purchases, which means that the exchange of drugs from Mexico up and the firearms from America down, we were trying to block that from happening. So you break that sort of violence cycle between cartels and firearms and drugs. The second thing we were able to do is pass a ban on so-called boyfriend loophole, which is where if you're involved in a domestic violence incident, but you're in a dating relationship instead of a marriage, the police couldn't do anything to take your firearm away. We closed that loophole, right? We try to close a loophole of background checks. So if you're under 18, you have a juvenile record, but you try to get a gun, your record is sealed. Police couldn't look into it. FBI couldn't do a background check. We closed that loophole. So those were some of the things that we tried to push through. What we couldn't get through is things like safe storage. Why? Because part of the country will do safe storage, but only if you give them a tax credit. They're not gonna do it if you require it. And people say, well, they're just looking for a handout. But when you think about the other way, if you're a poorer family and you're required by the government to do safe storage, where are you gonna find the money to buy a safe? So the tax credit for some populations does make sense, but we just couldn't find the money for it. On the mental health side, and this is kind of going to Eric's point, we were trying to figure out what can be fun and fund quickly, because this is the opportunity. This is the window of opportunity. So during sort of the weekend before we were getting to the point of agreement, I called Eric and I was like, Eric, give me a good idea. And Eric said, 988. And so we called the staff together and said, let's put a certain amount into 988. Ultimately, we got 150 million in supplemental funding. And then we did two more cycles through the end of the year. We did a billion dollars in school grants for putting in psychologists and social workers in schools. We did another 500 million in school safety. We did your CCBHCs, we expanded them. It's gonna be in all 50 states over the next 10 years. That's $8 billion worth of investment, right? So there's these multiple things. If you saw the president's announcement this week, Medicaid billing in schools is gonna get easier. That's from that bill. So trying to put this together in the space of four weeks doesn't happen in isolation. Part of it is, as far as I was involved, it's my story, what I've seen happen both in my personal life and as a provider with patients. Part of it is what all of you all have been doing for the past 20 years, or 30 years, or 40 years. Because just like I called Eric, the other people I called was, hey, SAMHSA, what is your idea? Hey, APA, government relations, what's your idea? And all of these people, ACAP, what's your idea? All of these people told us, these are the good ideas, these are the bad ideas. And they'd been doing that for the past two years prior to us arriving at that window of opportunity. So all this is to say that each time that you make a decision on whether to participate or not, it has a downstream effect. It doesn't happen on our timeline. Sometimes it happens because there's yet another tragedy. But if we put in the work ahead of time and we find that window of opportunity, we can get substantial things done. Oh, and the image there, this is the actual breaking the filibuster on the bill. So you get 14 Republicans, you can pass a bill. Back then, not anymore. So that brings us to another poll question. I think the great thing is you all are here, so I'm assuming you all have had that opportunity or that interest already. If you haven't had that chance yet, it's never too late, it's never too early. And if you don't know where to start, certainly we can provide you with as much information as we can, but there's a whole excellent staff at APA that will also help you get to that point of having that conversation. Another way is something Eric suggested, which is if you live in the same town as your lawmaker, invite them to your home, host a fundraiser. It can be a tiny one, but they will come, they will form a relationship with you, and they will remember year after year that you are someone that they should pay attention to. And why does this matter? Because it's a cycle. So this particular set of numbers is from a community's health survey. It's called the County Health Rankings Report, and it's done by the University of Wisconsin every year. And the blue ones are the top 10th percentile healthiest counties by various measures, and the orange ones are the bottom 10th percentile healthiest counties. And what you see there is a bunch of things that are considered social factors, not necessarily traditionally health care, but libraries, schools, parks, all of these things, when you look at the healthy counties, those are the ones that have the maximum access. And then it has a secondary impact, because the healthy counties are the ones that vote. And that's how you decide who gets to make the decisions for you, right? And those are the ones that also tell the census takers, we're here. So that decides how many congressional seats you get in your state. That is why New York loses one and Texas picks up one. So again, the social determinants of health end up becoming the political determinants of health, and that cycle then also makes a reverse impact, because who's voting is the ones that decide what kind of things get prioritized, which geographies in the US get prioritized. Which brings me to California. How's everybody doing? Anyone need a stretch break? Totally fine if you do. So just by a show of hands, who lives in California? Okay, great. This is how I know where to pitch this talk. And I know we did this at the beginning, so who's a psychiatrist again? I'm not. Demoing that. I'm a pediatrician. Any other kinds of MDs in the room? And what kind of medicine are you in? I'm sorry? Okay, great. And are there researchers in the room? You can double, double raise your hand if that applies to you. Great. Folks with policymaking experience of any kind? Great. What do you three have in your back pocket? Let's go with you first, yes. Thank you. Awesome. And how about in the back? We'll do the one in the corner first. The outer corner. What state? Texas, okay. No shade. All right. Oh, awesome. Great. All right. So let me give you a little bit about sort of what my lenses are in coming to this work. So I'm a pediatrician by training, a health equity researcher, and also a policymaker. So I spent three and a half years in state government. Initially as the first chief health officer at the Office of the California Surgeon General. Between 2019, the year it was founded, to 2022. And then I spent seven months as acting Surgeon General for the state last year. Now what I do is I wear a couple of hats. I am a consultant and an advisor to a number of entities that work on resilience or equity or both. And then I also do a fair amount of mental health activism. So I'm somebody with lived experience with bipolar disorder, and spend a lot of time putting up platforms to help people story tell to destigmatize mental illness. And so that's sort of the 50% of my life, which is great. So today we're gonna be chatting a little bit about a policy lens to preventing and addressing toxic stress. So this will be pretty familiar to many of you in the room. These are known as the 10 original ACEs, Adverse Childhood Experiences. First talked about in the 1990s. But actually, when you look at these 10 experiences, which are extremely common, they affect 2 3rds of the US population. And as many as one in six of us will experience four or more of them. Even though they are super common and super consequential and super costly at a systems level and a population level, they haven't quite made it down to the level of medical care provision. So I went to medical school fairly recently. I graduated in 2013 from Harvard and then did pediatrics residency at Johns Hopkins graduating in 2016. I mentioned those places and dates because nowhere in our curriculum, not one single lecture, was spent on adverse childhood experiences or toxic stress, the biological physiologic arrangements that they can drive. Even though they are super common and a fundamental root cause for a variety of acute and chronic health conditions. So this is, this represents a patient of mine. These are stock photos. And the patient's name was Cynthia. Her mom's name was Maria. We got really close over the three years that I spent in Baltimore taking care of them. And I helped them with Cynthia's ADHD. I helped with Cynthia's asthma management. We did a variety of things together that got us to be really close. And one day, Maria, the mother, very fearfully sort of approached me and said, hey, I know we've done so much together, but I kind of have a question. And I don't know if you're the right person to ask, but I just didn't know who else to talk to about it. And so essentially she told me that several years ago, she had left Cynthia's father who had been an abusive partner to her. However, Cynthia retained his last name. And every single day, this was a daily traumatic reminder of many experiences that she would rather leave behind her. And so even though this was sort of outside of the classic purview of the healthcare encounter, what we did was we had our health leads consultants, which we would refer families to for help with social needs, on really a name change for Cynthia. And that was honestly the most healing thing that we did with this family, was that single name change. And it was really meaningful. So ACEs and other risk factors for toxic stress, things like gun violence, racism, poverty, can drive a response that we call the toxic stress response. This is best known in the pediatric literature. I won't belabor the details too much, but essentially it involves a chronic dysregulation of a variety of symptoms, starting with neuro, endocrine, immune, metabolic, and even genetic regulatory mechanisms, setting you up for a whole host of health complications which range from homelessness to heart disease. And these are some of the mechanisms by which they act, and I'm gonna skip them in the interest of time, but you have these to refer to. And these are a list of not complete, but just a starting list of the health conditions that we see in adulthood that we consider ACE-associated. And we know that toxic stress physiology, when it's under-addressed, can actually change physiology for chronic and acute medical conditions in ways that actually have ramifications for treatment. So for instance, acute on chronic stress in childhood in patients with asthma is associated with reduced number of beta-adrenergic receptors and glucocorticoid receptors, which means that the two strong arms of treatment, which are albuterol and steroids, work less well on patients of ours who have the toxic stress response in place. But we also know that the effects of toxic stress are preventable from a policy lens and treatable from a policy lens. And these are seven evidence-based strategies for re-regulating the stress response and bringing it back to a healthy baseline. And they can be applied at any point of the life course. They can be applied as an adult at 80, at 50, at 20, and at five, and so these are really powerful. And they form the basis for our interventions at the ACEs Aware Initiative, which I'll spend a little bit of time talking about. So from a policy standpoint, when you think about how to prevent toxic stress, really what you're thinking about is decreasing the dose of adversity on the red side, increasing the dose of protective experiences on the green side, and potentially even changing the placement of the fulcrum so that those positive experiences have an outlasting and an outstanding impact relative to the negative experiences. So what you're trying to do is prevent ACEs and other stressors from ever occurring in the first place by surrounding families and individuals with policy supports to thrive. And when toxic stress does occur, which can occur by a variety of different mechanisms, you can find specific interventions that are toxic stress responsive and help patients to access those at the right times to prevent further decompensation and deterioration in health and well-being. And so let me just check where we are in time. Okay, we're good. So California has a series of sort of laddered approaches to both preventing and addressing toxic stress. At the very bottom are supporting families and children. So this is everything from home visiting to economic supports which have been shown to decrease the incidence of child abuse and neglect and other adverse experiences. Next, we have public education campaigns. So right now, this year, California's about to launch on a $24 million effort to educate Californians about how adversity and toxic stress can impact their health and also how they can heal. Then there's cross-sector trauma responsive trainings for all kinds of individuals who face families and individuals. So one that's coming online this summer in California is called Safe Spaces. And it really targets educators and childcare personnel where those are the settings that kids under the age of 18 are spending the majority of their time, right? So it's really crucial that someone who's running a daycare can understand how does toxic stress show up in terms of behaviors or needs that I have to respond to differently in my environment and how do I intervene in a way that doesn't re-traumatize or make the situation worse but actually helps support and help this person heal and be better. The second to the blue rungs are really about the ACEs Aware Initiative, which we'll get to in just a moment. And then the top rung is research into the mechanisms behind toxic stress and specific interventions that drive improvement. And the California Initiative to Advance Precision Medicine has devoted $20 million to seven demonstration projects that are all public-private partnerships and have a community basis to really be doing this work in a community-enriched way. And now this is the ACEs Aware Initiative. This is a half a billion dollar initiative that launched in 2019. And it has a few different aims. It really seeks to transform the way that healthcare providers think about and respond to the effects of toxic stress on health. And it also seeks to raise awareness broadly, practice change in the healthcare setting but also in allied cross-sector settings, and then to create networks of care that enable those evidence-based stress-buffering interventions that we spoke about on that wheel to be implemented in ways that are easy and sustainable. So here they are again, the seven evidence-based strategies, which are not the only ones. These are just the ones that have the best evidence to date. Coming online soon will be others, including spirituality and other ways of making meaning of experiences. And I wanted to present one non-state example of really enacting one of the interventions which is experiencing nature. And as Mandar talked about, there's a huge disparity in the way in which our exposure to green species is distributed across the country and across the world. And we know that prescribing nature as a preventive and a healing intervention is not only cost-effective but evidence-based. And so this is something that was based in the East Bay, just in this area, and the park district there allied themselves with healthcare providers, researchers, community leaders, and community-based organizations to enact prescriptions to nature as a way of both preventing and treating chronic illness. So at the clinic what happens is you get a prescription for part-time and there's murals and all sorts of other lovely things in the clinic to sort of show people what this can look like. Then there's community walks, group games, events that feature meditation and yoga and teach people how to do these things for themselves. And then the research angle here is to research the specific impacts of the interventions on certain kinds of outcomes. And it's all over the East Bay. It's really remarkable. So one thing I'll say before kind of moving to the next slide is when we look at the levers of what allowed the ACEs Aware initiative to emerge, there were a few things. One was legislation, right? So the first piece was creating the Office of the California Surgeon General with the express purpose of setting up the ACEs Aware initiative. Second was a huge bucket of money, which I mentioned, half a billion dollar initiative for the ACEs Aware screening and treatment protocol that went live with the Medi-Cal program to start with. So that's our Medicaid program in California. And subsequently, there was another policy that came into place called the ACEs Equity Act, which has now made it so you can have any insurance provider and you can be eligible for screening and assessment for toxic stress. And we know that the healthcare setting is sort of one really important place for us to start, but the California Surgeon General's report, which was published in 2020 called Roadmap for Resilience really lays out what it looks like to enact a policy blueprint across sectors to enable prevention of toxic stress and then effective interventions. And so this is light, you know, 450 page reader, if you're ever curious. It lays out sort of what the approach needs to be across the justice sector, the education sector, social services, early childhood, public health, in addition to what's in place right now with the healthcare sector and then ways we can expand that as well. And the vision is to really address the root causes of inequities in health and well-being everywhere to interrupt the intergenerational transmission of toxic stress and then really promote this healing-centered strengths-based approach to enable every single person and family to thrive. So that is my contact information in case you ever have follow-up questions for me. And we are happy to spend some time on Q&A. So, we have plenty of time for questions. If you have a question, I've been told that using the microphones is helpful because they record these things, and then someone who's watching from home can have access to your question as well as any information that we share with you. Thank you very much for your talk. I really enjoyed it. I'm just struck by how involved you guys have been able to get into government and making such large policy changes so early in your careers. As someone who's an early career psychiatrist myself, I'm curious to hear each of your paths and perspectives on how you were able to do that. Sure. Thank you for the question. For me personally, some of it is, I'll tell you, there's three things at play, I think. One is, sometimes it's sheer dumb luck, right? Sometimes it's your passion, your interest, your desire to firstly consume information and then be active with that information. And then three is, I think, the system of opportunities that fortunately is growing and makes these things possible. So in terms of my interest, I would say I got interested somewhere in medical school. I ran for student government, did that for a couple of semesters, had a couple of interesting experiences where we had a hurricane passing through our campus and the school's administration had not told us whether they were going to shut campus down or not until the night before. So as the student government pressed it and I was like, we need this answered because the students are not going to know what to do and there's anxiety. And so we found the administrators heading to dinner and we stopped their van and we asked them to provide an update. And this did not make them happy about being approached like that, but I think it led to a dialogue around systemic change to the policies around communicating with students. So that was, I think, a spark for me. And then during residency, there was some sheer dumb luck. I was working late in the hospital and looking for free dinner and across the street, the medical society was having its meeting. So I walked over and they said, we need someone to join the political action committee board. And I said, I have time. So I did that and that got me some access. In fellowship in Maryland, the psychiatric society staff, it's one of the best in the nation. They said, you want to do something in the policy space? We have a ledge committee, join it. Maryland's legislature is super active. So we reviewed something on the order of 60 bills that session. We were in the midst of COVID. So the question was around, do we extend telehealth beyond the pandemic? And so they asked folks to go and testify with the state house and state Senate. And again, sometimes I don't know if it's a good idea to do something, so I do it anyway. And so I did that and that sort of helped kind of further that along. And the sort of last piece of the puzzle was the Gene Sparlock Fellowship of the APA Foundation. So I applied for that. And again, maybe because it was the right time, maybe because I had the right experience, I was able to join with Eric over 2021, 2022, where we worked on, you know, he worked on the, with the house Democrats. I worked with the Senate Republicans and we did some good things together. And so that has continued. I guess I'll go next. I'm in the middle and then I'll have Dr. Bruchon go. So for me, I really got, the way I got involved was in 2016, I both started residency and we had a presidential election. And so those two things kind of came together for me. During residency, there were, you know, so many, as a resident, you see so many systemic issues that fall into the patients you take care of. And I realized that me seeing patients faster was not going to fix this. And that's sort of the answer that the health system gives you will just like work more. And then I also saw that, you know, I was in San Diego at UC San Diego, and we had a lot of issues at our Southern border with immigration and the way that the presidential administration was responding to that. And so, you know, volunteer as a resident in like the, you know, refugee health clinics and things like this, but that's not fixing the issue. And so I really started to look at, well, what's upstream from that. And so like Mandar, the easiest and most accessible way as a, as a resident was through the local psychiatric society. So we got involved as like a resident fellow representative, which is, you know, not super glamorous position, but it's a start. And so actually from there worked out to be the legislative director for a district branch representing the approximately 375 psychiatrists were members in the San Diego Imperial counties. And then from there to the board of our state psychiatric association and then went to DC. And so I also will say though, that there, in addition to like this kind of like physician as advocate, there also is a role for a physician as expert. And so that has been, has been another place as well to get involved, whether that is you testifying or you working on the agency side and lending your expertise to these decision making processes, which really are not run by physicians, although they are about health, they're run by people who have MBAs or JDs or MPHs or masters in public policy. And so it was really interesting to me being in Washington DC, working on these policies as being the only physician there in the room working on it. And then, yeah, I just have continued on that path. I'm just going to add to that real quick. You mentioned the hearings thing. There's nothing more fun than inviting some of you to be a witness at one of our hearings because it really gives us an opportunity to connect all of the experience from your personal and professional life that you bring to the table and really shine a light on issues that people don't understand very well. So that can be an opportunity and you don't need to have any experience with it. You can be prepared by professional staff. And part of it is we do it. And part of it is APA and other organizations do it. This is a really good question because it's one that I used to ask everybody as I was coming up and learning about different paths. And different people will come to it in different ways. For me, I think I, even as a medical student or even before that, was sort of dissatisfied with the medical model and the way in which you can address only so little of the patient's true needs in the classic context. And so I'd always been interested in the public health lens and the policy lens as a way to help systematically address the reality and move health and well-being for millions of people at a time. And so how did I get involved in all of that? So essentially, I spent a lot of time in different settings where folks were MDs doing public health or policy. So for example, during residency, I spent time at the Baltimore City Health Department really learning from the approaches that they were taking there. I spent some time interning with a really influential person in sort of my life in terms of his mentorship. He goes by the name of Dr. Josh Sharfstein. Maybe some of you know of him. He used to serve as the commissioner of the city of Baltimore and the Maryland director or the, what's the name in Maryland? Essentially the head of HHS in Maryland. And then he spent some time also at the FDA. So he had sort of the federal, state, and local perspective on how you lead as an MD. And I did some legislative advocacy in a few different ways while I was in training as well. And essentially, was training at Stanford, I was a fellow in a postdoctoral program looking at gender and equity and health when I met the first California Surgeon General as she was getting appointed and starting to do the beginning work of setting up her office. And I was in the lucky position, right place, right time, essentially with the right interest of being her first hire. And I think that also came about because I had the right mentors. I actually had a really kind mentor at Stanford who set me up on a walk with the first California Surgeon General. And I had about 15 minutes to really get to know her and pitch my interest and see what she thought. And that worked out. I'll just make a plug for, you know, this is a small world when you look at the people that are engaged in these dialogues. So if you start talking to that network, you can become part of it very easily. You mentioned Dr. Sharfstein. I meet with him about once a month. I can't really talk about what we're working on, but, you know, so those connections are important. I think you mentioned mentors. When you're a resident, when you're a fellow, it can be your program director. It can be your faculty that is, you know, maybe with that sort of experience and focus takes an interest in your interest. If you're an ECP, it's your department chair. So there's a lot of, you know, opportunities for folks that are a little bit further along to, you know, reach back and help those who are on the come up to get that sort of exposure. Thanks. You know, Mondar and Eric, we work together, but I'm Brian Marcoux. I was a fellow with Mondar and then rotated in residency back with Eric a few times. But I'm in the Navy now, so I see things in an interesting way, how that goes. But I was curious about, you know, when you're working with trying to build coalitions and build insight into why does this problem affect people in this way, when you're talking about building from the ground up of, well, if this happens, then, you know, it leads downstream to these problems, and then we get more patients with this problem and so on. So I guess what has that experience been like for you trying to build that insight into, you know, other coalitions who might have a different perspective on and a different kind of outlook on the bigger picture and maybe not recognizing that stream that happens when we talk about the effect of our social determinants on, like, overall well-being and health outcomes? I'll say a little bit, because I've been doing some of this work recently in California. So I think one piece is we have to take off our, like, our physician hat. And so as physicians, we think about things very narrowly sometimes, and we also use very specific words. And so when you walk into a room of, like, community organizers that really care about housing and, you know, clean water and schools, but you say social determinants of health, they, like, don't really know what that means. Or even if they do, they're, like, well, how does that, you know, how are we supposed to work with that? And so two things I think are key here. One, learning the ways that people think about the same thing, and then, two, learning who's doing that kind of work. And so as part of that, the kind of relationship developing that sometimes is unfortunately really political, but actually, like, really gets things done, I have seen. And so that's one of the reasons why I really like that kind of little fancy diagram. And so as Dr. Bouchon was saying, you know, this, you know, I'm really proud to be in California where we have this amazing ACES Aware initiative, but it was the voters that put in place the government officials who enacted this policy, and that continues to, like, be modified and intervened upon through this, the role of the advocates and outside experts and organizations. And that often, it almost always doesn't happen with just physicians alone. So I'll talk a little bit about leveraging relationships in different ways. So in terms of coalitions and where they can help, one example is when it comes to doing something in the mental health and substance use policy space. There are easily about 20 organizations that have frequent dialogue on those issues, you know, folks like NAMI, Mental Health America, et cetera, et cetera, and they all have their sort of differences in what they stand for. There's some where they just won't agree with each other. One example being assertive community treatment. There's those that strongly believe in it as a tool in your toolkit, and then others that are strongly opposed, right? We have, I don't know if you all noticed when you were walking into the convention center, we have our, you know, protesters out as we usually do, but they are not necessarily anti-mental health. They might have a very specific perspective on one intervention. So one of the things that worked when we were trying to do big sort of mental health legislation is a process of telling those folks to figure out their differences and present one message. So case in point, all of these mental health organizations, they clustered together. I think they started doing this over the past three, four years. It's called the Mental Health Liaison Group, and it's literally a coalition of all the mental health groups. And what they do is they still have their differences. So as an example, if you're a psychologist who is looking for prescription privileges, you are not going to agree with the psychiatrist who doesn't want you to have that. If you are someone who wants a collaborative care model to happen, but then you believe that the other guy believes that it's going to cut them out of the pie. So in putting them together, you force them to arrive at a single message, and they have to carve out what they don't agree on, which makes the lane clearer for someone who's not an expert but is a decision maker to say, this is what I can do right now. And it's incremental. Another way of leveraging relationships is finding unusual partners. So I go back to the Safer Communities Act. How do you get someone who has an interest in firearms, who happens to be from Texas, I'm not calling out the state, just could be from Florida, any other state. How do you convince them that this is in their best interest? So weirdly, one of the partners we had in that process was Matthew McConaughey and his wife. And so because this guy can actually talk to the folks and talk to them in their voice, which then gets them around to what you're trying to do, you're never going to get them to say, oh, let's just confiscate all the firearms and whatever else. But that's another way of leveraging. A third way is to put people at odds with each other when it serves your purpose. So I think I can talk about this now because it's in the past, but recently our committee did a hearing and markup on drug pricing. So the strategy was you have the pharmacy benefit managers and the pharmacies sitting at the same table. So they can duke it out, and you can arrive at whatever is beneficial to the American people. So some different ideas. I feel like we're holding you all captive. No, thank you all for attending. You're a very active and engaged audience. We love that. If you have feedback for what kind of directions we should go in next year, we're hoping to continue on this cycle, but build upon it. We don't want to give you the same content year after year, but we do want to make it more and more useful. So welcome any feedback. Feel free to email, stop by after. But we have another question. How to build on this into actually all the people who are actually interested in doing more activist work, what are the opportunities with the APA? Like trying to get the APA to join with all the other medical societies who are dealing with some of the policy changes that are happening now, that if there's a unified response, could potentially have more of an impact. But there's lots of ways we could be doing things. But I'm sure there are a lot of people who would want to do that. So maybe having some kind of caucus that's actually about political determinants of health, not just social determinants of health. I love that you framed it that way. Yeah, it's a really intentionally used word. I'll say something as a non-APA member, which is that the AAP, the American Academy of Pediatrics, does a fabulous annual conference that used to be called LegCon, legislative conference, and now it's called advocacy conference. And every year, essentially, they get hundreds of pediatricians together, train them up on how to do effective legislative advocacy, and then you go to the Hill, and you actually do it in person. And it's a several-day, just beautiful event. The two years I attended, the focus was on gun violence prevention. But I don't know if something like that exists at APA. Yeah, so I can talk a little bit about it. So I serve on the APA's Council on Advocacy and Government Relations. As of that, we support the APA in some of their policymaking and government relations. And so a couple of things. APA does have a advocacy conference. They actually have a state and federal. It alternates each year. So state was last year in Minnesota. And federal will be this year in October. I think it's October 16, 17. It's in Washington, DC. And it's very similar. Well, you go, and you have a day, and you learn in detail about the issues. And then APA staff does all the hard work of setting up your meetings and doing a quick training on how you interact with the elected officials and their staff, things like this. I attended as a resident and was fortunate to get a travel scholarship. So if there are trainees who are interested in attending, there is financial support there. There is a booth downstairs in the exhibit hall that has, I think it says advocacy on it. So APA government relations staff are there at that booth throughout the conference. And they'll have the exact details and things on that. Awesome. And if you don't want to do it full time like Eric with the cager, all of the APA councils have a role for someone who is sort of a corresponding member, someone who essentially gives them an update on the policy landscape as it happens, potentially talks to the Council on Government Relations. So you can potentially be on the Education Council, or the Child Council, or any other council and still play that role. In terms of outside of APA type of opportunities, one of the ways that we're seeing engagement with the political process is undergraduate campuses are starting to connect with DC alumni and start to develop that network. So more recently, I've had some folks from Hopkins, some folks from Rutgers University approach me with saying, these are our students. How can we build a curriculum for them that involves some of this engagement? Thanks, everybody. Just quickly, my email, I just noticed, so it has no periods in it. So just ericroffleon at gmail.com if you want to reach out. But thanks so much for your attention. And we're all open for questions. Thanks so much.

social determinants of health

mental health policy

988 crisis line

healthcare policy integration

adverse childhood experiences

toxic stress

health equity

trauma-informed training

public health campaigns

interdisciplinary collaboration

policy advocacy

systemic changes