“Translational Research and Health Disparities: The Nation’s Imperative”

by

Sidney A. McNairy, Jr., Ph.D., D.Sc.,LHD

Former: Associate Director, NCRR and Director Capacity Building Branch

National Institutes of Health, DHHS

Seminal Events in Translational Medicine

Seminal Events in Translational Medicine

• 1952 -Watson and Crick showed that each strand of the DNA molecule was a template for the other.

• During cell division-alpha helix the two strands separate and on each strand a new "other half" is built, just like the one before. This way DNA can reproduce itself without changing its structure -- except for occasional errors, or mutations.

Seminal Events in Translational Medicine

• 1963 the first descriptions of the self-renewing activities of transplanted mouse bone marrow cells stem (cells found in the bone marrow and blood of mice can "restock" a depleted ovary with new egg cells within weeks)

transplant of adult stem cells – have been used in patients receiving radiation and chemotherapy since the 1950’s.

developments in biotechnology in the 1980s and 1990s saw the introduction of techniques for targeting and altering genetic material and methods for growing human cells in the laboratory (opened the doors for human stem cell research).

Seminal Events in Translational Medicine

in 1998 James Thomson, a scientist at the University of Wisconsin in Madison, successfully removed cells from spare embryos at fertility clinics and grew them in the laboratory. This launched stem cell research into the limelight, establishing the world’s first human embryonic stem cell line which still exists today.

Seminal Events in Translational Medicine (cont’d)

Completed in 2003, the Human Genome Project (HGP) was a 13-year project coordinated by the U.S. Department of Energy and the National Institutes of Health.

During the early years of the HGP, the Wellcome Trust (U.K.) became a major partner; additional contributions came from Japan, France, Germany, China, and others.

PredictivePredictive PreemptivePreemptivePersonalizedPersonalized

2121stst Century Medicine Century Medicine

WHAT CREATED MY INTEREST IN

TRANSLATIONAL RESEARCH

1. SYNTHESIS OF QUIONOLINE

2. 1963 MARCH ON WASHINGTON FOR JOBS/FREEDOM2. ISOLATION AND CHARACTERIZATION OF TRITERPINOID GLYCOSIDES

3. BIOCHEMICAL BASIS OF SICKLE CELL DISEASE LECTURE –GRAND ROUNDS LSU/TULANE

4. MEMBER OF THE AMERICAN HEART ASSOCIATION OF LOUISANA

5. DEVELOPMENT OF RADIOIMMUNOLOGICAL ASSAYS FOR PRO-INSULIN AND TRI-IODTHYRONINE

6. AN OVER THREE DECADE CAREER AT NIH AS A MEMBER OF THE SENIOR EXECUTIVE SERVICE

What created my interest in translational Research

Quinoline Synthesis: condensation of unsubstituted anilines (1) with β-diketones (2) to form substituted quinolines (4) after an acid-catalyzed ring closure of an

intermediate Schiff base (3).[1][2]

Liver tumors (adenomas and hepatomas) were observed in newborn CD-1 miceExposed to quinoline via i.p. injection (LaVoie et al., 1987, 1988; Weyland et al., 1993).

Saponins or Triterpinoid glycosides*

*During my graduate career at Purdue University my research focused on isolation, chemical and biological characterization of tri-Triterpinoid glycosides or saponins.

Some Health benefits of Saponins

Studies have illustrated the beneficial effects on blood cholesterol levels, cancer, bone health and stimulation of the immune system.

 

“The ultimate measure of a man is not where he stands in moments of comfort and convenience, but where he stands at times of challenge and controversy” Dr.

Martin Luther King, Jr.

NIH Mission: Uncover new knowledge that will lead to better health for everyone

27 Institutes and CentersMore than $29 Billion

NIH MISSIONUncover new knowledge that will lead to better health for everyone. NIH conducts research in its own laboratories; supports the research of non-Federal scientists in universities, medical schools, hospitals, and research institutions throughout the country and abroad; helps in the training of research investigators; and fosters communication of medical information.

It is one of eight health agencies of the Public Health Services which, in turn, is part of the U.S. Department of Health and Human Services. Comprised of 27 separate components, mainly Institutes and Centers, NIH has 75 buildings on more than 300 acres in Bethesda, MD. From a total of about $30 K in 1887, the NIH budget has grown to more than $31 billion in 2009. This was augmented with 10.3 billion via the ARRA supplement

NIH improves the health of the Nation by Conducting and Supporting Research:

• Studying the causes, diagnosis, prevention, and cure of human diseases;

• Investigating the processes of human growth and development;

• Determining the biological effects of environmental contaminants;

• Understanding of mental, addictive and physical disorders; and

• Directing programs for the collection, dissemination, and exchange of information in medicine and health

Opportunities for Translational Research Opportunities for Translational Research

IDeA COBRE INBRE

Lariat and Co-funding

Other

RFIPAFIP

SCORESEPA

NARCH

RCMIRCRII/CCRE

CCHDCRECD

Co-funding

RCMI My Career My Career

335 NCRR and 7 NIAID C06 awards IDeA Program: INBRE- 23 statewide research networks; COBRE- 76 thematic research centersRCMI- 18 sites including 5 clinical research centers; IDeA + RCMI sites include 28 medical schools (8 GCRCs, 3 partner with CTSAs)

Some of The GranteesSome of The Grantees

IDeA

= CT, DC, MA, MD, NH, NJ, VT,

RCMIIDeA

C06

T1→T3T1→T3

COBRECOBRE

RCMIRCMIINBRESCORENARCH

RIMI

INBRESCORENARCH

RIMI

Basic Research

Basic Research

The TRANSLATIONAL RESEARCHParadigm:

Programs that I Developed while at NIH

Clinical ResearchClinical Research

Clinical ResearchClinical Research

CommunityImproved patient

care

Pre-clinical

Basic Research

Community based Research

From Basic Discovery to Translation to Improve Patient Care

animal models

Efficacy

Clinical Trials

Effectiveness DNA→ RNA→ Protein

Secretary’s Task Force on Black and Minority Health….1985

The 1985 Report of the Secretary's Task Force on Black and Minority Health released by then

Secretary of Health and Human Services, Margaret Heckler, documented significant disparities in the

burden of illness and mortality experienced by Blacks and other minority groups in the US

population.

Secretary’s Task Force on Black and Minority Health…..1985

The report laid out an ambitious agenda, including improving minority access to high quality health care, expanding health promotion and health education outreach activities, increasing the number of minority health care providers, and enhancing Federal and State data collection activities to better report on minority health issues.

Why Health Disparities

• Provides the greatest opportunity for understanding factors that influence clinical outcomes in real life settings (gender, ethnicity, age, environment, etc.)

• Translate those findings into strategies to improve clinical outcomes for all persons

• Opportunity to reduce health care system costs

Unequal Access to Health Care*

Language barriers Inadequate insurance coverage Bias among doctors and nurses Lack of minority physicians

* Institute of medicine “unequal treatment: confronting racial and ethnic disparities in health care”

USA POPULATIONYEAR 2050

GROUP PERCENT

WHITE 33

AFRICAN AMERICAN

27

LATINO/HISPANIC

33

Ten Leading Causes of DeathUSA

10 LEADING CAUSES OF DEATH 2009 USA  

1 Diseases of heart (heart disease)

2 Malignant neoplasms (cancer)

3 Chronic lower respiratory diseases

4 Cerebrovascular diseases (stroke)

5 Accidents (unintentional injuries)

6 Alzheimer’s disease

7 Diabetes mellitus (diabetes)

8 Influenza and pneumonia

 9

Nephritis, nephrotic syndrome and nephrosis (kidney disease)

10 Intentional self-harm (suicide)

Suroce: National Vital Reports Volume 60, Number 3, December 29, 2011. USDHHS, Center for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System.

STATE CARDIOVASCULAR DIABETES

IDAHO 13 21

OREGON 12 19

WASHINGTON 20 17

MONTANA 15 6 TEXAS 30 34

LA/MISS 46/50 46/50

MINNESOTA 1 3

UTAH 4 1

America’s Health Rankings

10 Leading Causes of DeathFor African Americans in 2009:

• Heart Disease Cancer Stroke

• Unintentional Injury

• Diabetes Kidney Disease

• Chronic Lower Respiratory Disease

• Kidney Disease

• Homicide

• HIV/AIDS

10 Leading Causes of death for Hispanics/ Latinos in 2009

• Cancer Heart Disease Stroke

• Unintentional Injuries Diabetes

• Chronic Liver Disease and Cirrhosis

• Chronic Lower Respiratory Diseases

• Influenza and Pneumonia

• Homocide

• Nephritis, Nephrotic Syndrome & Nephrosis

10 Leading Causes of Death Asian American & Pacific Islander

Population, U.S., 2007

• Cancer Heart Disease Stroke

• Unintentional injuries

• Diabetes

• Influenza and pneumonia

• Chronic lower respiratory disease

• Suicide

• Nephritis, Nephrotic syndrome, and Nephrosis

• Alzheimer’s Disease

Other At Risk / Vulnerable Populations

• Other At Risk / Vulnerable Populations

• Other vulnerable populations as defined by socio-economic status (social determinants of health, poverty, and education), geography, gender, age, disability status, risk status related to sex and gender, and among other populations identified to be at-risk for health disparities

The Prevention Imperative: Protecting the Health and Well-

Being of America’s Families

• http://www.americashealthrankings.org/Downloads.aspx

The Big Three Threats

OBESITY

CHRONIC DISEASE

SMOKING

33

34

Obesity is one of the fastest growing health issues in our nation

Obesity contributes to variety of diseases

– Heart disease– Diabetes– General poor health

27.5% of Americans are obese compared to almost 11.6% in 1990

This is the first year where no state has under 20% obesity

If current trends continue, 43% of the population will be considered obese by 2018*

*Source: The Future Costs of Obesity; Dr. Kenneth E. Thorpe

11.6%

27.5%

Obesity: The Biggest Threat to Our Health 1990-2011

35

• Health not only means living longer but living healthier and without the presence of disease. 

– Diabetes is one major chronic disease that increasingly is getting in the way of our healthiness.

• Diabetes continues to increase, now at 8.7% of the adult population.

– It was 4.4% of the adult population in the 1996 and 8.3% of the adult population in 2010.

• According to a report published in 2010, the U.S. was set to spend $208 billion on diabetes and pre-diabetes in 2011.

– If we don’t turn this around, we will spend $500 billion in 2020

Source: The United States of Diabetes, UnitedHealth Group

4.4%

8.3%

Chronic Disease: Growing Obstacle to Health 1995-2011

Smoking in USA: A Tough Habit to Kick1990-2011

36

• Smoking has been the biggest health battle of the past 40+ years

• Over the past year, the prevalence of smoking decreased from 17.9% to 17.3%

– The lowest in 22 years

• Adverse impact on overall health– Respiratory diseases– Heart disease– Stroke – Cancer

• Despite improvements, more than 1 in 6 people smoke

Prevalence of Smoking Since 1990

29.5%

17.3%

37

The Full 50: This Year’s RankingsRank State

35 Alaska36 Ohio37 Georgia38 Indiana39 Tennessee40 Missouri41 West Virginia42 Nevada43 Kentucky44 Texas

45South

Carolina46 Alabama47 Arkansas48 Oklahoma49 Louisiana50 Mississippi

Rank State1 Vermont2 New Hampshire3 Connecticut4 Hawaii5 Massachusetts6 Minnesota7 Utah8 Maine9 Colorado

10 Rhode Island11 New Jersey12 North Dakota13 Wisconsin14 Oregon15 Washington16 Nebraska17 Iowa

Rank State18 New York19 Idaho20 Virginia21 Wyoming22 Maryland23 South Dakota24 California25 Montana26 Kansas26 Pennsylvania28 Illinois29 Arizona30 Delaware30 Michigan32 North Carolina33 Florida34 New Mexico

Causes of Death in the United States (Most Common, 1999*)

*All data are age adjusted to 2000 total U.S. population. 

U.S. Infant Mortality Rates, by Race/Ethnicity of Mother, 1998

Source: CDC, National Center for Health Statistics.

Age-Adjusted Death Rates for Diseases of the Heart* Among Women, by Race/Ethnicity,

1996–1998

*Average annual deaths per 100,000 women, age adjusted to 1940 U.S. standard population, International Classification of Diseases, 9th Rev., codes 390–398, 402, and 404– 429. Source: Journal of Women’s Health and Gender-Based Medicine, Vol. 10, No. 8, 2001.

pp. 717–24.

Stroke

According to the Centers for Disease Control and Prevention: “Southerners and Blacks are more likely to die of Stroke than other Americans.”

Blacks are 40 % more likely to die of stroke than whites (hypertension, less access to health care, obesity, smoking and lack of physical activity)

Type 2 Diabetes

Native Americans, Hispanics, African Americans, and Asian Americans and Pacific Islanders are at particular high risk of developing type 2 diabetes.

The prevalence of diabetes is nearly 70 percent higher in African Americans than in Caucasians.

End Stage Renal Disease

In 1997, the incidence rates were 218 per million population in Caucasians, as compared to 586 in Native Americans and Alaska Natives, and 873 in African Americans.

The leading cause of ESRD is type 2 diabetes.

ESRD Incidence Rate per Million By Race/Ethnicity (2001)

254

988

696

395325

471

0

250

500

750

1000

White Black NativeAmerican

Asian Non-Hispanic

Hispanic

Odds Ratio 1 3.89 2.74 1.56 1 1.45

*P < .0001

Ref

*

*

**

Ref

USRDS. Annual Data Report. 2003; adjusted for age and gender.

Annual Fiscal Impact of Racial/Ethnic Disparities in ESRD

Gross Estimate of ESRD Cost in 2001 Due to “Excess” Minority ESRD Population

22.8

15.8

7

0

5

10

15

20

25

ESRD Costs ESRD Costs withoutexcess minorities

Excess costs fromdisparities

USRDS. Annual Data Report. 2003; adjusted for age and gender.Estimated excess costs if minority ESRD point prevalence rate= White ESRD point prevalence rate based on 2001 point prevalence counts and adjusted point prevalence rates (not adjusted for estimated changes in transplant and other ESRD specific costs)

Dol

lars

(B

illi

ons)

Cancer continues to be the leading cause of death in the U.S.

Only a slight decline in cancer deaths in the last 20 years

CDC estimates that if tobbacco use, poor diet and physical

activity were eliminated, 40 % of cancers would be eliminated

2013 Estimated US Cancer Cases*

*Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder.

Men854,790

Women805,500

29% Breast

14% Lung & bronchus

9% Colon & rectum

6% Uterine corpus

4% Thyroid

4% Non-Hodgkin lymphoma

4% Thyroid

4% Melanoma of skin

3% Ovary

3% Kidney & renal pelvis

Prostate 28%

Lung & bronchus 14%

Colon & rectum 9%

Urinary bladder 7%

Non-Hodgkin6% lymphoma

Melanoma of skin 5%

Kidney & renal pelvis 5%

Oral cavity 3%

Leukemia 3%

Pancreas 3%

Source: American Cancer Society, 2013

HIV and AIDS

HIV incidence is growing at a faster rate in minority women than in any other group.

In 1998, more than 77 percent of the women infected with AIDS were from minority groups, with 57 percent African American and 20 percent Hispanic.

HIV and AIDS

An estimated 42 M people around the world will be living with HIV/AIDS by the end of 2002 according to the U.N. Program on AIDS and WHO.

29.4 M in sub-Sahara Africa; 6 million south and southeast Asia; Ca 1.0 M in north America

About half the people infected with the AIDS virus world-wide are women (19.2 m); 3.2 M children (under the age of 15).

Of the 41.8 Million People Living with HIV/AIDS Worldwide………

Women46%

Men46%

Children 8%

46% Women

8% Children

46% Men

SOME WAYS TO ADDRESS HEALTH DISPARITIES

BASIC RESEARCH

CLINICAL RESEARCH

COMMUNITY ENGAGEMENT

Trial DesignTrial Design

AdvancedAdvanced Degree-GrantingDegree-Granting

ProgramsPrograms

ParticipantParticipant& Community& CommunityInvolvementInvolvement

RTRN RTRN BiostatisticsBiostatistics

ClinicalClinicalResourcesResources

BiomedicalBiomedicalInformaticsInformatics

ClinicalClinicalResearchResearch

EthicsEthics

CTRsCTRs

NIHNIH

OtherOtherInstitutionsInstitutions

IndustryIndustry

RCMI/IDeA Awards: A Home for Clinical and Translational Science

Louisiana IDeA CTR

CTSA Medical

University of South

Carolina

CTSA Medical

University of South

Carolina

Collaborations

Louisiana Clinical and Translational Science Center (LA CaTS)

West Virginia IDeA CTR

University of West Virginia Clinical and Translational Science Institute

University of

Kentucky

Indiana University

Ohio State University

Department of Health and Human Resources

West VA Higher Education Policy Commission

Endorsement Collaboration

University of Cincinnati

Other Regional Institutions

Appalachian Translational Research Network

IDeA / CTSA Collaborations Supported IDeA / CTSA Collaborations Supported by DRI/ARRAby DRI/ARRA

WA

OR

CA

NV

AZNM

MT

UT

WY

CO

SD

ND

NE

KS

OK

TXAK

AR

MO

IA

MN

WI

IL IN

MI

OH

KY

TN

MS AL GA

FL

LA

NC

SC

VAWV

PA

NY

VTNH

ME

MA

DEMD

RIID

HI

Biosurveillance ProjectBiosurveillance Project(U of Idaho(U of Idaho

U of Washington)U of Washington)

MetabolomicMetabolomicImmunotherapy for Q FeverImmunotherapy for Q Fever

(Montana State U )(Montana State U )Translational Neuro. CoreTranslational Neuro. Core

(U of Montana)(U of Montana)

Colorectal Cancer Colorectal Cancer Screening ProjectScreening Project

(U of Nevada , Reno(U of Nevada , Reno& UC Davis)& UC Davis)

Pregnancy outcome in Pregnancy outcome in DiabetesDiabetes

(U of Kentucky & (U of Kentucky & Vanderbilt)Vanderbilt)

NIMHD/NCRR-Division of Research Infrastructure

Comprehensive Centers On Health Disparities:

Meharry Medical College - Nashville, Tenn.

Charles Drew University – Los Angelus, Ca.

Morehouse School of Medicine – Atlanta, Ga.

UPR Medical Sciences/ Universidad Central del Caribe/ Ponce School of Medicine –San Juan, Puerto Rico

NIMHD/NCRR-Division of Research Infrastructure

Comprehensive Centers On Health Disparities:

Meharry Medical College: examine the effect of depression on immune function in HIV-positive women, and increased HIV risk associated with sexual abuse and drug use in the African American community. develop and disseminate diverse preventive strategies for addressing HIV/AIDS disparities in the African American

NIMHD/NCRR-Division of Research Infrastructure

Comprehensive Centers On Health Disparities

Charles Drew University:conduct research on chronic kidney disease (CKD) aimed at reducing disparities in CKD and CKD risk factors for disadvantaged African American and Latino patients. increase the participation of medically under-served minorities in evidence-based health promotion and disease prevention directed toward CKD

NIMHD/NCRR-Division of Research Infrastructure

Comprehensive Centers On Health Disparities

Morehouse School of Medicine:* conduct population-based community studies of stroke

risk factors; prevention; incidence; prevalence; natural occurrence and/or recurrence; stroke outcome; and patient adherence to education in the African American community.

serve as a regional resource in stroke education and intervention in the Southeastern United States.

*Supported by NCRR; NINDS; and NHLBI

SOME WAYS TO ADDRESS HEALTH DISPARITIES

BASIC RESEARCH

CLINICAL RESEARCH

COMMUNITY ENGAGEMENT

COBRE for Cancer and Signal Transduction West Virginia University

WV lung cancer rates exceed national average

•WVU is working to establish an NCI-designated Cancer Center for WV and Appalachia

•COBRE research focuses on cancer health disparities in WV (lung, breast, ovarian, cervical, head & neck)

•To date, nine COBRE junior faculty have obtained independent funding, while 5 additional faculty are currently supported

February 2007

http://www.alaska.edu/canhr/

Research Centers in Minority Institutions (RCMI) Research Centers in Minority Institutions (RCMI) 18 Centers in 10 states, the District of Columbia, and Puerto Rico18 Centers in 10 states, the District of Columbia, and Puerto Rico

Xavier UniversityUniversidad Central del Caribe

Ponce School of Medicine

= RCMI G12 Centers

= RCMI Clinical Research Centers

Charles R. Drew University

University of Texasat El Paso

University of Hawaii at Manoa

Texas Southern University

University of Texas at San Antonio

Jackson State University

City College CUNY

Hunter College CUNY

Howard University

Tuskegee University

Clark Atlanta University

Florida A&M University

Morehouse School of Medicine

U Puerto Rico Medical Sciences Campus

Meharry Medical College

Why Health disparities

• Provides the greatest opportunity for understanding factors that influence clinical outcomes in real life settings (gender, ethnicity, age, environment, etc.)

• Translate those findings into strategies to improve clinical outcomes for all persons

• Opportunity to reduce health care system costs

“Colloborating through the RCMI TranslationalResearch Network

• The RCMI Translational Research Network (RTRN) will be a cooperative research network that will facilitate translational research in health disparity areas.

• A consortium of clinical investigators from the RCRII, RCMI, CRECD & CCHD programs; institutions, GCRCs, and relevant organizations including community health centers, with an interest in health disparity areas;

• Data and Technology Coordinating Center (DTCC)

RCMI Translational Research Network

Intra-RCMI Network via DTCC

Reducing & Eliminating

Health Disparities

RCMI Basic Science Research

RCMI Clinical Research

RCMI Educational Programs

RCMI-DTCC

RTRN Pilot Project The Effect of 25 Hydroxy-Vitamin D3 [25 (OH)D3] on

Cardiovascular Risk Factors and Cardiovascular Function

Cardiovascular disease (CVD) and related disorders are the leading cause of death in the nation. Hypertension, diabetes and obesity are more prevalent in ethnic populations and Caucasians. Early data has linked an increased rated of cardiovascular disease in ethnic populations to an insufficiency of Vitamin D3. Research teams at Charles Drew University – in collaboration with the RTRN Data Technology Coordinating Center (DTCC) have conduced the first clinical study for the network. The study examined the effects of Vitamin D on vascular function and selected cardiovascular risk factors and also served as a model for standardizing the network’s research processes and achieving good clinical practices and uniform standards (HIPAA). The study is a randomized trial observing 130 African-American participants taking either Vitamin D3 or a placebo once a month for 90 days.

Principal Investigators:

Keith Norris, M.D. (Charles Drew University)Gary Gibbons, M.D. (Morehouse School of Medicine)

Genomics/ProteomicsGenomics/Proteomics

Clinical/PhysiologicClinical/Physiologic

Socio-culturalSocio-cultural

Reducing Health DisparitiesReducing Health Disparities

PolicyPolicy

CommunityCommunity

Systems and Translational Research Approaches for RCMI

Systems and Translational Research Approaches for RCMI

Infrastructure Development and the Creation of a Translational Research Network Infrastructure Development and the Creation of a Translational Research Network

Improving Clinical Outcomes

Improving Clinical Outcomes

The DTCC at Jackson State University

• Collaboration between database and computational/computer science innovators

• Provide a scalable coordinated clinical data management system for collection, storage, and analysis of data of the RCMI CRCs and other collaborators

• Provide a portal and tools for integration of developed and publically available data sets for data mining at RCMI institutions*

• Provide web based recruitment and referral; and • Develop a user friendly resource site for the public,

research scientists, and clinicians.

RCMI Translational Research Network

Builds upon & will expand RCMI strengths in:• Racial/ethnic diversity & Bioethics• Clinical Research Center infrastructure• Genomic, Proteomics & Molecular Medicine• Pharmacology• Biostatistics & Epidemiology• Information Technology & Related Systems• Geographic Information Systems• Computational Biology• Neuroimaging• Other

1-A Health Disparities Opportunity

Collaborative research in health disparity areas:including longitudinal studies of individuals with diseases that disproportionately impact minority populations, clinical studies, phase I and II clinical trials, and/or pilot and demonstration projects focused on health disparitiesIdeas may emanate from clinical to include understanding basic components or vice-versa

Training for translational investigation in health disparity research - primarily, but not limited to clinical investigators

1-A Health Disparities Opportunity (cont’d)

Test bed for distributed clinical data management that incorporates novel approaches and technologies for data management, data mining, and data sharing across specific health disparity areas, data types, and platforms;

Access to information related to health disparities for basic and clinical researchers, academic and practicing physicians, patients, the lay public, and health policy makers.

2-A Health Disparities Opportunity

Facilitate the identification of biomarkers for disease risk, disease severity/activity, and clinical outcome

Encourage the development of new approaches for diagnosis, prevention, and treatment based on continuous improvements in understanding of disease/health

To Improve Health Outcomes & Reduce/Eliminate Disparities

RTRN Translational Research Cluster System (www.rtrn.net)

• THE END

“The Power of One who Believed- Thirty-five Years and Counting”