There we go. All right. Thank you very much. It's really a pleasure to be here, and thank you for inviting me. And I'm going to talk about the efforts to eliminate viral hepatitis in the Alaskan native population, but the last part of it I'll talk about in hepatitis C elimination in the state of Alaska. So, let's see if I can... Here's my conflicts of interest. And so I'm going to talk about the main three viral hepatitises that occur in Alaska and the U.S., hepatitis A, B, and C. And then I'll talk about the comparing what we have accomplished in Alaska to what the U.S. and WHO goals are for 2030. And then I'll talk a little bit about what we've learned from Alaska in viral hepatitis elimination that might be applicable to other populations. So excuse me, so since 1973, the Alaska Native Tribal Health Consortium and the Center for Disease Control and the DVH, Department of Viral Hepatitis in Atlanta, and the state of Alaska, and the tribes of the Alaska Native Tribal Health Consortium have all been collaborating and conducting studies and programs to understand the epidemiology, transmission, and control of viral hepatitis in Alaska. So in 1981, we started our elimination program, and I'll talk about that in a minute. And then our hepatitis A elimination program started in 88, and the hepatitis C elimination program started in 95. And we don't have delta hepatitis, fortunately, in Alaska. And as far as hepatitis E goes, there's not been any cases that have been identified in Alaska. But HEV is found in several animal species, including caribou, reindeer, and Aleutian Island rats. So the Alaska Native Tribal Health Consortium is a non-profit health maintenance program. It's owned and operated by the Alaska Native people, and the primary care is provided by regional hospitals and clinics, and 200 rural village clinics, and most of these clinics are isolated from the road system. Each clinic has one or more community health aid practitioners who take a 16-week crash course on how to be a provider in their local community. They're in communication every day with the regional hospital, which may be 200 or 300 kilometers away from their village. And then tertiary care is provided at our medical center in Anchorage. So if you look at Alaska, this is all the villages, and you can see that Alaska stretches across the United States. So if Anchorage is where Kansas City is, we have patients in Savannah, Georgia. We've got patients in Sacramento, California, up in Duluth, and down in Tulsa, Oklahoma as well. So this is one of the examples of a village on the Bering Sea coast. It's in danger of washing away from global warming and rising seas. Another village also on the ocean, more in the southwestern part of Alaska. And here is a village out in the Aleutian Chain with the Russian Orthodox Church there on the left. And then this is the clinic of one of the community health aid practitioners. This is actually a CDC nurse that's standing in front of that clinic. And these are the people that we serve in Alaska. This patient has given us permission to show her picture. So this is the tertiary care center in Anchorage where I work, the Alaska Medical Center. It has pretty much all the facilities of any tertiary care center that you could imagine. So the liver disease and hepatitis program, which I am the director of, we have daily liver clinics. We conduct 13 clinics a year, 13 regional clinics in hospitals and clinics around the state of Alaska from Barrow to Ketchikan. We use a fiber scan to assess the amount of fibrosis. We have a portable fiber scan that we carry out to the field. And our care is supplemented by Project ECHO, telemedicine, and also we do a lot of telephone calls with providers helping them to provide care to patients. And we provide educational, monthly educational programs via telemedicine for the whole state. So starting with hepatitis A, we used to have these huge epidemics of hep A that the rates were the highest in the United States. And in between these epidemics, there wasn't much going on. But the last epidemic that started in 1986 involved about 4,000 people altogether. And we did a clinical trial of hep A vaccine. We did actually the registration trial for pediatric patients during that epidemic. And once that trial was over, we were able to contact the company that made the vaccine, it was GSK, and asked them if we could get 5,000 doses of vaccine and try to go out and stop this epidemic. So we went to 25 villages and we gave one shot to the susceptible age group that we determined was susceptible. And within three weeks, we stopped the epidemic in each one of the villages. And then the vaccine was licensed. So the state of Alaska chose to give this vaccine to all children above the age of two as the first state to do so. And since then, we really have not had hep A and we have not seen a homeless outbreaks of hepatitis A yet in Alaska, and hopefully we won't because of the high rate of vaccinations. As far as hepatitis B goes, when I came to Alaska in 1972, I was out in the rural area of Alaska. I was like some of those pictures. And we found that there were very high rates of acute and chronic hepatitis B in population there. And the Alaskan native population along Western Alaska is really the only endemic population, the U.S.-born endemic population in the United States. We also found high rates of the parasitic carcinoma. And what really drove this program was seeing parasitic carcinoma in children as young as the age of eight years of age. Subsequently, later on, we found that there's actually five different genotypes of hepatitis B found in Alaska. And this is a population that is 90% Yupik, Inupiat, or Siberian, what used to be called Eskimos, but they're all essentially genetically very, very similar. And transmission differed by the genotype. So up in Northwest Alaska, where genotype C was predominant, it was perinatal. In Southwest Alaska, where the genotype C was not found, but the other genotypes were found, it was predominantly horizontal, and only about 15% of pregnant women were E antigen positive. So we did a clinical trial of hep B vaccine in 1981. And then we started universal newborn vaccination in 83. And because of the fact that we were seeing liver cancer in children, and because of the political power of the Alaska native population, who went to a very powerful senator, Ted Stevens, who was chairman of the Appropriations Committee at the time in Congress, we were able to get $9 million to go out and screen the entire Alaska native population, which at that time was about 75,000. We screened 53,000 persons. That was 90% of the persons in the endemic area. The overall prevalence in the state was 3%, but in the endemic areas, actually closer to 8%. And we vaccinated 40,000 persons who were seronegative of all ages. We identified 1,500 carriers. And we have seen no acute cases of HPV in children since 1990. There are no children under the age of 20 who are HPV, who are HPSAG positive. We actually added giving antiviral therapy in 2000 to children, to mothers who had high viral loads. We started with lamuvidine and then switched to tenofovir. And so the rates of liver cancer in children, which were the highest reported in the world, fell to zero in the mid-1990s. So here's the number of carriers we identified initially. And we don't have any carriers that are under 20. These are the children that were under 20 years of age. And if we look at liver cancer rates, that rate was 10 times higher than was found in Taiwan. And it was because of this one genotype, which I'll mention in a minute, we found that we haven't seen any cases of liver cancer in children. So this goes to show you that you can actually have a generation of children that are free of infection and free of the risk of liver cancer. So these are the genotypes that we have. But you can see that liver cancer is predominantly, as I'll show you in a second, due to genotype F and genotype C. And this shows the incidence rate in genotype F. So if we look at the incidence, this is data that was actually presented in a poster by Alicia Nolan yesterday, that the incidence per 1,000 person years of HCC in persons under the age of 50 and 40, which is where we are doing surveillance, where we were recommended to do surveillance for liver cancer, is really quite low, except in genotype F, which is extremely high. You notice that it's zero in genotype B. Well, genotype B in Alaska is the genotype B that's similar to what's seen in Japan. It does not have that recombination on the core region that genotype B, Asia, does. So it seems to be a very low incidence rate of liver cancer. And genotype B, it's B5, is also found in Canada, in Inuit populations in Canada and in Greenlanders. And they report that they have never seen a case of liver cancer with genotype B, nor have we. So how do we follow these patients in those remote villages? 75% of our hepatitis B patients live in remote communities that aren't accessed by... Many of them are not accessed by road. Even 25% of those communities don't yet have water and sewage in the homes. So basically, we use a computerized registry that has all the information about the patients with chronic hepatitis B. We have one for hepatitis C. We send letters out to each of the patients every six months. And we send a list of those patients to the local community clinic and also the regional hospital with lab slips and also that are bar-coded. The community health practitioner draws the blood in the village, spins it down, separates it and sends it in to us. We run AFP, liver functions, and HPV DNA. And I sit in front of the computer every week and read all these results. It takes a couple hours a week. And then if everything's okay, we send letters back to the patients. Oftentimes we'll put in little messages like, drink coffee, it's good for your liver, things like that. And then if the AFP is elevated above 10, we have the patients go to the nearest hospital to try to get an ultrasound. We found that AFP has a good negative predictive value but a very lousy positive predictive value. And if we set the barrier low enough, we can eliminate most people who don't have cancer. But still we miss about 20% even with a cutoff of 10. If they have other abnormalities such as liver function abnormalities, we may bring them into our clinic or to one of our regional clinics, try to get a fiber scan or even a liver biopsy. So here's our cascade of care for hep B. We know everybody who's infected because we screen the whole population. Ninety-three percent of those have agreed to be linked to care. Sixty-three percent we've seen within a year in one of our clinics. And only 10% at this time are candidates for therapy because a lot of them are now E-negative. There's very few E-positive patients. One percent of those who are candidates are on therapy and 65% have complete viral suppression. So now I'm moving on to hepatitis C and we've seen the same thing that's going on in the lower 48. The opioid epidemic has hit really hard. Even in some of these small villages, there's distribution of heroin and fentanyl and other injecting drugs. So we've seen that the baby boomers, the numbers that we see every year are about pretty constant but a great rise in the number of patients, new patients with hepatitis C who are born after the baby boomers. And the genotypes are similar to what you see in the United States, a little bit more two and three. And so we do the same thing. We send letters out to everybody every six months that has hep C. And we really try to find people that have F3, F4 fibrosis and get them in for ultrasounds every six months, even if they're cured. We invite them to visit one of our liver clinics and we use video, telephone consultations, Project ECHO. We have three Project ECHOs a month and other means to help manage patients living in remote areas. And the goal is to evaluate and treat all patients with hep C. So here's our cascade of care for hep C. We screened about 30,000 people and we reflex at our laboratory to HCV RNA. So most of them have had that testing. 62% of those who are RNA positive and 83% of those are linked to care. And 76% are either in the treated or in the queue to be treated. We've treated about 800 patients with DAAs. So as far as screening for HCC goes, we're doing a better job than we had done. We send letters out for ultrasound for the appropriate ages. But we include in that letter everyone with genotype F, whether they're over 40 or under 40. And you can see that we're finding more tumors early than we did. We like to find them when they're two or three centimeters so we can actually ablate them with radiofrequency or microwave ablation. But the blue bars are the number of patients that we find that within the Milan criteria that could potentially be transplanted. Probably about half of those are small enough to ablate and the other half are bigger and need to be referred for transplantation. So again, we send the letters out to everybody for HCC. The problem is that most patients can't get from a village into the regional clinic unless they have Medicaid or some form of insurance. The local regional tribal organizations can't really afford to bring everybody in. And we target the same groups that the ASLD recommends, men over 40, women over 50, family history of HCC, cirrhosis, and then everybody with genotype F regardless of whatever their age is. As far as hep C goes, we target everybody with F3 and F4, even if they've been cured. And then we also have other liver diseases that we target if they have cirrhosis. So our goal is to eliminate, we worked with the state to eliminate hepatitis B in the native population, but one problem in Alaska is that the state doesn't have a program like you see in San Francisco to deal with the non-native population. We have a lot of Asian South Pacific Islanders and also people from West Africa that have immigrated to Alaska. And those people are unfortunately not being screened at the rate that they should be screened. With hepatitis C, we're actually working very close with the state as partners to eliminate hepatitis C. So as far as hepatitis B goes, if you look at the Alaska, this is the global population, which I think you're familiar with. The goal is in 2030, or on the far right, and that is to screen 90% of the people with hepatitis B and C will be diagnosed, and at least 80% of them will be linked to care and on treatment if they need treatment. And so if we look at the Alaska native population, we've actually reached all those goals for vaccination and for the diagnosis and for treatment or linkage to care for hep B, but we've got a long way to go for hepatitis C. So we have a program with our partners in Alaska, it's called the HOG program, that's the Hepatitis Alaska Working Group, and it's a community-wide participation. We have all kinds of people involved. The goals are to screen the baby boomer population, and soon, as soon as the U.S. Preventive Health Task Force okays screening of all adults, to screen all adults, and we're working hard to try to find people in the homeless population, needle exchange programs, and screen for both hepatitis B and C. The prisons have just okayed screening everybody that enters prison for hep B and C and treating them for hep C if they're going to be in prison for longer than six months, and then vaccinating those who are negative for hepatitis B markers. We're working on trying to start programs in pregnant females and the emergency departments. Our homeless program, we just got a grant to start, and there was a clinic that's actually run by one of the Alaska native tribal organizations that serves every homeless person, both native and non-native, in Anchorage, and we got a grant to start screening and start a program for hep C in that population. Here's all our partners that are working on the elimination of hepatitis C in Alaska, and here's what our accomplishments to date are. I think one of the best things we've done is we've developed a curriculum for primary care providers to treat hepatitis C, and we offer this course in each major city in Alaska. We get providers, both Alaska native providers and non-native providers, and they get free four to six hours if we only get with HIV, which we have in some of the cases. They'll get up to six hours of free CME, donuts and coffee, and we have it on a Saturday. We've had really good turnout. We've educated about 100 providers statewide to primary care providers, nurse practitioners, assistants, and physicians to treat, diagnose and treat hep C, and included in that is how to get your patient the drug, either from the drug company or from Medicaid, Medicare, so all that really important information. And again, we do a lot of telemedicine and Project ECHO, and I invite you to visit our website because we have all the tools for providers and for patients to actually treat hep C with easy algorithms and all the forms that they need. So it's anthc.org slash hep. we're doing a lot of research, trying to find out if the rates of liver cancer and liver failure and liver-related death are decreasing because of our treatment, and we've got a poster on liver cancer after HCC that was on Thursday evening, Friday evening, I guess. We are looking at resolution of fibrosis by FibroScan in 300 patients that were treated when they had FibroScan before at SVR and yearly after that. We also just published a paper on partial restoration of immune function and Treg cells after SVR. So, what have we learned that might be applied to other populations? Well, all you need is one shot of Hep A vaccine to quickly stop an epidemic, and you can give that second shot a lot later or not, maybe we don't even need the second shot. And if we screen newborns and do catch-up vaccination, we can actually have a generation of persons that are free of HPV infection. And linkage to care for both B and C can be accomplished even in persons living in isolated communities. This applies to places in the world where people aren't close to the hospital. And community health workers who have a very shortened education, of course, can play a crucial role in viral hepatitis elimination. We're just getting ready to start a program where the patients stay in the village with Hep C. The health aides do finger stick Hep C tests, make the diagnosis, draw the blood if it's positive and send it in to us, and we'll run the RNA. And then the patient stays in the village, and they do the treatment with us helping them over video telemedicine. So hepatitis C can only be eliminated with community-wide aggressive approach. Hepatitis C knows no ethnic or racial boundaries. It's throughout our community, and I think in the same way in the lower 48. And also, HCC screening can find liver tumors early enough to cure these patients. So I'll just go to my last slide, Remember Treatment as Prevention. And this is a picture of an Alaskan native who made a mask for us when we told him about viral hepatitis. This is the mask that he made for us. And this is our website. Welcome to join in. And here's Denali, the highest mountain in North America. It's the Athabascan name, Denali, means the high one. Thank you very much. Thank you. Thank you. At this time, we'd like to have all of our speakers come up to the podium so they can join us for panel discussion. This is the opportunity for you as the audience to participate and ask any questions that you may have based upon their presentation or questions that may help you figure out how you can actually implement some of these opportunities in your own community. As they're coming forward, I'd like to announce that tomorrow we will have a diversity reception. It will be in the Sheridan Hotel. It will be at 6.30 p.m. And the room for that will be Back Bay B, B as in Boston. We invite all of you to attend. Please spread the word and have your friends come as well. Are there any questions? You can feel free to come to any of the microphones that are in the room with any questions you may have. Hi. Andrea Reed, Washington DC VA. Thank you all of you for your presentations. They're really fantastic work. One of the challenges that all of you mentioned is the fact that it takes a lot of resources to be able to eliminate all of these conditions. And we know, based on the work that you presented, that there are things that can be done for elimination of colorectal cancer disparities, for hepatitis B, hepatitis C, for transplant. The problem is that they're located within individual communities, within individual resource-rich institutions, or supported by industry or government. That's great for those people that live in those places, and I really salute that. And even within the VA, we have provider reminders that are part of the EHR, so people have to hit these targets. What is happening above the level of the individual institutions that might sort of normalize the kind of work that you're doing or that you're hearing about that might eliminate some of the disparities for people that don't live in either resource-rich areas or that are at institutions, linked to institutions that don't have such dedicated, resource-driven kind of care programs? Is there anything happening on the governmental level that might sort of start from the top and eliminate some of the disparities rather than it being linked only to the individual institutions? And it really applies for all of you. Thank you. Well, it's a very interesting question, and I'm one of the surgeons in Northwestern. Then I think the most important thing is to have people really motivated to do something. Because we went to the government and said, let's do something. We passed a law in Illinois to transplant people that didn't have insurance, and most of them maybe were undocumented. And even though we passed the law, there was no budget. Then did it happen? Then you say, you know what, let's do it with politicians. Sometimes you waste a lot of time. Then you organize yourself. We know we're part of the OPO, the Hispanic Council. We get together. We, for example, developed a not-for-profit organization called Illinois Transplant Fund that followed what the American Kidney Fund did. They were able to pay a premium insurance, the premium for insurance. And then the patient would come into our transplant centers, and we have been able to transplant more than 10 people with a kidney, sliver, and heart that didn't have any insurance to start with. Then there's a lot of, I mean, we can be very creative. And I think the most important thing is to have kind of the motivation to do something about it. And we can find the solution. The problem is the money, in my mind. The problem is to have the decision and to do something. As soon as you have the idea, you can get all the money and resources as has been presented, but it's just to have the champion to say, okay, let's do it, and it can be done. I'll just add that, Andrew, you bring up a great point that we have to engage our policymakers. And oftentimes, some of these projects that show that vaccination is effective or screening is effective is evidence. We have a very active group in the state of Michigan, fortunately, the head of our Institute for Health Policy and Innovation has a whole group of people that's in Lansing all the time, that's our state capital, to try to advocate this. This was also pushed when the ACA Act was enacted in 2010, I believe, and states had the option, after the Supreme Court ruling, to opt in or opt out of Medicare expansion. And some states did, and some states didn't. And you can see the difference between the states that did and how some of their screening and vaccination efforts were markedly different than the states that opted out. And I know states like Tennessee, I'm not in Tennessee, anyone from Tennessee, they were trying to neutralize some things, because I think they were an opt-out state, whereas Michigan was an opt-in state, despite it having a Republican legislature and governor. So these things take advocacy. I'm fortunate to be in the cancer arena, as many of you are, where there's patient advocates, too. And some of the other organizations I'm involved in, they're knocking on the congressmen and senators' doors for some of these things. And so it's going to take... We get evidence, we have great evidence in Alaska Native populations, we have great evidence in certain populations that X, Y, and Z works, it's just convincing the policy makers who control the reins of the funds, for the most part, to vote in. And so that's going to take advocacy. Maybe I can just also highlight exactly what was said, in that both recognition of champions within the community, as well as advocacy through patient programs, that just remind us that the Hep B Free campaign really was initiated within the business community, the patients, the media, and it just took on a life of its own with regards to its collaboration with the health department, and became really a national model. Hep C was the same, that it was volunteer work and initiation of some of those activities to begin with, then with a little bit of seed money got traction, and from then onwards, others came on board in providing additional funding, and truthfully, those fundings are also very fluid, so we are continuing to bang on their doors, whatever agency it is, and I highlight industry as a great partner in that setting, to ensure that we actually have continued effort for these measures. Yeah, I would just like to say two things I think that would really help a lot. I think we all know that targeted screening doesn't work, it didn't work for HIV, it didn't work for pregnant women, and we're about to get universal screening for Hep C, but we really need universal screening for Hep B, because there's stigma associated with Hep B, and if we tell, if we have universal screening, then everybody will do it, and they'll carry the vaccine in their clinic, so they can give the vaccine to people who don't have it, and if you look at the indications for hepatitis B vaccine now, it's approaching 50% of the population, because it's recommended for all diabetics, it's recommended for everybody with any kind of fatty liver or other liver disease, and then of course, people who have more than five or six sexual partners, it's recommended for them, and so it's really, it's at the point now where I think what we should look at is, instead of picking out ethnicities and groups that we're going to screen for hepatitis B, we should just say, let's screen everybody, let's get the, push the CDC to tell them to do universal screening, and then vaccinate those people who are negative, and link the care of the people that are positive. The second thing I think that can make a difference is that, as you know, the HIV program is really well-funded in this country, and they've done a wonderful job, and they deserve tremendous amount of credit, but we've heard over and over again that, well, we've done this once for HIV, it's not going to happen for viral hepatitis, but we need to push our HIV colleagues to piggyback some of their work to, that they are doing to include viral hepatitis, so when they screen for HIV, they should screen for hep B and hep C, and they should help link those patients to care, and I think if we can do those two things, we can make a big dent on viral hepatitis in the US, because we haven't really made much of a dent on viral hepatitis, I mean, there's wonderful programs like San Francisco, but in general, the dent has been very, very shallow. Before we go to the next question, it seems to me that we walk the walk, or we talk the talk and we don't walk the walk, and you guys are four people that represent people that have implemented strategies, and it could be that many communities already have those champions. The question is that we are very isolated. Perhaps we should try to bring us all together and try to see, at least for the hepatology groups, we can try to work together to implement those strategies. Otherwise, we will continue working in isolated states, in isolated communities. That champion will potentially get frustrated and nothing will happen, and we talk all the time about diversity, we talk all the time about vulnerable populations, but we don't just do anything to really, really, really change it. You guys represent people that have changed it, so maybe that's something that we should consider. That's such an important point, Mauricio, I thank you for that, but I also want to highlight that now through, I think, an effort, CDC, John Ward, there is also a website that is currently the Viral Hepatitis Elimination Coalition website, for which we are going to certainly put our program in there, again, with the intent of dissemination of the information, but within the hepatology community, you're absolutely correct, this gap certainly exists, and we have to do better. Hi, I'm Dylan Bush from UCSF San Francisco General Hospital. I had two quick questions, so firstly, for all of you, but specifically Dr. Carethers, you showed a really interesting and, I think, important graphic of the pipeline and the different points of flow, and I think, for me, what's very interesting is that while it's important to focus on all of those points of flow, it seems to be less on people before medical school, and so a couple of years ago, and the Diversity and Inclusion Committee knows about this, we did a small pilot project exposing undergraduates to hepatology and GI, and I think we had really interesting results in our surveys, and I was wondering if you could talk about some points of flow that you think are really important to work on in order to increase the overall flow into hepatology and GI, and then secondly, for Dr. McMahon, I think the images of those communities in which you work are extremely, not only interesting, but important, as they're small, and I can imagine that there's both an interplay between support in such a small community, but also, perhaps, stigma, as everyone in the community might know everyone's business, and so I was wondering what you found in terms of how that has impacted treatment and also prevention in those small communities, thank you. So thank you for that comment, so just to repeat the question is, what about the pipeline before we get to, say, medical school or residency, and I 1,000% agree with you, in the article that Luke John Day and Sandra Cosetta and myself published earlier this year, we mentioned, we looked at all four of the GI societies and what they were doing, and there was one or two that was inviting some high school students to either the city that either DDW or ASLD was in, and to expose them, but I think we have to do more, and that's the challenge, because usually the realm of our societies and the realm of our training is at the much higher levels of training, and getting people to that level is the key challenge. I'll just mention a couple of things, so when I was at UC San Diego, I was on the faculty there for 15 years, and there was a push by one of the provosts to develop a high school on the campus of UCSD, ultimately it became the Preuss School, but I'll tell you, being on that committee and working with the chancellor on that, we told the chancellor, no, we don't want a high school, we want a school that goes from six through 12, because you have to go reach down earlier, and the goal was to take first generation, potential first generation college students under a certain level of family income, because it was illegal to use race or anything else as a choice, that was Ward Connelly's push in California and then later in the state of Michigan, and I lived in both those states recently. The bottom line, that school opened in 1997, with kids bused in as a charter school on the campus of UCSD, that school is now the number two school in California, and like number 50-something in the country, they all have to have below a certain family income, and that school now took kids who were having matriculation rates to college from their schools of 10, 12, 15 percent, to now a school that does 94, 95 percent, with the goal of by the time they get to 12th grade, that they would be eligible to enter the UC system, which is 10 campuses. In reality, about 60 percent go to UC, and the other 40 percent go all over the country, including Princeton and Harvard and other things, and it's a small pipeline, but it basically tells you that if you move your environment and put you in the right environment, people can do well. I'm not saying everyone goes to Princeton or Harvard, but the matriculation rate for college is markedly different. The second thing I'll mention, at the University of Michigan, we're in a college town, and so what was done on UCSD's campus is not quite the same, because the University of Michigan, for the most part, is not in a community, even though the University of Michigan has campuses in Flint, which is a large minority, and Dearborn, which has a different type of minority, largely those from a Chaldean and Middle Eastern background. But I'll tell you a couple of things that have happened there. One is, there's been a huge outreach, which we call Wolverine Access, into at least high schools, not necessarily grade schools, but high schools in the surrounding Detroit community that we develop relationships with to try to make sure that people are eligible to come into the University of Michigan. The second thing is, it was just announced recently, that we're going to have a bigger presence in the city of Detroit by the old Wayne County Jail, and we're putting a new building in, and we're going to have graduate students down there to expose kids more to the University of Michigan. So these are small things in a scheme of things. Again, going back to Andrea's question about resources, how do you get to someone who's in fifth or sixth or eighth grade and convince them that this type of career in medicine and diversity, and where are those resources? Is it the responsibility of us as individuals, is it the responsibility of ASLD or the AGA or ACG? Is it the responsibility of the universities, is it the responsibility of the federal government or the state government or the city? I think these are the challenges, because I don't think... I think we all have the responsibility, but aligning of resources through these different entities that we all belong to is the big challenge. So I think that's really important. I just want to comment on what was just said, that in Alaska, the University of Alaska started a summer program for kids living in remote villages to come in and spend a summer learning about engineering. And it resulted in a tremendous amount of kids ending up going into engineering, native kids going into engineering. And they have advertisements wearing their traditional garb saying, I am a BP petroleum engineer, and I lived in Newtok. And now they're doing it with medicine now, too. They're bringing students in. They live on campus for 10 weeks, and they get courses, and they mentor in our hospital and stuff. And they're junior high and high school kids. And I think grade school kids would even be better. There are ways to do this to get students that don't have that opportunity to learn about it. As far as the question that you asked me, and I'm trying to remember what it was, it was about the small communities. And so because of the liver cancer that was occurring in children, the small communities actually really welcomed us to do this program. And when we did, we proposed the vaccine trial to the board, the UConn Cuscombe Health Board, which is where I'd started out in Bethel, Alaska. I thought they would never agree to do a trial with a vaccine, a plasma-derived hepatitis B vaccine. And one of the board members got up and told the story of who had taken care of a young Yupik girl who was valedictorian of her class. And then she suddenly got sick and developed severe hypoglycemia, and started vomiting blood, and had HCC, and died two weeks later. She had a full ride to University of Alaska. He was in tears. And the rest of the board said, do the vaccine trial. And then when we'd finished the vaccine trial, then they said, what are you going to do next? And we said, well, we don't have any money. Well, then they got all upset. And then they went to Ted Stevens, and he got the money. So, I mean, it's just, it's seen in a way, a different way maybe in Alaska than it is in the Asian community. But I think if there's cases of liver cancer in young people that occur, that's a motivation for people to start to advocate for more resources to help people. And so I think that there's ways to do this. And I really think that what you've done in San Francisco has been just, that's the way to go. Let me just also say, Dylan's actually one of our coordinators currently. I think we've hooked him in hepatology, and who has contributed tremendously to the homeless program. And I would encourage you, Dylan, as you have been, to really champion that cause that you indicated as well in exposing individuals to this specialty. Sorry. My question is actually related. So my name is Sana. I'm a third-year resident working at Highland Hospital in Alameda County, which is kind of right next door. What you have mentioned about SF CAN has been tremendous. And so I have kind of a two-part question. One is, does SF CAN have any plans to support campaigns to decrease rates of alcoholic liver disease and non-alcoholic fatty liver disease? And then selfishly, do you foresee SF CAN spreading to the East Bay? And how can our program be a part of this movement? Oh, yes, thank you. Good questions. In fact, you have an incredible individual there, Robert Wong, who I collaborate with and I adore, so who is championing these causes as well. So your point is very well taken. This is to be in the Bay Area and beyond. So I will definitely explore this option of ensuring that we engage other communities within our groups and why not? It has to be. And so definitely. Secondly, about other preventative measures, I think your point is very well taken. We initially started off thinking very broad. And then it's always a matter of resources, support, bandwidth, and all the activities for which we want to sort of ride the coattail of in order to ensure that there's significant impact. So we started off focusing on efforts that had already been in place, that have been successful or initiated, and there were gaps to be filled to then direct these efforts. And then bringing together these communities to really discuss lessons learned to ensure that we can replicate or expand these models. Absolutely, that is a part of our agenda as we move forward. So for sure that, and I would say fatty liver disease is another one close to heart as well that we should certainly be making impacts on. So for sure. Can I ask a question? And this is more to two people, one to my right and left. I've heard a couple people at this meeting talk about the cost of HCV drugs and how some companies may provide certain countries in Africa and other places a reduced cost. I was wondering, and I know like through the VA system, Andrea works, where sometimes you gotta watch your yearly budget and target higher risk people first and then wait till next year and then target the next level. I was wondering in both the SF initiative and maybe this is part of federal government, how are you dealing with the cost of use of HCV drugs to implements? I noticed you had a couple 300 people or something treated and they're coming in and et cetera. I was wondering if you can address that. So for our hospital, which is a nonprofit hospital, it's a moneymaker. And the reason for that is they buy the drug through the VA and they get about anywhere from, depending on the price of the drug, anywhere from $10,000 to $30,000 profit to each patient they treat. And then we get the drug for free from the drug company using their program that they have for people who don't have enough money that they can apply for the drug for free. And that's a bit unusual and I think the companies did that because they realized that they were gonna be charging so much money for these drugs and that people couldn't afford them. So they wanted to make a lot of money, which they have, from the insurance companies and then make the drug available to everyone. So it's a two-edged sword, I guess, in the moral field. But they make those drugs for about $200 in India for an eight weeks course. When I was at the viral hepatitis elimination program, because I do work on a project in East Africa for the last decade, and I was at the meeting in June, a viral hepatitis elimination in Africa meeting. I drove past the company that makes EPCLUSA for $125 for eight weeks of EPCLUSA. So you can imagine that this drug is not expensive to make and the price should really be a lot lower. And I think if they would lower the price, we would be able to treat all people in the prisons, which is what we have to do to eliminate this, and treat people who don't have resources or insurance or can't get the drugs. On our end, actually, with the Affordable Health Act, we've had a significant push in insurability of this population. So majority of our patients are Medi-Cal insured that would fall into the unable to access these drugs in the past. And so with that, we're now not dealing as much about access through insurance, although it is still some work, more about the barriers of really linkage and also the acceptability of treatment, et cetera. So a lot of work has been done in expansion of treatment within the primary care setting, any other type of setting, any provider who's touching the patient. So that's one aspect, and another is really through these programs. So enhance patient's acceptability of these drugs. We've gone through the no hanging fruit, as they say. So now these are the most difficult population to reach, and so the barriers are several. Thank you. Of course. I'm Lauren Nephew from Indiana University. Thank you all so much for talking to us about solutions to healthcare disparities. I think we all sometimes get a little bogged down in finding disparities, and it's refreshing to hear about solutions. But the solutions are expensive, and patient navigation, for example, has been shown in the cancer arena to be effective in colon cancer and breast cancer and other arenas. We haven't quite adopted it, particularly in HCC, but do you think cost-effective analysis, what do we need to do to try to show that this patient navigation is feasible to be implemented in other arenas? And do you think cost-effective analysis is the way to go? I'd be interested to hear your thoughts about that. Well, I can speak from the cancer side, at least the colon cancer side, that it is cost-effective. So if you just look at screening by itself, and I'm sure this is probably true for even liver cancer screening in populations, screening by itself, even with colonoscopy, even if you compared it to everything else, is still way cost-effective. And there was the recent analysis, I think within the last two years, when the USPSTF published their analysis in JAMA on colorectal cancer screening, that colonoscopy was one of the top, along with FIT, as one of the most cost-effective prevention of colorectal cancer. Navigation is only a tiny, it's even a small, tiny, tiny, tiny piece of cost of that, because when you do a colonoscopy, they look at the general cost, and then also the life you're saved, and it's still very high, even if you throw in navigation. And certainly navigation has largely been targeted to more vulnerable populations who don't have necessarily the access to colonoscopy. So it is a fraction of a fraction of the fraction of the total cost there. Some of the barriers, particularly when I was in California, was not just colonoscopy, because most of the cost-effective are colonoscopy and FIT. The least cost-effective, and it was not recommended by USPSTF, is actually the multi-targeted stool test, because its cost is much higher. And when they look at the cost, they look at the cost of the test itself and the subsequent colonoscopies that are needed. And that one generated excess numbers, and so it wasn't recommended as a cost-effective test, believe it or not. But one of the barriers I had when I lived in California, and this is some degree true in Michigan, is that even if you went with FIT testing, so FIT was, I believe it was covered, but the follow-up colonoscopy was not covered. And this has been a problem with general insurance in the United States, because you go from a screening colonoscopy to a diagnostic colonoscopy, which is coded differently, and some insurances require payment by the patient for the diagnostic colonoscopy versus a screening colonoscopy. Whereas you do the colonoscopy upfront as a screening, then you don't have to worry about it. But if you do another test first, it changes the nature of the colonoscopy from the insurance standpoint, and there's a big push to try to change that. So that's another thing. But navigation is a tiny fraction of all those costs, and it is, there's several papers on it that it is highly cost-effective. In fact, Uri Ladebaum, I think who's at your institution, has published some of this data as well, and it's highly cost-effective. So we just have to implement it, and maybe it's part of the global cost of getting screening versus an individual lined-up item thing. And this is true how surgeons, when a surgeon does an appendectomy, they get a global cost of doing a surgery and seeing the patient and whatever, and I think these should be part of the, perhaps the global cost for screening. My thoughts. I think your point is very well taken. I wanna be sure that it's also recognized there's a tremendous number of individuals in these kind of efforts, community efforts that I highlighted, that the websites that are listed in the program should help you access these individuals. Who have worked tremendously in trying to expand these measures and initiatives. And so oftentimes what we get from any kind of funding sources, et cetera, is the pushback about the fact that navigation programs work, been there, done that, it's very helpful and successful in achieving enhanced screening, testing, linkage to care, yet it's still an issue. And so as I was sharing with you that in the Hep C free campaign, they've really sort of worked on the peer navigation, for example, along with other types of resources that may exist within certain populations. So for example, in the underserved communities, these programs do exist for various conditions that you can be leveraged to some degree. But there's certainly more funding, for example, needed to be able to show that these really small amounts of effort can be implemented and sustained. Because it's not that costly to maintain. Julio's short question and short answer. Okay. Actually, I just want to now interject in the transplant arena for liver transplantation. Actually, for example, to try to implement solutions that are culturally sensitive, that can be very, I mean, with high impact, the cost is less than 1% of the organ acquisition cost. Yes. And that can be reimbursed by the Medicare, for example. That is the bigger payer, for example, for many programs. Then it's very cost efficient. The budget impact analysis is showing that centers will recover. And the second thing that we're working in the transplant society is trying to empower our diverse workforce that we have currently. Because people think that we don't have diverse workforce. But actually, when you start looking at very carefully, actually the diversity is higher. But even though there's a diverse workforce, it's not empowered to start doing something specifically for their group, whatever it is. For the African Americans, or for the Asians, for the Hispanics. But if we can help them at the ASLD, or the ASTS, or the AST, can help to empower people, that can increase the amount of program that can help to solve disparities. My name's Julio Gutierrez. I'm a transplant hepatologist in Southern California. This is something the whole panel can comment on. But one of Dr. Crother's slides, he showed the comparison of colorectal cancer incidents to blacks, white, and to Hispanics. And what always strikes me about these types of studies is the most divergent rates of cancer are usually between blacks and Hispanics. For a lot of different cancers, including liver cancer, I think it's also dramatic like this as well. Should we be focusing more on the differences between minorities, rather than the differences of minorities to whites? I like what Dr. McMahon said about universal screening. So I think the data shows that there's disparities against the general population. Not necessarily a disparity between blacks and Latinos, or blacks and Alaskan natives, but there's a disparity against the general population. And in that, you can focus your attention to try to fix that. I will tell you that even though the numbers, and as I was brought up, I think by Mary Ranella, Hispanics is a greatly diverse group. And so there are some higher pieces in there, depending on their actual background, compared to just the group in general. So we have to be careful of that, but that's how it's classified when the data comes out. So I will say that there are other nuances too. For instance, over the last 25 years, the number of rectal cancers in those classified as Hispanic has gone up tremendously. Why is that? We don't know. And so there's subtext of this, that understanding differences in areas, whether you're Asian, Alaskan, Hispanic, Latino, African-American, that we need to address because you see the differences. I like the idea of universal screening, because there's one or two, and I showed you the Delaware Cancer Consortium for colorectal cancer. There's actually another study that shows if all things are equal, you can eliminate a lot of these disparities, despite the changes in incidence, and just like universal vaccination and all these other things. So I think we could really eliminate some of these disparities if the right implementation is done. I heard a wonderful, well, not a wonderful, under a disparaging study on cervical cancer screening. This is with HPV. And I learned from a guy named Reed Lee Riley that in the Southwest United States, there's a predominance of a different genotype of HPV than what's in the typical vaccinations out there. And so the vaccination does nothing to that community at all. And so these are the things we need to understand why those disparities might be perpetuated. And so that's where the data helps you. But I think it would be good for everyone to get HPV vaccinated, because it will eliminate a lot of head and neck cancer and a lot of cervical cancer in the end. I don't know if anyone else wants to address that. I agree with you. Thank you. And with that, we are gonna close this session. And thank you for your participation.

viral hepatitis

Alaskan Native population

hepatitis A

hepatitis B

hepatitis C

elimination programs

Alaska Native Tribal Health Consortium

universal screening

underserved populations