Then we can continue with the last talk or the last formal talk of this the summer school And now we go even one step further and it's like almost like the final step that you can go with VPH technologies and with modeling and combining it with information and data and data analysis And that's going towards use it for for example Searchery for surgery planning for doing the experiments It's my great pleasure to introduce Michelangelo Gonzalez Baiste who is also working here at UPF He's also an Ikea research professor here in Catalonia, and he's working together with us like in the whole set of groups where Oscar and me are focusing mostly on the cardiovascular application and Michelangelo is doing all the rest and is doing it much better than us So we are looking forward to hearing your talk Michelangelo. Thank you very much So I always joke saying that there is a very strong group on on brain Analysis here in the university a very strong group with heart analysis here with Oscar and Bart And I'm the person without the brain and without the heart that works on the rest Which is not true because actually by also the neuro things and cardiac things When when I looked a bit at the the program of the of the summer school, which I think is great We had some really really good speakers I Tried to think about how to focus my talk because we've seen a lot of work or a lot of presentations on on imaging on image processing on modeling for like Understanding the basic workings of physiology on modeling for also patient specific diagnosis and prediction But then I want to give a bit the the complementary view of Okay, once you've done all this analysis and you want to treat the patient what sort of technologies or was what sort of approaches can we do? Also instead of focusing the presentation on Talking about my research. I Structured it more like a lecture. Okay, so we will go through some of the basic things that I think are fundamentally different From what we've seen up to now and maybe focus on three main things one is navigation technology So things that you can implement to help the surgeon or to guide the surgeon in the operating room To reproduce the plan that he or she has done prior to the surgery The other is interoperative imaging that can help you Compliment the information that you have during the intervention and the other is surgical robotics So there will be two main take-home messages in what you will see one is this so the basic idea of computers It's that surgery the basic elements, etc And the other is that the need to think out of the box Which I think we've seen the previous presentations as well. Okay, but When you go into a lab There is always a tendency that you continue the work or the lines of work that are in the lab But I always try to To expose students from the beginning to the application to get them to talk to the surgeons or to the doctors or whatever and come up with their own crazy ideas before Giving them a sort of root of what they should implement So I think this is also very important. So to think about What is your view and to have some sort of scientific? Let's say science fiction type of ideas That maybe are not feasible nowadays, but they will in the future so Focusing on treatment of course not all treatments are based on surgery There are a lot of treatments that don't involve any type of surgical intervention But to think a bit about What should be the future of surgery? Maybe I will deviate a little bit Focusing on what is the past of surgery first and to give a sort of brief Overview of the whole process that has taken us to the the current setup in the operating rooms Of course, anciently 7,000 years ago There were some very basic Interventions that are documented that were already done in prehistoric times and then later in Egypt and then later on in Greece and Rome, etc. So there is a long history of documentation of surgical procedures But until like the mid 19th century nobody thought really about antiseptic Aspects of the surgery so nobody thought about washing your hands or watching the instruments basically before him So think that the whole process progress that has been going on in surgery is fairly recent and things that we Nowadays think, okay, so this is crazy. These guys were doing things without any safety So probably people in a hundred years from now will think about the way we do surgery and think that we are crazy And we're doing some really silly things Anyway, so coming a bit more to practical things So that the recent past of surgery has been hugely influenced by the advent of of imaging technology and Since Philips is in the room. So we should acknowledge also that part of this is of course thanks to Philips and other manufacturers But so where should we go from now, okay And there are if you look around a bit just out in the internet whatever there are different views where people have seen We should go from now. Yeah, one is of course the integration of robotics. So having more and more automated treatments Robots that operate on the patient or more than robots tools that operate on the patient Part of this is already there. So we have some surgical robots that are in the market and we will see some some examples Another idea is the idea to Incorporate information in the operating room So have not only the patient laying there and being locked in the room But actually have access to a lot of external information as well to integrate all these So, of course, this is also things that are happening and this is the whole concept of the digital operating room There's a big community and led by many manufacturers That are trying to integrate all the devices and have connected operating rooms and these sort of things What else well new ways of interacting with with things is from a movie And these are some prototypes that people use with the Kinect and things like that to To access data or more robotic systems that operate in the In the patient and in particular this robot is from a movie But it's also a prototype that is actually used in Experimental surgery was developed by a university. What else? I have also the concept of like Let's say Things that require less intervention, okay, so now the the concept of surgery is about opening the patient and doing things, right? This is going to change I think it is and in fact there has been a lot of ideas about how to operate from inside or have to have How to have devices that cure the patient without being so invasive and This relates a lot with the concept of nanotechnology And maybe some years from now people will think that we are doing all these blood and all these cuts for nothing, right? In any case in the situation in which we are now is that we are dealing with surgeons, of course And we have to provide tools to them to be able to guide or to be able to Help them perform the surgery Okay, this also involves the need for being fault-tolerant and to kind of monitor What's going on in the operating room and be able to integrate all these Okay, anyway, so the first block that I wanted to discuss was about surgical navigation The idea of surgical navigation is of course well, it's very similar to car navigation. Okay, you want to go somewhere You have made a sort of route a plan and You want to have some external device or some system That is able to guide you to the location or to the anatomical or pathological structure where you want to go So what sort of technologies or what sort of devices have people thought of and have implemented in in routine? From the past again, so just briefly to give the perspective that the first idea was this Stereotactic frame concept that was used in neurosurgery. I Was just a fixed frame that was attached to the the skull of the of the patient So the frame was attached with with some screws And then it was used to guide electrodes into the brain of the patient So what do we gain from this? We gain having some sort of reference system So it defines a Cartesian space in which we can relate positions and you can say okay So so many millimeters in this direction so many in this other This is still used in fact, and this is a modern version of the stereotactic frame But some some of the main limitations that led to further development and in fact The most crucial Flow of the system was that it was assuming that the anatomy inside is more or less constant So it was assuming that if we if you move three millimeters from here and five millimeters from there in this direction You should aim the to find the brain ventricles for example Obviously especially for pathological cases, this is not the case. There is quite a lot of variability and And it was not until much later when we had better Imaging equipment that we were able to integrate 3d imaging and 3d information and more let's say meaningful coordinates to guide the operation This is a picture from Hansfield who invented as you know the city scanner And well, this is why this whole field started to develop in the in the 90s basically Towards more integrating the 3d imaging and having more computing power To guide the surgeon and the first development that was let's say commonplace Was the use of articulated arms which are these sort of things? Okay, where you have a tool and you had a set of articulations and if you have a study robotics and You maybe are familiar with the whole concept of having several Articulations and doing the inverse problem to be able to guide to a particular location, etc In this case this this was a sort of passive robot So it didn't have any any autonomous movement of the of the articulations But it was able to compute What is exactly the 3d location of the tip relative to the reference? So if you had some three data of the patient and you were aligning through a calibration process this 3d data to the origin of this tool and If the anatom of the patient doesn't change while you are doing things to him or her Then this gives you a reference frame basically and this is still somehow in use Okay, this is a more modern navigation system What we have normally is that we have some pre-operative images They can be CT MRI whatever you have that you have used to diagnose the patient to plan the intervention From these pre-operative images You can have also some pre-operative plan and there is a whole field on how to do interfaces to plan interventions And to plan trajectories, etc in a way that is useful for the surgeon And this can be shown in this displays you have then also devices that are able to do tracking Here and tracking in this case in this device would be this camera here Which is basically like an eye that is looking at the scene and is able to track what's going on So what is actually the surgeon doing? Where is the patient if there has been any sort of? variations in terms of relative positions of the tools of the patient, etc And we will very briefly explain the basic workings of how optical tracking and electromagnetic tracking work And what's very important is that we have many different Coordinate systems, so we have the coordinate system of the pre-operative image And this can be many different coordinate systems because we we need to align all the pre-operative images as you know by image registration But then also we need to align all the pre-operative data to the patient because the patient is lying there on the on the bed And this concept is also known as registration is patient registration And there are quite a lot of ways of doing it, but the basic idea is that you have your images somewhere and you put them on the patient So you're able to work on the same 3d space. So the camera is Measuring 3d positions in the patient and these 3d positions they can be related to the image That's a bit the idea So this is an illustration from a very early navigation system It's from 90s and it was developed by the group where I worked for several years in Bern And it was the first system that was doing navigated spine surgery So you would have some pre-operative data of the patient and this data was shown in this in this display You would have also the camera that is the tracking system that was looking at the scene so it was looking at all the instruments And you can see that there are some small devices here which are sensors that are looked by the camera So they can be located and the 3d position of these things can be found And these sensors are attached to the anatomy, so to the spine And this is the tool of the patient that has also some sensors, so the 3d positions can be related And the basic idea is that then you can map the tool on the image So as the surgeon is doing things, he is able to see what is at the tip of the tool Even if he cannot have a direct view of the anatomy inside So that's the basic idea. If you cannot look inside directly thanks to this You can have access to the full 3d information and you can navigate the tip of the tool Ok, in terms of technologies that have been developed for tracking And that's something that if you work on this field or if you collaborate through your work with some people that are doing interoperative navigation There are a number of choices in terms of the available technologies So you have of course articulated arms, it's an inexpensive option Some early technologies that were tried were also based on ultrasound So 1d ultrasound probes just to locate positions of points Electromagnetic tracking which we will briefly discuss later Optical tracking and there are a number of choices and we will see now as well Or things like structure light or patterns of light that you project on the patient And then you are able to reconstruct the 3d shape based only on this projected light So there are a number of technologies that are used to be able to track the movements of the tools and the patient In terms of optical tracking which is probably the most common nowadays What you have is a camera or a set of cameras In this case this device has two cameras that are in a certain configuration that is well calibrated and controlled And you have tools where you need to attach some thing that has to be seen by the camera You have two types, active optical tracking in which is this configuration here You have LEDs that are emitting light on the tool And these LEDs they emit light and the light is seen by the camera And this allows to be able to track the tool However they need some power source, so either a local battery or some cables, etc The accuracy is better though Then you have passive tracking in which you have some coated markers So you have some reflective balls and there is light that is emitted by the camera and reflected So these are less expensive but also they are less accurate in terms of tracking accuracy The problem with optical tracking is of course that you need direct line of sight So if the surgeon gets in the middle between the camera and the tool Or if you want to reach a certain location that is inside the body where the sensors cannot be seen Then this poses quite a lot of problems and you are not able to track In any case, as I said, this is the most common technology And it's for example in some of the integrated operating rooms of BrainLab in this case Or in some other surgeries, you can see the camera hanging from the ceiling and looking at the scene It's a bit like a tennis referee type of thing One thing maybe to mention is that for every different tool that you want to use What they do is they have a different configuration of the markers So they are identifiable So if you look at the pattern of the shape of these balls, you are able to identify which tool it is And also the idea of tool calibration Tool calibration means that you have a CAD model or you have a computational model of how is the tool So the camera only sees the balls So you need to somehow calibrate and be able to tell where is the tip exactly relative to the balls Or what is the shape of the tool basically That is what is known as tool calibration To track the patient, it depends a lot on the type of intervention of course Just to illustrate, so for example for orthopedic interventions It's quite common that the use of a dynamic reference base A dynamic reference base is the same type of sensor In this case it is an active marker, so you have the LEDs here emitting And it is rigidly attached to the anatomy So if the patient moves, you can track the location of the patient And this is in fact one of the main limitations nowadays of these systems Even though they are quite used commonly For example for orthopedic interventions you are requested to attach these markers rigidly to the bones that you want to track So if you want to track what is the flexion of the knee in this case Or you want to track the movements so all the plan moves together with the patient Then you need to invasively attach these DRPs to the bones And the attachment is quite important, so this is a practical thing It's nothing really fundamental scientifically But if you kind of kick the marker during the intervention, which is something that happens quite often And it's not rigidly attached, then the system will think that the whole anatomy has changed So you will need to recalibrate and redo the whole planning Let's say, or update the whole planning during the intervention The other technology that I mentioned, apart from optical tracking, is electromagnetic tracking In this case this is based on generating a magnetic field through a field generator And then this magnetic field is in a way that your tools can be located in 3D Without going into detail, but it generates a field And you can imagine that the sensor locally or the tool is able to read the value of this field And through triangulation and things be able to locate the 3D position Of course the good thing of this is that it doesn't need any direct line of sight So you can use it for example at the tip of the endoscopes So you can put one of these sensors at the tip of the endoscope And even if the endoscope is inside the anatomy of the patient And it cannot be seen directly by the eyes The 3D position can be tracked anyway The cons of this technology is that it's sensitive to the presence of metallic or ferromagnetic objects So of course you need to control a lot the type of instruments that you use for these interventions Okay, so that was the first part So this idea of tracking systems or navigation systems and how you are monitoring the intervention The other concept that I wanted to throw during this talk was to mention a few types of interoperative imaging That are used in computer assisted surgery and some example systems Of course one of the most common is X-ray fluoroscopy So as you know fluoroscopy is continuous X-ray exposure so you have dynamic sequences It's used a lot for orthopedic interventions It's used a lot for catheter interventions in vessels, stenting, things like this In this case for the use in navigation it's very important to calibrate or to take into account The exact configuration of the X-ray machine So where is the source, where is the sensor to be able to interpret the images So to be able to let's say calibrate the dimensions of the images So if you measure three pixels how many millimeters this is basically And there are a number of procedures that have been used or that have been devised To be able to calibrate these in very non-invasive ways Of course nowadays with the use of advanced C-arms you are able to have continuous 2D fluoroscopy But also by doing a full rotation you are able to have combim CT scans Which give you a full 3D image of very good quality And you can relate this 3D image with the 2D projections This can be done in a number of ways For example here this is work that is done in our group by Chong Zhang That is so registering or maintaining the correspondence updated all the time Between the 3D dataset which is a pre-operative CT But it can be also an interoperative combim CT And the continuous 2D projections through fluoroscopy To be able to guide interventions of abdominal aortic aneurysms Other modalities that are commonly used in navigated surgery Ultrasound of course because it is cheap it is non-radiating And it's available in most hospitals This is for example work on guiding right the frequency ablation of the lever With the help of the view of ultrasound So you can imagine what is the basic idea here So you are monitoring the intervention and you are tracking the position of the tip of the probe This is another example and in fact it is from work that was going on in India When we both were working in India Was that like 15 years ago? And in this case it is for neurosurgery Where the idea was to have a robot doing the surgery And you would have a pre-operative MRI where you are able to plan the interventions So to see, analyze where is the tumor or where you want to go And exactly what you want to do with the patient And then have interoperatively ultrasound scans So this is possible because there is a window that is close to the ear Where you can have quite good ultrasound images during the intervention And the whole process was defined as a problem of registration basically Because you would have many ultrasound images You would be continuously monitoring the intervention But you would have only one MRI volume And the idea was to fuse this information and be able to keep updated the location of the tool relative to the MRI And to do this we thought of some methods for registration This would be an example of the pre-operative MRI, the ultrasound image This is a 3D ultrasound And this would be the result of the registration and the overlay of the gradient of the MRI on the ultrasound So to just monitor if the registration was correct Okay, what else? So apart from fluoroscopy and ultrasound I also mentioned that there are quite a number of interventions that are CT guided Mostly things related to needle biopsies So you would see the needle here and you are able to track if you are actually in the right location The basic thing is to be able to track if there is some deformation So if the needle has bent or if the trajectory has been modified relative to the planning And the same idea also for MRI So in particular open MRI, as you know, or maybe you don't There are open MRI magnets in which the magnetic field is generated by these two donuts here And you have an area that is open so the surgeon can stand here and operate And then he can go back and get a new image and go in and it's kind of flexible for interventions Okay And then there are a number of combined suites that have appeared lately I think we mentioned one, you mentioned the one of KCL also But for example, this is a combined operating room in which the patient can be moved Inside a pet machine or a city machine and the data can be updated So basically during the intervention the patient can be cleaned, let's say, and then thrown for imaging So we have updated information while we are doing the intervention Okay, then moving to another type of imaging and maybe showing some more examples of things that are more related to what we do here This is an example for surgical microscopes And surgical microscopes, of course, they give optical imaging So you see things bigger, that's the idea for microscope And they are very much used in neurosurgery and also in ENT surgery So ear, nose, and throat, so tumors in the skull base or endonacell type of tumors, etc This is a system that we built that was incorporating the tracking camera attached to the microscope And in fact this configuration was fundamentally much more accurate than other existing systems Because the other systems had the camera outside, so that needs to track the microscope device as well In any case, this was implemented, we were able to overlay through augmented reality the position of the tumor For example inside the patient, this is the mouth, the nose, etc And the access here for the tumor removal was endonacell And you're able also to overlay through augmented reality also things like the CT slice at a particular depth Relative to the position, etc And this was tested on a number of cases in Bern Other things that are coming up quite strongly is of course the combination of optical imaging With markers such as fluorescent probes that can be injected in the patient And they go naturally to certain locations that relate to the activity of the tumors So they fluoresce and of course they can provide complementary information to be able to delineate clearly the bounds of the tumor And thus update the margins of the removal area that you want to act upon Similar to microscopy, there is endoscopy as you know Endoscopy, the camera is at the tip of a tool So you are looking through a keyhole type of thing There is rigid endoscopy and also flexible endoscopy And the idea of this diagram is again to stress the importance of keeping track of all the reference systems Because we have the reference system of the preoperative data, we have the reference system of the patient There is the natural reference system of the camera, the marker that is attached to the endoscope The position of the tool relative to the marker, etc And I would say that this is in fact one of the things that always goes wrong So there is always something that either because the origins are switched or there is some, let's say, bad maintenance of all the transformations that are required It requires always some debugging In any case, then there is always, of course, the calibration of the camera itself As you know, in the scope cameras they have a bit of a fisheye type of optical view So you need, of course, to calibrate the focal length, well, all the parameters of the camera So you are able to relate, let's say, what you see in the image with the fisheye dimensions This gets even more complicated if we deal with flexible endoscopes And this is our case because most of our applications use flexible endoscopes In this case, the camera is at the tip of the endoscope and is this type of camera This channel through which you can put things inside, so you can put tools to remove small polyps and things like that You can have lasers that burn tissue or a number of things But as you can imagine, this is used, for example, for colonoscopes or for abdominal interventions So there are a number of very complex processes that go on here The only just being able to track the tip of the camera is also being able to monitor the deformation of soft tissue organs And this is where a lot of modeling and simulation comes into play To be able to kind of predict what are the deformations that are happening And compare them with the visual information that you are acquiring And these things So these are some examples If you have calibrated your camera, you can then also generate virtual views So in this case this would be a virtual view of the endoscope inserted in a pig in this case And you can compare the virtual view or overlay the virtual view with the optical view that you have in the endoscope One thing that we recently developed here at the university And this is work of Marta Guardiola in collaboration with Oscar as well Is the integration, it's basically a new imaging device integrated in the endoscope So it's based on microwave imaging And we built a system with a number of antennas that are attached at the tip of the endoscope And these antennas generate and get back signal And this is able to locally create an image And this image is also related to the dielectric properties of the tissue And in a sense it's a bit like doing local non-invasive biopsy So you are able to hopefully, once we get all the validation done You are able to have not only the optical view of what's in the colon But also to characterize if the tissue that is around is benign Or has a certain probability of being cancer And then you move and have a pattern for this So it's related to endoscopy and things that we do here in UPF One of the main lines of work in our group is on fetal medicine In our group and also in the group of parts So related to brain development in the fetus Related to cardiac problems in the fetus And also related to intervention in the fetus So there are a number of pathologies where the babies have to be active upon before birth Otherwise they die For example in this case we have a case of twin-twin transfusion Which we will mention now And in this case we have rigid endoscopes We may have some monitoring through ultrasound that is looking at the scene And we want to track everything that is happening to be able to guide the surgeon One thing is that the whole environment is quite complex So there is a small room, a lot of people Because you need somebody to use the ultrasound machine You need of course the surgeon that is using the endoscope, nurses, etc And you want also to integrate all this and provide the information at the right time And with the right accuracy So in particular for this case of twin-twin transfusion What happens is that we want to burn, as you will see here There is a laser that is burning some vessels This is because in these cases these are pregnancies of twins of course And there are connections in the vessels of the placenta And then blood is flowing from one baby to the other And we need to do something to close these connections Otherwise what happens is that one of the babies gets too little And the other gets too much nutrients And what this means is also that this is bad of course for the one that gets too little But also for the other one Because this deregulates completely the way the body is working And this can cause very severe problems leading to death as well So this is one of the big projects that we have running In collaboration with the fetal medicine unit here in Barcelona Okay so we talked a bit about computer-assisted surgery and navigation We talked a bit about different intraperative imaging modalities And how computer-assisted surgery has been used in some example projects And I will close with some considerations about surgical robotics You may be familiar with this device I don't know if you have seen or you have been exposed to one of these interventions So this is the DaVinci robot In fact there is quite a lot of controversy as to whether this is a robot or not Because what happens is that the surgeon sits in a console And they have some very sophisticated joystick type of thing And a visualization system that is a 3D view And sort of gives the view of the surgery But it's tele-manipulated So it's not a robot in the sort of conventional sense that you would think of it There are some cases of robotics that I think I just want to throw Because they give a bit of the idea of all the status Of all the problems that are related to robotics in surgery There was a system called Robodoc that was quite successful It was built and sold in many places and it was for hip surgery So the robot would attach to the femur and to the hip And then it was used to perform the cutting of the femoral neck And to cut the planes and so you would put the implant in the hip in a certain way What happened with this robot is that it was successful But then there was a study proving that the stresses that you force on the muscles By having these attachments in the femur were actually damaging the leg So it's not that the accuracy of the intervention was wrong or anything It's just that because it's a bulky robot and it has to be attached to the bones And it's putting stresses in the surrounding tissue Then this was creating problems And of course this means that the company went bust and sort of robotics went down This is another example of robotics This is related to a European project that I'm coordinating on cochlear surgery And this is a robot developed by the University of Bern And the idea is to have a drilling robot So this robot is able to basically orient this drill in a certain orientation Relative to the patient, here we have a skull, a calaveric skull And to drive the drill to a certain depth So in general it seems quite simple There is a whole amount of work on doing the planning of the intervention Because in cochlear surgery you want to reach the cochlea And the cochlea is surrounded by structures such as the facial nerve And some other risk structures that you don't want to touch And it's very, very important to be very precise So one of the things is that the building of the robot itself was not very difficult So it's not something that took a lot of time But actually getting the robot to be in a range of precision that is good enough That took many years And this is why we have for example a system that is a closed system So you have the monitoring of all the sensors and everything that is inbuilt in the robot But also a very, very, very precise camera that is monitoring the scene And there is a kind of feedback loop between the tracking that gives the camera And the information of the sensors So to be fully sure that the intervention is reaching exactly the position that it was planned Well, some considerations about MRI compatible robots Just to mention that there are some robots that need to comply with the way they are built So they can be put close to the magnetic field of an MRI And you have here for example an MRI compatible robot for prostate surgery I think you don't need more explanation on this And also similarly there are CT mounted robots So devices that are thought for intra-imaging use, let's say So these are robots that can be attached somehow to the reference frame of the CT So this provides also a certain simpler configuration So the accuracy of the intervention is relative to the image And it's quite accurate, it's another example And maybe to finalize also that there was a very interesting concept by a company in Israel Which is a mass of robotics And it's to have a very, very compact robot And this is used for example for spine surgeries And what they do is they mount the robot on the bones of the patient So it has to be of course stable enough But instead of having to track the patient and everything They put it in a way that moves with you So all the locations are relative to the anatomy that you want to target And not so much tracking all the deformations Okay, and then this is my last example I think So these are some crazy concepts of people that are doing robots For example for cardiac interventions in the shape of a snake That would get into your heart and would act upon certain structures inside it Okay, so summary and conclusions We saw some deviations about the future of surgery and science fiction and things We saw also some things about the basic idea of computer-assisted surgery Surgical navigation, historical things about frames and articulated arms Navigation workflow, so pre-operative, interpretive tracking, etc And some of the tracking technologies, optical, electromagnetic And some examples of navigation in the context of different modalities So fluoroscopy, ultrasound, microscopy, endoscopy, etc And some considerations about surgical robots One of the key things is the whole idea of minimally invasive surgery So to have interventions that require little incisions And that can go through small holes because you have a better understanding of what's below Because you have a plan that you did before and you have some tracking That is able to provide you the location of the tools relative to the anatomy Without having to open to really see it And in terms of future directions or current limitations It is quite obvious that nowadays tracking technologies is still too bulky So you need to still attach a lot of markers to the anatomy And attach bones to the cranium to have some fiducials, things like this The use of predictive models Or maybe not so much in terms of models But the need to have some way to update the information that we have That is given by the pre-operative images, the pre-operative plan, etc To be able to update it relative to what we are doing So if we are removing tissue from a tumor or something like that To be able to have a plan that is updated relative to what we did And not just the pre-operative plan that doesn't take that into account And then while in general this type of technology is currently available in many hospitals But still there is a lack of strong conclusive results proving the cost-effectiveness So proving the improvement that you get in the treatment of patients when you use this technology Relative to not using it and the analysis of cost And this is quite a big debate because people say these systems are expensive But if they save operating room time, which is the highest cost in the hospital as you would know Then actually it's cheaper if you use them, if you save certain time in the operating room And then while in terms of surgical robotics it's just not material enough And there is a lot of development but as many people would agree this is a bit the future So it will come, maybe not today And that was me, that was the presentation Thank you very much So I think this was very complimentary to what we have been hearing today And maybe when you hear your talk you might wonder a little bit like especially when you do surgical robotics Which is now the major field of research because all this looks like mechanics, electronics and things like that Is that the bottleneck or is it more for example the image processing side Or is it more the models that we need in order to do soft tissue or planning or whatever Where are the current bottlenecks and where are the kind of research questions now, the burning questions going on I mean I try to focus on the complementary aspects So obviously in our group what we have is we have image analysis, we have modeling and simulation And we have navigation as well and the group involves Gemma, Jerome and I And we focus on concrete clinical questions so we need to target all of that To be able to reach a practical system In particular for robotics a bit the tendency is to develop mechatronic devices That's a bit the hip term nowadays So to be able to integrate sensors and actuators on tools that the surgeons are used to use So if you come with your whatever your cuckoo robot or something and it's there and the surgeon would hate it It's a big machine and it's there and it's on the way and it's a bit his enemy Whereas if you have some sort of forceps integrated, some force sensor integrated into tools that are more usable But the surgeon that provide information that is complementary Then this may be the way also that they get into using these sort of devices Maybe partially related to that is how is it with regulations and things like that If you come with a device it's like what do you need to prove, do you need to prove accuracy or efficacy Or where are the things that's going on that you need to take into account So there is of course a big continuum in terms of what you promise So you can promise a planning system and just say okay I'm just showing the information that is anyway in the image in a different way So then you don't need so much regulation or you can do planning system where you are telling the surgeon what to do And then you need regulation or you can actually act on the surgery with a robot In which case the regulations are very very tricky and that's of course one of the big hurdles for the systems Very very interesting I would like to know your opinion about the new kind of 3D visualization systems with the glasses, the Oculus Rift etc And how you see this integrated with the robots and the surgical planning etc Well you know it's a bit, everything old comes back Now it's neural networks and mainframes and all these things that were passed now they come back It's the same with music, every like 30 years you get the revival of music So for example you've seen some things on augmented reality And this is very much research work but actually the technology of the commercial companies has overtaken this So now you have your mobile phone and it gives you augmented reality And I think the same is going to happen with virtual reality in a sense So still the use of glasses, Oculus Rifts and all that in a surgical environment has been tried many times And it's not a way forward, you can ask the surgeon to have these big glasses At least in the operation room maybe for planning is different And it's a bit the same with virtual reality, I think we are in a stage in which it can really happen finally I mean it comes back every like 5-10 years in virtual reality So I think this is going to change quite a lot of things So all these interfaces I think are finally moving forward Because companies are pushing them for the general public in like mobile apps and things like this And as a research community I think we need to be very careful in terms of monitoring what the companies are offering as well Because I see that for example in terms of image analysis for cardiac Where actually companies are doing better than the research community So something has happened, maybe we should wake up and think of new things to offer them So I think it's the same a bit with the solicitation tools Ok thank you very much So a last thing


Hey guys, Brian here with freestyleneducation.com and it's wanted to go over a fun little set that we did with the new NeuroCell from Paul Mitchell. It's the new take on hot rollers. It's really cool. It's got these little velvet line guys and what's neat about this is unlike traditional hot rollers where it just sits on a hot rod and then the whole thing gets really, really hot and you can't even touch it. So it gets hard to work with. It's brand new technology where it's actually got something inside of it with the SmartSense technology that's going to charge it from the inside out. So when I put it on the base and then press it in, depending on what type of hair I've got it set for it's going to take anywhere from 8 to 14 seconds to get warm and then it's going to beep when it's ready just like that. And when I take it off what's great is it's not warm yet so it's easy for me to work with. It's going to slowly start to heat up. It takes about 20 seconds for it to get to its full heat. So I go in, wrap the hair around it and then as you can see just let it set. It's got this great little indicator on the side to let you know when it's hot and then it goes back to black when it cools down so you know when to take it out of the hair. So we've got her set. Actually this is just traditional round brush kind of styling going for a little bit of body. As I took the hair off the round brush I wrapped it around one of the NeuroCells and we're going to take her out here in just a second and see what it looks like. Alright, thanks.


So, I actually did this saying structural racism in the United States is because I did a webinar for people in Tehran on the first, and I use these slides to talk about that. And so, my basic point is that COVID-19 is just another manifestation of the impact of chronic racial stress, and that all of the other things people talk about, those are symptoms, not the cause of the problem. The cause of the problem is our history and chronic racial status. And so, first thing I'm going to talk about is the impact that COVID-19 has had on the dependence of Africans and slaves in the United States. That's a term that I've been using at least 15 years, because early on I recognized the Center for Disease Control and the World Health Organization and other organizations have collected race-based data for very long time. Okay, so you can find out things dating back to 1970 in terms of health status of blacks. But it became clear to me that as immigration, as we had more and more blacks immigrating, as there was the distinct difference between what was happening to immigrant blacks, that because there were studies on immigrant blacks, so that one of the things we have learned is that when it comes to low birth weight babies, for instance, immigrant blacks have health outcomes that are more similar to whites than blacks who have been here out of slavery and here for a long time. But within two generations, so once they've been here, their children have outcomes more similar to us. Okay. But we have never been able, they've never really done studies on descendants of Africans and slaves in the United States and we need that. We need to know for sure how we are doing compared to other groups. And so I use that terminology. But using that terminology, I have to recognize that we don't have that data. Okay. But we have this data on African Americans, which is over inclusive and data on our in our blacks, which is over inclusive. Right. The assumption that I'm making is that until proven otherwise, descendants of African Americans is not better than but worse than so that we're at least the average number. So what we see in terms of COVID-19 deaths per 100,000 is African Americans twice any other group. The only group that we don't know is American Indians and native slash Native Americans, but that's because they've been. Well, first of all, Native Americans are sovereign entities. And so we don't always get the information from them as quickly as and we meaning the CDC. But the other problem is the CDC often groups them in the other category because they don't. I don't know the percentage of Native Americans is very small. But at any rate what we see is twice the number of deaths. That difference is, is significant in particular areas. So like in Louisiana, 70% of the deaths in Louisiana are in black people whether it's Louisiana blacks only compromise a third of the population. And I'm not going to read all this because I don't believe in reading. And so I think I will you talk about some of the information, but I will provide you the slides. You know, in Michigan blacks account for only 14% of the population and they account for almost half of the Michigan deaths. Okay, so clearly something is going on that is significant that in COVID-19 at least visually now to people personally I'm not so sure it's all that different. We've just never had a real time study of a real illness point this out. So there are some problems. There's problems with the data. First of all, they're about five states that are not collecting data at all. Why wouldn't they collect the data. You know that's a great question. And especially I have decided that this that this needs to be investigated. Because I just don't understand what they would have collectively to gain by not. If you know if you suspect, if you have a real time epidemic. So so much of the race based health data comes after the fact. Okay. So, you know, the deaths from diabetes that people ain't hearing about that on a day to day basis. No one's saying on a day to day basis. If you're in denial about how race impacts health, but you got a real time epidemic to deal with. You don't want to put race data in real time. Right. Right. It's like the George Floyd that's real. I mean, all the things that what's happened with George Floyd is not new. Real time. Right. And it's being televised. That's right. And you sitting up with a real time epidemic. And you don't want and personally, I kind of think maybe the federal government left it up to them. Right. They knew some of them wouldn't do it because the CDC and state health departments have always collected in my lifetime and I'm in my 70s. I've collected race data. Right. Why suddenly stop? You're right. But you're going to collect age and you're going to collect gender? Right. Right. If they had said we're not going to collect any demographic data, that would have been terrible, but it would have been understandable. Right. That would have made sense. But they're saying, oh, we're just not going to collect race data. Right. And I think it's because they knew they had to know. And I'll talk a little bit when you talk about who gets sick for morbidities and all of that stuff that they knew coming in from Asia and Europe, they knew what was going to happen. And I think that's why they left it up to states to decide, left it up to states to report. And it was only when the communities start pushing for it to be reported that states begin to report, cities begin to self-report. And then there was repressure. And still, like I said, the five states doesn't collect and the United States is not recording. Wow. So, so, so, so there's a data collection. Okay, so we can talk. So I was going to ask for comments and questions, but we've been talking so other comments or questions. Well, I mean, it just makes me think I've just become aware of like, they're collecting stats that in the black community, sometimes for diabetes removal of limbs, and that seems to be higher in the black community than other communities. So that's what made me interested in this. Yeah, you know, I'm starting to get interested in this. This alone should really pick up my book dying while black and there's a long, the health disparities is a long standing problem. And including the, I mean, I think that every generation, every group of people, especially young, young researchers want to do some new research and then they come out with something like amputation of limbs and blacks but writing about that. My entire career. Wow. So that's not a new problem. Okay. Okay, so. So there's some common explanations for the COVID-19 racial disparities. One common explanation is living conditions. Black people live more in more dense populations, have food deserts, we have more health care deserts, multi-generational homes. I'm living like I, I'm in my seventies, my son is close to 50, and I got two grandkids that are 10 year old. So that places me at a much higher risk. Right. Then someone, an older person who lives alone. Correct. Because we're not going to be exposed and I do think we live in many more multi-generational homes. Yes. Either with kids who are working or with grandkids. Okay. We're over-representing facilities that are high risk. A facility is high risk is if you're in close quarters, can't leave, and you've got people coming in and out of it who can carry the disease in. Right. Jail, prisons and detention centers. And I should put nursing homes. My sister's in a nursing home. And so I should have nursing homes up in there because I was going to suggest that too. I just thought about that because my father's in a nursing home. Exactly. The exact problem. High risk people close quarters with people coming in and out who can carry the disease in.  Right. And it wouldn't be that high risk. Right. But. Exactly. But you have that. Another explanation is our working circumstances. We work in service industries so where you don't get to stay at home and work behind a desk. Exactly. Or work over the computer like I'm doing now.  Whether it's a clerk in the store or a person driving a garbage truck or are a, you know, any number of the service industries of worse than our in an LPN. You think of all the service industries and unless they close down. Yeah. That's true. We are not in for the most part jobs where we can work from home. It's correct. The closing down thing is we often are essential workers, poorly paid essential workers, but essential. So, so when you think about that, many black people didn't get to take off and isolate themselves because they had to go to work. That's right. Didn't get a chance to be bored. Had to work. And so they go home. They go to work. They get infected. And they bring the infection home to their grandmother. Yeah. Yeah. And then even if they're, and I think low salary and no well. So even if you're even if you're not an essential worker, you may still try to work. Right. Because you need the money. Yes. You know, and they're talking about the one of the things we know about an epidemic is is that if you want people not to work, you got to pay them stay home. And everybody has to be paid. You can't decide that some people deserve. So everybody in your country should be getting money to just stay at home. You know, unless you're an essential worker, and then no paid leave, we're opening up the country, but we still haven't required paid leave. So if you have a low salary and no, well, you are not going to take off of work. No. No, you're not.  Exactly. Many people are on jobs.  Or if they don't threaten them the first time they do it. My son worked at my youngest son worked at home depot for a long time, and they had all these no contracts. No our contracts. Yeah. You, you don't have any guaranteed hours. And if you don't come in, they quit scheduling you. They just, they don't, you know, they're just like, So we know paid leave. So people are going to go into work. They're going to go to work sick. They're going to, they're going to convince themselves that it's not COVID-19 because they got to work. They're working circumstances. So the other is comorbidities and comorbidities are those things. COVID-19 is a very infectious this virus, but actually not very lethal, except unless you have comorbidities. Okay. So that's why young people in their 20s and 30s who get sick don't get very sick from it. That it's a, it requires.  Right. So what are the comorbidities that are most often found in death, diabetes, obesity, and hypertension. All of the things that are running rampant in the black community. Yeah. I mean, you know, we have one, we have more diabetes, we have more obesity, and we have more hypertension and and we probably have more of those in combination. I am diabetic, obese, and hypertensive. And it's not uncommon for those to run in. Oh, this is my, I might have to restart this because I'm on that. It says it's going to stop in 10 minutes. Okay. And then I just have to start another one up. Okay. So, but the problem is that none of those things distinguish race from class. And there is a distinction that needs to be made. And oftentimes you hear people talk about it as a class issue. So more poor blacks. And all those explanations are sort of class issues. They're true, but they're overly look the fact that middle class blacks are dying more not we don't know about COVID-19, but in other areas, being middle class being even upper middle class doesn't mean you don't that there's no race difference in health. We know for instance that middle income income wife with 10 years longer than middle income blacks. Most people think it's all about poverty and middle income blacks live longer than poor blacks. That's true. But they don't live as long as middle income whites. And that's what makes it a race issue. Okay. And right now with COVID-19 we're unable to tell how much poverty plays in versus in class. We come up with these explanations, but we really don't know. And here's another chart that I use and I actually didn't edit this chart very well so the same chart is listed twice. But this is on low birth weight babies. We often use education as a proxy for class. Okay. Lower education, someone who didn't graduate from high school, someone who graduated from high school, and someone who has 13 more than 13 years of education. What you see with this chart is that at every level blacks have more low birth weight babies than whites. Blacks who didn't graduate from high school, blacks who graduated from high school, blacks who have more than 13 years of education. But what's astounding is that blacks who have more than 13 years of education have more low birth weight babies than whites who didn't graduate from high school. And we're seeing that over and over again, that even though there's a class issue when you compare poor blacks to middle class blacks, the race issue supersedes that. Wow. In a lot of ways where that middle class blacks health wise are worse off than poor whites. People are the ones that make this about habits and I'm like, no, it's not about habits. Middle class blacks are exercising and eating like middle class whites. Correct.  So poor blacks and poor whites should have the same bad health. Right.  Okay, a problem that this doesn't address is that impact of chronic racial stress. And that's an intergenerational impact of slavery and segregation. And so we need to talk about what happens when I they kick me off. So it what I'm going to do. So anything about the health questions about health status and my book goes in the his health status and all of this stuff in significant detail. Well, I'm definitely going to check it out because if I just feel like this if we can order everything else on Amazon, it's going to be beneficial, you know. Okay, so what I wanted. Okay, so I'm going to start here with the impact of chronic stress of racism on COVID-19 in the black community. One of the things I want to talk about is the importance of chronic stress as a cause of either causing illness or making it worse. And when I talk about chronic stress here, I'm talking about all forms of chronic stress. If you're in a bad work situation, if you're in a bad family situation, if you have a lot of illness, if you're not sleeping well, if you have any kind of stress that goes that is chronic, that stress either causes illness, or making the illness worse. And I don't worry about, let me stop just for a second and say, don't worry about trying to write down anything because I will be posting the slides. So one of the things that you from the list of chronic stress, one of the things that I'm going to talk about is chronic stress. One of the issues is chronic stress either causes are worse than autoimmune diseases, diabetes, hypertension, and obesity. Four of the basic comorbidities with COVID-19. Now, chronic stress, there's certain kind of chronic stress that is not racial. You've got people having families that are having trouble, people who are having trouble with their children, people who are having trouble with those jobs. What distinguishes the chronic stress that is common to everyone is racial stress. That is the stress that black people carry that on a job, that is from being black on the job. The stress that people carry worrying about their children that is from being black and worrying about their children. That is the chronic stress of racism. It is an added stressor on to all other kinds of chronic stressors. And just like every chronic stressor, though, it causes illness and worsens illness. And we have known this for a long time because even before COVID-19, being black in America was dangerous to our health.  That's what excess deaths mean, excess black deaths. And those deaths go unacknowledged, un-debt with, because they're hidden, they're one at a time, and they're not caused by an epidemic. We know that black health is worse than white health and long standing because of life expectancy. One of the things that people in the health area acknowledge, even people outside the health area, like the CIA, is that life expectancy is an indicator of the quality of life that people have in a country. The longer the life expectancy, the better the quality of life. The shorter the life expectancy, the worse the quality of life. Well, what this says then is that, first of all, there's something terribly wrong in America where we're the richest country, but where white males are ranked 30th as a country in life expectancy. But black males are ranked 75th behind Jamaica, Bahamas, Barbados, all countries much poorer than the United States. The same sort of issue is similar with life expectancy for females. Now, we know that in every country that I know of, females live longer than males. But even in, so white females are ranked 29th behind, if they were a country, they'd be ranked 29th. But black females would be ranked 46th, again, behind countries that are much poorer, like Bosnia, Barbados, Cuba. These are all indicators that there is something going on in the United States related to black people that is causing their quality of life to be much worse than white people. Let's see. I can't see the title on this. I've got to, excuse me, I've got to move this indicator. Maternal deaths. One of the big issues that people have been looking at over the last few years is maternal deaths. And we know that white, that black Americans would rank 56th after Costa Rica, Barbados, Bahamas on maternal death. And maternal deaths are seen as preventable deaths. There are some years that some countries have no maternal deaths. And we have 31 per 100,000. Infant mortality, similar kind of distinction. White Americans ranked behind Cuba in terms of infant mortality. Black America ranked behind Bahamas, Barbados, and Chile in terms of infant mortality. Low birth weight is a significant issue. And I talked a little bit earlier about low birth weight, but I want to come back to this slide because black Americans have a higher percentage of low birth weight babies than many African countries. In fact, I always laugh because some of the things that white supremacists, racists will say is you have it better in the United States. You don't like it here, go back to Africa. Using Africa like it's a country instead of a continent. But then when you look at the statistics, you think, well, at least when it comes to low birth weight babies, black Americans are doing worse than African Americans in low birth weight babies. And this is a significant issue because low birth weight has been documented to be related to other kinds of problems, both health problems in later life. And low birth weight has been shown to be not related to income. That is middle class and upper middle class black people have more low birth weight babies than middle class and upper middle class whites. So I can't take any comments and questions now, but if you want to put in some questions and comments, please go ahead. When I finish with this slide presentation, I'll come back on and go through your comments and questions and answer them. So there's some common explanations. And we talked about those early, the living conditions is a common explanation. The working circumstances is a common explanation. The presence of many COVID-19 co-morbidities is a common explanation. But the thing those common explanations fail is they fail to address the intergenerational impact of the stress of slavery, segregation, and historic racism. I'm with really stress. Congratulations. Now you're stressed too. Thanks, oh mama. Back in 1998, an ice storm hit North America. And if you live anywhere near the Canadian border, you probably remember it. I do. It was crazy. Everything was covered in ice from Michigan to Maine and Ontario to Nova Scotia. The weight of all that ice caused massive damage to infrastructure in both countries. And then power outages dragged on for weeks afterward, not to be caught out in the rain, so to speak, researchers at McGill in Canada found pregnant mothers who were without power and followed them and their offspring for 13 years to see how it affected them. Turns out, the North American Ice Storm in 1998 affected the kids' DNA. It used to be thought that if I was physically stressed in my body, it wouldn't affect my kids at all. If I was in a famine, then my kids wouldn't be affected by that. And then it turns out that's not true at all. In the 1990s, the field of epigenetics came onto the scene and we discovered what happens to our parents who affect us and what happens to us affects our kids and so on down the line forever. This study published in POS 1 found that the children of those mothers had, quote, a quote, distinctive patterns in their DNA methylation. DNA methylation is the on-off switch for how the DNA gives its instructions, whether to produce a bone or a red blood cell, for example, would have a different methylation. Alterations of that process change how the same DNA can be read by your body. In this case, a correlation appeared to exist between the length of time without power and subjective suffering of these mothers and the methylation of their children's DNA. 36 of the children tested showed the same pattern of methylation on their T cells. That was the most stressed mother. These cells are part of the immune system. So chances are the kids are going to have some kind of a different immune system response than their parents do. You're wondering what that will mean. You're right there with the other scientists. Nobody knows yet. It's not like they can compare kids pre and post DNA methylation. They were born that way. But this is the first time ever in humans that science has been able to show that a single maternal stressor was able to affect the DNA of the offspring. Now that we know this happens in humans, we can go back into history and see what we can learn from these epigenetic changes. Using the AVON longitudinal study of parents and children in England, a study of 14,000 pregnant women, their husbands, and their children who have been going since the 90s, they found that men who smoked during puberty, way before they sired a kid, were sons or fatter than average. Even fatter than those who started smoking later. Daughters were fine, by the way. But for some reason, the methylation affected the boys disproportionately. A different study found that a famine feast cycle in 19th century Sweden altered the DNA of kids born as late as 1905. So grandfathers who were over nourished just before puberty had grandchildren who were at risk of early death, which is freaky if you think about it. What about the Great Depression here in the States? How did my grandmother living through that affect me? What about the 9-11 attacks? That's a major stressor. What about going into space? How will that affect future humans and their epigenetics? So this little film laid out the whole theme of epigenetic inheritance. It has significant issues for us who are descendants of Africans enslaved in the United States. The health of the parents affects the health of the great grandchild, essentially, because the studies are showing that it can take up to two generations for a DNA switch to cut back on or off as it should be. That means that my grandchildren are affected by their great-grandfather, who was affected by his great-grandfather, who was in slavery. So when we say that slavery affects the health of the child now, this is solid science. This is not just we have worse health. This is telling us how and why we have worse health. And the science seems to say that it takes up to two generations to correct this issue. But then you think about the status of descendants of Africans enslaved in the United States, and you don't have a two-generation period in which we was not under chronic racial stress. My great-grandparents was under chronic racial stress from slavery and inherited the impact of chronic, the transatlantic slave trade began the process of impacting health. And over half of the people died in the millions were taken off the continent of Africa, and half of them died without reaching land. And I know that we like to joke that we have stronger genes. Well, we survive the trans... Our ancestors survived the transatlantic slave trade, but not without injury. In fact, one of the things that happened is they would take the enslaved people to the Caribbean for the purpose of getting them well and ready for auction. We don't know what impact that had, but we know that chronic stress impacts the health of the person and that they passed that down to their children. We know that enslaved people had worse health than poor whites because there are studies that show that. We know that my enslaved ancestors passed down the impact of that enslavement to their children who passed it down to their children. We know that people born during Jim Crow and having to undergo the impact of segregation, they never recovered from the impact of slavery and never had anything done to fix that problem. And then they went through the impact of segregation and passed that down. I am in the last generation of people born and raised in segregation. And so I carry in the body the impact of slavery, the impact of segregation and the impact of racism, de facto segregation, and neo-slavery. So there is not a black person living in the United States today who is not under chronic stress of racism and descendants of Africans enslaved in the United States have had that impact passed down to generations. And that impact has infected their immune system, which has made us have more illness, stress related illness. Go back and look at that list of diseases. We have a lot of those stress related illness and our children have those stress related illness. And slavery may have altered black people's genes and researchers have found that certain genetically are altered by traumatic change. It's called, I must stop playing this because I don't know. So write any comments or questions you have about that I'm going to move into the next section now. The question becomes, how, given COVID-19 and how do we eliminate the racial disparities in black community. I'm not going, I'm only going to talk about one specific suggestion with in terms of dealing with COVID-19 because I think that lots of people are going to have lots of suggestions that are related specifically to COVID-19. But my concern is that COVID-19 is just making visual the problem we have in every other health area and that without eliminating racial health disparities that we are going to continue to have this problem and continue to be more more accessible to infections and disease and death. Now, when I talk about health disparities, I'm not talking about making people healthier. And that's often what people, when they talk about, they, they will start talking about, well, they should eat, you should eat right, you should exercise. That's making people healthier. But that does not remove health disparities because health disparities have their roots in racism and racial stress. And so if you don't do anything about racism and racial stress, all the eating right exercising and, and, and doing those individual behavior things is going to be of no avail. So the first thing I think needs to be done is we need to recognize this and we, the United States needs to adopt a multi-generational plan to repair the harm that has been done to the descendants of Africans enslaved in the United States by slavery, segregation and racism. I say multi-generational because this is a multi-generational problem and it will take more than two or three years, five or 10 years, 30 years, even 60 years. It may take up to 100 years to really get rid of the health disparities and repair the harm that has been done to death. The only way to repair the harm is to adopt the social determinants of health model. This is a model that is well accepted in the health area. It is understood that while individual behavior and choices affect health, that individual behavior and choices are dictated by social determinants. So wealth and income, education, criminal justice, environment, healthcare, housing, targeting of tobacco guns, alcohol and drugs, employment, food and water and stress. A multi-generational plan would have to deal with removing disparities in all of those areas. We would have to remove wealth disparities, education disparities, criminal justice disparities, etc. So that the individual behavior and choices so that people can make the individual behavior and choices that will give them better health. We know that this happens because there's been other studies in other kinds of ways. For instance, one of the things they found in terms of improving the health of women is for them to have fewer children. And what are the things they found to help women have fewer children is not the availability of birth control, but increasing wealth and income and education. Once you increase income in wealth and education, people will do, people have a different perspective and different resources that allows them to be able to make the individual behavior and choices that we want to make. As difficult as it may be, we have to accept the fact that health, that the environment, the social determinants of health, affect not only physical health but mental health, not only biochemistry but genetics. And so this is why it's going to take multi generations to happen. Similarly, what we have already talked about the impact of slavery legal apartheid, which is known by some by Jim Crow racism and neo slavery, and I currently think that we are in a period of neo slavery, largely because a large portion of our population is enslaved, ie prisons and 13th amendment and disenfranchised laws, and a large portion, and we are undergoing significant violence by the state in order to contain control of the black population. So we have historical and current deprivation and oppression, which had led to embedded social racial inequalities in our communities. Equalities in wealth and income, education, criminal justice, environment, healthcare, housing, targeting, employment, food and water and stress. If we want better behavior and choices is not enough to just educate people.  It may help an individual and close up an individual hole. But if the diet is worn out and broken, it's not going to stop the leaks it's not going to stop the disparity. I do think that we, the COVID-19 data needs to be collecting socio economic data. We are reluctant in this country to recollect collect data based on class. And I'm not just saying whether someone is poor on Medicaid on our are getting welfare checks. I'm saying knowing what class people are in so that we can definitely see whether or not and know whether or not there's an different impact of COVID-19 based on race. We know that there's a different impact based on race. We need to know whether there's a different impact based on class. Because it really makes a difference in how you're going to go about it. If you make the assumption that there is no different income, no difference based on class, then you may ignore black, upper middle class people who are high risk for COVID-19 deaths. If racial stress. So, we've already talked about that in the long the long term approach to addressing racial health disparities is to take a social determinant health approach of eliminating the harm caused to our health. But we also have to reduce the current racial stress, because without reducing current racial stress, we are just re injuring people, even as we're trying to heal them. And to reduce current racial stress, we have to eliminate racial disparities in area area of every area of American life, and we have to eliminate discrimination. And that's a huge issue because we have a lot of legal discrimination in this country. We only outlaw intentional discrimination. Now, in criminal law and tort law, there is a continuum of culpability. You can be responsible if you intend something, you can be responsible if you're reckless. You didn't intend it, but you acted recklessly. You can be responsible if you're negligent. And we have some areas that we say we don't care what your state of mind was. We're going to hold you responsible just because you did it. If you run a red light, there's no state of mind. We don't care if it was tension, reckless, negligence. The fact that you did it is enough. Well, in this, in every area, there are three major areas where we have victim injuries, criminal, tort, and discrimination. In two of the areas, we have a person can be responsible, the whole continuum, the person can be responsible. Intentional discrimination, reckless, excuse me, intentional, reckless, towards negligence, towards strict liability, toward indicates of discrimination only intentional, which means that currently most discrimination in the United States is legal.  And we come up with two names for the very, we call it disparities because we, we use discrimination only to mean intent. But in fact it is discrimination. You know that you're going to do what you're going to do is going to cause discrimination, cause a disparity. You do it anyway. That's recklessness.  And we don't care whether you were intentional or reckless, you that the high degree of knowledge is not necessary with negligence, because you should have known. And there's a lot of discrimination willful blindness, where people are willfully blind to the impact their decisions are going to have on different racial groups. Or they are negligently buying, they should have known and they didn't know and they went ahead. And because they can have 10 they can discriminate. It is legal to discriminate in this country, as long as you don't intend it. And that has to change because we cannot reduce racial stress until we eliminate racial discrimination. And until we eliminate racial discriminated are are as much as possible, we will continue to have a large number of people who are suffering under health disparities, large number of black people who are suffering under health disparities. We need to reduce racial stress by eliminating meal slavery. We need to get rid of the 13th amendment. Get rid of most get rid of mass incarceration. And we need to get rid of police brutality, misconduct and killings. We probably need to get rid of a police and think of something other way for communities, because there are alternative ways of communities making themselves safe without police as they are situated now. There is no way to reduce racial stress without eliminating meal slavery, because everyone is connected to someone who's incarcerated. And all of the mass incarceration, even if you're not even as a black person if you're not just the knowledge of all these people who 25, we are 4% of the world's population and 25% of the world's prison population. That's not about bad people needing to go to jail, unless you define black people bad by definition, which is what is happening. And so we need to get rid of the 13th amendment. We need to start an amendment, not get rid of the 13th amendment, excuse me, I misspoke. We need to get rid of the clause in the 13th amendment that makes that imprisonment as slaves. Okay, and we need to get rid of police police brutality. I recently saw an email by a white cop who went into this long and heartfelt discussion about how bad he felt that black people did couldn't walk down the streets and feel safe and that he was going to do something about it. What he was going to do is he was going to individually be a good cop. He didn't say it just like that. But that's the way I took it. But the good cop is not the problem. It's the bad institution. You keep good cops that work in bad institutions. Good people who work in bad institutions become one or two things. They quit early because they can't take it. We need to change their value system because we know that through psychology that the best way to get people to change their values is to get them to engage in behavior or to accommodate behavior that they previously had deemed unacceptable. They're saying, yeah, we got to do this because yeah, they do more crime. Yeah, they're more we've got to stop more black people because yeah, and they they justify it.  Are you just be you become numb and ineffective to what is going on. Are you a lot of it of course is people, they hire people to agree with it. They hire people who have not very high IQs. There's a Supreme Court case where a person did really, really well on the police exam, and he didn't get a job. And he was like, wait a minute, I scored really high. Why didn't I get a job and they said it was their practice not to hire people who score too high, because those people are became dissatisfied to dissatisfied with the job. They hire people who come from a military background. They promote a military culture. The United States is pronounced promoting a military culture. And they the police as an institution has evolved into one where they want obedience more than anything else.  Now, the other problem is they also hire and not a lot of racist white supremacist. So the institution is, you know, they like to use your one. They like to use the idea of when one cop does something bad, they, they say one bad apple. Well, if you want to use that analogy, say the rest of it spoils the whole barrel. One bad apple spoils the whole barrel and the barrel of police institution has been so spoiled that there's no recovering from it. If you, if we want to reduce racial stress and thereby reduce disparities and not have a reoccurrence of COVID-19 disparities, we have to eliminate meals.


import of animals and animal products and approved countries, EU exit, amendment regulation 2022. I refer members to papers 3 and 4 from page 23. Do any member have any comments on this instrument? Are members content to agree with the Scottish Government's decision to consent to the provision set out in the notification being included in UK rather than Scottish subordinate legislation? Is the committee content to delegate authority to me to respond to the Government and, in doing so, to include the information set out in paragraph 2 of annex A of paper 4? That concludes our business in public, and we will now move into private session.


So what next? That's a really great question. I think what's clear is change is inevitable. From all the speakers today, it's fast-paced, is what's also very clear. We as leaders have to think differently. That message has been sent over and over again. And I'm going to use an example. So my background is accounting. I'm a bank counter. And I worked for 10 years counting beans. And during that process, I charged my time. So I was valued based on how much time I charged and how productive I was. Over 80%, I had a smiley face. Under 80%, sad face. A very different world to the world I work in now. And that's how my brain works. I think of every minute as has a dollar attached to it. It's ingrained in me. I was asked to speak today and tongue-in-cheek as it was. When I talk about thinking differently, I ask the question, how much will you pay me? Because as CEOs of organisations and leaders, we have to start to put a return on investment in our organisations. We have to say we're valuable. We have to say we're leaders. And we have to ask because our time is valuable and the work we do is valuable. It impacts on so many people in the community. So one vision. And I'll talk about NDIS, but we talk about one human services model as well. It's clear. It's happening. It's about providing a quality, cost efficient, effective service for the people in our community. It's about being price competitive. And it's about ensuring and maximising that every dollar we have goes to service delivery. That's a shift. It's a pretty big shift for all of us. So what are the challenges? I could probably stand up here in the detail of those challenges. Map out how you transition and how you transform. But that's what this support and this sector development program's here to do. But I wanted to talk honestly and openly about the challenges we all face. I think in its most basic sense, the current economy and the ACT environment, highest average earnings, Commonwealth government job cuts. We've all got to accept that that's happening right now. It's a big change in our contract requirements. So I explain this to my board of directors and they get it quite clearly because their risk has increased. Previously, $6 million of revenue, half Commonwealth, half ACT. Three years, recurrent, paid in advance. Cash flows easy, secure revenue. Everything's there. Our contracts didn't require us to be businesses. They simply didn't. They required us to put people first and report on outputs. The New World requires us a unique challenge and that is to balance a human service community model because that doesn't go away. We're about people with a business model. Reporting on outputs and outcomes for people. That wasn't ever expected before. So those things have changed. So actually, funnily enough, five years ago today, I took the job as CEO of Kamari and at that week I said, so what's the data? So if we're going to start to plan this organisation and work out who we are and what we're doing, what does the market look like? What do our customers want? There's no easily accessible, clear data.  Do our services have a place in it? It's hard to do when there isn't the data to support that. Jillian spoke about that collation and collection and getting it right. That's a challenge for us because it's about where we target our efforts and how we ensure people are at the centre of those. So the other thing is the right people, the right workforce that also has an ACT context, highest average earnings competing with Commonwealth and government. How do we make sure that we have the right skills in our leadership, the right workforce to underpin that with a clear direction? When in lots of ways the pay that we've had in the past and the history of our organisations is built on passion but built on a low wage, I don't think I need to go on. That paints a pretty large picture of the challenges we face. We have a very big road ahead of us but there's one more thing for me and that is the speed and the magnitude of the change. For different areas, it's different. What we know is in the disability sector I could probably put on days or months but I don't know how to do that. So it's significant. So I talk about these in the context and go, bang, I've got a new workforce, excellent. Know how to be a business, great. Everyone's on board, it doesn't work like that.  You've got to spend some money, you've got to get the right people. It's a real challenge. If your purpose built, you've already got all those things. Double glazed windows, it's already there. So we do have challenges and time and expectation is one of them. What stands out is the people we support also are part of this. Actually, they're the whole reason why we're here. So they have to be built in as part of this change and ensure that no one's put at risk. So how do we do it? Great question. I'm going to use an example because I walked over, thought I'll run you through a better practice business model of how you transition and run you through the eight, seven steps. Everyone has a couple of different steps but that's not what it's about. It's about a really large understanding of what it means for us as leaders. In 2012, Kamari undertook a review in preparedness for being a better practice organisation with the NDIS in mind. Wow. I submitted it to my board of directors and they said, game on. I said, yeah, wow. I'm not sure we're even sustainable in the long term. Want to know why? We're a non-diversified, medium-sized, specialist disability service provider. We don't have a fundraising. We don't have different arms of our business that reduce the risk and exposure. We run four businesses that employ 182 people that aren't sustainable without government funding. Ooh, good. Glad I bought the 1950s house and we got to do some work. So we began our map. We began our three-year strategy to moving to being a better practice model. The gaps that we had were pretty clear. You've heard a lot about them today. The first was we didn't really understand our market. We didn't really understand our customers. In fact, our model meant people rocked up. We said, oh, we've got a gap. We've got a space. We can support you. Or we don't. Sorry. To, hi, how are you going? What can I do for you? That change is significant. What can I do for you? Which is fantastic, but is a different way of thinking. We couldn't and can't compete on price because of our size, because our overheads, maintaining our quality standards, maintaining the appropriate workforce standards simply don't allow us to compete. I look in the trial sites, I say a price, or at least I say, ooh, good. How does our model need to look? We didn't have the right organisational structures, the right skills in our house, in our house, because it feels like my house. To do this, we just don't. We haven't invested in our workforce because actually we're not for profit. When we make a surplus, it goes back. We don't have the cash reserves to invest because actually our whole model was built on a different thought. We don't have the business systems that I had when I worked in the accounting firm, client management systems, time sheets, reporting, efficient and effective systems to make sure that every dollar we had goes to service delivery. We didn't have that because it wasn't seen as a priority. So that magnitude of that shift in two years, just putting it out there, it's a big shift. I know that this is the right move for organisations such as ours because when I came in to this role, I was naive. I was that kid who said, game on, my background, what I do know is through reviewing our processes, systems and everything else, we can do this better, more hours of service delivery. Do you know what? I didn't understand the people part. I simply didn't, I couldn't grasp it. Five years later, that's the core part being built into our transformation. That person first approach means we will never compete with a business model that doesn't put people first because part of our cost goes to making sure people come first. It's built in our strategy. It's built on how I report to the board. So when we talk about values, David spoke about values being built in. They're built into our business rules. Have I learnt a lot? Yes. We're in year two of our transformation, an example. Previously I used to get my hair done and colour it every eight weeks. Now it's grey on the sides and up here. I go every six weeks, puts more money. It's like my budget's larger now. It's been significant, but it's been fantastic. In the last six months, we've seen some great outcomes because we're thinking differently. I'm not saying we've got it right. I'm not saying we've got it perfect. Actually, in fact, the next 12 months for us is make or break. It is make or break. And I believe in it. I'm committed to doing it and I'm committed to the 270 people we support getting a better service. So what do I want to leave everyone with? Change isn't inevitable. We need to embrace it. We need to put the people we support at the centre of it. We need to maximise the opportunities we're getting through this community sector development program because we don't have those resources in-house sometimes. We don't have those dollars. And every dollar given there means more dollars in our service. The people we have in our organisation, the skills, the leadership, without that we've got nothing. I think the challenge for us as we head in and we have new competitors come into the market is balancing the human services approach with a business model. Because they're not separate. We're not choosing to be businesses now. We want to succeed and make sure no one falls through the gaps and more service goes to more people than we have to put them together. And that's not a simple business model. We as organisations in this sector have to work together. In fact, Minister Barr mentioned that some people won't make it. That's true. We have to partner. We have to think about how we can do things better. And that may mean that we complement each other's services. It may mean that the areas we worked in before, someone else does really well. That's okay. And maybe we work better together on those things. My accounting brain says, and it's cheaper, which means more service hours. That's how we've got to think. Minister Barr spoke about that gap. It becomes our responsibility. If we're efficient and effective, we'll never be able to fill the gap, but at least we can make sure people aren't at risk. Have a clear picture of who your organisation is. What are you good at? Are you a generalist? I use this example and I think my staff are sick of it. Are you a takeaway who does pizzas, hamburgers, everything else? Or are you a gourmet pizza provider? And you understand who your market is, what they like, what they don't like. And can you do it and produce it, package it the way they want to see it? Know who you are because at outset, if you don't know that, it's a real challenge. Are you a specialist? Are you a generalist? I don't really want to talk too much more today than say the positive change for individuals we support is a real opportunity and we should take it, but we should talk to each other and work together. Thank you.


next up we are going to have a reading and it right okay we're gonna sorry we're gonna have a reading by a young woman here in Los Angeles and I will introduce who the reading is by and also who is reading it so the reading is from Alicia Drapko she is co-editor of resumen Latino Americano the US Bureau and co-chair of the National Network on Cuba and she coordinated the committee to free the Cuban 5 and they were freed so amen to that and our reader will be Brenda Lopez and she is a Chicana 25 years old from Inglewood, California she works as a graphic designer at Random Links News but is also an artist and activist and lead youth organizer for the LA Cuba Solidarity Coalition. Thank you for reading. Thank you for having me Rachel and thanks to everyone for sharing your experiences even though it might not be such an easy thing to do. Today I'll be rating Alicia's testimony and I'll start quote this March 24th will mark the 45th anniversary of the bloody military coup in Argentina that killed thousands particularly young people. The coup was a response to people struggling for a better world nothing different of what we are witnessing today. Right before and after the coup I lost some of my best and closest friends. I was studying journalism at the time and the School of Information Science in Cordova, Argentina. There were years of change, effervescence, optimism, joy, possibility and the time for young people to share their dreams. It was this growing movement that posed a threat to the power establishment and they responded with a military coup and everything changed to a period of terror. I still remember to this day those moments of sadness and pain. People disappeared in the middle of the night and were never heard from again. Cars with no license plates would drive around at night and stop people in the street or in buses and disappear them. It was a time of generalized fear where nobody felt safe. In the city of Cordova there was a big Catholic church in the downtown area and next to it was a police station where people were tortured before being sent to concentration camps. We always wondered how the Catholic authorities were capable of remaining silent before such an atrocity taking place right under their noses. At the journalism school, I was part of a student group with four other people. Two sisters, Maria Esther and Mabel, Jose Alberto, who was also Maria Esther's boyfriend and another woman who was afraid and left a group. We became an inseparable group of friends who shared a common political view, but also we had a good time playing guitars, singing songs, going camping, etc. We were far from imagining what was about to come. On May 11th, 1976, Mabel and Jose Alberto were kidnapped in the middle of the night by a police gang and never heard from them again. Along with them were 30,000 people. Then came the exile, the loss of family connection and cultural values, the uprooting and the guilt feeling for what I left behind. Time went by. My three children carry their memory in middle names after Mabel, Jose Alberto and Emma, who was not from the same school but affiliated to a revolutionary organization. I was one of the lucky ones that managed to stay alive to tell the story. What happened during the military dictatorship was nothing more than a barbaric crimes against humanity and changed our lives forever. But the memory of these young people and their example is always with me. To them, I dedicated my life and all the struggles I have been a part of from the moment I left my homeland. Living in the United States, I joined different struggles for peace and justice. I learned that no matter where one lives, the important thing is to engage and change to feel helpful and useful. In the early 90s, I traveled to Cuba with Passers for Peace, caravan challenging the US blockade on Cuba. Lucia's Walker, the leader of Passers for Peace, was an extraordinary human being. I learned a lot from him. The trip to Cuba helped me to visualize what solidarity was all about. It made me realize that Cuba is an example for a better world, so I gladly put a lot of time and energy in working in solidarity with Cuba. Then came the struggle for the return of Elián González to Cuba, a young boy who was rescued at sea after his mother and others trying to come to the US. I saw for the first time Fidel and the entire Cuban people in action demanding the return of Elián. He did return, and it was without doubt the struggle in Cuba and public opinion in the US that made it possible. From 2001 to 2017, I was involved in the struggle to free the Cuban five political prisoners in the US. There were five unarmed agents of the Cuban government who infiltrated and monitored terrorist organizations to protect Cuba against terrorist attacks. Along with my partner, I was able to visit Gerardo Hernandez in US prisons from 2002 until they returned as heroes to Cuba. It has been a long road full of learning experiences since the first time I left my homeland of Argentina. On March 24th, 45 years after the military coup of Argentina, I will always remember those who gave their lives for a better world, and their memory will accompany me forever. Nothing is gained without struggle, and that includes loss. On March 24th, we will join people in Argentina, the mothers and grandmothers of Plaza de Mayo and people around the world to say never again, we will never forget, but we will never forget either. We continue forward in their honor. End quote, Elisa Characo. Thank you so much, Brenda, and I know, Brenda, that Alicia knows of you from all your work on the NNOC. And this is a good friendship between the two of you. I want to show you, Alicia, I don't know if you are listening, but there is Alicia just victorious after the last of the Cuban five were released and back in Cuba. What a glorious, glorious mistake that Obama made. He had no idea what he was doing, but I'm glad he did it. So thank you so much and