e or twice that's a far different potential issue than if you are misusing opioids between 200 and 365 days of the year. So we're looking at a spectrum here and one of the things that happens is when you get into more frequent use you also discover that the difference in where people are getting their non-prescribed opioids flattens out from basically any source where they can. So why are you dwelling so much on this issue of opioid prescribing in part because there is a direct correlation between the amount or the number of morphine hologram equivalents which essentially refers to the strength of an opioid prescription. There's a direct correlation between the hazard of having an overdose and the strengths of those prescriptions. So again let me orient you to this picture again a different kind of view of understanding this epidemic. These are opioid prescribing patterns related to two types of pain that we commonly use opioids for. Acute pain meaning injury and chronic pain in other words long-term use. The red, red for far, are for acute pain. The gray reflects chronic pain. And then along the x-axis is the amount of morphine equivalents being prescribed. And what you see here is this red that he had is that the hazard risk of an overdose death greatly increases with a higher rates of NME equivalents. Oh my goodness the doctor is in the house. Let me pause for a moment and give Mark the opportunity to come and join us. Thank you. I had to participate in a history in the making. You may have heard a few shakes. We've heard nothing. We've been sheltered over here. The governor was signing his of the three gundams. It was a rather large crowd. Some four, some against. I thought it was truly a momentous occasion and a public health issue. I've been whipping two years. I don't know how much. This is good. I was starting to orient people to what the slide shows. You can tell us what it means. We're out of speed dating. Oh yeah. Bottom line is this X-axis is a morphine milligram equivalence which is just a measure of how potent the opioid is that you're giving the patient. How many pills, how many milligrams of a certain opioid and how they equate to morphine which is the standard. So needless to say if you're on a higher dose and higher potency you have a higher risk of death from an opioid overdose. So this gives us a little context as to Vermont's performance with regard to the rest of the country. The concerning features here is that if you look at our teenagers this is in white so they have amongst the lowest rates of past year pain reliever use. But when you get into the ages of 18 to 25 you're at the top. We kind of consider the ages teenage and young adult as where the brain is most susceptible to addiction and where those are our most vulnerable citizens if you will when it comes to this crisis. Good. If you look at heroin use former Governor Shumlin got us on a vat and got the country cured up for this because we're one of the states in red where we have the highest amount of heroin use. That is noteworthy because the northeast and Appalachia are really where the peak of the epidemic is so nobody is sheltered. In spite of having such a high rate of heroin use we have one of the very low rates of perception of harm from heroin. So simplistically if you try to put everything together as to how we get where we are we have wider availability of prescription opioids because doctors were actually charged with treating pain and making sure that everybody was satisfied with how their pain was treated and pharmaceutical industry was actually deceiving doctors in some ways and talking about the lack of addictive nature of some of their drugs we had basically economical changes that made it easier for someone to transition from abusing prescription opioids to going to heroin because the heroin was a much better economic proposition and at one time, but not now, we have problems with access to treatment for opioid use disorder so you put that all together and you end up with the crisis we're in but not to make it that simplistic, there's plenty of biological and social determinants of health risk factors that predispose certain individuals to substance use disorder with all of the above just compounded upon. From interviewing people in our current treatment system it's become very obvious that in the teenage years many of them would say they began with tobacco, alcohol and cannabis and then they'd evolve more time to the stimulant drugs on cocaine then around 20 he began with prescription opioids but not using them responsibly and then moving on to heroin and everything else so this is a stereotype kind of slide that actually is very typical to not ignore the fact that heroin is not a drug problem, but clearly when you talk about death rate it's clearly high up there but for what still has a big issue with alcohol use, this is from ages 12 through a thousand just regular substance use in the past 30 days alcohol, marijuana and then non-nickel use of pain relievers and then down to 0.8 heroin every substance that you have a problem with compounds the problem and makes it more likely you may end up with an addition to heroin so these things are very multiplicative if you want now to get to remote, that sets the context a few years ago the National Safety Council said we were one of the top four states when it came to our response to the opioid crisis and they said that because they assessed all of these areas and found us to be doing really good work, the mandatory prescriber education prescribing guidelines for clinicians, drug monitoring programs access to the lock zone and treatment available, pill mills wasn't really a problem for us many states don't have that as a problem so what we're going to do in the rest of the slide is lead you through elements of what we call a high functioning state of response to the opioid crisis and we'll weave you through the sort of four-legged stool of prevention and treatment and intervention in the cover without going into enforcement this slide is just to show you that we actually have a really good state when it comes to the governor being alive with us all across state government people are alive with doing something about this problem in a very constructive way and even now federal funders are actively alive as well so support at all levels is critical and you need a health department and state government that really seeks data, looks at data, analyzes data and uses data responsibly to enact policy change so in prevention if you have a state that's doing right things and we're going to brag about ourselves by the way but we're also going to show you where we have work to do you want to have education but education is always one of those necessary but not sufficient items so you've got to have more than that but clearly a lot is happening for education at the prescribing clinician level, at the medical student and graduate medical education levels prescribing rules and prescription drug modernity systems so the prescriber rules are based on the thesis that four out of five heroin users say they began by abusing prescription drugs and that of those who abuse those drugs seven out of ten received them through methods of diversion not because they were prescribed to them necessarily and their prescribing habits traditionally have been giving too many pills of too high a dose for too long a time and that needed to change some of the data behind that and this is one slide out of a million but this one will show very nicely if you look at the day supply of the first opioid description and the probability of continuing to use it several months later in this case one year and in this case three years later it's really about the third or fourth day that makes a big difference and someone potentially still being on that prescription a lot longer than it was prescribed for. If you look at the number of prescriptions it starts at the second prescription so pretty amazing data that was not available years ago this is data that's been available within the decade we're in now so we have a prescriber rule that from my standpoint the biggest thing it does is create conversations between clinicians and the people that they're seeing in their office so that the entire menu of alternatives for pain management are discussed that the individual knows that opioids are part of one pharmacology but there are other pharmacologic methods and there may be non-pharmacologic methods the prescriber rule also includes discussion about how to store these and dispose of them when you're done with them so your teenager doesn't find them during the party and distribute them around to their friends and patient education mandate and informed consent I'm not going to bore the group here with details about every bit of the rule just to say that this is something that was never done until the last year or two where we actually give a listing of commonly associated injuries, medical conditions surgical procedures and the expectation of what kind of pain management might be required for those from ones where maybe no opioids are needed like pulling a tooth to ones where a person could be expected to need quite a bit of opioid and a post-operative period from a very complex or repeated procedure and we've given them clues about the number of morphine milligram equivalents what that would equate to in terms of commonly prescribed opioids it's really been a revolution and something that most doctors will candidly admit they were poorly educated on pairing that with a prescription monitoring system that statewide that allows you to have a database of all prescriptions written for these drugs that allows pharmacists to really understand who's going where to fill these prescriptions that provides a clinical tool for preventing diversion and abuse of drugs and a surveillance tool where we can actually tell clinicians what patients going where for what prescription fill are they getting it from other doctors what is their own prescribing habit and they have outlier and way overboard in the opioids they prescribe compared to others in their same field very powerful information and that's mostly for acute pain we pair that with CDC guidelines that essentially say to be oversimplified opioids don't get used for chronic pain management and here's the results in one way of portraying the data which is total NAD of opioid analgesics per 100 residents 2017-2015 drop from 77,000 to 57,000 more importantly though the prescriber rule only went into effect July of 2017 so from here to here a further drop in a trend that was already beginning because people were already cognizant of the problem and we anticipate this is going to continue to drop down other parts of a high functioning response to the prevention area have to do with all the time prevention messaging campaigns the important thing here is these are carefully targeted to the audience of importance sometimes that's teenagers sometimes that's young adults sometimes that's adults and it's targeted to the media that they commonly use so you may say I've never seen one of these and it's because you maybe just watch TV and you aren't engaged on the social media that people in the age range that the messages targeted towards again we also have school based primary prevention programs that involve curriculum but also substance abuse professionals in schools and then community programs coalitions like dark and St. Johnsbury and CCOA and Burlington Project Vision in Rotland and then a whole area that we're very interested in now with all these alternatives to pain management because that's where we prevent the writing of a prescription open this is just an example of some of the health departments many many messaging campaigns I'm not going to go into detail on the purpose of this conversation but some of them may look familiar to you and again some may not and then there's plenty of other things that I'm not going to spend a lot of time on Paradox is an actual program that parents can go on a website and learn how to have conversations that they never thought they have to have a lessons about these issues we have academic detailing which is actually doing what the pharmaceutical representatives do in a doctor's office but doing it with academic people who can talk about dedication use and evidence based way and other things I've mentioned highlighted here are the things we feel we still have a lot of work to do with the non-highlighting and we will do it very well. I'm going to just go into harm reduction before I hand this off back to that harm reduction strategies are critical to managing the opioid epidemic and they do cost money like everything else so ways to dispose of drugs right now you all hear about take back days things of that sort they need to be really much more user friendly we need a 24-7 system where you can drop the drug off anywhere you need to and want to not have to wait twice a year to see some van come to town or bring it to your police station or stay trooper barrack where most people don't want to spend much time Sharks selection and disposal programs are a real important public health initiative as you know from the news we distribute naloxone everywhere we can all first responders have it in addition to the number of public who get it for free or if they want to go to a pharmacy and use their co-pay they can also get it there because there's a standing order that I sign once a year that allows naloxone to be given to anybody who walks to the door essentially there's also a good Samaritan law so your best friend or family member can use this naloxone on you if you happen to be lying down on the ground reading a book without that feeling like it could be a repercussion than maybe it could be Syringe services programs are places people with opioid addiction can go and exchange needles, exchange syringes get education about safety, get testing for HIV or hematitis and also have a human being who can actually talk with them and if they happen to be ready to go into treatment and that life ball has gone off that person can then help them get ready access to treatment. The Syringe Services program has also distributed naloxone that entertain people with their use and then of course alternative subcarceration so that we don't lock up people to get out of this epidemic we actually have to address it from the public health framework so family courts, drug courts, and so on. Somewhere over 20,000 naloxone kits have been distributed in not too many years and we know that at minimum we had at least 1,200 overdoses successfully reversed some people who potentially died and that's underreported because the people in the public aren't necessarily obligated to report to us that they use the kit to save their life whereas the first responders they do reclaim everything. And this just shows the number of syringes distributed by year and the number of people who are actually attending these Syringe Service programs we're still on a steady uptick. And that's a good thing even though you might look at it as a bad thing and why so many people still need to have the service it's a good thing they're accessing the service. So we think we're doing very well in our reduction strategies but the Syringe Service programs really need to be markedly expanded and there's a whole lot showing on in the law enforcement realm regarding the criminal justice system and how to improve on how we process people through the system to make sure they get the help they need. I'm going to turn this over to Beth now to give it to the Intervention and Treatment Recovery Part of the discussion. Thank you Dr. 15 minutes. Okay, thank you. Including questions? Let's go 10 minutes and then let's open it up for another 10 minutes of questions. So when we think about a common answer to the Intervention and Treatment system we're thinking about a classic pyramid where you try to have things that impact the biggest part of the population and most widely available and then focus the intensity of services as you move on off the pyramid and so things like hospital detoxification or residential treatment are at the top of the pyramid so you want to use them selectively and when indicated and things like prevention services and recovery supports are towards the bottom of the pyramid. You want them to be widely available to the population. One of the most important interventions that we can do is to more systematically identify across the population who may be at risk of risky substance use so that you have an opportunity to educate and support and perhaps divert from actually developing on into addiction. So for instance if you have a family history or personal use of some substances you might be more likely to be addicted if you were to strive additional like opioids and doing that might make a difference in how a provider interacts with you and what is offered to you at different points of care. So this screening, refiner mention, referral to treatment is a population-wide focus that's designed to help identify as we said, risky substance use, educate and provide support so that it doesn't proceed to addiction. I'm mentioning it because we're going to bring it up in terms of future development and access to home care. Specifically for the management of opioids, we have a very effective treatment we've all heard about it in some detail, medication-assisted treatment and what that really is is simply the use of certain medications in combination with counseling and behavioral health and other psychosocial supports. It's important to emphasize the combination there isn't just about the medication it has the typical medications that we talk about using are methadone, which can be only dispensed in highly specialized programs, programs that in Vermont we call hubs and then also medications like buprenorphine or vibratrol, which can be more widely prescribed by a host of MDs, nurse practitioners, physicians, assistants in any general medical setting. That combination of use of medications with the behavioral health counseling and psychosocial support strategies combined, whether it's buprenorphine, methadone or vibratrol, has been proven to be really effective in reducing opioid use for people who receive that service, increasing people's evasion and staying in treatment, which is incredibly important to recovery. It's associated with reduced morbidity and mortality. In other words, people who are in treatment are much less likely to die of overdose deaths. It improves social functioning. It's also medication assisted treatment is associated with reduced criminal activity and also reduction of the transmission of infectious diseases such as hep C. So in Vermont, what we did was essentially build enhancements into our existing methadone treatment programs. We arranged it so they had an additional nursing services, counseling services and consultant psychiatry. We had them begin to dispense all of the FDA approved medications for the management of opioid use disorder previously. We had only been using methadone. And perhaps most importantly, we endorsed caseload expansion to as many people as we needed the treatment as opposed to essentially treating the service like a waiver program with a capped number of people who were being served. When we began this work in 2012, our opioid treatment program for methadone was dispensed collectively served about 650 people. Currently now in 2017 they're serving close to 3,300 people. So it's a dramatic increase in access to treatment. We're currently operating five programs have nine sites across the state. The other thing that we asked these hubs to do was to be resources to the general network of outpatient providers who are offering medication assisted treatment in general medical settings. We referred these colloquially as our spokes and really what they are are any primary care office of any strike every qualified health center, small independent. Often outpatient substance abuse programs, pain clinics, OBGYN and psychiatry practices. These are where providers with mid-level or MD credentials are prescribing the morphine individual for the management opioid use addiction, opioid use disorder, and also who have additional staff that we put in place to support them specifically a registered nurse and a licensed mental health and alcohol addiction clinician. By putting the automated nursing and clinicians directly in the practices with the prescribers it made it possible to really link the assist along with the medication that are so critical to medication assisted treatment. We currently have a little over 64 full-time equivalent nurses and mental health addiction counselors working in 80 different practice settings across the state in Vermont. This is unique when we develop this. No one else was doing this combination of both enhancements both to the opioid treatment programs but also to the general medical centers and now other states are starting to replicate this type of approach. Let me just briefly say that this is a study conducted by our wonderful colleague Richard Lawson who has retired back to Vermont not really retired and engaged a really thorough and powerful qualitative study where he interviewed 80 people who were in treatment either in a heart or a spoke and then 20 people who were not in treatment but who clearly had an opioid use disorder. And for the folks who were in treatment he asked them think about how many days you were using opioids before you got into treatment and not think about the past month how much opioid use have you had. And so for those people who were in treatment their rates of reported opioid use or opioid ejection from the time before being in treatment to now being in treatment were dramatic and decreased. In other words people in treatment were not elicitly using opioids where the people who were still remained out of treatment were using elicit opioids at similar rates between the two time periods. The folks in treatment also reported to us that they had significantly reduced their number of emergency department visits, their overdoses their days participated increased their days participating in school or work had decreased the number of interactions with the legal system and they also report more stable emotional well-being. I can tell you that this is consistent with what we see in the claims data. We are tracking a group of people who are receiving medication assisted treatment in either hubs or spokes compared to beneficiaries who have opioid use disorder who are not getting medication assisted treatment and we see statistically significant lower rates of inpatient days and emergency department visits. We have published these findings. We are gradually and successfully eliminating weightless and dramatically increasing people access to treatment and the work that we did to augment the services in the hubs has been instrumental in this and also the creation of new programs in underserved areas so we introduced programs in Rutland and in St. Albans most recently and that's made a dramatic impact on being able to increase the number of people who are actually in treatment. We see a similar but less dramatic increase in what's happening in our spoke census although it's still a significant increase in enrollment and positions and providers and practitioners tell us that having the augmentation of the embedded nursing and counseling staff makes all the difference in being able to provide this service in a busy primary care practice. So things that we are working on going forward. We're engaged in a discussion with the Centers for Medicare and Medicaid Innovation Services and also with the commercial payers to help make what we're doing in terms of hub and spoke treatment something that becomes all payer. Currently Medicaid is the primary payer for these services and so this is an important policy threshold to have all payers recognize the importance of this epidemic and the significance of the service enhancements that we have been making. We are engaged in working hard to model what it would take to bring that population based intervention that I described screening, re-intervention, and referral to treatment to scale and all of Vermont's emergency departments and primary care practices. We have tremendous amount of working development that we are looking to do to help support the expansion of peer recovery supports. We have a very strong and impactful recovery center network but it is under resourced and undersized for the job that it really could be doing and should be doing and it's really on us to change that. And finally the other thing that I'd like to speak briefly about is the importance of providing a larger set of tools that we use in the management of pain. You'll remember from our earlier remarks related to how we got into this situation the use of opioids for the management of both acute and chronic pain is part of what has created so much exposure in the population. Now as we back off on our use of opioids and the science tells us more clearly what are the most effective treatments for pain and they do not necessarily include things like opioid prescribing but focus on things like physical recognition, cognitive behavioral therapies and approaches, essentially your physical fitness and your well-being have a tremendous impact on how we will do with pain. So as we use less opioids we need to develop better service models and better pain models to support the integration of alternative therapies and approaches in the management of pain. So Dr. Levine and I and a team of folks who are working across departments on this are working hard to get all payer participation across our hub and spoke initiative to develop and model a universal intervention and early intervention approach and screening brief intervention and treatment to create alternative approaches to management of chronic pain and finally to also greatly enhance and expand our access to peer support recovery services throughout the city. I'll be more clear. We're good. That was truly a very fast presentation of a ton of information done very efficiently. I just want to say that I'm proud to live in a state that as a college there's a problem rather than trying to hide it and try to seek solutions. I want to thank you both for your work and it was a lot of other people that you've done and so on and so on. A couple of stories harkened in my mind. One was from when he tells a story in the 70s where a group from Massachusetts wanted to buy a hotel here and set up an in a residency program. Basically they couldn't find enough addicts in the entire state of Vermont to even do it and then fast forward to where we are today. It's pretty scary and I remember being in the house as a lead sponsor of a bill that created the first drug court and it was actually Peg Flory who was in the house at the same time that actually carried the water and actually got it through. We thought we were in a crisis back then and that was over 15 years ago and here we are today. It's very depressing and yet uplifting to realize that you're confronting it and trying to move forward. Does the board have questions for Beth or Mark? I just have a comment actually. I just want to thank you again for having these remarks and also tell you that you both mentioned collaboration across the agencies to the extent that you know the remat and care board through our regulatory portfolio can be helpful in alleviating this crisis. Please let us know of opportunities that we might have because the data that you presented was pretty compelling and disturbing and it can be helpful. We have tried to provide a view of a comprehensive approach. We have rested on our laurels of how they spoke for a number of years now and we should. We should be proud of them justifying them and when you look at other states they are catching up but they are way behind in many cases. So what Beth outlined in her last sentence or two of a much more comprehensive approach I wouldn't say we haven't been doing a comprehensive approach but when you've got treatment kind of as a check mark we're doing that and they need to find out now because we have access to treatment and anyone who wants it can access it pretty readily. So now we have the luxury if you will of really expanding on the prevention and recovery science and really trying to make meaningful programming and meaningful interventions that are part and parcel of the overall health care. It should be included in what insurers consider comprehensive work in this arena so that they're not paying over and over again for the same person or for new people who should never have gotten to that point in the first place. So I think it's kind of a luxury that we can actually look in this very expansive way and very visionary and idealistic way if you will and say how can we really make our entire system better we will be looking to your option. Any other questions from the board? If not we're going to open it up to public questions or comments Dale. This might sound like a curve ball. I'm going to do my best to try to describe this. First of all I totally validate the crisis. I want to be clear on that. So there's a population of people who happen to be one above that brushes up against this policy but we aren't what this is describing. We happen to take either a controlled substance because we have epilepsy or some other medical condition and that's my own history, is epilepsy. Kevin you mentioned it. I can remember, I mean I didn't know what epilepsy was until like 1972 and in the hospital I've been diagnosed with it. Of course I'm not the ICU the first time. They put me on Phenogarbital. That's about as controlled as you can get as a substance and going back to my school and having kids wanting to buy it for me to get high and I'm trying to figure out why you want that kind of hell in your life. I don't think I just swore because that's what it was because within a month I'm in the ICU because the dosage since they didn't have BMI was so high, non-toxic. It took a very low amount for my body to get poisoned by it. I guess that's a simpler way to put it. I also had this ability to go into what they call Staniscentolectus which meant by the time you get to the dosage that would save my life. Now I'm in crisis because still of the dosage.  There's only one way I'm going to live. There's more ways I could die than I could live. I walked into my doctor office just last month. I've got one controlled substance still in my life. It doesn't bother me. These things have kept me alive. They are medicine to me. He puts this form before me that says I'm supposed to keep it in a safe and I'm supposed to sign it. I simply looked at him and said, you buy the safe, I'll keep it in a safe. Otherwise I'm not putting this in a safe. I don't own one. That was really what I was saying. But he explained to me how this is a problem and that's why you have this. Because other people, and I see it now in the chart. I didn't know that. It's like it comes through relatives and so forth. I honestly had no idea what he was really talking about. Why he was giving me this policy. But I just thought it was over the top. What do you do with these people? I can't be the only one. I know I'm not the only one. What happens to that population? They squeeze right in the middle. Do you want to tackle that, Dr. McGean? They may not require a safe. But it doesn't require you to be safe in your approach to how you store medications.  Are there people who do have bad habits in general in their lives in regard to addicted substances? Are there adolescents and young adults who may not have those bad habits but just the fact that it's available and they know where it is and their inquisitive could lead them down a path you never want to see them go down? So it's really the education about that and citing and informed consent that you understand that and you've been counseled about it as opposed to I agree to put it in a safe and no one else can get into it. For each household it will work differently. But it's really the process and the fact that you never had to have that conversation before with the doctor until all of these rules came down and that's a wonderful thing that we now have these conversations because it puts it on your radar screen whereas you may never have thought of the fact that the drugs you have in your house could be diverted in ways that you couldn't even have imagined before. I think it's really the education, the informed consent, the conversations and the critical part and you decide how you can navigate that and do the right thing in your house for the people around you. Sure. How do I validate though that I need that because they've got it so restrictive I feel like I'm going through chaos sometimes just to get to the medicine you can't pick it up until two days before what they call is the right time to pick it up and there is this thing about using it as needed because you may need to take it an extra one. You start to have an aura and it looks like you're going to have a seizure that is you take an extra one or you know you take your chances it's up to you. I don't particularly like it so what do you do with that? It's again the conversation and you and the physician understanding what are the circumstances that would make you utilize more in a given month than you theoretically needed to have and making allowances for that based on the fact that there's a trust built in between the clinician and you based on the experience you have with each other but I know it does seem like you're jumping through hoops sometimes and you're actually having to justify a behavior that you never would have thought you'd have to justify knowing your own condition but that's kind of the world we need to live in with the severity of the problem that we have with these kinds of prescription drugs. Think of it this way Dale you may be going through some inconvenience and a little bit of struggle you may be helping someone else to never get addicted to something so. And I can live with that. Good, thank you. Okay. Kevin. Yes first a quick disclosure I had mentioned to Beth Tansman today over lunch at the state house that I was hoping to meet the health commissioner not quite this way but that's the way things unfold I think he could stop you on the basketball court. Well, we're going to talk about that because I did hear that he might have Yukon on this background We'll talk about that but I directed the mental health association for 30 years and I think Beth and I interacted over maybe 20-25 years so we kind of we aren't that old and yes and you know I do want to say that I think the presentation is quite good particularly for somebody from Yukon I mean it's really having said that there's one shortcoming that I really want to take to task I think that in the presentation there's much too light and not educating the public about the role that the pharmaceutical industry played in creating this problem in 2009 I was very involved in a piece of legislation that passed that ban gifts from the pharmaceutical industry to Vermont doctors and I was around this time of year where several legislators came to me and said we should extend this ban to other regulators and other elected officials and I'm a very compromising, easy going guy so I decided not to do that because I wanted to pass the bill and if we had tried to do that in April it would have gone down I think. Having said that it was Purdue Pharmacy and several other pharmacies that created this problem they lied and misled physicians to a point that there's a major lawsuit and so I have a couple of questions I presume that Vermont is now part of that lawsuit against Purdue Pharmacy Pharmaceutical where the charge is that they absolutely misled physicians as to the potential side effects and addictive qualities of opiates so that's one question. The second question has to do with the health department it's great to have a new leader and it's great to have a spokesperson particularly one who is going to be standing up tall above others but it was very upsetting a year or two ago after the legislation passed I happened to notice the health department allowed a number of pharmaceutical companies to be participants and the health department functions. I think that's a bad policy and I ask you to take a look at it. It sends the wrong message from the point of view of an advocate and that could be argued. And the last part which has to do with not letting history repeat itself and this is what's troubling because unless we really educate the public as to how the pharmaceutical industry can distort frankly, part of our whole health care complex, look at the amount of money we're spending what you outlined today is millions and billions of dollars and it really partially stems from the behavior of the pharmaceutical industry and perhaps the weakness of doctors in not questioning more what they were observing. So creating a firewall between pharmaceutical industry and leaders in the state may help not have this repeat itself in 5, 10 or 15 years. So my last request or question is I hope that you will seek out people in the state below you and above you to find out if they are taking pharmaceutical money and perhaps you should start at the top because I can tell you that's an issue. I remember all the questions you raised. Those slides didn't get a sentence to the issue of pharmaceutical companies misrepresenting their drugs. You're absolutely right. Misrepresenting the addictive potential of the drugs in an almost reassuring way to clinicians saying that these are wonderful drugs, we have a revolution in management of pain and by the way not much harm associated with them.  So that needs to be stated. With regard to Vermont and the lawsuit we all want to see Vermont in that lawsuit that's an attorney general's office decision and they are completely invested in the process of figuring out but that I have not got word finally from them yet as to are we signed on or not. And it may be the difference between doing it independently as Vermont versus signing on with a number of other states that have already done it but they haven't taken their eye off the ball. I just can't give you an answer as to what their final decision is going to be about how we do that. Because I agree that it does need to be accountability in that quarter. I can't say much about Health Barbon prior to one year ago in terms of events that pharmaceutical representatives might have been at or what have you. I can certainly tell you that like any industry we get advocates knocking at our door wanting to meet with us and it's quite clear when they're meeting with us that we're not endorsing anything of theirs or whatever. We're just there to hear what they have to say. But in terms of a public event since I've been a health commissioner I can't recall any in the last year where they would have been front center in a setting that might have been inappropriate for that to occur. Again thank you very much. We've learned a lot. And if that can come down thank you. Robin can you confirm her on the phone? I must both. Great. All of us are sending you love and well wishes. Thank you. We'll do. You all have time to think as possible. I'm really just recapping some of this discussion from the last few weeks about the fiscal year 17 approaches. So I'll start by recapping the enforcement options and really the focus is on the middle three here. One option is to reduce UBMC's commercial rate by anywhere from one to three percent effective October 1st. Second option is to reduce CBMC's commercial rate by one percent also effective in October. And then the third option is to allow UBMC to self-restret to approximately 21 million of its actual overages to enhance and patient mental health treatment capacity in the state. And those are really the options of the board as before. So quickly the impact of the rate reduction if UBMC and CBMC engage in commercial rate reduction is usually the health network work estimates that for each one percent reduction for UBMC it would be valued at about seven million and the one percent CBMC rate reduction would be valued at about 900,000. And then the next two quotes are directly from Blue Cross Blue Shield from some information that Sarah gave us. And basically she said that based on their 17 calendar year charges for members of the cloth like health plan, large group and ASO lines of business, that each one percent reduction would be worth about $280,000 per month. And similarly a three percent reduction would take place on July 1st. And this is for UBMC would result in about a $5 million saving according to Blue Cross or if it was implemented on October 1st about $2.6 million. This really just encapsulates some information that Mike Deltrack gave us last week from VOD about what's happening in terms of mental health outpatient ER utilization. And I highlighted some of these numbers because what you can see is that for discharges, numbers of discharges, the same day discharges are actually falling as a proportion of total discharges, well the same time those folks were spending at least one day in the ER and in some cases more than 10 days that proportion is increasing pretty significantly over the past three years. You'll also see that the percent change in overall numbers of discharges isn't that great. It's a fairly stable sort of a modest increase. But what's really notable is the number of days. Again a really large increase from 15 to 16 in the number of days that people are spending in EVs and similarly 2016 to 2017. So it's really those that length of stay or the number of days that's driving the increase. And this just provides more detail that you can look at at your leisure. We heard from Commissioner Bailey on April 4th and we heard from Dr. Paratini from UVM as well at that meeting. And there really were some capacity issues that they pointed out. These are just the ones that I made there but there were many others. They said that in addition to people waiting in ERs for beds, others are also likely waiting in medical surgical units or at home and they particularly noted that kids may be waiting at home. The capacity issues are driven partly by increasing numbers of people needing services partly by increasing intensity for those people who need services and then also they talked about the inability sometimes to readily move people to the next level of care. Elected mental health admissions are rare. Most of them are emergencies I was pointing out. It was noted that CBMC in particular is close to six courts and so there's an increasing court order of cases at that institution. There was quite a bit of discussion on what's happening with federal funding for the Institutes of Mental Disease and I have been affiliated with hospitals. My understanding from their presentations of that will be phased out beginning in 2021. That could impact 25 adult beds at the Vermont Psychiatric Care Hospital and 89 adult beds and 30 children's beds as there were three. And then Commissioner Bailey noted that the state's been working on those issues since at least last year. So I'm going to restore my reading and that this is going to require a multifaceted solution. A key part of that is developing additional inpatient capacity. This is a synopsis of the UVM Health Network proposal that was outlined at the last meeting. So the proposal was to build additional beds and to build that at the CBMC campus. That then determined Dr. Paratini in a way that would require additional analysis. The second part of that proposal was that the Vermont Psychiatric Care Hospital could potentially be transformed into a secure residential facility. That speaks to some of the other levels of care where additional capacity may be needed. UVM Health Network indicated that they would continue work that they've been doing on other initiatives. Medication assisted treatment, which we just heard about. They're intensive outpatient care, partial hospitalization. They talked about charging crude additional child psychiatrists and then integrating primary care and mental health care. And some of the benefits that were outlined is that people could in fact get more time to care. There would be improved after care for when they were discharged from inpatient care from the ER, decreased burden and wait time in the ERs and then the resolution of the IMD issue. So additional benefits could occur. It's a little hard to predict these without a firmer proposal. But there are some benefits that could occur if capacity was enhanced and that might be a little more financial in nature. Some examples are that perhaps there could be reduced expenditures on observers. UVMMC noted in their 2017 actual narrative that they recently employed 120 observers at TEs and the average cost at millions 5.4 million. Clearly there could be reduced inpatient days if people were able to get to care sooner or could be reduced ER days as well. And if hospitals are thinking about expanding or reconfiguring ERs to deal with the mental health crisis, that could be a little bit of additional capacity as well. So I'll stop there and allow you to engage in discussions. Thank you, Pat. Before I open up the public discussion, does the board have any questions, Pat? If not, would anyone be able to push to offer a question or comment? So at this point we're going to open it up. We didn't receive any public comment either with public comment. Right. There was no response to the public comment period. So at this point we'll open up the discussion on a potential vote. Would somebody like to make a motion? I would. As many people know, I think I'm pretty optimistic about UVM's proposal and the opportunity that this brings to maybe alleviate the financial and clinical crisis that we see in the mental health system. So I'm going to propose some language here that I think allows UVM to self restrict that $21 million to invest it in patient bed capacity but add some language to ensure accountability. So here it goes. Pursuant to Green Mountain Care Board Rule 3.0, Section 3.4, in order to address the fiscal year 2017 actual budget performance at UVM Health Networks Vermont hospitals, the Green Mountain Care Board would provisionally allow UVMMC to self-restrict $21 million in surplus funds with the condition that such funds be used solely for investments that measurably increase in patient mental health capacity in Vermont. Beginning July 1, 2018 and quarterly thereafter UVM Health Networks shall report to the Green Mountain Care Board on details of its plan for making such investments including all progress on Green Mountain Care Board established milestones to date and must quantify how the plan will significantly increase access to and quality of mental health treatment and lower overall system costs. UVM Health Networks shall continue to report quarterly until such time as the Green Mountain Care Board determines that one the Health Network has made sufficient progress on its investment plan so that no further reporting is required or that reporting may occur at longer intervals. Or two that UVM Health Network has failed to make sufficient progress on its plan to substantially improve the patient bed capacity to alleviate the mental health crisis. If the Green Mountain Care Board determines insufficient progress has been made, it may order that UVM Medical Center use all or a portion of $21 million to benefit retailers through a commercial-rated production. Open that up for discussion. Is there a second? Not a second. So it's been seconded by Robin. Now we'll open it up to discussion. Tom? So I'm going to offer an alternative to that or a substitute to that motion. I think we're trying to get to the same place maybe in a different way and so I'd like to take a minute here just to kind of frame my proposal. I think that we have two crises here. One is a crisis of affordability and the other is a shortage of inpatient mental health beds. Those are both very evident. Regarding affordability, we have the REMD study sponsored by the legislature that concluded that low and middle income folks in Vermont pay more of a share of their income than those of our income. We have the health care advocates analysis, kind of three macro approaches to looking at affordability and the advocate concludes and I quote, all three models demonstrate that unaffordability is both unquantifiable and that health insurance plans offered by the Vermont Health Connect are unaffordable to many wide range of Vermonters. We have Divas analysis on affordability that shows folks at 400% of poverty in Vermont who just use an average amount of health care utilization are paying 80-18% of their incomes for health care and people are high utilization, they're paying 15-30% in high utilization years, inclusive of subsidies. We also have the Divas analysis of migration plan that folks move from one type of plan to another from 2017 to 2018 showing Vermonters moving to bronze plans and lower actual value silver plans thus confirming the above pressures regarding inpatient best, I wasn't here then but I understand it's been a healthy discussion back in 2017 on this issue. Unlike Pat presented I respect and understand the information that the Vermont Association of Hospitals and Health Services presented we have a problem that's growing. I personally witnessed this last week when I visited Northwestern Hospital and I see an armed guard outside a cubicle or a room in the emergency room so it is a real issue. In terms of the recent process in this regard the administration and former chair here made a proposal to the legislature that legislature has not gone very far on that so far and the houses voted yes to replace the middle sex beds that were created in response to Irene and as under significant pressure to do that because FEMA is threatening to claw back the money that was used to build those beds the houses rejected the administration's proposal to build 12 temporary beds at the Northwest Correctional Facility and they've taken no action on any long term solution to this problem such as the one that Jess suggests the Senate has yet to act so we're in a situation where nothing is shovel ready even if approved today. There is no site plan. There are no environmental permits. There are no traffic studies. There are no certificate of need applications. There are no architectural drawings and any cost sharing agreement with the state has not been developed I mean we're here today I think because of some serendipity on March 14th the presentation from staff was totally in the arena of using these funds these over funds to reduce the rates of the hospital and that flows back hopefully to rate payers the staff recommendation was at 20 million for course grade reduction up to 3% from the UVM Medical Center budget overage and again as Pat's presentation profiles each 1% was worth $280,000 per month. At that March 14th meeting Jess raised the issue to her credit of the need to address this crisis and UVM expresses interest in building beds at Central Vermont though it is just a concept. There are no specific plans when asked what would be the number of beds we were informed that it was somewhere more than four or five and asked for a range well maybe it's around 30 so we are at a very preliminary point and substantial capacity is three to four years down the road in terms of the process to get through the design, the funding, the certificate etc. and I don't think that the bulge from 2017 and past year should be kind of held in advance held away from great payers when it can have or at least some of it can have some practical use in the immediate future to provide substantial reductions to the cost of health care for many designers to provide so the motion I'm going to make will be to provide substantial state background for mental health beds from the 2017 to any 2018 overages and get this project on a responsible track so that it is done well so I can this to be copies of my motion to my follow-up. I think it would be helpful if you read it. So I would like to substitute the following relative to UBM Medical Center's 2017 budget net operating income bulge of 20.64 million that 14 million be used to reduce UBM's medical center's commercial rates by 2% or 14 million whichever is greater. Effective October 1st 2018 and that 6.64 million be held in a designated reserve by the UBM Medical Center for the purpose of the planning, design, and construction of new inpatient mental health capacity at Central Vermont Medical Center inclusive of any cost-sharing agreements with the state and any marginal effects on the all-payer model targets. By December 31st 2018 UBM Medical Center may expand up to 10% of said 6.64 million designated reserve for the purpose of developing a certificate of need application for such new inpatient mental health capacity. The balance of the reserve shall be authorized for expenditure pursuant to any Green Mountain Care Board approval of the certificate of need for such new inpatient mental health capacity. Further it is the intent subject to further approval of the Green Mountain Care Board that any 2018 budget net operating bulge of the UBM Medical Center be allocated 67% to the designated reserve for new inpatient mental health capacity at Central Vermont Medical Center and 33% for commercial rate. I think if there was a shovel ready project today this approach wouldn't make sense. We'd be ready to go and we'd need the money but we're three or four years down the line and we also have a problem out there that we can address now. So this proposal allows us to send money back to great payers which is a good thing. It puts a substantial financial stake in the ground for UBM Medical Center for a facility at Central Vermont. It provides two years worth of investment in a reserve for that purpose, the 2017 overage and the 2018 overage. And it gets this project into the budget cycle for 2019 and 2014-20 and leaves opportunity as well for UBM Medical Center to negotiate with the state for some cost sharing if possible from the state. But at this point it's clear there is nothing at the state level. There's nothing at the legislature to move the development of these debts forward and I think an immediate investment of over six million dollars in the planning and buying makes sense. And then the 2018 overage is not a given yet. The 2017 overage is fact, the money is available. In 2018 though, because we benchmarked UBM Medical Center's budget based off its 2017 interest and they are through 2018 apparently running a little lot relative to their budget, there's likelihood that there will be a lot more money in 2017-2018 and this proposal takes two thirds of that and preserves it for the UBM Medical Center to basically construct these debts. So I think that this is a proposal that strikes at the two stars that you had on your first slide, which I didn't get to put that in my packet, but there wasn't anything there that I didn't know. But this is kind of a proposal to help repair and get UBM Medical Center on the road with a facility at Central Vermont and gets them in a position to have itself shovel ready three or four years down the road with funding to construct it. Thank you, Tom. Is there a second? You're still on the phone, right Robin? I don't have a second. I just want to say that I think that where we are today is far from where any of us were a month ago in that either one of the two alternative motions actually recognizes that there could be possibly a greater return to Vermonters by investing in trying to alleviate the bottlenecks in our emergency rooms there, causing hospitals to use expensive sitters, expensive security, and even more importantly than that that are denying patients the right to timely services. We would never tolerate someone sitting in an emergency room for days waiting for a cast to be put on a broken leg or what have you and yet the state has tolerated this for too long. So although there wasn't a second to your motion, Tom, I think that there's still the opportunity to get to what you're talking about if there's another hot year and at least this gives the opportunity to allow UVM network to move forward under the proposal that Jess has made and that Robin has seconded to try to work on the plan that actually achieves the core goal of reducing those wait times, creating better care for patients, and actually saving Vermonters money. So with that I think that the fact that we have all come to that same recognition when just a few short weeks ago prior to Jess making the motion, I would say that the only thing that was considered was a commercial rate cut. So I think we've come a long way and that speaks volumes to the crisis that we have in our mental health system in the state. Is there any further discussion? I appreciate the chairs commentary but I think given that we are at the very beginning of a facility at Central Vermont and it is going to take a while to do it, that's a very complicated site I live in Berlin that we can do both. We can help rate payers substantially and we can put UVM medical center on the path to build a facility of substantial size at Central Vermont. I just want to add to the motion that Jess put forward one of the things we really need to work on is the definition of sufficient progress and how we'll measure that and I think that's something we should focus on with work with UVM on what the expectations are going to be to give a plan for that usage of the 21 million. I obviously don't expect in July that it will have a flesh out plan for that but I mean certainly in the course of this year by whether it's going to be the second quarter or the third quarter of the September or the December, really having a plan because to the extent that the motion had the option to potentially put that money back towards rate to rate payers and rate decline, I think we really want to make sure we have something we understand when it's going to go into play when that money is going to be needed and also to something that Tom brought up the expectation is that there probably will be some over in 2018, in your 2018 year, I mean we did talk about replacing your budget $39 million on the top line what we have an address is along with that, there should be some increase in operating profit as well and the expectation would be that whether that's going to go into this mental health option or into another option, it will be looking to track that as well during the course of the year. I just want to say I agree that this is just a concept at this point a lot has happened over three weeks and to be fair it is short on details, yes, but I think it's long on vision and far reaching and potential impact and I would like to give EDM the time and space and the opportunity to work with the Agency of Human Services to come up with a concrete plan how we can alleviate this crisis and I think that we can work with staff and staff can work with AHS and EDM and the Office of Milestones which we really measure the progress on this plan and I think I understand that Pat has already been thinking about Milestones if this was to pass and Tom I understand your point about this is three to four years down the line, the reality is it's three to four years down the line whenever we start and I think given the crisis that we have now we need to start now. Just to be clear the timing of the start, we're both together because the six minutes, seven million dollars is the start. I don't think it's enough of an impact. Well, there we disagree the planning process has to start somewhere and putting six million dollars from the get-go today into that and then building on that through the 2018 process and then the 2019 budget process we will probably get to the same place down the road at the same time except taxpayers will have to use at least 14 million of that 20 million and we'll get to where we want to go. Robin, do you have anything to add? No, I'm going to be unfair personally by it today. Understandable. Is there further discussion? If not I'm going to ask the clerk to call the roll. My clerk? I'm also an ambassador for wellness. I will start Maureen. Yes. Tom? Yes. Robin? Yes. Sharon Mullen? Yes. Passed with one descending vote from member of Pellum. Thank you. I think we do have to clear up another item in that at previous board meeting there was a provisional vote and I think that has to be decided one way or the other. Does anyone have a motion on the CBMC? Yeah, I'll make a motion there. I think that we had a provisional rate cut of 1% for CBMC but since I believe that the 21 million dollars is inclusive of at least some of CBMC's overage I would move that we rescind that rate cut. Is there a second to that motion? Is there discussion on the motion? The discussion I would have would be, it's not quite all of the total. I mean if it was 20.6 million that was from UDM alone so that we rounded out I guess 21 million and it was 900,000 for CBMC whether we look at 22.5 million or keep the 1% in there just want to discuss what options anyone wants to look at there. So is there other discussion on the motion? Rob, would you have anything to add on this? Okay. The clerk will call the roll. Member Hallam. Yes. Maureen. Member Ucifer. I don't know. Ucifer. Ucifer. Yes. Pellum? Yes. Mullen? Yes. Lunch. Yes. Okay. Is there other enforcement action come before the board? If not, we'll consider the 2017 enforcement close at this point. Pat, am I missing something? I don't believe that. Okay. Thank you Pat. I know this is a bit of a trial like fire but you've been thrown into your new role. There's been a lot that's been happening and we really, really appreciate everything that you're doing. Is there any old business to come before the board? Is there any new business to come before the board? Is there a motion to adjourn? Pellum. It's been moved and seconded to adjourn. Maureen. Clerk. Call the roll. Yes. Lucifer. Yes. Mullen. Yes. Hallam. Yes. Hallam. Hallam. Thank you everyone. I know it's been a tough day and thank you very much.


Give the people what they want. Give the people what they want. Give the people what they want. Your weekly movement news roundup. It's the 24th of June. You're joining us at Give the People What They Want, brought to you from People's Dispatch and Globetrotter. I'm Vijay from Globetrotter, joined by my colleagues Zoe and Prashant from People's Dispatch. A difficult week, this one for the people of Afghanistan. They've actually had a run of difficult weeks, if not months and years. Major earthquake in Pakhtia province in southeastern Afghanistan, a province that borders Pakistan. This is the largest earthquake, 6.1 magnitude, the largest earthquake in about 20 years. Now, 6.1 might not be a very large number for many people who are used to seeing numbers higher than that for earthquakes. But you have to understand that this took place in a place, mountainous terrain. The devastation was immediate. A thousand people killed instantly, almost 1,500 people injured. These numbers are merely thumbnail figures. We'll get better numbers perhaps in six months, if not longer than that. These are thumbnail figures because the Afghan state doesn't have the carrying capacity to be out there to assist people and so on. The Afghan state now managed and run by the Taliban has greatly deteriorated. One reason it's deteriorated is, of course, it still cannot access its own revenues. The state is functioning basically blind without revenues, without proper mechanisms. Many talented people who worked in the Afghan state left the country when the Taliban came into Kabul. That is a real problem for the Afghan state, the health ministry. Many medical personnel as well left. NGOs that functioned as effectively a parasitical health ministry also left the country. The lack of personnel, lack of funds has left the Taliban in a sense unable to deal with this crisis. They have requested international help. We'll see what happens in the days to come. It should also be said, of course, that 93% of the people of Afghanistan are struggling with hunger. This is an extraordinary figure. That means that almost everybody in Afghanistan is having a hard time eating. You put hunger, you put a effectively compromised state into play with the largest earthquake in 20 years, and you have a real catastrophe not in the making, but already happened. We from People's Dispatch and Globetrotter want to send greetings to the people of Afghanistan. I know this is not always something that reporters and journalists are supposed to do, but this is a catastrophic situation. It's not a normal disaster where a state is able to come in and provide relief to people and so on. In this case, the state simply is unable to come in. I'd like to add as well that the Taliban, although it has governing experience, it governed from 1996 to 2001 in Afghanistan, it has governed many provinces in the country during the period when it was fighting the U.S. and NATO occupation of the country. It has experience. Nonetheless, the Taliban government has shown itself to be on top of its game at all. It in fact has floundered in the last several months. We've seen the Taliban who promised not to go in this direction to rule in the kind of nationalist way. We've seen the Taliban stumble into its old habits of constraining the rights of women. We've seen it stumble into its old habits of believing in ideas of Islamic finance, which are simply not going to help the Afghan people at this time. Stumbling into its habits of constraining the rights of women. It was the United States that invaded Afghanistan in October 2001. It was the United States that had to withdraw from Afghanistan in August 2001. And now it's in the United States where Taliban-like policies are making themselves manifest again. Zoe, we're coming on the 24th of June, coming live as we do every Friday to talk about world events. But just a few hours ago, the United States Supreme Court decided to do something which I've already called Taliban-like. Tell us what the U.S. Supreme Court has just done. Well, this Supreme Court, which is an unelected body, just decided to strike down the Roe v. Wade decision. And for those listeners who don't know what Roe v. Wade was, it was a decision in 1973 that essentially protected on a national level the right to abortion. And there are arguments about what legal reasoning was used there, what judicial argument was used, maybe it was weak. That all is there, that's fine. But essentially Roe v. Wade guaranteed that on a federal basis the right to abortion had to be protected. And in the beginning of May, a draft decision showing that the Supreme Court, a draft decision by Judge Alito, which said that they would attempt to overturn Supreme Roe v. Wade was leaked by a very brave journalist. And this draft decision, after it was leaked, many people said, no, this is not true. That's not going to happen. That's absurd. This would never take place in the United States. A lot of protests took place after that. Thousands of people on the streets. Some of the largest protests we've seen this year in the United States. However, a month and a half later the Supreme Court did exactly what it said it wasn't going to do. And they overturned Roe v. Wade. They took away federal protections for abortion rights. Abortion, access to abortion and legal abortion in the United States is supported by 79% of the population. We've done a poll that says this. 79% of the population believes that people should have access to legal abortion. However, the Supreme Court, an unelected body, a body that is appointed by the executive branch, just decided to take that right away unilaterally. And so now basically, essentially without Roe v. Wade in place, states which many are governed by conservative leaders have the ability to enact laws that further restrict this right. And so we've already seen in states like Texas, in states like Georgia, there have been extremely aggressive laws passed, which essentially completely take this away. People who want an abortion have to go through a series of obstacles. Now they really might even be a way to be able to criminalize this fundamental public health right completely. And so this is extremely worrying. As you said, it is Taliban-like to completely infringe on the rights of women, not respecting the masses' opinions on this fundamental right to public health. But I think as we've talked about in other moments, that this is really part of a broader trend of the right wing in the United States is extremely effective in imposing its agenda in the political scene. The Democrats have not been able to do anything to protect this right to abortion for decades. And as I said, this was a decision from 1973. It's a weak decision that doesn't enshrine abortion into law. It can be overturned at any moment like it just was, and that right to abortion disappears. There is an attempt to pass a law that would have given access to it, that would have made any restrictions on abortion illegal, that would have enshrined this right, Women's Health Protection Act. And what do you know, this was up for debate this year. It had not passed in the House or the Senate. It had been the opportunity to make sure that people had the protection to this right, and it was not passed. So this is really worrying at the same time yesterday, the Supreme Court ruled to overturn a New York state law regarding concealed carry of guns. It says that there is a constitutional right to carry a handgun in public for self-defense. You know, these are things that are up for debate. The right wing is winning all of these battles. Right now, we have a Democratic president.  So really what is democracy in the United States when the majority opinions is being overturned by an unelected body where, you know, right wing reactionaries are imposing their political agenda and actually winning victories. This is seriously troubling for the upcoming midterm elections. There's going to be a high turnout for conservatives. They're clearly effective in actually resisting true to their word, whereas Joe Biden, who said that he was going to pass large infrastructure bills that would have given a bigger social safety net. All of these initiatives have been defeated. He hasn't pushed Democrats to actually take these up to make these happen. And so I think this is an extremely crucial moment. We have to be following this. There are definitely going to be mass protests. We saw that even when the draft decision was leaked, tens of thousands of people were on the streets. They see what's under threat. They see that they're under attack and they're going to fight back. Well, Mr. Biden, President, U.S. President Biden seems more interested in the freedom of the Ukrainian people than the freedom of women in the United States. It's a shocking story, a shocking development. Just when many countries in South America, Catholic countries in Argentina and so on, advancing the cause of women's rights, legalizing abortion and so on, the United States deciding to take a U-turn in terms of the advancement of human freedom, shocking development. Thanks, Zoe. That's an amazing story. We're going to have to, of course, look into it in more detail. There's some better news coming from the U.K. and from Colombia. We're going to turn to that. But first, let's go to the U.K. National Union of Real Maritime and Transport Workers. Mick Lynch.  What are these working-class British people up to now in these last few days? Right, Mr. Jay. Zoe mentioned the global right-wing push on so many fronts and just as there's a social push in the United States, there's also an economic push in many of these countries. And I think the United Kingdom is one classic example of this conservative government, this conservative party, which has been in power for close to almost a decade now. And what they've been pushing is a relentless attack on the welfare, on the salaries, on the rights of working-class people. So it's no surprise that the U.K. also seeing what is being called the summer of discontent. We have strikes coming up in various sectors. And this particular strike by rail workers, that's around 40,000 to 50,000 people taking part, three days of striking. That's Tuesday, Thursday, and Saturday. And so we saw one yesterday. We're going to see another round tomorrow. Very important strike because its strike, it hits in the very root of this right-wing orthodoxy, which has been so prevalent for so many years, which is that government saying that, what we should just focus on is cutting spending. And this comes on the heels of 4 billion, the 4 billion pounds worth of cuts in transportation systems, which are going to have a wide variety of impacts. We're seeing the possible closure of ticketing offices. We're seeing the possible more and more compulsory redundancies being taken place. And of course, no increases in salaries. Now the media, of course, is spun this kind of greedy attempt by the labor bureaucracy or the working bureaucracy, so union bureaucracy to mislead the workers. But when you see the numbers that are coming out, it shows how nonsensical this narrative is because this is people saying that, this is of course about pay because inflation is very high. It's, I think, a 40-year inflation high that we're seeing right now. This is of course about pay, but it's also about basic job security. This is also about safety for passengers on trains. This is also about not cutting those services, which will lead to more safety risk taking place. So which is why there's also been an expression of support from non-workers as well. People who say that we stand with the union because we want to keep transport and the railways safe. We want to keep it running efficiently. And we've talked about this endlessly on this show before. The pandemic should have showed us by now we need more investment. We need more spending on public services. We don't need more privatization. But governments like Boris Johnson's government, which lost two by elections, by the way, which definitely gives a sign of how the public sentiment is continuing to keep saying that we need reforms.  What governments across the world mean is basically an attack on the lives of every of people throughout the society, especially the weaker section. So hats off to the workers who are, you know, who are sacrificing a lot in this kind of strike and who most probably are going to be an inspiration for many more workers across the country who are going to be taking up these kind of actions. So definitely more pressure on the conservative government, but very few signs that they're really going to learn from this and make an about turn. Fortunately, the Labour Party also taking a very regressive stance on this. In fact, I think Kerala Stammer has told his MPs, do not go to the picket lines and support the striking workers, which is highly ironical for a party named Labour. But that's really the political scene in the United Kingdom today. The two or three main political parties all united in this orthodoxy of suppressing the wages, suppressing the living standards of working people. Don't forget, Prashant, that is so clear Stammer. Make sure you mention that. His circular Stammer. I believe that his loyalties by that are more to the British establishment than to people like RMT President Alex Gordon, Mick Lynch and others who are standing on the front line, defending not only, as you quite rightly said, the working conditions and wages of train workers and rail workers and so on, but of the entire working class in Britain. Really great what they are doing. And we at UN People's Dispatch and we at Globetrotter are watching this carefully. We're going to do more on it. Give the people what they want coming again to you every Friday. This Friday, again, another piece of good news because last Sunday, Gustavo Petro and Francia Marquez prevailed in Colombia first leftist to win that election. Pretty amazing, Zoe. Tell us about it.  And they finally said yes to change and they said yes to Gustavo Petro, yes to Francia Marquez, to the people who are committed to really bringing their demands into the public sphere, into politics, into bridging the gap between the people on the street, mobilizing for the past decades and demanding peace, demanding justice and bringing those to the institutional realm. And so I think it's a crucial victory. It was expected, it was unexpected. There was expectations that anything could happen.  But in the end, the will of the people really prevailed and Gustavo Petro, Francia Marquez won these historic elections. I think historic is the word that's been used constantly to refer to this victory. A former member of an armed movement, of a guerrilla movement a ferocious environmentalist who fights for the rights of indigenous people in Afro-Columbian communities in Colombia who has gone head to head with security forces, head to head with illegal miners, with paramilitary groups. And this is the pair that is going to run the country that has been so plagued by decades of neoliberalism, by US imperialism, by militarization. These people that really understand the conditions people are living in, the enormous amount of poverty in the country, the high levels of unemployment, the lack of access to education, to basic health care. These are the people that are going to attempt to really right the wrongs of decades.  Colombia is in one of the worst crises in its history because of the pandemic, because of the mismanagement of the pandemic, the proliferation of violence in the territories, the strong control that paramilitary groups, the drug trafficking groups have in the country. This of course was cemented and really supported by conservative governments over the decades. And so they have a huge task ahead of them. A lot of people say that once the first electoral victory is won is when the real conflict and where the real debate and tension is going to arise. We saw it in Peru after a very challenging victory of Pedro Castillo who has been in constant tension with the dominant classes in the country. This is of course going to happen in Colombia, but the people on the streets who brought this victory, who made this victory possible, who mobilized, who were active on social media, it's going to be, these are the people who are going to have to remain active in this battle in the next period. I mean, there's been a shockwave has really been sent through the region and across the world with this victory. Everyone knows of Colombia as being the US's biggest ally, the Israel of Latin America. Some people like to call it. And so the fact that there were six decades of war, of conservative politics has been reverted is such a huge victory and it can't be underestimated. Of course there are limitations and of course there's huge challenges ahead, but this fact in itself is something that has to be celebrated. We have to look at how this was possible, how the people mobilized, what organization they did to make this possible and really build towards the future, congratulate the people of Colombia for this and really look at this historical moment. It's a major victory and during the last phase of the campaign, Gustavo Petro's daughter, Sofia, came to campaign events with a t-shirt that bore the likeness of Meryl Franco, the Brazilian socialist who was assassinated a few years ago. I found that very interesting. It was almost a wink and a nod to say after Colombia, Brazil, which has an election in October, certainly an interesting moment for Colombia, a tough road ahead. Already Governor Ron DeSantis of Florida, who is going to run for the president, made a ghastly remark about Marxist taking power in Colombia. You know when people in the United States say that people who have just withdrawn the right of women to control their own bodies, these same people, they like to go and make coup d'etats and so on. So this is a serious situation for the country of Colombia. Just north of Colombia, in Mexico, most interesting president, Andrés Manuel López Obrador, most interesting man leads a political party called Morena National Regeneration Party. Very interesting because in the first period of Morena's time in office, Amlo's time in office, Andrés Manuel, he was mainly concerned with domestic matters, except of course confronting Donald Trump who was then the president regarding the question of the border migration and so on. He showed that he could be quite firm. Well, in this new phase of his presidency, he's really gone out as an internationalist. He has been driving the agenda for CELAC to go ahead of the OAS. That's the community of Latin American and Caribbean states to basically overtake or transcend the organization of American states controlled by the U.S. He refused to go to Biden's meeting in Los Angeles, the so-called summit of the Americas. He categorically refused and his refusal opened the door for Honduras in Bolivia and others not to go. In fact, it was Andrés Manuel López Obrador who scuttled Biden's summit in many ways. Now, when UK Home Secretary Priti Patel says that the British government has no problem extraditing Julian Assange from Belmarsh prison, the dungeon where he's sitting illegally because after all, Mr. Assange has actually completed his sentence of skipping the warrant for his arrest. He's completed that sentence. He should actually be released. They are holding him there pending extradition. There is no need for the British government to hold him. That's actually against the rules of British jurisprudence and prison policy. At any rate, Mr. Assange is sitting illegally in Belmarsh prison being held there by the British government. Priti Patel, the Home Minister of Boris Johnson's government says Britain has no problem sending him along to the United States where he would be found guilty and he would have to serve consecutive life sentences, 100 plus years in prison. Well, at that moment this Tuesday, Andrés Manuel López Obrador sales the Mexican ship into this debate and says two things to Mr. Biden which I thought were quite interesting and worthy of our reflection and give the people what they want. One of the things Andrés Manuel López Obrador said was that the persecution of Julian Assange, a reporter and publisher, is an embarrassment. He used the word embarrassment. He said Mr. Assange is one of the great journalists of our time. Also, he could have mentioned he is an important publisher because really what Julian Assange is being persecuted for is being a publisher at WikiLeaks. Not exactly a reporter but a publisher. At any rate, Mr. Andrés Manuel López Obrador says that the persecution of Julian Assange is an embarrassment and then he said that if there is any way possible for Mr. Assange to leave Belmarsh prison, Mexico would be happy to give him asylum Remember that he initially Assange initially had asylum in the embassy of Ecuador. Ecuador, by the way, right now is in the middle of a major political crisis where the deputies of the party of Rafael Correa are going to put an impeachment motion forward against the president Guillermo Lasso. Lot of violence, extra judicial use of force against political opponents like the leaders of the indigenous movement front and so on. Ecuador itself drowning in its own contradictions. Ecuador had actually revoked the asylum for Mr. Assange which brought him into the direct clutches of the British legal system. Now, Mexico sails in much more powerful country in a way and says we will give him asylum. Gotta watch out for what's going on. Do not underestimate Andrés Manuel López Obrador. People who say Andrés Manuel or Petro or Boris and so on they are not part of a kind of very, you know, far left or as it were. Well, but they are very interesting and one must pay attention to them as we do on this show. Well, let's end on a more sober note. We started sober with the earthquake in Afghanistan. Something quite painful took place for the family of Patrice Lumumba. A very painful moment, but also perhaps a relief for the people of Congo as well. Prashant, what's the latest story on the Patrice Lumumba case? Right, Vijay, you talked about Assange, of course, continuing trend of, you know, suppression of torture of people who resisted imperialism in all its forms and there's probably no greater example than that of Patrice Lumumba, the first prime minister of the Atlantic Republic of the Congo, a revolutionary and icon for people across the continent, people across the world who, you know, led his country's struggle for independence at a very young age, became the first prime minister of the country, but it was very short, very soon overthrown in a coup that was backed by Belgium, that was backed by the United States, that was backed probably by the United Kingdom as well and all of these, all of them were probably involved. And, you know, he was arrested, tortured, brutally murdered and shortly after his body was dismembered, the parts were dissolved in acid so that his memory should never inspire or, you know, serve as a rallying point for the people of his country and for the people in the continent again. And this was a very deliberate act, let's not be too very clear about it.  Similar thing happened with Che, if you remember. And, you know, that tooth has been in Belgium for decades now and, you know, it was recently recovered, the Belgian government made this whole thing of giving it back to the family of Lumumba. It's going to be kept, you know, there's going to be a period of mourning in Congo. But the important thing, of course, is that, which we have carried a story, one of our colleagues, Sarupri, has written it with extensive quotes from our friend Kambali Musawili who is an activist there. Very important aspect to note about the pure symbolism of this, without any meaningful attempts at justice, without any meaningful attempts at accountability, stemming from the fact that, you know, Belgium has expressed some anodyne comments about how they hold moral responsibility or whatever. There is no real accountability for the crimes of imperialism. There's no real accountability for this long period of involvement. And, you know, nobody, of course, has been arrested or persecuted, nobody punished or no reparations in any meaningful sense of the term. And this is especially important in the Congo because from 1885 onwards, we, Belgium and King Leopold II, maintained personal control of the Congo for 20 years. There was a reign of brutality, which is probably unprecedented, you know, even by the gory standards of colonialism. And the photos, for instance, the stories are like really, you know, quite unbelievable. And this is continued in new ways. Even to this day, the Democratic Republic of the Congo is used as a pawn by, say, Western powers with their allies in countries such as Rwanda. Even today, Rwanda and Uganda have continued to, you know, exploit the resources of the Congo with the connivance of their allies in the West, armed conflicts going on even now. All of the stretching from that pivotal moment, the assassination of Lumumba, who, you know, who dreamed of a different way, who talked about who worked for a different way along with his allies across the continent. So the assassination of Lumumba was, you know, in that sense it was a strike against those aspirations for a different kind of Africa, for a different kind of world and the impact of that continues to this day, which is why it's so significant that, you know, while this symbolic action is being hailed, it does of course bring some amount of closure to Lumumba's family, while the symbolic action is being hailed. In truth, it is just an empty act without any true, you know, answering the questions of justice and accountability. But nonetheless, as you say, it's important that it happened. This has been a poignant show because there's up and down emotionally.  We, Zoe Prashant and I from People's Dispatch and Globetrotter, try to bring you in half an hour the most important or at least what we consider to be the most significant stories. So join us every Friday. I want to end with a little note that as the US Supreme Court has overturned what's known as Roe vs. Wade about the right to women's freedom, one of the Supreme Court judges, Clarence Thomas, has now said he's next going to try to make contraceptives illegal. That's the world we live in, friends. See you next week.


The biggest thing that bothers me, as I look around, is that discoveries that don't turn out to hold up. Discoveries that aren't reliable, that aren't replicated when you look at new data. It's easy to find things in the data, but you can torture data until it confesses. And this happens more often than we'd like, especially in extraordinarily important data like medical research. Even the optimists in the medical field believe that half of the results that are published in journals, and again, journals only publish in some cases 5% of what's presented to them. So even cherry picking the results, half of what is published is probably not true. They just don't know which half. And pessimists believe that perhaps 95% of what's published is not true. So there's a lot of money wasted on medical research and we can't trust most of the results that appear. It's very, very disturbing. And half of the problem can be solved by doing data analysis better. And we've developed some techniques to do that. The problems were very well described in a cover article for The Economist magazine a few years ago on how science goes wrong. Very, very well written article. I highly recommend it's available on the web. And half the problems there were scientific in nature. We've developed new methods, pretty much rediscovering old methods, but methods that haven't been in use to solve that half of the problem. And the other half is more the business and the economic incentives of science where people are rewarded for discovering new things and they're not rewarded so much for confirming or verifying old discoveries. And that part of the problem needs more attention by journals and also making people supply the data that backs up their findings so that others can confirm it. This is still not enforced in a lot of places even where it's supposed to be. When I taught at the University of Virginia, which I do occasionally, one of my homework assignments for the graduate students was to find a favorite research paper that they had and ask the authors for the data. And over the semester only one out of my 20 students was able to get the data from a paper that they were found. So it's still not very well enforced for data to be available for other people to verify the work. And this needs to improve. So the medical science is probably one of the most important and one of the most egregious examples where reliability is not there. But in all of our work this reliability issue is paramount because the most important place for the model that you've found you've found some purported relationship between something you can measure and something you want to predict. The most important place for that to work is on new data you haven't seen before. Otherwise you've wasted your time.