Lynch is the Distinguished Professor at the John Jay College of Criminal Justice and has served as the representative of the American Society of Criminology on the COSSA Board of Directors.  Sen. Ted Kaufman (D-DE), who chaired the hearing in place of Committee Chair Sen. Patrick Leahy (D-VT), introduced Lynch as one of the "foremost experts" who has worked to improve criminal justice data systems.  Also noted was Lynch's service on the National Academies' panel that produced the report Ensuring the Quality, Credibility, and Relevance of U.S. Justice Statistics.

At the 142^th meeting of the National Advisory General Medical Sciences Council (NAGMSC) to the National Institute of General Medical Sciences (NIGMS) on January 22, director Jeremy Berg discussed the launch of the Institute's process to undertake a strategic plan focused on research training. 

Addressing his council, Berg observed that research training is supported by a number of mechanisms at the Institute.  He also pointed out that the biomedical workforce and especially academic faculty is not representative of American society in terms of gender, racial and ethnic diversity.  Individuals trained with support from the National Institutes of Health (NIH) pursue many career paths, including academic research, teaching, industrial research, start-up companies, science policy, among others.  Berg noted that there has been a sense that NIH training is to produce R01 investigators and that is the only successful outcome; an assumption that might need rethinking.

The Institute has established two committees:  1) Training Data Inventory Committee led by Berg and 2) Strategic Plan for Training and Career Development led by NIGMS' deputy director Judith Greenberg.  In the coming days, the Institute will post the intended process and a statement of intent explaining why and what it is seeking to accomplish.  The goal of the plan, according to Berg, is to examine existing activities and articulate strategies to help the Institute build and sustain a workforce.  The groups are wrestling with core assumptions, the distinctive features of an ideal training model, and potential obstacles.  The Institute will seek stakeholder input via a website in March/April.  It will also hold meetings across the country in San Francisco, CA; Chicago, IL; Philadelphia, PA; and Atlanta, GA.  In addition, there are plans to hold a webinar in late June 2010.   In May, NAGMSC will hold a "richer" discussion on the subject.  The first draft will likely be written in July-September and finalized in October-December.

In a request for information (RFI) that NIGMS intends to issue in coming months, the Institute will be seeking comments to six questions from the stakeholder community:

1.    What constitutes success in biomedical research training from the perspective of an individual trainee, an Institute, and society?

2.    What can NIGMS do to encourage an optimal balance of breadth and depth in research training?

3.    What can NIGMS do to encourage an appropriate balance between research productivity and other training activities for mentors' trainees?

4.    What can NIGMS do through its training programs to promote and encourage greater diversity (broadly defined) in the biomedical research workforce?

5.    Recognizing that students have different career goals and interests, should NIGMS encourage greater flexibility in training, and if so, how?

6.    What should NIGMS do to ensure that the Institute monitor, measure, and continuously improve the quality of its training efforts?

Rich, an expert in inner city health problems, characterized the lecture as different from those typically given as part of the NIH lecture series by "brilliant biomedical and genetic scientists."  His topic was how to improve the health of men of color.  He argued that connections can exist between trauma experienced by young people and the mechanisms that make their health less than optimum.

Rich's current work examines trauma and violence in healthcare settings and what it means for the research, clinicians and public health.   Rich came to his research as a clinician.  He realized as a primary care physician that he saw very few black men despite seeing them throughout the hospital.  In recognition of their need for primary care, Rich and his colleagues started a clinic - the Young Men's Health Clinic.  The idea was to see if there was an opportunity to bridge the gap between pediatric care and adult care for these young people.

They found that among their subjects --  80 percent were uninsured, 20 percent had never seen a doctor, 25 percent had never seen a dentist, 45 percent had a violent injury in the past, 51 percent had witnessed a shooting or a stabbing, 25 percent do not feel safe, and 44 percent had been harassed by the police.  These statistics, said Rich, made him aware that the issue of trauma and adversity was very much primary in the lives of these young men.   He pointed out, however, that not all the young men had been involved in activities considered criminal. 

Using data from Philadelphia, Rich looked at male homicide from 2000 through 2008.  For Black males younger than age 17 there were 25-30 homicides per year; for black males ages 18 -23 the rate was 75-130; and for those less than 40 years old the homicide rate was 75-100.  In 2006 alone, for those under the age of 40, Philadelphia had 406 homicides.  For white males, while still tragic, the homicide rate was much less.

 Life Expectancy for Black Men 'Still Lags Behind In a Troubling Way'

He cautioned that if we only look at the homicide rate, however, we miss most of the action about trauma and violence.   While there were 406 homicides, there were 2,004 known shootings, 9,000 aggravated assaults reported (more violence is not reported).   In these communities and neighborhoods where these young men live they are constantly surrounded by violence, whether it affects them directly or not.

The Centers for Disease Control and Prevention (CDC), according to Rich, estimates that for every homicide there are 94 nonfatal incidents.   CDC also reports that there are 16,800 homicides and 2.2 million medically treated injuries.  In 2007 the cost was $33 billion in lost productivity and $4 billion in medical treatment, according to the Journal of Preventive Medicine, he reported.   Trauma and violence affects all of us, if only through the cost of health care, Rich stated.

Rich pointed out that black men suffer from many ill health issues.  In fact, they have the worst health status of any other race-sex group, he explained.   They have the second lowest life expectancy at birth, second only to Native American men.  Black men have the highest death rate from all causes and the highest death rate from cancer, cardiovascular disease, and homicide.  They also have the highest rates of sexually-transmitted infections, including HIV.  Showing data from 1975-2007 that revealed an increase in the life expectancy of all Americans, Rich noted that the life expectancy for black men "still lags behind in a troubling way."    

This led Rich to discuss the social context of stigma for black men.  They are: more likely to be stopped, mistreated and killed by the police; more likely to face discrimination in hiring; and more likely to be depicted in dehumanized or objectified ways in the media.  Further, stigma is more likely to follow them into the health care system; and a there is a lack of willingness to separate the victim and the perpetrator.

Rich noted that he has observed the tendency toward the belief that "all victims must be perpetrators."   Within the health care system there is sill this dichotomy of how young black men who are victims of trauma and violence are approached by the professionals there.   This is an ongoing concern because of the rise of recurring violence, he explained.

Why the Narrative Method?

Through talking with the young men, Rich realized that what was his "normal" was not "normal" for these young people.  Therefore, he could not draw upon his own understanding to put together the questions for his research to examine the experience of violent injury from the perspective of the victim.  He decided to use a research methodology that employed open interviews and qualitative analysis of the data.  

According to Rich, predictors of recurrent injury include such factors:  African American male, unemployment, lack of medical insurance, income less than $10,000, current drug use, past/present drug dealing,  positive toxic screening for psychoactive substances, incident related to "dissing" or disrespect, prior incarceration, weapon carrying, past psychological trauma, unsafe neighborhoods, and numerous other factors.

The key themes that emerged from the research included:  respect and code of the street, mistrust of police, and traumatic stress which manifested itself through self-medicating and weapons.   The themes, said Rich, suggest more complexity than the assumption that "these were just bad people behaving badly."

He talked about what it means to be a "sucker."  It is not defined as being gullible as is thought by many, but is what happens when you lose respect.  According to one of his research subjects, "a sucker is a person that if someone says something to them or does something to them they just sit there and take it and don't retaliate.  If you are living in the inner city you wouldn't want to be a sucker because everybody will take advantage of you."

Rich referenced Elijah Anderson's Code of the Streets which is defined as:  "In the inner-city environment respect on the street may be viewed as a form of social capital that is very valuable especially when other forms of capital have been denied or are unavailable.  Not only is it protective; it often forms the core of the person's self-esteem, particularly when alternative avenues of self expression are closed or cease to be."

 PTSD

Rich related that was most compelling and surprising was the role of traumatic stress association with trauma and violence.   These symptoms that are common in combat veterans and victims of sexual assault are present in every form in these young people, he explained.  They include:  hyper-vigilance, jumpiness, depression, avoidance, nightmares, flashbacks, insomnia, generalized anxiety, emotional issues.  Sixty-five percent of their follow-up patients met the full criteria for PTSD (post-traumatic stress disorder).   Another prominent symptom of great concern to Rich and his colleagues is the blunting of emotion or dissociation that the young men experienced after the trauma, which has implications for safety and the inability to feel fear or love.   There is a disruptive sense of safety, Rich explained.  As a form of self-treatment, many of the men turn to weapons.  "Traumatized young people with a disruptive sense of safety, who obtain weapons or get involved in an illicit economy, increases their risk for re-injury."  They lack the ability to move away, avoid public transportation or "stay in the house."  Rich sees this as an alternative explanation to the notion that "these are bad people doing badly or sick people acting out their sickness."

Self-medication and weapons are rooted in intrusive symptoms and hyper-arousal, he explained.  For the most part, Rich asserted, patients and providers do not make this connection between their behavior and the symptoms the young men are having.  This disconnect arises in part due to the lack of education among providers about the presence of these symptoms.  That means we lose a window of opportunity to intervene in that vulnerable moment, Rich lamented.   From the clinical perspective, there is an opportunity to tell people they may have these symptoms after they leave the hospital.  He pointed out that in most emergency departments, if an individual comes in with a violent injury, nine out of ten times they are not admitted to the hospital.   Most of the time, Rich explained, no one talks to you about your safety - "it is not reimbursed, nor is it part of the protocol."

Rich observed that since conducting this research he has an appreciation for the narrative.  In medical schools, doctors are taught to get information and not stories.  The stories take too long.  Yet, for providers, hearing stories are humanizing, and may reveal complexities that they do not learn by simply asking questions.  More important, it lets doctors hear from people whose experience is least like their own.  Rich noted that telling stories, particularly about difficult circumstances, is a way of healing, creating order and containing emotions for those telling the stories.

 Childhood Adversity, the Most Important Predictor of Chronic Disease?

Rich turned his discussion to the Adverse Childhood Study (ACE) funded by the CDC.  ACE is the largest study of its kind and has almost 18,000 participants.  The study examines the health and social aspects of adverse childhood experiences over the lifespan.  The majority of the participants are middle class white Americans over the age of 50 (77 percent white and 72 percent attended college).   The study defined abuse as physical and psychological abuse by parents, sexual abuse by anyone, and emotional and physical neglect.  It also looked at household conditions which included:  substance abuse, mental illness, parental separation and divorce, mother treated violently, and imprisoned household member.  Witnessing violence in the street was not included in the survey, Rich pointed out.

One-third of this middle-class population had none of these, 25 percent had two or more, and 16 percent had a score of four or more.  Most provocative, he explained, was that there was a strong dose-response relationship between the number of childhood adversities and diseases and conditions:  smoking, COPD, heart disease, diabetes, obesity, hepatitis, and alcoholism.   There is also a strong direct relationship with substance abuse, attempted suicide, victimization, teen pregnancy, fractures, promiscuity, sexually-transmitted diseases, poor job performance, poor self-rated health, and poor relationships.   "That makes childhood adversity the most important predictor of chronic disease that we know," Rich asserted.  Prolonged stress becomes "toxic" triggers for emotional, behavioral, and physiological responses.  He pointed out that the mechanisms are still under study.   "Stress is greater for those at the lower end of the social ladder," he added.

Returning to his discussion of young men, Rich noted that trauma and exposure to violence and PTSD lead to psychological altercations including poor coping and anxiety, hostility, biological altercations, including dysfunction of fight or flight mechanisms, depressed immune function and potential changes in brain development in the hippocampus, which is responsible for learning and memory.  Health risk behaviors such as violence, retaliation, smoking and substance abuse interacting with each other are the cause of morbidity and mortality.   He emphasized that personal, social and cultural factors influence this relationship.  "There is a broader context in which we ought to discuss childhood adversity and violence," Rich concluded.