The overall goal, as you point out is to deliver the right medication to the right patient at the right time and not to over treat people because we know that overtreatment can sometimes actually have serious side effects. Recently, for example within the i supported research it was reported that giving people with Colorectal Cancer less treatment they actually did better than people with more treatment, an important part of the Precision Medicine initiative which, thanks to your committee and congress has been strongly supported, we have been conducting research that is trying to understand better how the molecular abnormalities with Breast Cancer and other cancers can have implications for what treatments should different patients be obtaining as we try to refine those opportunities and interventions. Doctor gibbons, there is new research that would suggest having the stroke more than doubles the risk of dementia. Could you talk about that a little bit and in that area you might further define as people get older a stroke may not even be a apparent but what is the cumulative impact, my question, stroke as it relates to dementia . An important question you bring out in which we now appreciate that there are many forms and pathways that promote dementia. You are very familiar with alzheimers but theres also another category called vascular dementia that could affect one in 5 individuals affected by the debilitating condition. It can be insidious as you imply, in which it may be cumulative effect of vascular disease overtime that leads to cognitive decline promoted by risk factors such as high Blood Pressure and other risk factors for not only Heart Disease but compromise brain health. This is an area of investigation. It is one area where women appear to be particularly predisposed in terms of the cause of dementia as well as africanamericans, relating to an earlier question by senator cochran as to why in the jackson heart study we are particularly interested in the study of africanamericans, the causes of dementia vascular and alzheimers might give insights in that regard and in collaboration with our colleagues at National Institute of aging and stroke are engaged in the sprint trial, looking at lowering Blood Pressure in terms of preserving cognitive function so this is an active area of research. I would think that is another verification of my view and the committees view that while prescribing funding in some areas is helpful to get these funds increased and make the case, as in alzheimers we have gone from 400 million to 1. 3 billion in two years, but one, you are better at knowing where the pathways are than we are and 2, there is more than even chance that you will find something somewhere differently than you were looking for and theres lots of research that suggests that is the case. Perhaps this is for doctor honus, we have had a number of topics of dementia and alzheimers. What is the current state, one of the things i think, i have told chairman blunt this and we are in agreement that one of the opportunities the subcommittee has is to highlight to americans ways in which they can change their lifestyle, dietary intake, what is the status of the research regarding alzheimers and dementia that we would want every american to know in regard to their activities, behavior and nutrition and diet . That is a very important question. All of us want to make sure we are doing all we can to decrease the risk of dementia, it is an important enough question that nih commissioned a study on the level of evidence for the kinds of interventions which might have the desired effect in reducing risk. It was released today and some of your staff may have been briefed as recently as yesterday about it. The keywords were that there were a great deal of encouraging but in most cases inconclusive evidence for what we can do. I can identify three critical areas, the implication for what we know now, what we need to do, what is control of hypertension. There is very Strong Association between hypertension and its control and the risk of alzheimers disease and dementia. One study, sprint was designed to look at the impact of aggressive control of Blood Pressure on multiple outcomes and this is a case where the institute is working together, using alzheimers funding have supplemented that study to look at it impact on dementia. Those studies are ongoing. It is an area of great promise for Clinical Trials may give conclusive evidence but we have to take out the evidence of controlling Blood Pressure and decreasing stroke is so critical that it must be part of our Public Health imperative as we communicate. Another area is physical activity and exercise, shown to decrease the risk of death, cardiovascular disease and where again there is suggestive evidence it may play a role in decreasing risk of dementia. Number of studies including some going on at university of kansas which we discussed last year that are looking directly at randomized Clinical Trials to see what forms of physical activity may make a difference in lowering the risk of cognitive decline and dementia. The other area is cognitive training and one study supported by nih some year ago caused cognitive training was able to induce sustained improvements in cognitive function as individuals age. That study needs to be extended further to see if it will have an impact on dementia. What is the example of cognitive training . There was a specific studies called active that looked at older americans, men and women who have normal cognitive function and trained them in speed, reasoning or memory and studied them over years to see the impact of that training and it was an extremely positive outcome. Those individuals were trained in those areas did have improved function in 5 to 10 years in that domain. The National Academy report stresses that there is not yet compelling evidence for the other activities including computerdriven games that identify whether they provide similar outcomes. Good number of studies, where thanks to the increased funding in all dimers research we were able to look what might play a longterm role in decreasing decline and dementia. In response to the suggestion that nih should receive more credit for its work, certainly want that to occur. One way americans could relate to nih is hearing the things that if you do, chances of your Health Improving or being maintained, theres a consequence to this behavior. It is a way that you can tie nih to Everyday Americans and their lives, their worry about themselves and their families. Let me tie another topic that i care about, down syndrome. We have had conversations in which down syndrome and alzheimers, perhaps there is a connection. What is the status of our research and down syndrome . I will keep looking to my right. What is the status of that research and what do we know about the relationship between down syndrome and alzheimers . It is an important area of research that begins on a genetic basis, down syndrome associated with an extra copy of one chromosome, chromosome 21 which is the chromosome on which the amyloid protein and peptide lie, reflecting off of that, we have seen an increase in Life Expectancy, remarkable accomplishment over 30 years, average Life Expectancy not 30 but 50, and 60, individuals at an early age in high proportion i developing alzheimers like dementia in terms of symptoms and brain function. Because this population is a special high risk deserving of attention and because studying this population is likely to inform what we know about Alzheimers Research we have in collaboration with the child health institute, using some of the funding provided over the last fiscal year and initiated longitudinal studies in individuals over a range of age with down syndrome to study what is happening in the brain through imaging, bio markers to better understand the basis for ultimately intervening in these people, highly vulnerable population in learning more about the more general problems surrounding alzheimers type dementia. Thank you all for being so capable of speaking a language in terms that are reasonably understandable to me. Senator alexander. Let me thank you for what you do for our country, we are all excited about the future of the National Institutes of hope as doctor collins calls it, we are delighted the president has asked doctor collins to lead that, we look forward to your implementation of the 21st century cures act which we worked on, voted for and in effect past, what could we make it easier for you to succeed and i want to salute senator blunt, senator murray, senator cochran, senator durbin, senator more and for their bipartisan support, increasing Biomedical Research. Very little has happened in terms of technological change in our country since world war zero max it hasnt had some Government Research as part of it. We are leading the world in Biomedical Research and want to what accelerated, not slow down. Doctor collins, am i correct that a goal of the trump administration, to keep more american jobs in the United States . That is my understanding. We have 50 Major Research universities, 17 national laboratories, no other country in the world has anything like them. Is it true that around those and we spent a lot of money on them, the office of science supports 5. 3 billion in the laboratories, the energy departments, 28 billion goes through your agency to universities for research. Is a true that around these universities like stanford university, Oklahoma University of kansas, tennessee, missouri, grow complexes of industries attracted by the research and as a result create jobs around the centers of research . Absolutely true. If you look at the geography of where those places have sprung up it is very much attached oftentimes to a university that is a generator of a lot of interesting ideas, a credit mass of visionary scientists. Is a true the china is making extraordinary investment in new Research Even though they have one fourth out goes to mystic product they may exceed us in the amount of funding for research and as a result, a number of chinese scholars at graduate schools or universities are being attracted back home . That is also true. Recent paper pointed out in 2000 china spent 12 of what the us does on by a medical research. By 2015 it was 75 . Not talking about gdp, on track to surpass us in the next three or four years. One of the more harebrained recommendations that came to us is we lower the amount of indirect cost allowable for research grants, and average of 28 to 10 . This came up when i was education secretary, a huge uproar. Most universities and colleges said to us at the time we spend a lot more on research and the net effect of taking that would be Less Research. To cluster around the research wherever it is in the world. And losing 10 million when the new policy went into effect, kansas, 4 million, tennessee, missouri, kansas might not be. Only way i can think of to make that money up is either higher tuition or Less Research, Less Research is not our goal because Less Research means more jobs overseas. I understand you may be asked, because of your agency to your universities for the kind of research we are trying to increase, not decrease, to report to secretary price, the office of management and budget, what the effect of this would be. I ask you put in your report the following. If there is to be any change, Congress Wants to be involved. I want to get in the middle of that and i bet i can get a Bipartisan Group to make sure we are. Number 2, will us the university especially the state universities how much they would lose in funding, how much they contribute to their own administrative funding for the money you give them and whether there would be more or Less Research as a result of this policy, include that in your report, let us know about that as well. I hope we can nip this idea in the blood, one of those ideas in the president s budget out there to stir up conversation but it is a thoroughly awful idea, bad policy, it would not do what i know the president whats to do which is create more american jobs, not fewer. More research, not less. This policy would be less. My time is up but if you want a constructive way to get more money out of nih, look at the national academies, just to finish up, the national academies, two report said 40 of Research Time is spent on administrative tasks. Most of those come from the office of management and budget too so if they want to reduce those administrative attacks and free up more money for research grants, that would be a good area to work on, we could talk about that at some time in the future. My time is up but i want to register my strong concern about indirect cost policy and ask that you be so pacific and polling universities around the country about how much money would you lose, how much do you put into research your self and would there be more or Less Research as a result of this policy, thank you for your courtesy. Im happy to work with you on that. For senator alexander as well, your extra 60 seconds, that is where i was beginning. I appreciate your hospitality and a chance to see what is going on. We are looking forward to quite a bit of what we saw in research in initial levels and clinicals after the general population and a chance to see that. Everyone would benefit from universal flu vaccines, zika vaccine that is progressing, aids vaccine which is progressing, getting closer and closer, those are remarkable discoveries and a tremendous amount of people, cancer, Mental Health and everything else, we appreciate the Ongoing Research benefiting families all over the country and all over the world. Lets talk about what senator alexander was talking about administrative costs. How grants are done and approved talking to great recipients, i apply at nih and anywhere else i think it is close, to do their research. It is up to the entities to determine we got this one, you shouldnt take this one, they what they have. In the Research Area it is tougher to do blues not from the grant recipients, they are eager to get the grant money from our end, how do you coordinate that to make sure we have good coordination, that doubling up on research and other areas, and 40 of the costs with Research Dollars are paperwork being completed, get to greater discovery. How do we simplify the process on research and reduce the burden of the researcher but make sure we are coordinating from a federal level. Those are two great questions. In terms of the Administrative Burden we are interested in how to achieve at. This 42 never came out of the National Academy, 22 of that may be the part, the grant proposal, making sure there were great science ideas putting them forward and giving us annual progress reports so we know what they are doing, but that leaves a lot and we have some levers we could pool to reduce those things or oversight of conflict of interest. Some of those levers we dont hold and that includes other discussions, and that will ask us for a summary, responsibilities and where those are decided, a good list of those if that would be useful. Others included. The National Academy of published a report on this going through a good deal of that information as well. To increase others. Without duplication, and nip it in the but if it was starting to happen. We have better tools for doing analytics in our portfolio and what is in the portfolio, the National Science foundation and the permit of Defense Medical Research and the permit of energy efforts, and increasing intensity to be able to identify if there are unintended duplications. Sometimes it is good to have efforts going on in different ways. Certainly nsf has a lot of areas we specifically coordinate. The brain initiative, the nih and a few other organizations, we are meeting regularly to make sure that is going the way it is supposed to. We have a pretty good swim lane definition, and usda does agricultural plants and animals, nih does those that are relevant to human health and pretty good taps on those things, and listing their support. You have to look at that and make sure what they put their doesnt sound familiar. We ask carefully if that is the case, we dont have a lot of unintended overlaps, but there may be an opportunity to do a better job. Would love to follow up. The grant recipients and other fundings that is the area i see is a weak spot. There has to be a way to coordinate, and who has what lane. And the Research Done efficiently. Senator shelby. Very sorry. How much money overall in the us, all of the governmental ages. And Biomedical Research, the private sector, whatever it is and isnt enough. The budget you have overseen. Over many decades, in fiscal year 17. The number in front of me, 1 billion i am happy to do that. The private sector outspend government supported by medical research by a factor of two or more than two. And an overall spend in the neighborhood of 100 billion. How much is complementary, do you coordinate some degree, investigators in the private sector, nih and government, a lot of overlap. A personal priority to identify ways that w