AcknowledgementsThis paper is the product of a collaborative effort led by IAM LabExecutive Director Susan Magsamen with writing and researchsupport from Sarah Pitcock. The IAM Lab would like to thank themore than 30 researchers and reviewers that helped to preparethis document and recognize the contributions of Emily Stine,Valerie May, and Lee Scott. Cover art: “Hippocampus II” by artist Greg DunnWho We AreInternational Arts + Mind Lab (IAM Lab) is a multidisciplinaryresearch-to-practice initiative from the Brain Science Institute atJohns Hopkins University accelerating the field ofneuroaesthetics. Our mission is to amplify human potential. What We DoIAM Lab is pioneering impact thinking, an outside-in approach tohealth, well-being and learning. How We Do ItIAM Lab brings together brain scientists and practitioners inarchitecture, music, and the arts to collaborate inmultidisciplinary research, foster dialogue, and spur continuedinnovation by sharing these findings with a broader community.Everything is aesthetic. The environments in which we live and work, the sounds we hear, sights we see,and smells we encounter are the pathways through which we experience the world around us. Andaesthetics is so much more than enjoying beautiful things. The uniquely human response to aestheticsconstantly influences our mental and emotional states. We know more than ever before about the sensorysystems that enable us to process and decode the world around us. Still, we are just on the cusp ofunderstanding the potential of aesthetics to maximize those systems for improved health, wellbeing, andlearning.Today, as the incidence of chronic disease and depression, anxiety, and stress rise, and the gaps in health,wellbeing, and learning outcomes expand, we turn most frequently to the medical profession for traditionaland pharmaceutical solutions. Despite great advances, these approaches still fall short in offeringpreventive, non-invasive, timely, and sustainable solutions. What if we could incorporate other interventionsthat are engaging, empowering, and affordable?There is much promising evidence that a variety of arts approaches work to improve mobility, mental health,speech, memory, pain, and learning, potentially improving outcomes and lowering the cost and burden ofchronic disease and neurological disorders for millions of people. These approaches, including visual arts,dance and movement, music, and expressive writing are timely, responsive, and cost-effective. Moreover,research suggests that other types of aesthetic experiences, including immersive and virtual reality andarchitecture are also associated with improved health, wellbeing, and learning outcomes.To date, neuroscientists, social scientists, and practitioners interested in these topics have largely operatedin isolation, lacking high-quality data sets, standardized measures and implementation protocols, andstatistical power to make any causal claims regarding impact or influence evidence-based practice broadly.With rising acknowledgement of the limitations of this disparate effort, researchers and practitioners arecalling for an approach that brings together studies of the behavioral outcomes of arts experiences withbiological markers to map the neurological bases for various aesthetic experiences. This approach wouldenable researchers and practitioners to document, refine, replicate, and scale successful interventions. For this shift and collaboration to take root, research questions must be defined across diverse disciplines.The growing and interdisciplinary field of neuroaesthetics is a logical home for this work, exploring the roleof the arts, music, architecture, and natural environments as they alter and shape individual brain responses.Beyond a disciplinary base and theoretical frame, this work needs an organizing mechanism that facilitatescollaboration across disciplines and sectors, builds a common research vocabulary and approach, houses acentralized database for researchers and practitioners, and leads field-building and dissemination efforts. As such an interdisciplinary hub, the International Arts + Mind Lab at the Johns Hopkins University School ofMedicine’s Brain Science Institute proposes a research translation approach to fill these gaps and unify afield around impact. We believe that together with our partners, we can use neuroaesthetics to solveintractable problems related to health, wellbeing, and learning for diverse populations. Through muchcollaboration we have developed Impact Thinking: an eight-step consensus framework that appliesrigorous, evidence-based brain science research methods to arts, architecture, and music interventions byengaging a broad and multidisciplinary team. Beginning with a problem identification workshop andcollaborative discovery process and concluding with dissemination and scaling, Impact Thinking isdesigned to build open-source capacity and expertise and a research-to-practice pipeline forneuroaesthetics focused on impact. With this paper, we lay out the rationale and initial building blocks for a long-term approach to improvinghealth, wellbeing, and learning through neuroaesthetics. We recognize that the challenges are many, butare encouraged by the convergence of ideas and degree of consensus found in our outreach andresearch to date.The State of Health,Wellbeing and Learning While globally we continue to make great advances intechnology and research, a variety of social,environmental, and biological factors continue to limitequitable access to health, wellbeing, and learning amongthe populace. As people live longer and diagnoses ofdiseases continue to improve, and as assessments ofwellbeing and academic progress continue to becomemore sensitive, so grows the ranks of people in need ofnew forms of care, prevention, intervention, and support.What follows is a review of key health, wellbeing, andlearning indicators and a discussion of disparate outcomesbased on socioeconomic and demographic factors. HealthThe World Health Organization defines “health” as a stateof complete physical, mental, and social wellbeing.Extending beyond the mere absence of disease or illness,this definition acknowledges the importance of thepatient’s holistic care experience and the social andenvironmental determinants of health.1 Still, most peopleexperience a separation of health and wellbeing inpractice. Diseases are treated by different industries,practitioners and approaches than those that promoteholistic wellbeing. The past decade has seen many transformativeadvancements in health and wellbeing. New “cocktail”treatments for HIV make the patient’s drug protocol moremanageable and effective, and pre-exposure prophylaxisprovides the first-ever protection from the virus. Targetedcancer therapies and immunotherapy are dramaticallyimproving the prognosis for many cancer patients.Additionally, rates of smoking have dropped considerablyafter 25 states banned smoking in all workplaces.Yet for every advance, there are many intractable globalhealth and wellbeing issues. Non-communicablediseases, long the most common cause of death indeveloped nations, are now the leading cause of deathand disability in developing countries2 Such diseasescaused 37 percent of deaths in low-income countries in2015, up from 23 percent in 2000.3 With increasinglyearly onset, treatment of non-communicable diseaseslasts many years, is costly and affects not just patientsbut their caretakers and families, too. Specifically, there is ample evidence that neurologicaldisorders are one of the greatest threats to public healthand account for a significant proportion of the globalburden of disease. In 2010, mental and behavioral disorders comprised 7.4percent of the global burden of disease. Neurologicaldisorders comprised 3 percent, and stroke aloneaccounted for an additional 4.1 percent of the burden.Among mental and behavioral disorders, unipolardepressive disorders, anxiety disorders, and drug andalcohol use disorders account for 76 percent of theburden. Migraine, epilepsy, dementias, and Parkinson'sdisease account for 72 percent of the burden ofneurological disorders.4 Millions of people are living with chronicneurological diseases and disordersGlobally, an estimated 300 million people are affectedby depression.5 In 2015, an estimated 43.4 millionadults in the United States reported a mental illness inthe previous year, representing 17.9% of all adults.6 Worldwide, 47.5 million people have dementia andthere are nearly 10 million new cases every year.7Alzheimer's disease is the most common cause ofdementia and may contribute to 60–70% of cases. TheAlzheimer’s Association (AA) estimates that 5.5 millionpeople in the U.S. have Alzheimer’s disease, and withan aging population, this number is predicted to growsharply as the baby boomer generation reaches oldage. By 2050, the AA estimates that between 11 millionand 16 million Americans will have the disease, with onenew case appearing every 33 seconds. More than 10 million people worldwide are living withParkinson’s disease. As many as one million Americanslive with Parkinson’s disease, and approximately 60,000Americans are diagnosed with Parkinson’s disease eachyear.8 According to the Centers for Disease Control andPrevention (CDC), about 1 in 68 children in the U.S. hasbeen diagnosed with an autism spectrum disorder. Boysare about 4.5 times more likely to have the disorderthan girls. Studies from other parts of the world haveconfirmed similar prevalence.9 Developmentaldisorders usually have a childhood onset but tend topersist into adulthood, causing impairment or delay infunctions related to the central nervous systemmaturation. The economic and social costs of braindisorders are large and growingThe economic costs of brain and mental healthdisorders are large and growing, in line with the scopeand duration of affliction. “These include not only thecost of treatment, but also the lost productivity ofpatients and their caregivers, for whom looking afterchronically disabled family members can represent anenormous source of emotional, practical, and financialburden.”10 “The total economic burden of mental depressivedisorder is now estimated to be $210.5 billion per year,representing a 21.5 percent increase from $173.2billion per year in 2005. Of particular interest is thatnearly half of these costs are attributed to theworkplace, including absenteeism (missed days fromwork) and presenteeism (reduced productivity while atwork), whereas 45-47 percent are due to direct medicalcosts (e.g., outpatient and inpatient medical services,pharmacy costs), which are shared by employers,employees, and society. About 5 percent of the totalexpenditures are related to suicide.”11 The global costs of dementia have grown from anestimated $604 billion in 2010 to $818 billion in 2015,an increase of 35.4 percent. Direct medical care costsaccount for roughly 20 percent of global dementiacosts, while direct social sector costs and informal carecosts each account for roughly 40 percent.12 In the U.S. alone, costs of care for people living withAlzheimer’s was estimated at $226 billion in 2015, withMedicare and Medicaid paying 68 percent of the costs.Without a new treatment, costs are projected toincrease to more than $1.1 trillion in 2050.13 Treating the chronic pain associated with chronicdisease and illness also comes at a tremendouseconomic cost. Estimates of the total incremental costof health care due to pain range from $261 to $300billion. When combined with lost productivity frommissed work, lost work, and lower wages, the estimateof total financial cost of pain to society ranges from$560 to $635 billion (in 2010 dollars).14 Pharmaceuticals are only part of the solution NIH will spend more than $17 billion on clinical researchand clinical trials in 2017.15 Pharmaceuticals play acritical role in preventing, managing, reversing, andcuring diseases, but with prohibitive costs and adverseside effects, they alone will not address the epidemic ofchronic neurological diseases. Many people with chronic diseases are prescribedmultiple drugs, leading to confusion, adverse sideeffects, and financial concerns. Nearly 1 in 10 Americansreport not taking drugs as prescribed because theycan’t afford them,16 and 1 in 4 report having difficultypaying for prescriptions. Estimates of the proportion ofpeople who can’t afford their drugs range from 1 in 10to 1 in 4.17 Additionally, drugs don’t always work. In 2016, after adecade of trials, Eli Lilly announced that solanezumab,its experimental drug for Alzheimer’s, failed toimprove cognition in a large clinical trial.18 Lilly’s drugis not alone. Many other drugs designed to preventthe formation of the amyloid plaques that are seen inthe brains of patients with the disease failed in trials.Solanezumab, like most drugs seeking FDA approval,was in development for a decade, potentially leavingthe millions of people suffering with Alzheimer’s towait 10-15 years for their next best hope for atreatment or cure. WellbeingWhile pharmaceuticals may help patients manage theirsymptoms, they alone do not provide the “completephysical, mental and social well-being” described bythe WHO in its definition of health. Moreover, they donot often offer a strategy for prevention. Accordingly, inaddition to health care system interventions andepidemiology and surveillance, the CDC also calls forenvironmental approaches and community programslinked to clinical services as a four-part strategy forpreventing or lessening chronic disease.19 Expanding on environmental and community programs,according to the National Conference of StateLegislatures, “wellness policy options also includepromoting health and wellness programs in schools,worksites, and communities, enabling healthy choicesand environments, ensuring access to a full range ofquality health services for people with chronicconditions, eliminating racial, ethnic, and socio-economic health disparities, and efforts to educate thepublic about their health and how to prevent chronicdisease.”20 This vision of holistic health and wellbeing isaspirational, but not unattainable. Wellness is as muchabout prevention as it is about intervention. Many morepeople today are accessing wellness programmingthrough their employers and accessing complementaryor integrated medicine. Still, living with a chronicdisease or caring for someone with a chronic diseaseputs a strain on many facets of quality of life. Being sickor caring for a sick family member while working full-time or struggling to make ends meet adds anadditional layer of stress. Even without a diagnosedillness, a number of studies, discussed in the followingsection, demonstrate that living in or near povertyThe State of Health, Wellbeing and Learning 5comes with its own set of health and wellbeingchallenges and disparities. In short, we have a lot ofwork to do to realize this vision of holistic wellbeing forpeople of all ages across the income spectrum. Stress is a barrier to wellbeing and prevention The American Psychological Association’s (APA) annualStress in America survey shows trends in stress overtime. In 2016, stress factors included work, money, theeconomy, health concerns and family responsibilities.More Americans reported experiencing “extremestress” at 24 percent in 2016 compared to 18 percent in2014. Seventy percent of adults reported theyexperienced discrimination, such as unfair treatment bypolice, being unfairly fired or denied a promotion, orreceiving poor treatment from health care providers.21 Work-related stress is the leading workplace healthproblem and a major occupational health risk, rankingabove physical inactivity and obesity.22 Two-thirds ofboth men and women say work has a significant impacton their stress level, and one in four has called in sick ortaken a "mental health day" as a result of work stress.23Sixty-eight percent of workers say that their employershould offer a program that helps build resilience tostress.24 According to the U.S. Bureau of LaborStatistics, workers who must take time off work becauseof stress, anxiety, or a related disorder will be off the jobfor about 21 days. While workplace wellness programs are becoming moreand more common as a way to reduce absenteeism,presenteeism, and employer-sponsored healthcarecosts, these opportunities are often limited to those inaverage- and high-paying jobs.25 Access to a healthy lifestyle is inequitableSince its inception in 2007, money has been the topreported stressor in the APA’s Stress in America survey.In 2015, almost one-third of respondents said that lackof money prevented them from living a healthy lifestyle.Young people, particularly those in inner cities, are alsoliving with increasing stress. The America’s PromiseAlliance conducted a survey of youth in five urban citiesto assess barriers to wellbeing. In all five cities,respondents described employment concerns, racerelations, violence, lack of community resources, andother environmental challenges as meaningful barriersto their wellbeing. Young people reported feelingunsafe in their communities, citing stereotyping andracial bias as reasons they feel unsafe and unwelcome.26 A growing body of research shows that the stressesassociated with living in poverty affect brain function. Anew study assessed the long-term impact of suchenvironmental stress. Researchers found that “testsubjects who had lower family incomes at age nineexhibited, as adults, greater activity in the amygdala, anarea in the brain known for its role in fear and othernegative emotions. These individuals showed lessactivity in areas of the prefrontal cortex, an area in thebrain thought to regulate negative emotion.”27 These findings translate into the classroom. LearningThere is a growing gap between the academicperformance of higher and lower income students.The National Assessment of Educational Progress(NAEP), known as the nation’s report card, is a nationallyrepresentative standardized test given every year tofourth, eighth, and twelfth graders in subjects includingreading, mathematics, science, writing, the arts, civics,economics, geography, and U.S. history. Across the NAEP sample from 2015, 40 percent offourth-grade and 33 percent of eighth-grade studentsperform at or above the proficient level in mathematics.In the aggregate, these levels of proficiency are notimpressive for the richest nation in the world. However,disaggregating the data by income tells an even morenuanced story: 58 percent of fourth graders who do notqualify for the national school lunch program are at orabove proficient, compared to 24 percent of studentswho do quality for the national school lunch program, aproxy for low-income households, who meet theproficiency benchmark. For eighth graders, thosefiures are 48 and 18 percent proficient for higherincome and lower income students, respectively.Results for reading are similar, though with an overalllower proficiency rate in the subject when compared tomathematics.28 The 2016 NAEP music assessment, administered in theeighth grade, also shows differences by income level,with a 26-point gap (out of 300 points) in average scorebetween lower and higher income students. Resultsalso show statistically significant gaps between maleand female students, city and suburban schools, andpublic and private schools, with the former at a deficit ineach case. The same significant gaps were present inthe results of the visual arts assessment as well. Theassessment showed that 63% of 8th graders took amusic class and 42% took a visual arts class, slightlydown from 2008.29 Whereas income achievement gaps have grown, racialachievement gaps have narrowed in core academicsubjects and arts assessments in recent years.30Nationally, high school graduation rates are up for allstudents, including those with disabilities.31 Still foryouth with an autism spectrum disorder (ASD),postsecondary employment and education outcomesare low. A recent study published in Pediatrics foundthat of high school graduates with an ASD, 35 percenthad attended college and 55 percent had held paidemployment during the first 6 years after high school.More than 50 percent of youth had no participation inemployment or education two years after completinghigh school. Those from lower-income families andthose with greater functional impairments were atincreased risk for poor outcomes.32 The State of Health, Wellbeing and Learning 7Next >