>> GOOD AFTERNOON, EVERYONE. I WANTED TO THANK YOU ALL FOR COMING OUT THIS RAINY AFTERNOON TO THE OFFICE OF DISEASE PREVENTION, MEDICINE, MIND THE GAP LECTURE GIVEN BY THOMAS LAVEIST. THE MINE THE GAP LECTURE SERIES EXPLORES A WIDE RANGE OF ISSUES AT THE INTERSECTION OF RESEARCH, EVIDENCE AND CLINICAL PRACTICE, ESPECIALLY AREAS IN WHICH CONVENTIONAL WISDOM MAY LEAD US ASTRAY. TODAY AS PART OF THE LECTURE SERIES, DR. LAVEIST WILL DISCUSS THE STATE OF EFFORTS TO EXPLAIN RACE DISPARITIES IN HEALTH AND WHY BIOLOGIC AND GENETIC APPROACHES HEALTHCARE ACCESS AND SOCIOECONOMIC STATUS HAVE ALL FAILED TO EXPLAIN RACE DISPARITIES IN HEALTH. THE RESULTS FROM A STUDY BEING CONDUCTED AT THE HOPKINS CENTER FOR HEALTH DISPARITIES SOLUTIONS DIRECTED BY DR. LAVEIST SHOWS SOCIAL FACTORS SEEM TO BE THE PRIMARY REASON FOR HEALTH DISPARITIES. DR. THOMAS LAVEIST IS PROFESSOR, AUTHOR AND PUBLIC SPEAKER. HE IS DIRECTOR OF THE HOPKINS CENTER FOR HEALTH DISPARITIES SOLUTION AND WILLIAM C. AND NANCY F. RICHARDSON PROFESSOR IN HEALTH POLICY AT THE JOHNS HOPKINS BLOOMBERG SCHOOL OF PUBLIC HEALTH. DR. LAVEIST HAS BEEN FEATURED IN NEWS WEEK, NEWS DAY, BLACK ENTERPRISE AND THE BALTIMORE SUN. HE HAS ALSO BEEN SEEN ON CNN, NATIONAL PUBLIC RADIO, AND OTHER NATIONAL MEDIA OUTLETS. ON BEHALF OF THE OFFICE OF DISEASE PREVENTION, THE OFFICE OF BEHAVIORAL AND SOCIAL SCIENCE RESEARCH, AND THE HEALTH DISPARITIES INTEREST GROUP OF THE NATIONAL CANCER INSTITUTE, PLEASE JOIN ME IN WELCOMING DR. THOMAS LAVEIST. [APPLAUSE] >> WELL, THANK YOU. IN 2006 THERE WERE OVER 286,000 DEATHS TO AFRICAN AMERICANS NATIONWIDE. THERE WERE 44,000 ASIAN DEATHS NATIONWIDE. THE AFRICAN AMERICAN CRUDE DEATH RATE WAS 1330, PER 100,000, THE ASIAN POPULATION 44014. WHAT IF AFRICAN AMERICANS HAD THE DEATH RATE THAT ASIANS HAVE? THAT IS, THE DEATH RATE OF THE GROUP WITH THE LOWEST DEATH RATE IN THE UNITED STATES. IT WOULD HAVE BEEN 115,000 AFRICAN AMERICAN DEATHS THAT YEAR, 170,000 FEWER DEATHS, 59% OF ALL DEATHS THAT YEAR COULD BE CONSIDERED EXCESS MORTALITY IF AFRICAN AMERICANS AND ASIANS HAD THE SAME DEATH RATE. THAT'S 14,000 DEATHS PER MONTH, 3200 DEATHS PER WEEK. 468 DEATHS PER DAY. 20 DEATHS PER HOUR, ONE DEATH EVERY THREE MINUTES. AND THE TIME IT TOOK ME TO DO THAT, THERE WAS AT LEAST ONE EXCESS DEATH IN THE UNITED STATES TO AN AFRICAN AMERICAN. THIS IS THE ESSENCE OF WHAT HEALTH DISPARITIES ARE ABOUT. BY RACE AND ETHNICITY. DEATHS THAT OCCUR AT HIGHER RATE, YOUNGER AGES, BASED ON CHARACTERISTICS OF INDIVIDUALS THAT SHOULD NOT NECESSARILY DETERMINE HOW LONG AN INDIVIDUAL LIVES. THIS IS THE CORE OF WHAT THIS IS ABOUT. WE APPROACH IT FOR THE MOST PART FROM THE STANDPOINT OF SOCIAL JUSTICE. IN FACT, IT IS WRONG AND INCONSISTENT WITH THE VALUES OF OUR SOCIETY TO HAVE DIFFERENTIAL QUALITY OF LIFE, RATES OF MORBIDITY AND MORTALITY BASED ON RACE OR ETHNICITY. BUT THERE'S ALSO A UTILITARIAN ARGUMENT. THAT THERE IS A COST TO THE ECONOMY, A COST TO OUR SOCIETY, THAT GOES BEYOND SOCIAL JUSTICE AND THAT COST CAN BE CALCULATED, WE HAVE DONE THIS IN A REPORT RELEASED IN 2009 WHERE WE CALCULATED AN ESTIMATED BURDEN TO OUR ECONOMY OF HAVING PEOPLE BE SICKER THAN THEY SHOULD BE IN TERMS OF DIRECT MEDICAL CARE COSTS, COST IN TERMS OF LOST PRODUCTIVITY AND ALSO COSTS ASSOCIATED WITH PREMATURE DEATH. MUCH OF WHAT I JUST SAID I THINK IS NOT NEW TO MOST OF YOU HERE. WE KNOW THAT WE HAVE SUBSTANTIALe DIFFERENCES IN HEALTH OUTCOMES BASED ON RACE AND ETHNICITY. BUT I WANT TO ASK YOU THIS QUESTION. CAN YOU IMAGINE OUR SOCIETY WITHOUT RACIAL AN ETHNIC DISPARITY? THINK ABOUT THAT A MOMENT. I HAVE ASKED THIS QUESTION TO MANY AUDIENCES. WHEN I ASK YOU TO DO THAT IDEAS POP INTO YOUR HEADS, AS IT WOULD IN ANY AUDIENCE. YOU'RE A UNIQUE AUDIENCE BUT YOU'RE ALL UNIQUE IN YOUR OWN -- IN THE SAME WAY. WE'RE ALL UNIQUE. BUT WHEN I ASK PEOPLE THIS QUESTION, SEVERAL IDEAS POP INTO PEOPLE'S HEADS. THERE'S THE -- THEY'RE THE THOUGHTS THAT THE RACIAL DISPARITIES ARE REALLY ABOUT GENETICS, BIOLOGICAL DIFFERENCES BETWEEN RACIAL ETHNIC GROUPS. DISPARITIES ARE ABOUT SOCIOECONOMIC STATUS. IT'S NOT REALLY RACE, IT'S SES. MORE POVERTY AMONG RACIAL ETHNIC MINORITY GROUPS. IF THAT WAS TRUE WHY IS THAT ACCEPTABLE? THINK HOW IN OUR SOCIETY SES IS A PREDICTOR OF HEALTH. OR THERE'S NOT REALLY A MATTER OF RACE, IT'S ACCESS TO HEALTHCARE. THIS IS REALLY THE HEALTHCARE ISSUE. SO I WANT TO TALK ABOUT EACH OF THESE POSSIBLE EXPLANATIONS, I WANT TO TALK A BIT ABOUT WHERE I THINK THE RESEARCH IS AND SHOULD BE GOING IN THIS AREA. AND SEE WHAT YOU THINK. I CAN IMAGINE A SORT WITHOUT HEALTH DISPARITIES BECAUSE THERE WAS A TIME WHEN I DIDN'T KNOW THEY EXISTED. THIS WAS MANY YEARS AGO NOW SADLY, MANY, MANY YEARS AGO WHEN I WAS WORKING ON MY DISSERSATION, I WAS WORKING ON A DISSERTATION IN SOCIOLOGY OF ALL THING, POLITICAL SOCIOLOGY, UNAWARE THERE WERE DIFFERENCES IN HEALTH. AS I WROTE MY DISSERTATION, I WAS LOOKING FOR WAYS OF MEASURING QUALITY OF LIFE OF COMMUNITIES WHICH IS THE OUTCOME THAT I WAS INTERESTED IN. IF ANY OF YOU HAVE WRITTEN A DISSERTATION YOU'LL KNOW WHAT I MEAN WHEN I TALK ABOUT THE ISOLATION, BORE DOME AND TEDIUM OF RUNNING A -- BOREDOM AND TEDIUM OF RINNING A DISSERTATION. I WAS PROCRASTINATING FRANKLY, SO I WENT OUT ONE DAY AND TOOK A WALK IN DOWNTOWN ANN ARBOR, MICHIGAN. IF YOU HAVE BEEN TO ANN ARBOR, MICHIGAN, IT'S A SHORT WALK. WALKING AROUND DOWNTOWN IN ANN ARBOR AN FIND MYSELF IN A USED BOOKSTORE. SO I'M LOOKING FOR A BOOK TO READ. ANY BOOK THAT DID NOT HAVE A BIGLY OGOGRAPHY IN IT. I FIND MYSELF IN THE CLEARANCE SECTION. SO I'M IN THE CLEARANCE SECTION OF A USED BOOKSTORE SO TELLS YOU SOMETHING ABOUT MY ECONOMIC STATUS. THAT'S WHAT I COULD AFFORD. SO ON THE 50-CENT RAC I FIND THIS BOOK. A NIGHT TO REMEMBER. THIS IS A BOOK ABOUT THE TITANIC. AND TO SHOW YOU JUST HOW MUCH I WANTED SOMETHING TO BE THAT WAS -- TO READ THAT WASN'T ACADEMIC I THUMB THROUGH THIS BOOK. I KNOW HOW THE STORY ENDS T SHIP GOES DOWN, SO THERE'S NO SURPRISES HERE, BUT EVEN THAT IS PREFERABLE TO READING ANOTHER JOURNAL ARTICLE AT THAT POINT. I THOUGHT THUMBING THROUGH THIS BOOK, I COME ACROSS THIS PAGE WHICH LED ME TO KNOW JUST HOW FAR GONE I WAS TOWARDS JUST BEING AN ACADEMIC, I COULDN'T HELP MYSELF, JUST WHAT I WAS. I COME ACROSS THE PAGE THAT IS TALKING ABOUT WHO SURVIVED THE TITANIC. I SAID THAT'S NEW. I THOUGHT THE SHIP WENT DOWN, EVERYBODY DIED. THAT WASN'T THE END OF THE FT STORY. I HAD NO IDEA PEOPLE SURVIVED. THIS IS BEFORE THE MOVIE CAME OUT. YEARS BEFORE THE MOVIE CAME OUT. SO I'M READING THIS DATA ON WHO SURVIVED. AND I WAS SO FAR GONE THAT I HAD TO CALCULATE THE DEATH RATES. I KNOW. I KNOW. BUT I WAS FASCINATED BY WHAT I FOUND. WHAT I FOUND IS THAT THE CLASS OF TICKET ON THAT SHIP THAT NIGHT DETERMINED YOUR SURVIVAL. IF YOU WERE A FIRST CLASS TICKETED WOMAN, 97% SURVIVED. 3 OF THE 4 WOMEN THAT DIED GAVE UP THEIR SEATS VOLUNTARILY. IF YOU WERE SECOND CLASS TICKETED WOMEN 84% SURVIVED. AND THIRD CLASS, ABOUT 55% SURVIVED. SO EVEN IN THIS UNUSUAL CASE WITHIN AN ENTIRE SHIP WENT DOWN, SOCIAL CLASS DETERMINED YOUR SURVIVAL. BY THE WAY, IF YOU WERE A MALE, THAT WAS AN EVEN MORE POWERFUL PREDICTOR OF SURVIVAL. IF YOU WERE A MALE YOU HAD ALMOST NO SHOT OF MAKING IT. SO WHO YOU ARE MATTERED EVEN IN THE MOST UNUSUAL OF CIRCUMSTANCES. BUT THE MAGNITUDE OF THE DISPARITY IS AND WHY IT HAPPENED. HOW IT PLAYS OUT. YOU SEE, THERE WERE ONLY 53%, ONLY ENOUGH LIFE OR SPACE TO ACCOMMODATE 53% OF THE PEOPLE ON BOARD THAT NIGHT. SO ON THE EVENING OF APRIL 15th, 1911 AT 11:40 P.M. IN THE NORTH ATLANTIC SPACE ON THE LIFE RAFT WAS A SCARCE RESOURCE. AND WHEN IT COMES TO DIVVYING UP SCARCE RESOURCES, WHO YOU ARE DETERMINES WHO GETS WHAT. SEEMS TO ME THE TITANIC IS A APT ANALOGY FOR THE U.S. HEALTHCARE SYSTEM. BIG EXPENSIVE UNEQUAL QUALITY OF CARE DESTINED TO HIT AN ICEBERG AND SINK. THAT WAS 1911, 100 YEARS AGO, THIS COULD NEVER HAPPEN TODAY. WELL, THIS IS THE US AIR AIRLINER THAT LANDED ON THE HUDSON RIVER BACK IN 19 -- 2009. I DID NOT PHOTO SHOP THIS EXCEPT TO PUT IN FIRST CLASS AND COACH CLASS. WHEN YOU ASK PAY FOR THE FIRST CLASS TICKET, I WANT YOU TO THINK ABOUT THIS. A SET OF POLICY WAS MADE. THERE WAS A DECISION MADE SOMEWHERE THAT WE WOULDN'T REQUIRE SPACE TO ACCOMMODATE EVERYONE ON THE AIRLINER. THERE WAS A POLICY DECISION MADE BY THE MANUFACTURER OF THE AIRLINER NOT TO VOLUNTARILY PUT ENOUGH LIFE RAFT SPACE ON THE AIRLINER. THERE WAS A SET OF POLICY DECISIONS, CORPORATE POLICY AS WELL AS GOVERNMENTAL POLICY WHICH LEADS TO THIS. THAT'S ANOTHER CONVERSATION FOR ANOTHER TIME. BUT JUST SO YOU KNOW, SCARE RESOURCES ARE DIVIDED UP IN PART BASED ON WHO GETS ACCESS, WHO HAS THE POWER, WHO HAS THE ABILITY TO GARNER THOSE RESOURCES. SO HEALTH DISPARITIES CAME ON THE NATIONAL SCENE IN A BIG WAY IN 2002 AT THE PUBLICATION OF UNEQUAL TREATMENT. A REPORT BY THE INSTITUTE OF MEDICINE, WHICH COMPILE THE EVIDENCE THAT THERE WERE DIFFERENCES IN QUALITY OF CARE RECEIVED AMONG PEOPLE THAT HAD HEALTH INSURANCE. I WANT TO STRESS THAT. THE BOOK IS NOT A BOOK ABOUT HEALTH DISPARITIES, IT'S A BOOK ABOUT DISPARITIES AND QUALITY OF CARE RECEIVED BY PEOPLE THAT HAD HEALTH INSURANCE, SHOWED UP IN THE HEALTHCARE SYSTEM, GOT SEEN, BUT DIDN'T HAVE THE SAME QUALITY HEALTHCARE. IT'S DONE A GOOD JOB, THIS REPORT OF PLACING THE ISSUE ON THE FRONT BURNER OF THE NATION'S HEALTH POLICIES. IT'S STAYED THERE FRANKLY MUCH LONGER THAN I THOUGHT IT WOULD. THIS IS A QUOTE FROM A POLICY MAKER WHO STATED KEY TEST FOR ANY NEW SYSTEM IS ABILITY TO PROVIDE ACCESS TO QUALITY CARE FOR THE POOREST AND SICKEST AMONG US AND ELIMINATION OF HEALTH DISPARITIES MUST BE A CRITICAL GOAL. NO AMERICAN CAN BE LEFT BEHIND. THIS WAS A QUOTE FROM FORMER SPEAKER OF THE HOUSE NEWT GINGRICH WHO HAS BECOME KNOWLEDGEABLE ABOUT HEALTHCARE ISSUES AND DISPARITIES SPECIFICALLY. ANOTHER LEADING POLICY MAKER MAKES THIS STATEMENT. AFRICAN AMERICAN MALES DIE SOONER THAN OTHER MALES BY MEANS THE SYSTEM IS INHERENTLY UNFAIR TO A CERTAIN GROUP OF PEOPLE, THAT NEEDS TO BE FIXED. ANYBODY KNOW WHOA THAT IS? -- KNOW WHO THAT? ANYBODY? PRESIDENT OBAMA. NO. THIS WAS FORMER PRESIDENT GEORGE BUSH WHO MADE THIS STATEMENT IN 2005, NOT IN THE CONTEXT OF ANNOUNCING A NEW PROGRAM TO FIX THE PROBLEM, HE WAS IN FACT MAKING THE ARGUE THAT SOCIAL -- BECAUSE OF THE HIGHER DEATH RATE AMONG AFRICAN AMERICANS THAT AFRICAN AMERICANS SHOULD SUPPORT HIS EFFORT TO PRIVATIZE SOCIAL SECURITY BECAUSE THEIR BENEFITS WOULD BE INHERITABLE TO THEIR FAMILIES. SO POLITICAL CONSIDERATIONS ASIDE, THERE CLEARLY IS AWARENESS AT THE HIGHEST LEVELS OF GOVERNMENT THAT WE HAVE GOT A PROBLEM WITH HEALTH DISPARITIES IN THIS NATION. WE'RE PAST THE AWARENESS PHASE, I THINK. AT THE CORE IS THIS SLIDE. THIS IS A SLIDE SHOWING AGE-ADJUSTED MORTALITY BY RACE AND GENDER. IN 2003. I USED TO UPDATE THIS SLY EVERY YEAR BUT I STOPPED IN 2003 BECAUSE IT BECAME POINTLESS BECAUSE IT'S THE SAME SLIDE EVERY YEAR. IT'S THE SAME PATTERN. THE RATE HAS BEEN SLOWLY DECLINING FOR EVERYONE BUT THE DIFFERENTIAL IS EXACTLY THE SAME. SO THIS IS THE CORE OF WHAT WE'RE TALKING ABOUT. THIS DIFFERENTIAL. HEALTHCARE DISPARITIES I THINK ARE NICELY ILLUSTRATED BY THIS CHART. THIS IS A REPORT DONE ON DATA FROM THE MEDICARE PROGRAM AND I WOULD JUST BRING YOUR ATTENTION TO THE MUTATIONS, ONE OF THE GREAT BEST ILLUSTRATIONSCH THESE ARE PROCEDURES THAT YOU DO NOT WANT. THESE ARE PROCEDURES THAT OCCUR BECAUSE OF LONG-TERM INADEQUATE ACCESS UTILIZATION AN QUALITY OF CARE RECEIVED BY PATIENTS. AS YOU CAN SEE IN EACH CASE WE HAVE SUBSTANTIALLY HIGHER RATES OF UTILIZATION AMONG AFRICAN AMERICANS, FOR EXAMPLE AMPUTATIONS AMONG DIABETICS, IT SHOULDN'T HAPPEN, IT ONLY HAPPENS BECAUSE OF LONG TERM MISMANAGEMENT OR POOR MANAGEMENT OF DIABETES SYMPTOMS. AND EACH OF THESE WOULD BE IN THAT CATEGORY. THIS IS A STUDY BY SOME GUY NAMED LAVEIST WHERE WE WENT INTO THREE HOSPITALS IN BALTIMORE, I GUESS I OWE TO MY EMPLOYER THAT JOHNS HOPKINS WAS NOT A HOSPITAL IN THIS STUDY BUT THIS WAS A STUDY WHERE WE PULLED RECORDS FOR FIVE YEARS, ALL PATIENTS AT THESE HOSPITALS, THAT HAD A DIAGNOSIS THAT WAS SUGGEST THEY COULD BE A CANDIDATE FOR CARDIAC CATHETER SAIG, AN INVASIVE PROCEDURE USED TO DIAGNOSE HEART DISEASE. WE IDENTIFIED PATIENT WHOSE BASED ON MEDICAL RECORDS SHOULD HAVE RECEIVED A REFERRAL FOR CATHETERIZATION. AS WE SEE EVEN WHEN WE REVIEW THESE RECORDS AND SEE SEE THERE'S A DISPARITY HERE WHERE LITTLE MORE THAN 80% OF WHITE PATIENTS GOT THE REFERRAL, WHICH IS ALREADY LOW, TOO LOW, BECAUSE IT SHOULD HAVE BEEN 100% BUT WHEN YOU LOOK AT THE AFRICAN AMERICAN RATES, LOWER, LESS THAN 60% OF AFRICAN AMERICAN PATIENTS WHO SHOULD HAVE BEEN REFERRED WERE ACTUALLY REFERRED. WHAT'S INTERESTING ABOUT THIS, IS THAT THESE WERE ALL INSURED PATIENTS, SEEN AT THE SAME HOSPITALS CURGT SAME TIME PERIOD -- DURING THE SAME TIME PERIOD. THIS IS A PROCEDURE WHICH THE HOSPITAL WOULD BE REIMBURSED. SO IF THERE WERE ECONOMIC INCENTIVE THAT WOULD BE OPT SIDE OF PROVIDING MORE CARE, NOT LESS. AND EVEN IN THAT CONTEXT WE FIND A DISPARITY. ANOTHER STUDY THAT I LIKE, I REALLY LIKE THIS ONE BECAUSE IT'S DONE IN THE VA SYSTEM AND THIS ONE IS LOOKING AT REVASCULARIZATION AND THIS IS AMONG PATIENTS, ALL OF WHOM WERE A APPROPRIATE CANDIDATES TO RECEIVE REVASCULARIZATION AND WE SEE SUBSTANTIAL DISPARITY, 50% OF WHITE PATIENTS THAT SHOULD HAVE RECEIVED REVASCULARIZATION DID AND LESS THAN 30% OF AFRICAN AMERICANS DID. THESE ARE ALL PATIENTS IN THE SAME SYSTEM THAT ARE ON VA WHICH MEANS THIS IS A COVERED PROCEDURE. AND THE PHYSICIANS ARE ALL ON SALARY. SO THERE'S NO ECONOMIC INCENTIVE ON EITHER SIDE TO PROVIDE CARE OR NOT. AND WE SEE WE HAVE A HUGE QUALITY PROBLEM BUT WE ALSO HAVE A DISPARITY INEQUALITY PROBLEM. SO THIS IS WHAT HEALTH DISPARITIES ARE REALLY ALL ABOUT. EVEN WITHIN THE CONTEXT OF HAVING ACCESS, HAVING INSURANCE, ACCESSING THE CARE, WE STILL FIND THESE DIFFERENCES. I WOULD SAY IN SPITE OF THE FACT THAT MUCH ACTIVITY HAS OCCURRED OVER THE LAST 10, 15 YEARS AROUND HEALTH DISPARITY, MUCH OF WHAT WE HAVE DONE AND ARE DOING ABOUT HEALTH DISPARITIES WILL FAIL. AND THE REASON THAT I BELIEVE IT WILL FAIL IS BECAUSE OF THE INCORRECT DIAGNOSIS. IF A PATIENT SHOWED UP IN YOUR TREATMENT ROOM, BEFORE DOING ANYTHING YOU WOULD STOP TO TRY TO MAKE SURE YOU HAVE THE DIAGNOSIS RIGHT. BUT WHAT WE DO IN HEALTH DISPARITIES IS WE THROW RESOURCES AT IT, WE CAN ARGUE ABOUT WHETHER THEY'RE ADEQUATE RESOURCES BUT WE THROW RESOURCES AT IT. WITHOUT FIRST STOPPING THE MAKE THE DIAGNOSIS. THERE'S A CHANCE WE'LL RANDOMLY HIT UPON THE RIGHT SOLUTION BUT I THINK OUR CHANCES ARE BETTER IF WE STOP FIRST AND FIGURE OUT WHY DO WE HAVE THESE DIFFERENCES ACROSS RACIAL AND ETHNIC GROUPS. SO I WANT TO ADDRESS THREE OF THE MOST POPULAR EXPLANATIONS THAT I RECEIVE ABOUT THIS. THE FIRST ONE I WANT TO TALK ABOUT IS THE IDEA THAT THERE ARE GENETIC OR BIOLOGICAL DIFFERENCES. SO DOES ANYONE HERE NOT FAMILIAR WITH THE CASE OF BIODIL? ANYONE NOT KNOW WHAT THAT IS ABOUT? I'LL GIVE A READER'S DIGEST OVERVIEW OF WHAT THAT'S ABOUT. BIODILL IS A DRUG THAT IS USED TO TREAT CONGESTIVE HEART FAILURE, WHICH IS A DEBILITATING DISEASE THAT AFFLICTS A HALF MILLION PEOPLE PER YEAR IN THE UNITED STATES. IT'S AN EXPENSIVE DISEASE BECAUSE THESE PATIENTS UTILIZE A LOT OF HEALTHCARE RESOURCE, SHOW UP IN THE EMERGENCY ROOM OFTEN, AND BIODILL WAS DEVELOPED INITIALLY IN THE LATE '70s, EARLY '80s DURING A TIME WHEN THERE WERE A NUMBER OF NEW MEDICATIONS ON THE MARKET. CALCIUM, CHANNEL MARKERS BETA BLOCKERS COMING ON TO TREAT HEART DISEASE. WELL, BIODILL IS A COMBINATION DRUG OF TWO GENERIC DRUGS, AND SOME PHYSICIANS BEGAN USING THIS DRUG, THESE GENERICS IN COMBINATION WITH THE BETA BLOCKERS AND OTHER TREATMENTS OF THE DAY AND THEY WERE EXPERIENCIALLY FINDING THE RESULTS. SO ONE GROUP OF PHYSICIANS GOT THE IDEA OF ACTUALLY DOING A CLINICAL TRIAL TO SEE, DO A RESEARCH TO SEE CAN WE DOCUMENT, BENEFIT TO THIS NEW THERAPY OF THIS COMBINATION OF DRUGS. THEY FOUND THAT THERE WAS A BENEFIT, THAT THERE WAS A -- PATIENTS ON COMBINATION THERAPY WERE HAVING BETTER OUTCOMES AS THE EXPERIENCE SUGGESTED. THIS ARTICLE WAS PUBLISHED IN THE NEW ENGLAND JOURNAL OF MEDICINE AND IT BECAME QUICKLY ADOPTED AS A STANDARD OF CARE, A LOT OF PEOPLE BEGAN TO USE. SO SOMEONE HAD THE IDEA OF WELL, WHAT IF WE PUT THESE TWO GENERIC DRUGS TOGETHER INTO ONE PILL AND MARKET THAT AS A SEPARATE -- AS A NEW DRUG. SO THEY DID THIS AND THEY WERE ABLE TO GET A METHODS PATENT TO DO -- TO DO THIS AND WHEN THEY WENT TO COMMERCIALIZATION IT WAS NOT APPROVED BY THE FDA. WHY WASN'T IT APPROVED? BECAUSE THAT STUDY THAT WAS PUBLISHED IN THE NEW ENGLAND JOURNAL OF MEDICINE WAS NOT DONE TO THE STANDARDS NECESSARY FOR IT TO PROGRESS TO COMMERCIALIZATION. NOW THEY'RE STUCK. THE MONOPOLY IS RUNNING OUT, THERE'S NOT ENOUGH TIME TO DO THE NEW CLINICAL TRIAL THAT WOULD BE THE FDA STANDARDS AND THEY'RE GOING TO LOSE OUT ON THIS OPPORTUNITY. SO BACK TO THE ORIGINAL DATA, THEY BEGIN TO DO ANALYSIS OR REANALYSIS OF THE DATA. AND THEY DO ANALYSIS BY RACE. NOW, LET ME STOP HERE AND MAKE THIS POINT, ESPECIALLY FOR RESEARCHERS THAT ARE IN THE ROOM. SAY WE HAD A DRUG AND WHICH ADMINISTERED THIS DRUG TO BLACK PATIENTS AND WHITE PATIENTS. WE FOUND THAT THESE ARE NOT THE CORRECT NUMBERS, THIS IS JUST AN EXAMPLE. LET'S SAY WE FOUND THAT 80% OF THE BLACK PATIENTS THAT HAVE THIS DRUG BENEFITED FROM IT. AND 70% OF THE WHITE PATIENTS BENEFITED. THAT WOULD BE PRETTY GOOD. THOSE ARE REALLY GOOD RATES OF SUCCESS. BUT THAT 10 PERCENTAGE POINT DIFFERENCE WOULD BE BOTH BE A SIGNIFICANT DIFFERENCE. WE WOULD GET A SIGNIFICANT ODDS RATIO, WE PUBLISH AN ARTICLE AND WE WOULD TITLE IT SOMETHING LIKE DRUGS MORE EFFECTIVE IN BLACKS. BECAUSE WE GOT THIS SIGNIFICANT RACE EFFECT. NOW, THINK ABOUT THAT STATEMENT FOR A MOMENT. THAT'S THE WAY WE TALK AMONG OURSELVES AS RESEARCHERS. THE DRUG IS MORE EFFECTIVE IN BLACK. THERE WAS AN ARTICLE SHOWED SIGNIFICANT RACE EFFECTS SO MORE EFFECTIVE IN BLACKS. IS THE DRUG IN THAT EXAMPLE MORE EFFECTIVE IN BLACKS? OR WAS IT EFFECTIVE FOR MORE BLACKS? THINK ABOUT THAT FOR A MOMENT. EVERYONE THAT GOT THE DRUG, IF YOU BENEFITED, YOU BENEFITED. YOU DIDN'T BENEFIT MORE IF YOU WERE BLACK THN THE WHITE PATIENT THAT BENEFITED. YOU EITHER BENEFITED OR YOU DID NOT BENEFIT. SO THERE'S NO MAGNITUDE OF LEVELS OF BENEFIT. A LARGER PERCENTAGE OF AFRICAN AMERICANS BENEFITED BUT THEY DID NOT BENEFIT MORE THAN THE WHITES. BUT THE WAY THAT WE TALK ABOUT IT AS SCIENTISTS, WE SAY THE DRUG IS MORE EFFECTIVE IN BLACKS WHEN IT'S NOT. WHEN THAT KIND OF TERMINOLOGY GETS OUT OF THE SCIENTIFIC COMMUNITY WHERE WE UNDERSTAND THE CAVEATS, AND PEOPLE START TO MAKE POLICY DECISIONS AN PEOPLE START TALKING ABOUT THIS INFORMALLY, THAT KIND OF TERMINOLOGY DOES HARM. I THINK THAT IS A LOT OF WHAT HAPPENED WITH THIS BIODILL CASE. SO THE DRUG IS MORE EFFECTIVE IN BLACKS. IF YOU ASK PHYSICIANS, MANY PHYSICIANS PRACTICING NOW THEY WILL SAY THE DRUG IS MORE EFFECTIVE IN BLACKS. WHEN THE REALITY, IT WAS EFFECTIVE FOR A LARGER PERCENTAGE OF BLACKS. VERY SUBTLE BUT IMPORTANT POINT. IT'S SOMETHING WE DO AWFNED AND I THINK IT MISLEADS THE PUBLIC AND EVEN MISLEADS OURSELVES. THIS WAS THE CASE WITH BIODILL. SO WHEN THEY FOUND THAT THE DRUG WAS AFFECTED IN A LARGER PERCENTAGE OF BLACK PATIENTS IN THEIR STUDY THAN WHITE PATIENTS, THEY THEN WENT BACK TO FDA AND SAID WE'D LIKE YOU TO GIVE US A NEW METHODS PATENT, THIS TIME THE PATENT SHOULD BE FOR USE ONLY IN BLACKS. AND FDA GIVES THEM THE PATENT. LARGELY WITH THE SUPPORT OF ADVOCACY GROUPS INCLUDING THE ASSOCIATION OF BLACK CARDIOLOGISTS, NAACP, THE CONGRESSIONAL BLACK CAUCUS WHO HELPED TO ADVOCATE FOR PASSAGE OF THIS APPROVAL. NOW THEY GO BACK AND THEY DO A NEW CLINICAL TRIAL, THIS TIME ON ONLY BLACK PATIENTS. AND WHAT DO YOU THINK THEY FOUND? THEY FOUND BIODILL WAS EFFECTIVE BECAUSE BIODILL IS EFFECTIVE WHETHER PATIENTS ARE BLACK, WHITE, ASIAN OR ANY OTHER ETHNIC GROUP, THE DRUG IS EFFECTIVE. SO WHEN THEY DID THIS NEW CLINICAL TRIAL, THIS TIME TO FDA STANDARDS, THEY FOUND THE DRUG IS EFFECTIVE AND FDA IN 2005 APPROVES BIODILL FOR USE IN BLACK PATIENTS.2L WHO DO YOU PRESCRIBE BIODILL TO? DO YOU PRESCRIBE BIODILL TO THIS AFRICAN AMERICAN GENTLEMAN WHO HAS ONE SCOTTISH GRANDPARENT, ONE IRISH GRANDPARENT AND TWO JAMAICAN GRANDPARENTS? DO YOU PRESCRIBE BIODILL TO THIS AFRICAN AMERICAN WHO HAS TWO KENYAN GRAND PARENTS AND TWO WHITE GRANDPARENT? PRESIDENT OBAMA. DO YOU PRESCRIBE BIODILL TO THIS AFRICAN AMERICAN GENTLEMAN? ONE CHINESE GRANDPARENT, ONE TAI GRANDPARENT, ONE NATIVE AMERICAN AND WHITE GRANDPARENT AND ONE AFRICAN AMERICAN AND WHITE GRANDPARENT. THIS IS TIGER WOODS. WHAT ABOUT THIS GUY? LOOKS LIKE A BLACK GUY TO ME. RIGHT? BUT OF COURSE THIS IS VIJAY SINGH FROM FIJI AND NOT AFRICAN AMERICAN AT ALL. THE FALLLY OF RACE IS THAT WE THINK BECAUSE WE CAN LOOK AT SKIN COLOR THAT WE UNDERSTAND WHAT WE NEED TO KNOW ABOUT THE INDIVIDUAL'S GENOME IN ORDER FOR US TO MAKE DECISIONS ABOUT WHAT'S HAPPENING UNDER THE SKIN. AND AS WE SEE IN THE CASE OF BIDIL, EVEN SCIENTISTS WHO ARE OPERATING AFTER HUMAN GENOME PROJECT RELEASED THIS REPORT, STILL CAME TO THE CONCLUSION IN 2005 THAT THERE'S A SCIENTIFICALLY VALID REASON TO APPROVE THE DRUG TO BE USED IN ONLY ONE RACE GROUP. IN 2005, NOT 1905. -- NOT 1805. THE ILLUSION OF RACE CAN CONFUSE THE BEST OF US. THE NEXT EXPLANATION I HEAR FOR DISPARITIES, RACIAL AND EVIDENCE IN THIS CASE DISPARITIES THAT I H THINK WILL LEAD US ASTRAY IS RACE DIFFERENCES ARE REALLY ABOUT SOCIOECONOMIC STATUS. REALLY INCOME, IT'S EDUCATION, ACCESS TO CARE, REALLY THESE OTHER SOCIAL FACTORS THAT ARE OUT OF THE CONTROL OF THE HEALTHCARE SYSTEM AND IS NOT REALLY ABOUT THE INDIVIDUAL. IT'S ABOUT THE FACT THAT YOU HAVE LARGER PROPORTIONS OF PEOPLE THAT ARE RACIAL AND ETHNIC MINORITY GROUPS IN THESE -- DISADVANTAGED STATUSES. THEREFORE, THAT'S REALLY THE PROBLEM. SO LET ME QUICKLY TRY TO DISPEL THAT. THIS IS JUST SOME ANALYSIS THAT I DID OF THE HEALTH ENTERRUE SURVEY LOOKING AT THE VARIETY OF OUTCOMES AND FINDING PERSISTENT DISPARITIES BY RACE REGARDLESS OF EDUCATION. THIS ONE ON INFANT MORTALITY COMES FROM NCHS DATA LOOKING AT INFANT MORTALITY RATES. I WANT TO POINT OUT THAT THE INFANT MORTALITY RATE OF AFRICAN AMERICAN COLLEGE GRADUATES IS HIGHER THAN RATE FOR WHITE WOMEN WITH LESS THAN HIGH SCHOOL EDUCATION. SO CLEARLY WE HAVE A DISPARITY BY SOCIOECONOMIC STATUS AND BY RACE IN THAT EACH INDEPENDENTLY IS AN ISSUE THAT WE NEED TO BE ADDRESSING. SES AS WELL AS RACIAL ETHNIC DISPARITIES. A BRIEF MESSAGE TO RESEARCHERS, BECAUSE SOME ARE SAYING WE DEAL WITH THAT USING MULTI-RARE YANT ANALYSIS, ESPECIALLY THOSE EPIDEMIOLOGISTS. SO WHAT I WANT TO DO IS ADDRESS THAT ISSUE AND TALK TO YOU A BIT. SO THIS IS FOR THE RESEARCHERS IN THE ROOM IN PARTICULAR. I'M GOING TO DO A BIT OF ANALYSIS FOR YOU WHICH IS VERY FAMILIAR, IT'S THE KIND OF THING WE DO EVERY DAY. WE READ ARTICLES USING THIS KIND OF TECHNOLOGY ALL THE TIME AND WE NEVER QUESTION IT. AND LET ME ALSO SAY BEFORE I MOVE FURTHER, THAT WHILE I AM STANDING HERE BEFORE YOU RAILING ABOUT CERTAIN SINS OF PEOPLE DOING HEALTH DISPARITIES RESEARCH, I AM NOT WITHOUT BLAME. SO IF YOU GO INTO PUBMED AND PUNCH MY NAME IS, YOU MAY FIND ME COMMITTING THE SAME SINS THAT I AM NOW HERE TALKING ABOUT. THE POINT IS NOT THAT YOU CAN'T CRITICIZE THE SIN BUT RATHER WE SHOULD ALL REPENT, GO FORWARD, AND SIN NO MORE. SO DON'T FEEL BAD IF YOU COMMITTED THESE SINS BECAUSE SOME OF YOU PROBABLY HAVE. I'M GOING TO DO ANALYSIS OF THE NATIONAL HEALTH ENTERRUE SURVEY. SO BIG NATIONAL DATA SET THAT EVERYONE HAS HEARD OF. I'M GOING TO DO A SIMPLE ANALYSIS OF THE ADULTS OVER AGE 40 USING ONLY THREE VARIABLES. RACE MEANING BLACK OR WHITE, INCOME LEVEL WHICH’M= IS CATEGORIZED TO THREE GROUPS, LESS THAN $25,000 T ABOVE $25,000 AND ABOVE $75,000. ONE IS HAVING ONE ADL OR DAILY LIVING LIMITATION. SO WE CAN AGREE I SET THE BARLOW. JUST ONE ADL LIMITATION. I PROBABLY COULD NEVER EVEN GET THAT PAPER PUBLISHED. ONE ADL LIMITATION AND WE'RE ONLY GOING TO LOOK AT RELATIONSHIP BETWEEN RACE AND HAVING AN ADL RIMMATION AFTER CONTROLLING FOR INCOME LEVEL. SO BIO STAT 101 CLASS WE'RE TAUGHT THE FIRST THING TO DO IS LOOK AT RELATIONSHIP BETWEEN RACE AND HAVING ADL LIMITATION AND HA THAT'S WHAT WE HAVE DONE HERE. WE HAVE AN ENVOY OF -- THE CONFIDENCE INTERVAL THAT THIS IS A SIGNIFICANT EFFECT AND WE WOULD CONCLUDE IN THE BIOVARIANT ANALYSIS, BLACK VERSUS A 46% GREATER ODDS OF HAVING AN ADL COMPARED TO WHITES. AM I RIGHT SO FAR? YOU CAN TALK, IT'S OKAY. SO THE NEXT THING WE WOULD DO, I GUESS THIS IS A BIOSTAT 201, I DON'T KNOW. WE WOULD THEN LOOK AT THE RELATIONSHIP BETWEEN INCOME AND HAVING AN ADL LIMITATION. SO HERE WE HAVE ODDS RATIOS ARE DECLINING, AS INCOME INCREASES, AND THE CONFIDENCE INTERVAL IS AGAIN SHOWING THAT THIS IS A SIGNIFICANT EFFECT. SO WE WOULD SAY THAT AS WE WOULD EXPECT, AS INCOME INCREASES THE LIKELIHOOD OF -- THE ODDS OF HAVING ADL LIMITATION DECREASES. SE NEXT WHAT DO WE DO? INCOME AND RACE IN ONE MODEL TO SEE WHETHER IT'S INCOME OR RACE THAT'S PRODUCING THIS OUTCOME. HERE WE GO. THE ANALYSIS TELLS US THAT THE RACE AFFECT IS NO LONGER SIGNIFICANT, THIS IS -- STATISTICALLY SIGNIFICANT, THE CONFIDENCE INTERVAL SAYS IT'S NOT SIGNIFICANT. THE INCOME EFFECTS HOW FAR, PERSIST SO WE WOULD CONCLUDE THAT IT'S -- THERE IS NO RACE DIFFERENCE IN ADL LIMITATION, IT'S REALLY A MATTER OF INCOME LEVELS. RIGHT? WE WOULD PUBLISH THIS ARTICLE AND GET A PROMOTION AND ALL WOULD BE RIGHT WITH THE WORLD, RIGHT? WRONG. EXCEPT WE NOW ADDED FALSE INFORMATION TO THE RESEARCH LITERATURE BECAUSE IF WE HAD TAKEN THE NEXT STEP, ARRAIGNED THE DATA BY RACE AND INCOME AND LOOKING WITHIN EACH CELL WE WOULD LEARN A FEW VERY INTERESTING THINGS. FIRST OF ALL, THAT IN THE LOWEST INCOME GROUP, LESS THAN $25,000 THRRK IS A RACE DIFFERENCE, AFRICAN AMERICANS HAVE A HIGHER RATE OF ADL, OF HAVING ONE ADL LIMITATION. AND THE HIGHEST INCOME GROUP THE AFRICAN AMERICAN RATE FOR $75,000 OR MORE IS CALCULATED ON THE BASIS OF ONLY 8 EVENTS. SO YOUR NUMERATOR IS 8. HOW CONFIDENT ARE YOU ABOUT CALCULATING A RATE BASED ON EIGHT EVENTS? SO IN THE NATIONAL HEALTH INTERVIEW SURVEY, OVER 30,000 CASES, WE CAN'T DO A SIMPLE MULTI-VARIANT MODEL REGRESSION ANALYSIS TO ANSWER A VERY SIMPLE QUESTION WITHOUT HAVING LIMITATIONS. I WANT YOU TO THINK FOR A SECOND ABOUT THE ARTICLE THAT YOU JUST READ THAT HAD A SAMPLE SIZE OF 500 PEOPLE, IN A TELEPHONE SURVEY OR SOMETHING. AND LOOKED AT RACE DIFFERENCES AND SOMETHING AND ASK YOURSELF HOW MANY EMPTY CELLS OR INADEQUATELY POPULATED CELLS MIGHT THERE BE IN THAT ANALYSIS? OF COURSE NOT IN YOUR PAPERS OF COURSE, BUT SOME PAPER YOU READ. SO WE HAVE GOT PROBLEMS. ANOTHER ISSUE IS THIS. I THINK ILLUSTRATED NICELY HERE. THIS IS A PICTURE OF A HIGH SCHOOL IN THE BALTIMORE METROPOLITAN AREA. AS I'M TAKING THE PICTURE I'M STANDING OUTSIDE THE CAMPUS AND WE SEE TREES AND GRASS AS I DRIVE THE CAMPUS YOU SEE MORE GRASS AN TREES AN IN THE DISTANCE WE SEE BUILDINGS WITH THE CLASSROOMSCH AS I DRIVE TO SIDE OF THE CAMPUS THIS IS THE GYMNASIUM WHERE THE VOLLEYBALL, BASKETBALL AND GYMNASTIC TEAM PERFORMS AT THIS HIGH SCHOOL IN THE BOSTON METROPOLITAN AREA. THIS IS ANOTHER HIGH SCHOOL IN THE BALTIMORE METROPOLITAN AREA. THIS IS AN UPPER MIDDLE CLASS SUBURB OF BALTIMORE, I'M TAKING THE PICTURE AT THE ENTRANCE OF THE BUILDING. THERE'S LAWN AN TREES. THE BUILDING IS CLEARLY VISIBLE TO THE STREET. AS I DRIVE TO BACK OF THE BUILDING HERE IS THE SOCCER TEAM GOING TO PRACTICE IN A WIDE OPEN FIELD WITH NO BLEACHERS FOR FANS TO WATCH THE BASEBALL GAME THERE. AS I COME AROUND TO THE BACK OF THE BUILDING HERE ARE THE PORTABLE CLASSROOMS BECAUSE IN THIS UP PER MIDDLE CLASS SUBURBAN HIGH SCHOOL T BUILDING IS NOT ADEQUATE TO MEET ALL THE NEEDS OF THE NUMBER OF STUDENTS THAT GO TO THAT SCHOOL. FINALLY, HERE IS A HIGH SCHOOL IN THE BOSTON MET METROPOLITAN AREA. WE HAVE NO LAWN BUT IF YOU LACK CLOSELY THERE'S WEEDS IN THE CRACKS THERE. AND THERE IS A TREE. AND MY POINT OF SHOWING YOU THESE PICTURES IS THIS: THAT THE GRADUATES OF THESE INSTITUTIONS ARE ALL RECORDED IN YOUR DATA SET AS HIGH SCAL GRADUATES -- SCHOOL GRADUATES. DO YOU THINK PERHAPS THERE'S MEANINGFUL QUALITATIVE DIFFERENCES AMONG THE GRADUATES OF THESE INSTITUTIONS? DO YOU THINK PERHAPS THEY ERASE DIFFERENCES IN WHO GOES TO WHICH SCHOOL IN AND DO YOU THINK THAT PERHAPS WHEN WE DO OUR MULTI-VARIANT MODEL AND WE ADJUST FOR EDUCATION AND THINK WE HAVE NOW EQUALIZED THE SAMPLE WHICH ALLOWS US TO MAKE RACE COMPARISONS, DO YOU THINK THAT PERHAPS WE'RE NOT CAPTURING SOCIAL STRATIFICATION CAPTURED BY THAT VARIABLE IN YOUR DATA SET. THAT SIMPLY SAYS HIGH SCHOOL GRADUATE. THESE ARE THE UNDERLIGHT PROBLEMS WITH MUCH OF THE RESEARCH THAT WE DO IN HEALTH DISPARITY, MUCH OF THE QUANTITATIVE RESEARCH IN PARTICULAR, USING NATIONAL DATA. WE DON'T ACCOUNT FOR THE FACT THAT THERE ARE SYSTEMATIC INEQUALITIES IN THE VARIABLES THAT WE RELY ON TO TRY TO EQUALIZE THE SAMPLES. WE TRY TO EQUALIZE SAMPLES WITH RESEARCH METHODS IN THE ANALYSIS PHASE RATHER THAN IN DESIGN. AND IT'S ALWAYS INADEQUATE TO DO THAT THE POINT. NOW, ANOTHER ASPECT IS THE FACT THAT WHILE WE ALL LIVE TOGETHER IN THE SAME COUNTRY WE EXPERIENCE THE COUNTRY DIFFERENTLY. BECAUSE OF THAT THERE ARE DIFFERENCES THAT ARE PATTERNED BY RACE AND ETHNICITY IN EXPOSURE TO RISKCH THESE ARE PICTURES OF CORNER STORES IN BALTIMORE. THIS ONE ACTUALLY HAPPENS TO BE JUST A COUPLE OF BLOCKS FROM MY OFFICE. AND THE RISK ENVIRONMENTS THAT WE LIVE IN ARE QUITE DIFFERENT. SO THAT WHEN WE LOOK AT NATIONAL STATISTICS AND WE CALCULATE RACE -- RACE BASED ON RACE ETHNICITY, WHAT EXTENT ARE WE CAPTURING DIFFERENCES IN THE RISK ENVIRONMENTS THAT PEOPLE LIVE ? IN? THIS IS MY FAVORITE HERE. I DID NOT PHOTO SHOP THIS. L AND M LIQUORS SELL BEER, WINE AND MEDICINE. I JUST LOVE THAT ONE BECAUSE OF THE TRUTH IN ADVERTISING. AND OWF COURSE THE MEDICINE THEY SELL IS OF COURSE, THE ELIXER FOR THE ILLS OF POVERTY, MALT LIQUOR. IF YOU DON'T KNOW WHAT IT MEAN, COME SEE ME AFTER WHAT MALT LIQUOR IS, SEE ME AFTER THE LECTURE, I'LL EXPLAIN THAT TO YOU. THERE WAS A STUDY THAT WE DID A FEW YEARS BACK LOOKING AT THE LOCATION OF THESE CORN STORES IN BALTIMORE AND ARRAYED THEM BY RACE AND INCOME TO SEE WHAT TYPES OF NEIGHBORHOODS TENDED TO BE TARGETED BY THESE KINDS OF STORES, AS YOU CAN SEE IT'S PREDOMINANTLY LOW INCOME IN AFRICAN AMERICAN COMMUNITIES. AS YOU MIGHT EXPECT. NOW, ONE MORE STORY BEFORE WE GET INTO THE RESEARCH PART OF THIS. I SHOULD POINT OUT, I'M GOING TO TELL YOU A BRIEF STORY ABOUT MG SOMETHING THAT HAPPENED, AND IT'S ABOUT AN ARTICLE I WAS ASKED TO REVIEW FOR A JOURNAL. A REAL FANCY JOURNAL. IF I TOLD YOU THE NAME YOU WOULD BE IMPRESSED. IT WAS BLIND REVIEW, SO I DON'T KNOW WHO THE AUTHOR IS. THE AUTHOR MAYBE IN THE ROOM RIGHT NOW. IF YOU ARE YOU'RE NOT GOING TO WANT TO CLAIM THIS ONE, IF YOU JUST REMAIN QUIET, I WON'T KNOW AND NO ONE WILL KNOW, SO DON'T OUT YOURSELF. I GET THIS ARTICLE REVIEW, THE TITLE IS SOMETHING LIKE RACE DIFFERENCES AND FIREARM USE AMONG BLACK AND WHITE ADOLESCENT MALES. YOU SEE TITLES LIKE THAT, RIGHT? SOMETHING LIKE THAT. UNFORTUNATELY FOR THIS AUTHOR, THEY USE DATA FROM STATE OF MARYLAND, UNFORTUNATELY THEY SENT THE ARTICLE TO SOMEONE WHO LIVES IN MARYLAND TO REVIEW THE ARTICLE. SO I'M READING THIS ARTICLE AND I SEE THAT ALL THE BLACK MALES ARE FROM BALTIMORE CITY. AND THE WHITE MALES ARE FROM GARRET AND ALLEGHENY COUNTY. SURELY DON'T HAVE TO TELL THIS AUDIENCE WHAT THAT MEANS. THE BLACK MALES ARE SHOOTING PRETTY MUCH PISTOLS, THE WHITE MALES ARE SHOOTING LONG GUNS OR RIFLES. THE WHITE MALES ARE SHOOTING AT I DON'T KNOW WHICH WOULDABEAST OR PHEASANT, WHATEVER THEY SHOOT IN ALLEGHENY COUNTY. I DON'T KNOW WHAT THEY SHOOT OUT THERE. AND THE BLACK MALES ARE SHOOTING AT -- RIGHT? I KNOW A LOT OF WAS BANG DISTRICTRY DISTRICTRY TO GET THE E TRICKERY TO CONFESS ANYTHING BUT I DON'T KNOW A TRICKERY THAT MAKES THE DIFFERENCE BETWEEN RACE DIFFERENCE AN FIREARM USE, THIS IS THE DIFFERENCE BETWEEN ONE TYPE OF HUNTING CULTURE VERSUS A DIFFERENCE TYPE OF HUNTING CULTURE, PERHAPS, A STUDY OF URBAN VERSUS RURAL POPULATIONS PERHAPS. BUT IT'S NOT A STUDY OF RACE DIFFERENCES. FIRST TO DO THAT WE HAVE TO GET BLACK MALES LIVING IN GARRET AND ALLEGHENY COUNTY AND WHITE MALES IN BALTIMORE AND WE LOOK AT THEIR FIREARM USE AND THEN WE CAN MAKE COMMENTS ABOUT WHAT THEY'RE DOING. THAT'S AN EXTREME EXAMPLE. IT'S AN EXTREME EXAMPLE BUT IT ILLUSTRATES A PROBLEM THAT IS USUALLY MORE SUBTLE IN HEALTH DISPARITIES RESEARCH. THAT IS WE DON'T ACCOUNT FOR THE FACT THAT THE UNITED STATES IS A HIGHLY RACIALLY-SEGREGATED SOCIETY. IN FACT, TOMORROW, WE'RE GOING TO BE RELEASING A REPORT ON LOOK AT THE RELATIONSHIP BETWEEN SEGREGATION AND HEALTH IN THE UNITED STATES COMING FROM THE NEW CENSUS DATA. I'M NOT SUPPOSED TO TELL THE RESULTS BUT I CAN GIVE YOU A PREVIEW SUGGESTING THERE IS A STRONG RELATIONSHIP AS IN PREVIOUS CENSUS DATA AND THAT RELATIONSHIP CONTINUES NOT ONLY PERSISTED BUT IT'S GOTTEN EVEN STRONGER. WE DON'T ACCOUNT FOR THIS SEGREGATION, WE LOOK AT NATIONAL STATISTICS AND NATIONAL RATES. WE MAKE POLICY BASED ON THE NATIONAL RATES. BUT WE DONE KNOW HOW TO COMMENT FOR THE FACT THAT PEOPLE LIVING IN DIFFERENT RISK ENVIRONMENTS BECAUSE THEY LIVE IN THESE DIFFERENT RISK ENVIRONMENTS WE DON'T KNOW WHAT TO WHAT EXTENT THE DAYS PARITIES WE SEE IN NATIONAL REPORTS ARE REALLY SOMETHING ABOUT RACE OR IS IT REALLY ABOUT RACISM OR IS IT REALLY ABOUT WHO LIVES IN WHAT NEIGHBORHOOD? AND WHAT DETERMINES WHICH NEIGHBORHOOD YOU LIVE IN. WE NEED TO START MOVING TO THAT PHASE OF RESEARCH IF WE'RE GOING TO UNDERSTAND RA REALLY IS THE ETIOLOGY OF HEALTH DISPARITIES AND MOVE TOWARDS A CORRECT DIAGNOSIS AN SOLUTIONS. SO IN ORDER FOR US TO DO THIS, WE NEED TO START FINDING ENVIRONMENTS WHERE PEOPLE ARE LIVING TOGETHER WITH SIMILAR RISK EXPOSURES, WITH SIMILAR SOCIOECONOMIC STATUS, AND SEE IF WE CAN THEN FIND THE DISPARITIES, WHAT IS THE MAGNITUDE OF THOSE DISPARITIES AND DO THEY EXIST ONCE YOU HAVE THAT ENVIRONMENT. THIS IS A STUDY THAT WE'RE -- WE'RE PURSUING AT THE SENT E FOR HEALTH DISPARITIES SOLUTIONS AT JOHNS HOPKINS. WE IDENTIFIED 425 CENSUS TRACKS AROUND THE COUNTRY THAT MEET THE CRITERIA THAT WE ESTABLISH TO INDICATE RACIALLY INTEGRATED CENSUS TRACKS, 35% AFRICAN AMERICAN AND 35% WHITE WOMEN IN THE SAME CENSUS TRACK WITH RELATIVELY SMALL DIFFERENCES AT BEST IN INCOME AND EDUCATION LEVELS. AND WE ASK CAN QUESTION WHAT IS THE NATURE OF RACE DISPARITIES BETWEEN BLACK AN WHITE AMERICANS WHEN WE DON'T HAVE TO CONTEND WITH RACE DIFFERENCES AND SOCIOECONOMIC STATUS OR RACE DIFFERENCES THAT ARE THE RESULT OF LIVING IN DIFFERENT RISK ENVIRONMENTS. WHEN WE LIVE IN THE SAME HEALTHCARE MARKET, WHEN THEY'RE EXPOSED TO THE SAME HEALTH RISKS OR PROTECTIVE FACTORS, DO YOU STILL FIND THE SAME DISPARITIES. AND JUST A LITTLE BIT ABOUT THE LOGIC HOW WE DO THE STUDY, WE IDENTIFY THE CENSUS TRACKS, WE GO IN AND DO A SET OF INTERVIEWS ON THE ADULTS, LARGELY THE INTERVIEWS ARE REPLICATEING QUESTIONNAIRES FROM THE NATIONAL HEALTH INTERVIEW SURVEY MAPS AND N HAYNES WHICH ALLOWS US TO CONDUCT SIMILAR ANALYSIS IN THE NATIONAL DATA AND THEN ALSO IN OUR DATA SET TO SEE IF DISPARITIES ARE THE SAME AND TO WHAT DEGREES THEY DIFFER. SO I'M GOING TO GIVE YOU THE RESULTS OF SOME OF THE ANALYSIS THAT WE HAVE BEEN DOING. AND WHERE WE ARE AT THIS POINT IN THE STUDY. SO FIRST, WE IDENTIFY THESE 425 CENSUS TRACKS AROUND THE COUNTRY, MOSTLY THEY WERE LOCATED IN THE MID ATLANTIC REGION OR IN THE WEST, CALIFORNIA, A FEW IN -- BUT MOSTLY MID ATLANTIC AND FORTUNATELY FOR US SEVERAL WERE IN MARYLAND AND IN BALTIMORE AND THE FIRST SITE WE WENT TO WAS ACTUALLY TWO CENSUS TRACKS, CONTIGUOUS CENSUS TRACKS IN BALL MORE WE PUT TOGETHER TO CREATE ONE STUDY SITE AND THESE ARE THE RESULTS FROM THAT FIRST ANALYSIS. SO THIS IS FROM THE 2000 CENSUS, THIS IS THE INCOME LEVEL OF -- IN THAT COMMUNITY, WE SEE IT'S A VERY LOW INCOME COMMUNITY. BUT ESSENTIALLY NO RACE DIFFERENCES IN INCOME LEVELS. POVERTY IS ALSO VERY MUCH EQUAL, DRAMATICALLY HIGHER THAN POVERTY RATES NATIONALLY BUT SUBSTANTIAL RACE -- NO SUBSTANCE, RACE DIFFERENCES IN RATES OF POTY. HERE IS EDUCATIONAL STATUS BASED ON THE CENSUS, YOU CAN SEE BLACK AND WHITE RESIDENTS ARE ALSO VERY EQUAL IN TERMS OF EDUCATIONAL LEVELS. THE DISTRIBUTION BY GENDER IS ALSO EQUAL. IT'S BEST YOU'RE GOING TO FIND IN NATURALLY OCCURRING ENVIRONMENT, THIS IS CLOSE TO GETTING EQUALIZED POPULATION SOME THE STATE -- IT WAS A STUDY OF TWO CENSUS TRACKS, WE DID A 40-MINUTE INTERVIEW CONDUCTED IN PERSON, BLOOD PRESSURE WAS A MAJOR OUTCOME AND WE DID BLOOD PRESSURE MEASUREMENTS ON THEM AND WE WERE SUCCESSFUL INTERVIEWING 42% OF ADULTS IN THOSE TWO CENSUS TRACKS. WE DID NOT SAMPLE, IT WAS OUR INTEND TO TRY TO GET A CENSUS OF THE ENTIRE CENSUS TRACK. WE WERE ABLE TO GET 42% OVER A 12 WEEK PERIOD. PRETTY GOOD. SO FIRST LET'S TALK THE REACH WE REPRESENTED THE COMMUNITY. HERE WE'RE COMPARING OUR RESULTS, SOME OF THE DEMOGRAPHICS FROM THE SAMPLE COMPARED WITH WHAT THE CENSUS FOUND. OUR STUDY OUR DATA COLLECTION MOVED IN 2003 SO THREE YEARS AFTER THE CENSUS. ACTUALLY FOUR YEARS, THE CENSUS WAS ACTUALLY OUT THERE IN 1999. BUT AS YOU CAN SEE WE HAVE -- WE ARE SLIGHTLY OVER-REPRESENTED FOR AFRICAN AMERICANS BUT NOT SUBSTANTIALLY SO. THIS IS PROBABLY MY FAVORITE SLIDE EVER IN MY CAREER. I THINK WE DID A GOOD JOB OF REFLECTING THE INCOME LEVELS IN OUR SAMPLE. COMPARED TO THE CENSUS. EDUCATION LEVELS, PRETTY GOOD, A LITTLE OVERREPRESENTED HERE AND HERE. BUT WE CAN ACCOUNT FOR THAT IN THE ANALYSIS AND ALSO DISTRIBUTION BY GENDER ALSO PRETTY REFLECTIVE IN THE SAMPLE AND THE CENSUS TRACK. SO I THINK OUR SAMPLE IS PRETTY REPRESENTATIVE OF THE COMMUNITY THAT WE STUDY. SO AGAIN, WE'RE DOING ANALYSIS IN THE NATIONAL STUDY AND -- NATIONAL DATA SET SUCH AS HEALTH INTERVIEW SURVEY OR NHAYNES, MAPS AND WE DO THE SAME MODEL WITH THE SAME CONTROLS AND MEASURE THE VARIABLES THE SAME WAY AS THE NATIONAL DATA SETS WHICH ALLOW US AS BEST WE CAN TO DO COMPARATIVE ANALYSIS. SO HERE I'M PLOTTING ODDS RATIOS. AND I'LL SHOW YOU THE ACTUAL TABLES IN A MOMENT SO YOU CAN LOOK IF UP TO BUT THIS IS SORT OF REFLECTING THE ODDS RATIO, THE ADJUSTED ODDS RATIOS, SO IN RED WE HAVE I THINK OF THAT AS THE ANALYSIS THAT YOU HAVE FOR -- THIS WILL BE WHITE THEN WE'RE PLOTTING THE ODDS RATIO FOR BLACKS IN THE NATIONAL HEALTH INTERVIEW SURVEY FOR DIABETES. 61% GREATER ODDS OF BEING DIABETIC FROM THE HEALTH ENTERRUE SURVEY AND THAT'S WHAT WE NORMALLY FIND, THAT'S THE RESULT WE FIND IN THE HEALTH INTERVIEW SURVEY DOING THIS ANALYSISCH WHEN WE DO THE SAME ANALYSIS, THE SAME MULTI-VARIANT MODEL WE GET 7% GREATER ODDS, NOT SIGNIFICANTLY DIFFERENT. SO THERE WAS ESSENTIALLY NO RACE DIFFERENCE IN DIABETES IN THAT COMMUNITY. THERE WAS A SIMILAR TYPE ANALYSIS DONE FOR OBESITY AMONG WOMEN. IN THIS ANALYSIS WE GET 87% GREATER ODDS OF BEING OBESE IF YOU'RE WOMAN NATIONALLY AND THIS WAS ALSO NATIONAL HEALTH INTERVIEW SURVEY. IN OUR SAMPLE IT'S 25% GREATER ODDS, ALSO NOT SIGNIFICANT, THE CONFIDENCE INTERVAL WAS NOT SOMETHING WIDE THERE. AND THEN THIS IS FOR HYPERTENSION. SO YOU HAVE 101% GREATER ODDS OF BEING HYPERTENSIVE FROM N HAYNES AND OUR SAMPLE WAS 42% WHICH WAS -- WHICH IS SIGNIFICANT, SIGNIFICANTLY DIFFERENT STILL. SO HERE WE DO STILL FIND A RACE DISPARITY IN HYPERTENSION BUT IT'S GREATLY REDUCED COMPARED TO WHAT YOU FIND IN THE NATIONAL SURVEYS. SO JUST SO YOU WANT, HERE ARE THE ACTUAL ODDS RATIOSCH THIS IS ACTUALLY A SERIES OF MODELS, I THINK I ACTUALLY HAVE THE -- I DON'T HAVE ALL THE CO-VARIANTS BUT THIS IS A SUMMARY OF THE RESULTS OF FULLY ADJUSTED MODELS THAT WE CONDUCTED IN THE NATIONAL SURVEY AND COMPARED TO WHAT WE FOUND IN OUR RACIALLY INTEGRATED COMMUNITIES. YOU CAN SEE SUBSTANTIAL DIFFERENCES, SUBSTANTIALLY SMALLER DISPARITIES OR NOT SIGNIFICANT DISPARITIES FOUND IN THE INTEGRATED COMMUNITY. SUGGESTING TO US IF PEOPLE LIVE IN A SIMILAR RISK ENVIRONMENT, THAT WE FIND MORE SIMILAR OUTCOMES ACROSS RACE GROUPS THAN WE FIND DIFFERENCES. THAT MUCH OF THE DISPARITIES WE THINK BY RACE AND ETHNICITY ARE DISPARITIES THAT ARE THE RESULT OF EXPOSURES TO RISK THAT PLACE INDIVIDUALS AT INCREASED RISK. DISPARITIES ARE NOT JUST ABOUT SOCIOECONOMIC STATUS OR GENETIC DIFFERENCES OR BIOLOGICAL DIFFERENCES BUT THESE DIFFERENCES THAT WE SEE NATIONALLY ARE THE RESULT OF LIVING IN UNHEALTHY ENVIRONMENTS. LET ME SAY A FEW THINGS ABOUT THE COMMUNITY WE STUDY. THERE WAS NO PHYSICIAN IN PRIVATE PRACTICE IN THESE TWO CENSUS TRACKS. THERE WAS NO PHARMACY. THERE WAS NO GROCERY STORE. THERE WERE NO CHAIN STORES OF ANY TYPE, NOT EVEN FAST FOOD. THERE ARE MOM AND POP FISH FRIES. THERE ARE CHECK CASHING PLACES, PAWNSHOPS, AND CORNER STORES SELLING ALCOHOL, LOTTERY TICKETS, AND CIGARETTES. IT WASN'T UNTIL WE GOT THIS DATA AND IT OCCURRED TO ME HOW MANY TIMES THAT I WOULD BE WALKING DOWN THE STREET IN THIS IMMUNITY, I WOULD BE ASKED FOR A CIGARETTE. IT BECAME SO NORMATIVE AFTER A WHILE, IT DIDN'T REGISTER ANY MORE. PEOPLE ASKING FOR CIGARETTES. SO YOU THINK WITH AN INCOME MEDIAN INCOME OF $25,000, HOW DO YOU AFFORD TO PURCHASE CIGARETTE? DO YOU KNOW WHAT A PACK OF CIGARETTES COST? DO YOU KNOW? THOSE OF US IN PUBLIC HEALTH, WE SHOULD KNOW WE SHOULD KNOW WHAT'S GOING ON. PACK OF CIGARETTES DEPENDENT UPON WHAT BRAND YOU PURCHASE AND WHETHER OR NOT YOU GET A SALE AND WHICH STATE CAN RANGE ANYWHERE FROM ABOUT $4 A PACK IF YOU'RE REALLY LUCKY AN FIND A GREAT SALE OF A GENERIC CIGARETTE, UP TO $7 OR $8 PER PACK. SO HOW DO YOU AFFORD TO DO THAT ON $25,000? WELL, BECAUSE MANY OF THESE STORES SELL WHAT THEY CALL LUCYS. INDIVIDUAL CIGARETTES WHICH ARE MUCH CHEAPER TO PURCHASE -- MUCH MORE EXPENSIVE PER CIGARETTE THAT WAY BUT OF COURSE THEY ARE MORE AFFORDABLE. SO YOU HAVE TREMENDOUS AMOUNT OF SMOKING. THE SMOKING RATES WERE THREE TIMES THE NATIONAL RATES IN THIS COMMUNITY. VIRTUALLY EVERY ADULT HAD AT LEAST AT ONE POINT IN THEIR LIFE BEEN A SMOKER. SO YOU HAVE A CLASSIC FOOD DESERT WITH VIRTUALLY NO MEDICAL CARE INFRASTRUCTURE IN THIS COMMUNITY AND WHEN YOU PLACE ANYONE IN AN ENVIRONMENT LIKE THIS, THEY'RE GOING TO HAVE POOR HEALTH OUTCOMES. I SHOULD POINT OUT TO YOU THE DISPARITIES WE'RE FINDING, WE'RE FINDING THE DISPARITIES ARE MINIMIZED OR ELIMINATED. BUT THEY'RE NOT MINIMIZED OR ELIMINATED BECAUSE THE BLACK LINK GOES DOWN, THEY'RE MINIMIZED OR ELIMINATED BECAUSE THE WHITE RACE IS MUCH HIGHER THAN YOU WOULD FIND NATIONALLY. AND THEY'RE EQUALLY UNHEALTHY IN THIS ENVIRONMENT THAT IS DESTINED TO PRODUCE UNHEALTHY PEOPLE. DID YOU HAVE A QUESTION? (OFF MIC) >> WE DID ADJUST FOR AGE AND EVERYTHING. THE AGE DISTRIBUTION WAS SIMILAR TO NATIONAL DISTRIBUTION AND WHAT YOU FIND NATIONALLY IS AFRICAN AMERICANS ARE YOUNGER THAN WHITES. AND WE FOUND THE SAME THING IN OUR COMMUNITY AS WELL. I SHOULD ALSO SAY, THIS IMMUNITY WAS NOT -- THIS IS NOT A COMMUNITY IN TRANSITION, THIS IS NOT A CASE OF WHITES MOVING TO A COMMUNITY TO REIDENTIFY. THIS IS A COMMUNITY THAT'S BEEN RACIALLY INTEGRATED AT LEAST SINCE THE MIDDLE OF THE 20th CENTURY DURING THE WORLD WAR II WHEN PEOPLE BEGAN TO MOVE TO THE CITIES FOR MANUFACTURING JOBS. WHITES -- THE MIGRATION PATTERN WAS MOSTLY BLACKS MOVED UP FROM THE SOUTH, MOSTLY NORTH CAROLINA INTO BALTIMORE, WHITES MOVED FROM WEST VIRGINIA TO BALTIMORE. THEY CONVERGE IN THE MANUFACTURING BASE OF THE CITY WHICH WAS IN THE SOUTH WESTERN PART OF THE CITY, WHERE THIS COMMUNITY IS, AND THIS COMMUNITY HAS BEEN RACIALLY INTEGRATED SINCE THAT TIME AND HAS REMAINED SO. YES. (OFF MIC) THE QUESTION, HAVE WE LOOKED AT SIMILAR INTEGRATED COMMUNITIES WITH HIGHER INCOME? WE HAVE ARE WORKING ON THAT. WE ARE WORKING ON GETTING RESOURCES INTO HIGH INCOME COMMUNITY AND DO THAT AS WELL AS OUTSIDE OF URBAN AREAS, RURAL AND SUBURBAN COMMUNITIES. THEN WE FIND DIFFERENCES THERE, IN A HIGHER INCOME COMMUNITY YOU MAY HAVE MORE SOCIAL MOBILITY, SO YOU MAY HAVE A LARGER PROPORTION OF PEOPLE IN PARTICULAR PROBABLY AFRICAN AMERICANS WHO ARE FIRST GENERATION AFFLUENT SO MAYBE HAD A CHILDHOOD IN POVERTY OR LOWER INCOME, UPWARDLY MOBILE AN MAY CARRY WITH THEM ENDOWMENT OF CHILDHOOD AND POVERTY, OR THAT'S ONE POSSIBILITY. ANOTHER POSSIBILITY IS THAT THEY ACTUALLY MAYBE MORE HEALTHY BECAUSE MAYBE THERE'S A SELECTION ON HEALTH FOR WHO CAN BE UPWARDLY MOBILE. THAT'S ONE OF THE QUESTIONS WE'RE INTERESTED IN LOOKING AT. THAT IS THE TRA TRAJECTORIES. YES. (OFF MIC) >> YOU MEAN IN THIS SAMPLE OR HIGHER INCOME SAMPLE? WE ASKED QUITE A LOT OF QUESTIONS ABOUT RACISM, STRESS, SOCIAL -- THERE'S ACTUALLY A LOT IN THERE. WE HAVEN'T USED ALL THAT DATA YET BUT YES, WE DO FIND THAT BUT WHAT WE FIND HERE INTERESTINGLY IS THAT YOU HAVE A HIGH PROPORTION OF WHITES WHO REPORT BEING THE VICTIM OF RACISM AND DISCRIMINATION AND HAVE THAT STRESSOR AS WELL. AND ACTUALLY WE HAVE A ONE PAPER WE'RE WORKING ON NOW LOOKING AT RACISM AND HEALTH AMONG WHITES IN THE URBAN ENVIRONMENT. WHERE WE'RE FINDING RACISM IS A PREDICTOR OF NEGATIVE HEALTH OUTCOMES IN THAT POPULATION AS WELL. WE ACTUALLY HAVE A LOT OF DATA ON THAT. NOT SURE HOW THIS GOES NOW. TAKE QUESTIONS FROM HERE? 425 TRACKS. (OFF MIC) CENSUS TRACKS, THEY'RE SMALL GEOGRAPHIC UNITS, YOU HAVE TO BE ABLE TO GET THE -- YOU HAVE TO BE ABLE TO GET THE GEOGRAPHIC IDENTIFIERS WHICH ARE USUALLY NOT PUBLICLY AVAILABLE IN THE NATIONAL SAMPLES. I DON'T KNOW THAT YOU CAN CALCULATE LIKE INFANT MORTALITY RATE LAKE A CENSUS TRACK. (OFF MIC) >> 168,000 CENSUS TRACKS, WE FOUND 425 THAT MET THE CRITERIA. IT COULD BE ONE APPROACH WE HAD THOUGHT ABOUT DOING NATIONAL TELEPHONE SURVEY WITHIN THE CENSUS TRACKS OR EVEN FACE THE FACE IN A SAMPLE OF THOSE TRACKS RATHER THAN COMMUNITY TO COMMUNITY, THAT'S ANOTHER APPROACH. I LIKE GOING INTO THE COMMUNITY BECAUSE WHEN YOU DO IT THAT WAY YOU'RE ABLE TO EQUALIZE AS MUCH AS POSSIBLE. LIVING IN THE SAME ENVIRONMENT, NOT SIMILAR ENVIRONMENT. THEY'RE EXPOSED TO THE SAME TOXINS OR SAME CRIME RATES OR ENVIRONMENT IN A WAY THAT YOU IF YOU DID A NATIONAL SAMPLE YOU HAVE TO TRY TO MEASURE ALL OF THOSE THINGS TO BE ABLE TO CAPTURE THAT. AND THAT'S PART OF WHAT I THINK IS THE PROBLEM WITH THE RESEARCH, WE CAN'T ALWAYS MEASURE THE SOCIAL DETERMINANTS. YES. (OFF MIC) >> I CAN REPEAT THE QUESTIONS IF THAT'S MORE EFFICIENT. >> SO MY QUESTION IS THE CENSUS TRACKS THAT YOU DO HAVE, THE 400 SOME ODD SENS IS TRACKS, DO YOU YET HAVE INFORMATION ON HOW MANY OF THOSE WOULD BE IN HIGHER INCOME BRACKETS SO YOU KNOW IF IT'S FEASIBLE TO LOOK AT THAT ASPECT TO SEE? >> IT IS FEASIBLE. I DON'T HAVE IN MY MEMORY HOW MANY OF THEM ARE BUT WE IDENTIFIED SEVERAL CENSUS TRACKS ALSO IN MARYLAND SEVERAL IN PRINCE GEORGE COUNTY THAT MET THE CRITERIA, THAT'S WHERE WE'RE HOPING TO DO THE NEXT DATA COLLECTION. SO THOSE TRACKS DO EXIST, THE HIGH INCOME TRACKS DO EXIST. MOSTLY SUBURBAN AREAS THOUGH. >> ANOTHER MAYBE MORE SUBSTANTIVE QUESTION THAN MY LAST. THIS IS REALLY OBVIOUSLY VERY, VERY INTERESTING FINDINGS. BUT IN TERMS OF THINKING ABOUT IMPLEMENTATION SORT OF IMPLICATIONS OF WHERE DO WE GO FROM HERE, WHAT ARE THE NEXT STEPS FOR RESEARCHERS, THOSE IN THE POLICY REALM, THE BEST NEXT STEPS, WHAT IS BEING DONE AND PREFERABLY IF YOU CAN TOUCH UPON WHAT SHOULD BE DONE WITH THIS TYPE OF INFORMATION, WHAT ARE THE KEY AUDIENCES THAT YOU FORESEE AND WHAT ARE THINGS FOLKS AT PLACES LIKE THE NIH CAN CAN DO TO POSITIVELY IMPACT THESE DISPROPORTIONATELY AFFECTED COMMUNITY? >> THERE'S A SOFTBALL QUESTION. GIVE ME A GRANT. JUST KIDDING. THAT WAS A JOKE. THAT WAS A JOKE. THAT WAS A JOKE. WELL SO I DID ACTUALLY INTEND TO END WITH SOME TALK ABOUT POLICY IMPLICATIONS BUT ESSENTIALLY YOU CAN DEAL WITH SOCIAL DETERMINANTS OF HEALTH BY EITHER WE -- WE DECIDED CULTURALLY TO DEFINE SOCIAL STATUS IN A WAY THAT WE CREATE SOCIAL HIERARCHIES. OR WE CAN UNDEFINE THAT, WE CAN MAKE INSTEAD OF MAKING RACE AN IMPORTANT DETERMINANT WHERE YOU ARE PLACED IN THE SOCIAL HIERARCHY, WE CANNOT DO THAT. THAT WOULD BE THE SIMPLISTIC RESPONSE. FILLING AT THAT, WE CAN LOOK TO INTERVENE. THERE ARE OTHER WAYS WE CAN INFUSE PROTECTIVE CHARACTERISTICS INTO COMMUNITIES THAT ARE HIGH RISK. IN OTHER WORDS, THROUGH POLICY CAN WE DO MORE TO REDUCE RISK, EXPOSURE IN CERTAIN COMMUNITIES. DO MORE TO MAKE SURE WE HAVE ADEQUATE RESOURCES SO WE DON'T HAVE FOOD DESERTS, MEDICAL DESERTS OR PLACES THAT PRODUCE SICK PEOPLE BY VIRTUE OF THEIR CHARACTERISTICS. WE CAN ALSO PROBABLY A LESS EFFECTIVE APPROACH IS TO HELP PEOPLE TO BECOME MORE RESILIENT AND HAVE BETTER COPING STRATEGIES SO THEY CAN MANAGE LIVING IN ENVIRONMENTS LIKE THAT. THE FOURTH APPROACH WOULD BE TO THROUGH USE OF MEDICAL CARE WAIT UNTIL PEOPLE GET SICK AND THEN PROVIDE EVEN MORE MEDICAL RESOURCES TO TRY TO MAKE THEM BETTER. THOSE ARE THE FOUR APPROACHES WE CAN TAKE TO ADDRESSING SOCIAL DETERMINANTS. AS FAR AS THE RESEARCH WHERE IT SHOULD GO, I KNOW WHERE WE'RE GOING IN THE RESEARCH, WE'RE GOING TO CONTINUE TO DO THIS WORK. WE WANT TO DO EVEN MORE TO BEGIN TO INTEGRATE THE SOCIAL BEHAVIORAL AND BIOLOGICAL SCIENCES TOGETHER. AND MULTIPLE LEVEL OF FACTORS AND MULTIPLE DISPARITIES WITHIN THIS CONTEXT. WE LIKE DIFFERENT COMMUNITIES, DIFFERENT CHARACTERISTICS, URBAN VERSUS RURAL, DIFFERENT REGIONS OF THE COUNTRY AND SEE IF THE RESULTS WE'RE GETTING HERE HOLD UP, IF WE'RE ABLE TO LOOK AT DIFFERENT TYPES OF COMMUNITIES. I ALSO THINK LOOKING AT SOCIALLY TRAJECTORY IS VERY IMPORTANT. THAT WE DO HAVE -- IT IS TRUE THAT IN THE UNITED STATES FOR THE MOST PART THE SOCIAL CLASS YOU HAVE GONE INTO WILL BE THE SAME SOCIAL CLASS YOU WILL LIVE YOUR ENTIRE LIFE IN, MOST PEOPLE WILL LIVE AND DIE POOR. MOST PEOPLE BORN AFFLUENT WILL LIVE AND DIE AFFLUENT. BUT THERE IS SOCIAL MOBILITY, THERE IS PEOPLE ABLE TO CROSS SOCIAL STATUS ACROSS THEIR LIFE SPAN. WE WANT TO LOOK AT THAT AND SEE SOCIAL MOBILITY, HOW SOCIAL MOBILITY MIGHT BE INTERACTING WITH RACE TO EFFECT DISPARITIES. YES. >> IN THE BEGINNING YOU SHOWED SLIDES THAT HAD TIGER WOODS, COLIN POWELL AND OBAMA. AND (INAUDIBLE) IN YOUR OPINION INCORRECT TO CONSIDER PEOPLE OF DIFFERENT ETHNIC BRAC GROUNDS ALL ONE RACE. AND THEN LATER IN OTHER STUDIES I SEE THERE'S BLACK AND WHITE SEEMS TO ME PEOPLE (INAUDIBLE) ALL CHECK THE SAME BOX EVEN THOUGH THEY COME FROM DIFFERENT BACK GROUND. IN MY EXPERIENCE AT NIH HE HAS A PROBLEM IN OUR SYSTEM WHERE ONE SYSTEM, THE CRIST SYSTEM ONLY HAS CERTAIN CHECKS, THERE IS NOT A SPAN OF CLASS, PEOPLE THAT NEED TO COME FROM OTHER HISPANIC BACKGROUNDS, WHITE, BLACK, OTHER MIXED RACE, BUT THERE IS A CONSISTENT WAY TO SEE THEM THRRVETION NOT SOME INDIAN PEOPLE CHECKED (INAUDIBLE) INDIAN BACKGROUND CHECK, OTHER SOME CHECKED ASIAN CLASS. HOW CAN WE AS RESEARCHERS FIND A SYSTEM THAT ADEQUATELY ADDRESSES THESE SORT OF MORE NUANCE ISSUES? AND HOW TO BE CONSISTENT SO THAT EVERYBODY SHOWS UP IN YOUR SETTING, IN OUR STUDY, AND ALL THE OTHER STUDIES IN AN APPROPRIATE MANNER? >> OKAY. FIRST LET ME SAY THAT HUMAN VARIATION DOES NOT CONFORM TO CATEGORIES. THAT'S THE FIRST PROBLEM. WE'RE TAKING HUMAN VARIATION AND PUTTING INTO CATEGORIES. THERE'S A LARGE PERCENTAGE OF PEOPLE THAT FIT COMFORTABLY INTO CATEGORIES BUT A LARGE PERCENTAGE OF PEOPLE DO NOT FIT INTO THESE CATEGORIES. THE PROBLEM IS WE'RE TAKING THIS SPECTRUM, THIS INHERENTLY CONTINUOUS VARIABLE AND TRYING TO MAKE AN INTERESTING CATEGORY. HAVING SAID THAT, IF YOU'RE GOING TO DO THAT, OFFICE OF MANAGEMENT AND BUDGET IN 1997 REISSUED DIRECTIVE 15 WHICH ESTABLISHES FEDERAL POLICY HOW DATA OUGHT TO BE COLLECTED ON RACE ETHNICITY. EXECUTIVE 15 IS NOT PERFECT, IT WASN'T PERFECT WHEN FIRST ISSUED IN '77, AND '97 REVISION WAS AN IMPROVEMENT BUT P STILL NOT PERFECT BUT IT DOES CREATE A POLICY MOST PEOPLE, RESEARCHERS THAT I KNOW FOLLOW DIRECTIVE 15 ACTUALLY FRANKLY STUNNED TO KNOW THAT NIH DOES NOT FOLLOW DIRECTIVE 15. THAT'S INTERESTING. GLAD WE GOT THAT ON TAPE. >> IT WASN'T MEANT TO BE RECORDED I DON'T BELIEVE IN THE RESULTS OF OUR STUDY BUT IT WAS FOR A FORM TO BE FILLED OUT. ONE SYSTEM CRIST, ONE ATV AND THEY'RE NOT EXACTLY THE SAME, AND (INAUDIBLE) I BELIEVE THERE WAS AN OPTION IN ONE SYSTEM TO CHOOSE HISPANIC, THE OTHER SYSTEM IN TERMS OF PUBLISHING RESULTS BUT SOME KIND OF CONTINUING REVIEW. >> SO I'M GOING TO ANSWER -- IF WE'RE GOING TO CONTINUE TO CATEGORIZE PEOPLE INTO RACE GROUPS, CONTINUE TO ACKNOWLEDGE RACE, AS IF IT WERE A REALITY, THEN WE OUGHT TO DO IT IN SYSTEMATIC AND CONSISTENT WAY. AND I THINK WE HAVE THE POLICY DIRECTIVE 15 WHICH IS WHERE IT IS AT THIS POINT. >> FROM THE OFFICE OF MANAGEMENT AND BUDGET. >> THANK YOU. I'LL LOOK THAT UP. >> LET ME STRESS THAT IT'S NOT -- IT'S NOT PERFECT. THERE ARE ISSUES WITH IT. BUT IT AT LEAST CREATES A BENCHMARK AND I WOULD THINK ALL DATA SYSTEMS SHOULD BE USING THAT. >> I HAVE A QUESTION ABOUT I KNOW A LOT OF GIS RESEARCHERS STRUGGLE WITH HOW TO CAPTURE SEGREGATION AND CENSUS TRACKS AND SORT OF THE BEST WE USUALLY HAVE IS THE CENSUS TRACK ITSELF. WONDERING IF YOU HAD MORE SUCCESS IN YOUR ANECDOTALLY IN YOUR EXPERIENCE TELLING WHETHER OR NOT WITHIN THESE 425 TRACKS HOW SEGREGATED THEY ARE AND WHETHER OR NOT LIKE THAT SEGREGATION PLAYS INTO YOU COMES, DO YOU STILL SEE THAT ARE DIFFERENT. >> WE DID DO THAT, YES. SO WITHIN CENSUS TRACKS WE HAVE BLOCK GROUPS WEDNESDAY DIVIDED THE BLOCK GROUPS FURTHER INTO WHAT WE REFER TO AS MINI NEIGHBORHOODS. SO WE CREATED SMALL GEOGRAPHIC AREAS THAT WERE ABOUT 8 BLOCK GROUP ACE CROSS THE TWO TRACKS AND WE CREATED NINE MINI HOODS WITHIN THE BLACK GROUPS. CITY BLOCK. WE HAD DATA HONESTY BLOCK AND WITHIN THAT WE HAD A SMALLER GEOGRAPHIC AREA WHICH IS THE STREET SEGMENT, YOUR STREET BETWEEN THE TWO BLOCKS WE LIVE IN. SO SO WE CAPTURE DATA IN EACH GEOGRAPHIC AREA WHICH ALLOWED EXTREMELY DETAILED DATA ON SEGREGATION WITHIN THE COMMUNE COMMUNITY. THERE IS SOME. PEOPLE ARE LIVING NEXT TO EACH OTHER BUT THERE WAS A TENDENCY OVERALL FOR WHITES TO LIVE TO BE SOUTH EASTERN SEGMENT OF THE CENSUS TRACKS AN BLACKS LIVING MORE TO THE NORTHWESTERN SEGMENT BUT THERE WAS A TREMENDOUS AM OF INTEGRATION, THE ANALYSIS THAT WE DID WHEN WE TRIED TO LOOK AT WHETHER THAT VARIABLE WAS PREDICTIVE DIDN'T PAN OUT TO SHOW ANYTHING. SO IT SEEMED THAT WITHIN -- WE'RE TALKING ABOUT A THREE SQUARE MILE AREA. THERE IS A SMALL GEOGRAPHIC AREA. WE DID ALL THE COLLECTIONS ON FOOT, WE WALKED THE COMMUNITY AND COLLECTED THE DATA. WE TRIED TO LOOK AT SEGREGATION EVEN WITHIN THIS SMALL AREA IT DIDN'T APPEAR PREDICTIVE TO ANYTHING SO FAR. >> THANK YOU. >> CAN YOU COMMENT ON ANOTHER POTENTIALLY ECOLOGICALLY VARIABLE DISTRIBUTION INCOME AND EQUALITY. I LAKE YOUR VIEWS ON THE OVERALL EFFECT AND IF YOU CAN CLEAR THE EFFECT OF THIS FACTOR IN DIFFERENT GROUPS. AND ALSO CAN THE JENNIE INDEX BE MEASURED IN THE CENSUS TRACK LEVEL? >> YOU COULD DO A CO-EFFICIENT IN THE CENSUS TRACK. YOU CAN DO THAT IN ANY GEOGRAPHIC AREA. YOU CAN DO THAT. >> MAYBE CAPTURE ELECTRICALLY TO CAPTURE THE DATA. >> YOU HAVE TO DO THAT IN DATA COLLECTION I THINK TO HAVE ENOUGH CASES. I THINK YOU COULD DO IT THAT'S WHAT IT WOULD TAKE YOU CAN PROBABLY DO IT IN OUR DATA ACTUALLY. MY SENSE THOUGH THERE IS NOT A LOT OF INCOME VARIATION IN OUR SAMPLE. SO IT'S A UNIFORMLY LOW INCOME AREA. THERE WAS A SMALL SEGMENT TO THE NORTHERN PART WHERE YOU HAD HIRING PEOPLE THERE. BUT THEY'RE CERTAINLY NOT DRIVING THE STATISTICS. >> I'M INTERESTED IN YOUR VIEWS NATIONALLY. NOT SURE WHETHER COMMENT IN THE NEW YORK TIMES ABOUT SPHK SWIX AND EQUALITY BUT IT'S AN IMPORTANT ISSUE AND I WOULD LIKE TO KNOW WHAT YOU THINK ABOUT IT, HOW IT PLAYS OUT IN TERMS OF HEALTHCARE AND MORBIDITY AND MORTALITY, UNLESS THAT'S NOT WITHIN YOUR PURVIEW. >> INCOME INEQUALITY, IT -- I THINK THAT'S SEVERAL WAYS WE CAN GO WITH THAT. ONE MORE IMPORTANT ASPECT OF IT IS INCOME IS TIED WITH EMPLOYMENT AND ACCESS TO HEALTH INSURANCE IS TIED TO EMPLOYMENT. SO THAT CERTAINLY ONE PATHWAY I THINK WE HAD THIS INEQUALITY. WHEN YOU LOOK AT INTERNATIONAL RANKINGS OF HEALTH OUTCOMES, THE UNITED STATES COMPARED TO OTHER INDUSTRIALIZED SOCIETIES, WE FIND THAT TYPICALLY THE UNITED STATES WE HAVE HEALTH OUTCOMES THAT ARE NOT AS GOOD AS YOU WOULD EXPECT, GIVEN THE SIZE OF OUR ECONOMY. WE HAD THE BIGGEST ECONOMY IN WORLD HISTORY. THE BIGGEST ECONOMY EVER EXISTED BUT WE DON'T HAVE HEALTH OUTCOMES THAT YOU MIGHT EXPECT. LARGELY BECAUSE OF INCOME INEQUALITY BECAUSE THE STATISTICS, YOU HAVE THE INCOME BEING CONTROLLED BY INCREASINGLY SMALLER PERCENTAGE OF THE TOTAL POPULATION, THEN YOU HAVE THE HEALTH STATISTICS BEING REFLECTION OF EVERYONE, SO WHEN YOU AVERAGE OUT TO MAKE NATIONAL RATES YOU HAVE RATES REFLECTING THE LOWER INCOME PEOPLE AS WELL. OTHER SOCIETIES WHERE YOU HAVE MORE INCOME INEQUALITY YOU HAVE LESS VARIATION IN HEALTH OUTCOMES ACROSS SOCIETY SO YOU HAVE SMALLER STANDARD ERRORS AND INCOME -- THE -- THIS WAS PROBABLY A BETTER REFLECTION OF THE OVERALL SOCIETY THAN WHAT WE HAVE IN THE UNITED STATES. SO INCOME INEQUALITY COMPLICATES OUR ABILITY TO DO THAT CROSS-NATIONAL COMPARISON BECAUSE OF THAT. >> THIS QUESTION SORT OF SPEAKS WHAT YOU'RE ADDRESSING NOW. THANK YOU SO MUCH FOR THE DATA THAT YOU HAVE PRESENTED, IT'S BEEN INSIGHTFUL. A LOT OF AFFLUENT AFRICAN AMERICANS NOW ARE FIRST GENERATION AFFLUENT. THEY COME FROM LOWER SES TYPICALLY. AS AFFLUENCE INCREASES IN MINORITY OPPORTUNITIES, AS OPPORTUNITIES AND EDUCATION INCREASES HOW DO YOU THINK THAT MIGHT IMPACT THESE HEALTH DISPARITIES THAT WE COMMONLY ASSOCIATE WITH RACE, SAY FIVE TO TEN YEARS FROM NOW AS YOU HAVE MORE SECOND GENERATION STUDENTS WHO ARE COLLEGE AND PROFESSIONALLY TRAINED OR HIGHER SES OR WHEN YOU LOOK AT SUBURBAN COMMUNITIES WHERE MINORITY POPULATIONS MAJORITY BLACK AND WHITE LIVE IN MORE SIMILAR SES TYPE OF AREAS, HOW DO YOU THINK THAT MIGHT IMPACT THESE DISPARITIES WE LOOK AT? >> SEVERAL DIFFERENT WAYS. ONE, YOU'RE GOING TO HAVE BIFURCATION WITHIN THE BLACK COMMUNITIES SO YOU'LL HAVE THOSE WHO HAVE BEEN ABLE TO BE UPWARDLY MOBILE ECONOMICALLY AND DO BETTER THAN THOSE LEFT BEHIND. AND YOU'RE GOING TO HAVE GREATER CONCENTRATION OF POVERTY AMONG THOSE LEFT BEHIND WHICH IS PART OF WHAT WE'RE GOING TO RELEASE IN THAT REPORT TOMORROW. BUT THEN WHEN YOU COMPARE THE UPWARDLY MOBILE BLACKS TO WHITE COUNTER PARTS YOU STILL I THINK WILL FIND DISPARITIES THAT EXIST BECAUSE YOU STILL HAVE -- FIRST OF ALL YOU HAVE THE STRESS OF SOCIAL MOBILITY AND HOW THAT ENDOWMENT OF CHILDHOOD AND POVERTY MAYBE IMPACTING THE OUTCOMES. BUT ALSO YOU'RE GOING TO STILL HAVE EXPOSURE TO RACISM AND DISCRIMINATION AND OTHER STRESSORS THAT ARE GOING TO BE HAVING A DIFFERENTIAL IMPACT. SO I THINK THAT INCREASING SIZE OF THE BLACK MIDDLE CLASS HAS A POSITIVE EFFECT IN OVERALL HEALTH BUT IT WILL BE SOMEWHAT MUTED I THINK. >> THANK YOU. >> I WAS STRUCK BY YOUR COMMENT WHEN YOU SAID MOST PEOPLE WHO ARE BORN, MOST PEOPLE STAY IN THE CLASS UNTO WHICH THEY WERE BORN. I'M WONDERING HOW EDUCATION IMPACTS THAT IF SOMEBODY IS BORN POORER OR LORE CLASS AND THEY HAVE AN EDUCATIONAL OPPORTUNITY DOES THAT MEAN THEY WILL STAY IN THAT CLASS, MOVE OUT, HOW DOES EDUCATION PLAY INTO THAT? >> EDUCATION IS USUALLY THE PATHWAY OUT OF LOWER SOCIAL ECONOMIC STATUS. THOSE ABLE TO TAKE ADVANTAGE OF EDUCATIONAL OPPORTUNITIES AND CHANGE SOCIAL CLASS STATUS, THOSE ARE THE ONES THAT MAKE IT OUT OF POVERTY. WE'RE GOING TO FIND PEOPLE LIKE THAT WHEN WE GO TO PRINCE GEORGE COUNTY, UPWARDLY MOBILE BY USING EDUCATION AS A PATHWAY OUT. THE FACT IS THOUGH MOST PEOPLE IF YOU WILL LIVING IN A LOW INCOME ENVIRONMENT, YOU'RE GOING TO SAY LESS PROFICIENT SCHOOLS IN THESE URBAN AND LOW INCOME ENVIRONMENTS ARE NOT GOING TO BE UPWARDLY MOBILE BECAUSE THE SCHOOLS TYPICALLY ARE NOT DOING A GOOD JOB OF PRODUCING THAT. WE HAVE A HIGH SCHOOL GRADUATION RATE IN BALTIMORE 35% OF BLACK MALES SO THE MAJORITY OF BLACK MALES IN BALTIMORE CITY ARE NOT HIGH SCHOOL EDUCATIONS AND ARE NOT UPWARDLY MOBILE BY DEFINITION. I DON'T THINK THAT'S UNUSUAL, OTHERS MAY HAVE SIMILAR STATISTICS. SO IT'S THOSE THAT ARE ABLE TO GET THOSE EDUCATIONAL OPPORTUNITIES, THOSE UPWARDLY MOBILE, USUALLY THROUGH EDUCATION IF THAT HAPPENS, IF THEY'RE ABLE TO MOVE TO THE DIFFERENT SOCIAL CLASS. THIS IS NOT RACE ISSUE, IT'S FOR ALL AMERICAN, MOST PEOPLE DO NOT CHANGE SOCIAL CLASS, WHATEVER CLASS YOU'RE BORN INTO TYPICALLY IS THE SOCIAL CLASS YOU'LL REMAIN IN. WE GO ON TO COLLEGE CAMPUSES, STUDENTS FIND IT HARD TO BELIEVE THAT BECAUSE THEY THEMSELVES MAYBE UPWARDLY MOBILE AND ALL MY FRIENDS ARE BUT BECAUSE COLLEGE IS WHERE THE UPWARDLY MOBILE PEOPLE COME TOGETHER IN ONE PLACE. SO THE PERCEPTION IN REALITY YOU LEFT MORE BEHIND IN THE OLD NEIGHBORHOOD THAN YOU BROUGHT WITH YOU INTO COLLEGE. SOCIAL MOBILITY IS PART OF THE AMERICAN ETHOS, THE IDEA THAT THROUGH MERIT AND HARD WORK WE CAN PULL OURSELVES UP BY THE BOOT STRAPS. THE EVIDENCE CLEARLY SHOWS THAT IS THE MINORITY PEOPLE IN THIS COUNTRY THAT ARE ABLE TO DO THAT. AM I DEPRESSING YOU? I KNOW THIS IS THE NATURE OF WHAT I DO, I DEPRESS PEOPLE. I THINK WE'RE OUT OF QUESTIONS. >> DO YOU HAVE ANY MORE QUESTIONS FOR DR. LAVEIST? I WOULD LIKE TO THANK YOU FOR COMING. I ENCOURAGE EVERYONE TO GO TO CONSENSUS.NIH.GOV/MIND THE GAP. WE HAVE A COUPLE OF MIND THE GAP LECTURES COMING UP IN MARCH. THERE WILL BE MANY MORE. IF YOU'RE INTERESTING IN JOINING OUR LIST SERVE AT THE REGISTRATION TABLE, YOU CAN DROP YOUR BUSINESS CARD OR SIGN IN FOR THE REGISTRATION TABLE. AND THANK YOU AGAIN. [APPLAUSE]