I'M ALAN SCHECHTER, AND I WELCOME YOU TO THIS LECTURE IN THE BIOMEDICAL LECTURE SERIES SPONSORED BY THE OFFICE OF NIH HISTORY. WE ARE VERY PLEASED TO HAVE AS OUR SPEAKER TODAY DR. OTIS BRAWLEY, WHO IS THE BLOOMBERG DISTINGUISHED PROFESSOR OF ONCOLOGY AND EPIDEMIOLOGY AT JOHNS HOPKINS, WHO WILL TALK TO US TODAY ON THE EVOLUTION OF MINORITY HEALTH RESEARCH. BEFORE I GO FURTHER ABOUT TODAY'S TALK, AND DR. BRAWLEY, I'D JUST LIKE TO MENTION THAT WE ARE VERY PLEASED THAT AN INDIVIDUAL WAS RECENTLY DESIGNATED AS THE OFFICIAL NIH HISTORIAN, STARTING I THINK NEXT WEEK, DR. KIM PELLIS, WHO HAS BEEN A SENIOR STAFF MEMBER IN THE OFFICE OF THE NIH DIRECTOR FOR MANY YEARS, WHO WILL BECOME THE DIRECTOR OF THE OFFICE OF NIH HISTORY AND THE STETTEN MUSEUM VERY SHORTLY. BUT NOW LET ME RETURN TO TODAY'S TALK AND OUR SPEAKER. DR. BRAWLEY WAS TRAINED IN MEDICINE AT THE UNIVERSITY OF CHICAGO, AND THEN DID FURTHER INTERNAL MEDICINE TRAINING AT THE UNIVERSITY OF MICHIGAN BEFORE COMING TO THE NIH, THE NATIONAL CANCER INSTITUTE, IN 1988, TO DO AN ONCOLOGY FELLOWSHIP, WHERE HE REMAINED FOR 13 YEARS, JOINING THE STAFF OF THE NCI. BUT IN 2001, HE WAS RECRUITED TO ATLANTA, TO EMORY UNIVERSITY SCHOOL OF MEDICINE, AS MEDICAL DIRECTOR OF THE GEORGIA CANCER CENTER, AND ALSO AS A SENIOR PROFESSOR IN THE ONCOLOGY PROGRAM AT EMORY. FROM 2007 TO 2018, HE WAS ALSO THE MEDICAL AND SCIENTIFIC DIRECTOR OF THE AMERICAN CANCER SOCIETY IN ATLANTA, AND HAD A VERY DISTINGUISHED TRACK THERE, BEING INVOLVED IN MANY DIFFERENT STUDIES, INCLUDING HEALTH DISPARITIES AND THE ROLE OF SCREENING IN DIAGNOSING AND EVEN OVERDIAGNOSING CANCER IN THE COUNTRY AND IN THE WORLD, IN FACT. IN 2018, DR. BRAWLEY LEFT ATLANTA AND CAME TO HOPKINS, WHERE HE IS A PROFESSOR OF ONCOLOGY AND EPIDEMIOLOGY AS I MENTIONED. HE ALSO HAS ROLES IN THE KIMMEL CANCER CENTER THERE, AND THE SCHOOL OF PUBLIC HEALTH. EARLIER THIS WEEK HE PRESENTED A TALK TO THE NIMH INNOVATIVE SEMINAR SERIES ON BEHAVIORAL EFFECTS ON CANCER INCIDENCE AND OUTCOMES, BUT TODAY'S TALK IS COMPLEMENTARY TO THAT TALK IN WHICH HE WILL TALK ABOUT HIS OWN THOUGHTS AND PERSPECTIVE ON THE EVOLUTION OF MINORITY HEALTH RESEARCH. IT'S GOING FROM VARIOUS TITLES, INCLUDING SPECIAL POPULATIONS AND HEALTH DISPARITIES TO ITS CURRENT FORM, WHICH HE WILL PRESCRIBE HISTORICALLY AND HIS PERSPECTIVES FOR THE FUTURE. IN THE MEANWHILE, I'D LIKE TO TURN THE SCREEN OVER TO PROFESSOR BRAWLEY FOR HIS TALK ON MINORITY HEALTH RESEARCH. DR. BRAWLEY. >> THANK YOU. I WANT TO THANK DR. SCHECHTER, MY OLD FRIEND DR. GOTTESMAN, DR. WANJEK FOR ARRANGING THIS. IT IS REALLY A PRIVILEGE TO BE HERE AND A PRIVILEGE TO TALK A LITTLE BIT ABOUT HISTORY AND THE NIH. I REALLY GREW UP AT THE NIH, AND REALLY BECAME A DOCTOR THERE SO I'M VERY FOND OF IT. I AM A PROFESSOR AT THE SCHOOL OF PUBLIC HEALTH AT JOHNS HOPKINS AND THE SCHOOL OF MEDICINE AT HOPKINS. IN ADDITION, I DO SOME CONSULTING BOTH FOR THE NIH, CDC, THE DEPARTMENT OF DEFENSE AND SEVERAL COMPANIES. NONE OF THIS TALK HAS TO DO ABOUT ANY OF THOSE EXCEPT A LOT HAS TO DO ABOUT THE NIH. I'M GOING TO TELL YOU RIGHT NOW, I WAS TAUGHT FROM AN EARLY AGE THAT YOU SHOULD LABEL THINGS WHAT YOU KNOW, WHAT YOU DON'T KNOW AND WHAT YOU BELIEVE, BUT QUESTION WHAT YOU KNOW MORE SO THAN ANYTHING ELSE, BUT QUESTION ALL THINGS. AND THESE ARE GOOD RULES FOR HEALTHCARE. AND I'M GOING TO APPLY THAT TO A FEW THINGS AS I MAKE A FEW COMMENTS DURING THIS TALK. WE'RE GOING TO TALK ABOUT THE EVOLUTION OF AN ACADEMIC DISCIPLINE. IT WAS FIRST CALLED MINORITY HEALTH BACK IN THE 1970s AND 80s, AND THEN SPECIAL POPULATIONS HEALTH, IT EVOLVED INTO HEALTH DISPARITIES OR THE STUDY OF DISPARITIES IN HEALTH UNDER THE LEADERSHIP OF DAVID SANCHER. OTHERS HAVE STARTED CALLING IT HEALTH EQUITY AND IT'S NOW STARTING TO BLOOM INTO THE PHRASE "HEALTH JUSTICE." MORE ON THAT IN A BIT. WHEN WE TALK ABOUT HEALTH EQUITY, I WANT YOU TO THINK ABOUT THE FOLLOWING. EQUALITY IS EVERYBODY GETS THE SAME THING. EQUITY REALIZES THAT SOME PEOPLE, SOME GROUPS, SOME POPULATIONS WHEN WE'RE DOING HEALTH, MAY NEED A LITTLE BIT MORE THAN OTHER POPULATIONS TO GET TO WHERE WE ALL WANT TO BE. SOME PEOPLE MAY NEED A LITTLE BIT MORE. NOW, HOW CAN WE PROVIDE ADEQUATE HIGH QUALITY CARE TO INCLUDE PREVENTIVE SERVICES AND PREVENTIVE SERVICES ARE FREQUENTLY FORGOTTEN, IS ONE OF THE MOST IMPORTANT QUESTIONS THAT WE CAN ASK. HOW CAN WE PROVIDE ADEQUATE HIGH QUALITY CARE TO POPULATIONS THAT SO OFTEN DON'T RECEIVE IT? I WANT TO START OUT WITH A LITTLE HISTORY. REVEREND RICHARD ALEB ALLEN AND REVEREND ABSALOM JONES WERE TWO BLACK MINISTERS TOWARDS THE END OF THE 17 HUNDREDS LIVING IN PHILADELPHIA. THIS WERE ONLY ABOUT 50,000 PEOPLE IN PHILADELPHIA AT THE TIME, ALTHOUGH IT WAS THE LARGEST CITY IN THE THEN EARLY UNITED STATES. IN 1793, THERE WAS A YELLOW FEVER EPIDEMIC. IT WAS BELIEVED WIDELY THAT BLACK PEOPLE, NEGRO PEOPLE, DID NOT GET YELLOW FEVER, THIS WAS ONLY SOMETHING THAT WHITE PEOPLE GOT. AS A RESULT, THERE WERE ALL KINDS OF REQUESTS THAT NEGROES COME AND NURSE THE SICK, BURY THE DEAD, AND SO FORTH. THIS WAS WRITTEN BY ALLEN ABOUT THE FACT THAT BLACKS ACTUALLY DID GET YELLOW FEVER. THIS WAS THE BEGINNING, AT LEAST THE FIRST THAT I CAN FIND DOCUMENTED WHERE THERE WAS THIS DIFFERENCE BETWEEN BLACK AND WHITE OR NEGRO AND CAUCASIAN BIOLOGY. AND THAT'S GOING TO BE A THEME FOR THE REST OF THIS TALK THAT WE HAVE BEEN STUCK ON THIS THING ABOUT RACE FOR SO LONG. NOW THIS HAS BEEN WRITTEN ABOUT A FEW TIMES. HARRIET WASHINGTON WROTE THE MOST AUTHORITATIVE BOOK THAT I KNOW OF CALLED "MEDICAL APARTHEID," AND IT TALKS ABOUT MEDICAL RESEARCH AND DIFFERENCES IN RACIAL TREATMENT OVER A PERIOD OF ABOUT 200 YEARS. ANOTHER WONDERFUL BOOK, "BAD BLOOD" BY JAMES JONES. THIS IS BAD BLOOD ABOUT THE TUSKEGEE SYPHILIS EXPERIMENT, NOT BAD BLOOD ABOUT THE COMPANY THERANOS. AND I WANT TO TELL YOU A LITTLE ABOUT THE TUSKEGEE SYPHILIS EXPERIMENT WHICH IS NOT REALLY APPRECIATED BY A LOT OF PEOPLE. FIRST, THE OFFICIAL NAME OF THE STUDY WAS THE STUDY OF UNTREATED SYPHILIS IN THE NEGRO MALE. AND BACK IN THE LATE 1920s, THERE WAS SIGNIFICANT SYPHILIS, ESPECIALLY IN THE SOUTHERN UNITED STATES. SYPHILIS CONTROL EFFORTS, WHICH WERE LARGELY SEX EDUCATION, IDENTIFICATION AND ISOLATION OF THE INFECTED, AND TREATMENT WITH MERCURIALS, OF ALL THINGS, WERE STYMIED BY THE DEPRESSION. MANY FELT THAT MONEY FOR SYPHILIS CONTROL, WHICH WAS SHORT, SHOULD BE SPENT ON THE WHITE POPULATION BECAUSE BLACKS DON'T DIE OF SYPHILIS. AGAIN, THIS THEORY THAT BLACKS ARE BIOLOGICALLY DIFFERENT FROM WHITES SUCH THAT AN INFECTIOUS DISEASE DOESN'T AFFECT BLACKS VERSUS WHITES. NOW, SOME OF WHAT I WILL CALL THE GOOD WHITE PEOPLE BACK IN THE LATE 1920s, ACTUALLY GOT INTO A LITTLE BIT OF TROUBLE WITH THEIR EXAGGERATION. THEY WOULD GO TO A 2 BY 2 BLOCK TENEMENT HOUSING PROJECT IN BIRMINGHAM, ALABAMA, TEST ALL THE MEN LIVING THERE FOR SYPHILIS, FIND THAT 25% OF THOSE MEN HAD SYPHILIS, AND THEN THEY WOULD SAY, SEE, WE DESPERATELY NEED TO SPEND MONEY ON SYPHILIS CONTROL IN THE BLACK POPULATION. 25% OF ALL BLACK MEN IN THE SOUTHERN UNITED STATES HAVE SYPHILIS. AND THEN, OF COURSE, THE MORE RACIST WHITES WOULD SAY, YOU'RE MAKING OUR POINT. THEY'RE NOT DYING. SHOW US THE BODIES IF 25% HAVE SYPHILIS. SO WHAT ENDED UP HAPPENING WAS THE U.S. PUBLIC HEALTH SERVICE, CDC DIDN'T EXIST AT THE TIME. THE U.S. PUBLIC HEALTH SERVICE ORGANIZED THE STUDY OF UNTREATED SYPHILIS IN THE MEE GROW MALE. WE IN THE NEGRO MALE. WE WOULD CALL THIS A CASE CONTROL STUDY TODAY. IT COMPARED 399 MEN WITH SYPHILIS WITH AN AGE MATCHED 201 MEN WHO DID NOT HAVE THE DISEASE. THEY WERE FOLLOWED OVER A PERIOD OF TIME TO SEE WHAT THE RESULTS OF SYPHILIS WAS. YOU SEE, IRONICALLY, THE TUSKEGEE SYPHILIS STUDY WAS DESIGNED TO SHOW THAT BLACK PEOPLE ARE LIKE WHITE PEOPLE. PARTICIPANTS UNFORTUNATELY WERE LIED TO. MOST WERE TOLD THEY HAD BAD BLOOD AND THEY THOUGHT THEY WERE ALL GETTING SOME KIND OF TREATMENT FROM THIS STUDY. IT WAS USUALLY VITAMINS. PARTICIPANTS GOT FREE MEDICAL EXAMS, FREE MEALS, BURIAL INSURANCE. THEY ALSO GOT TO DRIVE IN THE SHINY CARVE A BLACK NURSE WHO ORGANIZED THE ROUNDUPS. HERE'S A ROUNDUP WHERE MEMBERS OF THE STUDY WERE LOOKED AT ONCE A YEAR. THEY ACTUALLY HAD ROUNDUPS ONCE A YEAR FROM 1930 TO 1971. THEY GOT MEDICAL EXAMS, WHICH INCLUDED PAINFUL SPINAL TAPS, UNNECESSARY X-RAYs. I SHOULD NOTE THAT PENICILLIN BECAME THE TREATMENT OF CHOICE FOR SYPHILIS IN THE MID 40s, BUT THESE MEN WERE NOT TREATED. THE STUDY WAS ENDED IN 1972, AFTER THE ASSOCIATED PRESS PUBLISHED ARTICLES ABOUT IT. NOW THE STUDY WAS NEVER A SECRET. LOCAL DOCTORS WERE TOLD NOT TO TREAT THESE MEN IN 1936 AND BEYOND. RESEARCHERS KEPT THE MEN OUT OF THE DRAFT BECAUSE IF THEY WERE DRAFTED INTO THE MILITARY, THEY MIGHT BE DIAGNOSED AND TREATED. THE MAYCON COUNTY, ALABAMA MEDICAL SOCIETY, WHICH WAS A CHAPTER OF THE BLACK NATIONAL MEDICAL ASSOCIATION, ENDORSED THE STUDY IN 1969. THOSE OF YOU WHO REMEMBER HISTORY MAY RECALL THAT WE HAD A BLACK SURGEON GENERAL NOMINEE WHO LOST HIS NOMINATION BECAUSE HE WAS INVOLVED IN THIS, OR THERE WERE RUMORS HE WAS INVOLVED IN THIS. SEVERAL ARTICLES WERE PUBLISHED OVER THE YEARS IN MAJOR JOURNALS ABOUT THE TUS KEY GOA SYPHILIS STUDY. INTERESTINGLY, SEVERAL OF THESE ARTICLES WERE PUBLISHED IN PLACES LIKE THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION. SO THAT GIVES YOU A LITTLE PICTURE AGAIN OF THIS BELIEF THAT BLACK BIOLOGY IS DIFFERENT FROM WHITE BIOLOGY. THEN OF COURSE WE GO INTO THE 1960s, AND WE HAVE THE CIVIL RIGHTS MOVEMENT. THE CIVIL RIGHTS MOVEMENT BECOMES EVEN MORE OF AN APPRECIATION OF HEALTHCARE ISSUES. MANY PEOPLE DON'T REALIZE THAT IN THE 1960s, HOSPITALS WERE SEGREGATED BLACK VERSUS WHITE, SCHOOLS WERE SEGREGATED BLACK VERSUS WHITE, SCHOOLS INCLUDING MEDICAL SCHOOLS. IN THE 1970s, THE EARLY 1970s, RICHARD NIXON SIGNED THE NATIONAL CANCER ACT. NOW THIS PUT A LOT OF MONEY IN THE CANCER RESEARCH AND REVITALIZED THE NATIONAL NATIONAL CANCER INSTITUTE, BUT IT ALSO CREATED SOME PROGRAMS THAT GAVE US MORE AND MORE INFORMATION ABOUT OUTCOMES, AND IT HELPED TO STIMULATE THE BEGINNING OF OUTCOMES RESEARCH, NOT JUST IN CANCER BUT IN OTHER THINGS. ONE ASPECT OF THE NATIONAL CANCER ACT WAS THE CREATION OF THE NATIONAL CANCER INSTITUTE'S SURVEILLANCE EPIDEMIOLOGY END RESULTS PROGRAM. IT, ALONG WITH SOME OTHER STATE REGISTRIES, THEN ALLOWED US TO ACTUALLY GET INCIDENCE AND MORTALITY DATA AND FIGURE OUT WHAT SURVIVAL RATE WERE, FIGURE OUT WHO WAS GETTING CANCER. ALSO EVEN DO SOME WORK ON WHY THEY WERE GETTING CANCER. THE SEER PROGRAM EXISTS TO THIS DAY AND HAS DONE SOME MARVELOUS WORK. ONE EXAMPLE OF WHAT THEY DID WAS PLOT MORTALITY BY RACE. AND HERE, YOU CAN SEE INTO THE 1980s, THEY ONLY DID BLACK, WHITE, FROM 1975 ONWARD, AND YOU CAN SEE IN THE 1970s, INTERESTINGLY, THERE WAS NO DIFFERENCE IN BLACK OR WHITE MORTALITY FOR BREAST CANCER. FOR EVERY 100,000 BLACK WOMEN, IT WAS ABOUT 32 DEATHS A YEAR, FOR EVERY 100,000 WHITE WOMEN, IT WAS ABOUT 32 DEATH PER YEAR. THE SEER PROGRAM WHICH ACTUALLY GIVES US DATA USUALLY ABOUT THREE YEARS BEHIND. THE 2019 DATA IS COMING OUT RIGHT NOW. THE SEER PROGRAM DOCUMENTED INCREASING BREAST CANCER DISPARITY, BLACK VERSUS WHITE, FROM A TIME WHEN THERE WASN'T ONE. BY THE WAY, BY EXECUTIVE ORDER IN THE 1980s, RONALD REAGAN ORDERED THAT WE START COLLECTING AND PUBLISHING DATA FOR HISPANICS, NATIVE AMERICANS AND ALASKA NATIVES AND ASIANS, AND THAT'S WHY THE LINES FOR THOSE GROUPS START IN 1990. HERE YOU CAN SEE ALL THE WAY TO 2015. BUT IN THE LATE 1970s, EARLY 1980s, STARTING TO GET A SENSE OF SOME OF THESE DISPARITIES. NOW PATRICIA ROBERTS HARRIS WAS SECRETARY OF HEALTH EDUCATION AND WELFARE IN THE LATE CARTER ADMINISTRATION. SHE WAS ACTUALLY THE HUD SECRETARY BEFORE SHE WENT TO HEW. IT WAS CALLED HEW AT THAT TIME, FOR THOSE OF YOU WHO DON'T HAVE GREY HAIR. AND SHE STIMULATED SOME GREATER INTEREST IN STUDYING SOME OF THESE DIFFERENCES AMONG POPULATIONS. AT THAT TIME, IT WAS STILL CALLED MINORITY HEALTH. MARGARET MARY HECKLER WAS A REPUBLICAN CONGRESSWOMAN WHO PRESIDENT REAGAN APPOINTED TO BE SECRETARY OF HEALTH AND HUMAN SERVICES, EDUCATION HAD DROPPED OUT TO BE ITS OWN DEPARTMENT BY THIS TIME. AND MARGARET MARY HECKLER, OUR SECRETARY HECKLER WAS VERY INTERESTED IN THIS ISSUE, AND WITH THE ENCOURAGEMENT OF SEVERAL VERY PROMINENT BLACK PHYSICIAN, ONE OF WHOM YOU'LL SEE A PICTURE OF LATER, A MAN NAMED SULLIVAN, SHE COMMISSIONED THE HECKLER REPORT. AND HERE'S THE REPORT OF THE SECRETARY'S TASKS FORCE ON MY MORTGAGE HEALTH. THIS IS A GROUP OF PEOPLE WHO MET VERY MUCH LIKE THE SURGEON GENERAL'S TASK FORCE ON TOBACCO. THEY MET REGULARLY AND THEY PUBLISHED THIS VERY LARGE REPORT ABOUT BLACK AND MINORITY HEALTH, AND THIS REPORT ULTIMATELY CAUSED A NUMBER OF THINGS TO OCCUR. IT LED TO PIVOTAL LEGISLATION, FUNDING, POLICY, RESEARCH, AND INITIATIVES FOCUSED ON MINORITY HEALTH AND LATER HEALTH EQUITY. IT LED TO THE ESTABLISHMENT OF THE OFFICE OF MINORITY HEALTH, FIRST WITHIN THE DEPARTMENT OF HEALTH AND HUMAN -- THE NIH OFFICE OF MINORITY HEALTH UNDER THE LEADERSHIP OF JOHN ROFFEN ULTIMATELY BECAME AN INSTITUTE. NOW HERE'S LOU SULLIVAN, SECRETARY OF HEALTH AND HUMAN SERVICES IN THE GEORGE H.W. BUSH ADMINISTRATION, AND BEFORE THAT, WAS A MEMBER OF THE CANCER ADVISORY BOARD. HE WAS A REAL MOVER AND SHAKER IN THIS AREA OF MINORITY HEALTH. THIS TIME THE EMPHASIS WAS ON RACE, AND MINORITY HEALTH CULMINATED WITH THE 1993 NIH REVITALIZATION ACT, WHICH WE STILL LIVE WITH, WHICH SAYS THAT ALL NIH FUNDED PHASE 3 STUDIES SHALL BE DESIGNED SUCH THAT VALID SUBSET ANALYSIS CAN BE DONE BETWEEN THE RACES. HERE WE HAVE THAT SAME THEME OF RACE, RACIAL DIFFERENCES, AND BLACK-WHITE BIOLOGY BEING DIFFERENT. INDEED THERE WERE CONGRESSMEN WHO SAID THE BLACK-WHITE DISPARITIES ARE DUE TO MINORITIES NOT BEING INCLUDED IN CLINICAL TRIALS. I ACTUALLY THINK THAT'S WRONG. AND WE'VE DEVELOPED TREATMENTS FOR WHITE AND NOT BLACKS. THAT'S A DIRECT QUOTE FROM JESSE JACKSON, JR., WHO WAS THEN A CONGRESSMAN. THESE MANDATES FOR SUBSET ANALYSIS WERE MADE BECAUSE DRUGS MAY NOT WORK IN MINORITIES AS THEY WORK IN MAJORITIES, IT WAS SAID. TRUTH IS, AND WE'LL SHOW SOME DATA ON THIS, FOR MOST PART, THE DRUGS DO NOT WORK BECAUSE UNDERSERVED PEOPLE DON'T GET THE DRUGS. ONE OF THE THINGS THAT MOTIVATED THIS LEGISLATION, THERE WERE SEVERAL, BUT ONE THAT MOTIVATED THIS LEGISLATION, AN EXAMPLE OF HOW THIS CAN REALLY CAUSE THINGS TO BE MUCKED UP, IS THIS STUDY WAS PUBLISHED IN JAMA IN 1991. IT WAS ONE OF THE FIRST RANDOMIZED STUDIES TO SHOW THAT THE DRUG WAS EFFECTIVE IN DELAYING THE PROGRESSION OF HIV/AIDS. THERE WERE SEVERAL STUDIES THAT WERE PUBLISHED BY JAMA IN THAT YEAR, ACTUALLY IN THE SAME ISSUES, THAT SHOWED THAT WHITE PEOPLE BENEFITED MORE SO THAN BLACK PEOPLE FROM AS TEE., AND ZIDOVUDINE THERAPY. NOW, THE FOLKS WHO WROTE THIS PAPER WERE ACTUALLY SUCH THAT THEY DID EVEN FURTHER STUDY TO TRY TO FIGURE OUT WHY AZT WAS A BETTER TREATMENT FOR WHITES VERSUS BLACKS. THEY WERE ACTUALLY ABLE TO NAIL DOWN THAT THE BLACKS IN THE STUDY WERE SOCIOECONOMICALLY LESS SUPPORTED THAN THE WHITES IN THE STUDY, AND THE BLACKS IN THE STUDY DIDN'T TAKE THE DRUG AS OFTEN AS THE WHITES IN THE STUDY. INDEED ADHERENCE TO TAKING THE DWRUG WAS SOMEWHERE DRUG WAS SOMEWHERE AROUND 50% OF WHITE ADHERENCE TO TAKING THE DRUG. AGAIN, IF YOU DON'T TAKE THE DRUG, NOW THEY PUBLISHED THIS AND WENT ON TO PUBLISH OTHER STUDIES TO SHOW THAT AZT OR ZIDOVUDINE IS EFFECTIVE IN TREATING BLACKS OR NEGROES, BUT IT IS A FACT TO THIS DAY IN MANY OTHER URBAN CITY, I HEARD IT IN BALTIMORE LAST WEEK, THERE'S FOLKLORE THAT NIH DRUGS HAVE BEEN PROVEN NOT TO WORK IN BLACKS. NOW, IT INTERESTING, AZT ISN'T EVEN USED TO TREAT HIV ANYMORE, BUT THIS FOLKLORE THAT ANTI-AIDS DRUGS DON'T WORK IN BLACK PEOPLE IS STILL PERSISTENT, AND STILL A REASON MANY BLACKS AND ESPECIALLY IN AMERICA'S INNER CITIES, DON'T TAKE THE DRUGS. NOW, LEGISLATION LED TO MANY EFFORTS TO INCREASE MINORITY ACCRUAL. THERE HAVE BEEN NUMEROUS NIH-SPONSORED MEETINGS ON RECRUITMENT, ACADEMIC INSTITUTIONS ACTUALLY HAD TO DEVELOP RELATIONSHIPS, THAT'S THE ONE GOOD THING OUT OF THIS, AND THEN THERE'S SOME CLINICAL RESEARCH ORGANIZATIONS THAT MADE IT INTO A BUSINESS. THAT MAY NOT BE SUCH A GOOD THING. I'M ALSO PERSONALLY CONCERNED, I'VE BEEN OUTSPOKEN ABOUT THIS, THAT THE FEDERAL MANDATE PUTS UNDUE PRESSURE ON NIH-FUNDED RESEARCHERS, ESPECIALLY DATA MANAGERS, TO GIVE WHITE PATIENTS THE OPTION OF ENTERING A CLINICAL TRIAL AND GIVE BLACKS AND OTHER MINORITIES THE HARD SELL BECAUSE THEY REALLY NEED THE MINORITIES ON CLINICAL TRIALS. NOW, THE OTHER PROBLEM, OF COURSE, IS THERE'S NO SUCH THING AS A VALID SUBSET ANALYSIS, IT SCIENTIFICALLY IMPOSSIBLE. LET'S LOOK AT A CLINICAL TRIAL THAT I WAS INVOLVED WITH IN THE EARLY 1990s, WHEN I WAS AT THE NCI. THAT IS PACLITAXEL AND CISPLATIN VERSUS CYCLOPHOSPHAMIDE AND CISPLATIN. THE OLD STANDARD WAS CYCLOPHOSPHAMIDE AND CISPLATIN AND WE THOUGHT MIGHT BE PACLITAXEL AND CISPLATIN. WOMEN WITH OVARIAN CANCER WERE ENROLLED, 386 WERE FOUND TO BE ELIGIBLE AND RANDOMIZED TO EITHER GETTING PACLITAXEL AND CISPLATIN OR CISPLATIN AND CYCLOPHOSPHAMIDE. YOU CAN SEE OF 216 WITH MEASURABLE DISEASE, YOU CAN SEE 73% VERSUS 60%. MEDIAN PROGRESSION-FREE SURVIVAL WAS ALSO BETTER. PROPORTIONAL REPRESENTATION OF BLACK WOMEN WAS THERE, BY THE WAY. THERE WERE 26 BLACK PATIENTS. IF ONE BELIEVES THE ANSWER IS DIFFERENT IN BLACK WOMEN VERSUS WHITE WOMAN, YOU ACTUALLY NEED 216 BLACK WOMEN COMPARED TO 216 WHITE. YOU CAN'T DO IT WITH 26 OF THE 216 BEING BLACK. NOW, WE NEED TO WORRY ABOUT TREATMENT EFFECTIVENESS, ESPECIALLY IN A POPULATION, WE ALSO NEED TO WORRY ABOUT EFFICACY. WHEN I TALK ABOUT EFFECTIVENESS, WE'RE TALKING ABOUT IN AN IDEAL SITUATION LIKE IN CLINICAL TRIALS, WHERE THE DATA IS MORE PERFECT, THE PATIENT ARE HEALTHIER, EVEN THOUGH THEY HAVE CANCER, THEY'RE HEALTHIER, THEY VOLUNTEER TO GO INTO THESE TRIALS. THE PHYSICIANS ARE OFTEN MORE EXPERT AS WELL. EFFICACY IS HOW IS IT WORK -- DOES IT WORK IN THE REAL WORLD. SO OUR SEER AND POPULATION BASED REGISTRIES TELL US ABOUT EFFICACY, CLINICAL TRIALS TELL US ABOUT EFFECTIVENESS. NOW, FOR GENERALIZABILITY, WE WANT A POPULATION THAT MIRRORS THE POPULATION IN GENERAL, BOTH IN CLINICAL SETTING AND SOME OF THE EPIDEMIOLOGY I GET INVOLVED WITH, WE WORRY ABOUT PEOPLE TREATED AT UNIVERSITY HOSPITALS VERSUS PEOPLE TREATED IN COMMUNITY HOSPITALS. RICH VERSUS POOR, AS WELL AS WITH GENETICS, WE SHOULD PAY ATTENTION TO THINGS LIKE RACE. THE CLINICAL TRIALS PARTICIPANTS NEED TO BE A REPRESENTATIVE BIOPSY OF THE GENERAL POPULATION IF THIS MEDICAL AUDIENCE WILL LET ME GET AWAY WITH USING THE PHRASE "REPRESENTATIVE BIOPSY," IN ORDER FOR A FINDING TO BE GENERALIZABLE TO THAT ENTIRE POPULATION. THIS IS VERY DIFFERENT FROM APPLICABILITY. APPLICABILITY, BY THE WAY, IS A WORD NEVER SEEN IN THE NIH REVITALIZATION. APPLICABILITY IS SPECIFIC TO AN INDIVIDUAL OR THE PEOPLE WITH SPECIFIC GENETICS OR SPECIFI% TARGETS. THIS IS PERHAPS THE MOST WONDERFUL, GENTLE, SMART MAN I PERSONALLY HAVE EVER MET. DAVID IS SATCHER WAS THE 16TH SURGEON GENERAL OF THE UNITED STATE AND 11TH ASSISTANT SECRETARY OF HEALTH. HE MOVED US INTO THE AREA OF HEALTH DISPARITIES. HE BROADENED IT MUCH MORE SO THAN BLACK/WHITE BUT INTO OTHER RACES, SOCIOECONOMIC STATUS. I'M GOING TO SHOW YOU SOME DATA TO SHOW EVEN GEOGRAPHY. HE IS THE PERSON WHO YOU'D FIRST PUT THE TWO WORDS "HEALTH" AND "DISPARITIES" TOGETHER. IN MY FORREST GUMP LIFE, I WAS ACTUALLY IN MONROE WHEN HE SAID, I WANT TO START CALLING IT WHAT IT IS. DISPARITIES IN HEALTH, OR HEALTH DISPARITIES, AND LET'S SEE SOME POLITICIANS SAY WE WANT PROGRAMS TO HEALTH REDUCE DISPARITIES IN HEALTH. THE CONCEPT THAT SOME POPULATIONS, HOWEVER YOU DEFINE THEM, HAVE DIFFERENT OUTCOMES. AND POP LAILINGS ARE POPULATIONS CAN BE D EFINED IN A NUMBER OF WAYS. NOT JUST RACE. SEX OR GENDER, AREA OF GEOGRAPHIC ORIGIN, WHICH IS DIFFERENT FROM RACE, FAMILY OR TRIBE, ETHNICITY AND CULTURE. KEEP IN MIND, ETHNICITY AND CULTURE INVOLVES SOME ENVIRONMENTAL INFLUENCES ON HOW WE GET CANCER. ITALIANS ACTUALLY SMOKE CIGARETTES DIFFERENTLY THAN GERMANS. AREA OF RESIDENCE. SOCIOECONOMIC STATUS. ALL DIFFERENT WAYS OF DESCRIBING POPULATIONS, AND WE CAN SHOW DISPARITIES BY ANY OF THESE. NOW AGAIN, DISPARITIES ARE THE CONCEPT THAT SOME POPULATIONS DO WORSE THAN OTHERS. WORSE CAN BE INCIDENCE OF DISEASE, IT COULD BE MORTALITY, IT CAN BE SURVIVAL, IT CAN BE QUALITY OF LIFE. HERE I'M GOING TO SHOW YOU AGAIN SEER DATA LOOKING AT RACE, BLACKS IN BLUE, WHITES IN ORANGE, NATIVE AMERICANS, HISPANICS, AND ASIAN PACIFIC ISLANDERS, AND THIS IS DEATH RATE FROM 1990 TO 2017. NOW YOU CAN SEE THE BLACK DEATH RATE WAS HIGHER THAN THE WHITE DEATH RATE, BUT OVER TIME, IT'S GOTTEN CLOSER AND CLOSER TOGETHER. IF ONE IS INCREDIBLY OPTIMISTIC, ONE CAN IMAGINE A TIME ABOUT 2030, 2035, WHERE BLACK AND WHITE AND NATIVE AMERICAN DEATH RATES WILL ACTUALLY ALL KIND OF MERGE TOGETHER. WITH HISPANICS AND ASIAN PACIFIC ISLANDERS AND THEY'D STILL BE BELOW. NOW THESE CATEGORIES ARE DEFINED BY THE U.S. OFFICE OF MANAGEMENT AND BUDGET EVERY 10 YEARS. THEY ARE SEWS YOASH POLITICAL AND NOT BIOLOGIC BY OMB DEFINITION. RACE AS DEFINED IN BIOLOGY OR AS A BIOLOGIC CATEGORIZATION, HAS BEEN REJECTED BY THE ANTHROPOLOGICAL COMMUNITY AS NON-SCIENTIFIC. SOME CALL IT PSEUDOSCIENCE. RECENTLY, THE AMERICAN MEDICAL ASSOCIATION HAS ISSUED STATEMENTS REGARDING THE BIOLOGIC -- IT IS INCREDIBLY BROAD. AREA OF GEOGRAPHIC ORIGIN, ON THE OTHER HAND, WHICH IS DIFFERENT FROM RACE, IS MORE SPECIFIC AND A LITTLE BIT MORE SCIENTIFIC. I'M GOING TO SHOW YOU SOME EXAMPLES OF AREA OF GEOGRAPHIC ORIGIN AND SOME GENETIC DIFFERENCES. BUT ALZHEIMER'S BUT ADMIXTURE COMPLICATES BOTH. I'M REMINDED BY THE FACT THAT THEY CONSIDERED BARACK OBAMA BLACK IN 1970 AND WHITE IN 1980. THERE ARE 109 AREAS OF GEOGRAPHIC ORIGIN IN AFRICA, MORE THAN 600 IN EUROPE. AS WE STUDY MORE, THERE WILL BE MORE AREAS OF GEOGRAPHIC ORIGIN, BUT YOU CAN SEE SOME OF THESE NAMES AND SOME OF THESE AREAS, AND THIS IS TO SAY THAT -- TO CALL ALL BLACK PEOPLE AFRICAN IS WRONG. BY THE WAY, MOST AFRICAN AMERICANS ARE ABOUT 20 TO 30% EUROPEAN. SO ADMIXTURE IS INCREDIBLY IMPORTANT. IT'S NOT WHAT GENES YOU HAVE AS MUCH AS IT IS WHERE SPECIFIC GENES CAME FROM. RACE AS FACTOR IN OUTCOME. FREQUENTLY CONCERN IS EXPRESSED ABOUT BIOLOGICAL DIFFERENCES IN TREATMENT OUTCOME BY RACE. IN MOST CASES, DISEASE, CLINICAL TRIALS AND SINGLE INSTITUTION EXPERIENCES, I'LL SHOW YOU A FEW, SHOW THAT EQUAL TREATMENT YIELDS EQUAL OUTCOME AND RACE SHOULD NOT BE A FACTOR IN OUTCOME. NOW, RACE SHOULD NOT BE A FACTOR IN OUTCOME BECAUSE EQUAL TREATMENT YIELDS EQUAL OUTCOME, BUT THERE IS NOT EQUAL TREATMENT. IT IS RARE THAT A DRUG OR THERAPY DOESN'T WORK, IT IS COMMON THAT MINORITIES DON'T GET THE DRUG. RACE SHOULD NOT BE A FACTOR IN OUTCOME, BUT IT VERY FREQUENTLY IS. IT SHOULD NOT BE A FACTOR BIOLOGICALLY, AND IT IS NOT USUALLY A FACTOR BIOLOGICALLY, BUT IT IS A FACTOR SOCIOPOLITICALLY. THIS IS A NON-CANCER EXAMPLE, AND THIS IS FROM THE LITERATURE RIGHT NOW. WE HAVE FOR THE LAST 20 TO 30 YEARS USED A RACE-BASED ESTIMATE OF RENAL FUNCTION. WE'RE STARTING TO REALIZE THAT THAT RACE BASED ESTIMATE OF REAL FUNCTION IS WRONG, AND THE END RESULT OF US ASSUMING THAT BLACK RENAL FUNCTION IS BIOLOGICALLY DIFFERENT FROM WHITE RENAL FUNCTION IS A LARGE NUMBER OF PEOPLE WHO ARE BLACK WHO WOULD HAVE BEEN ELIGIBLE TO BE KIDNEY DONORS HAVE BEEN TOLD YOU HAVE KIDNEY DYSFUNCTION, YOU SHOULD NOT BE A DONOR. NOW, POPULATIONS DO DIFFER, AND THIS SHOULD BE KEPT IN MIND WHEN WE STUDY VAIR VARIOUS TREATMENTS. CYSTIC FIBROSIS, VERY COMMON, ESPECIALLY IN NORTHERN EUROPE, THE AREA AROUND DENMARK, THE NETHERLANDS. ALCOHOL DEHYDROGENASE DEFICIENCY. VERY COMMON IN EAST ASIA. PORTIONS OF CHINA AND PORTIONS, NOT ALL, OF JAPAN. AND PROSTATE CANCER INCIDENCE IN MEN FROM NORTHWEST SUB-SAHARAN AFRICA, NOT EAST, NOT SOUTH, BUT NORTHWEST SUB-SAHARAN AFRICA. OTHER EXAMPLES OF GENETICS AND VARIATION. G6PD DEFICIENCY. WE ALL KNOW IN MEDICAL SCHOOL WHEN YOU GET SOMEONE BACK FOR URINARY INFECTION, YOU ASK ABOUT G6PD DEFICIENCY BECAUSE CERTAIN PEOPLE HAVE VARIOUS TYPES WHERE CERTAIN DRUGS, QUININE OR BACK BACTRUM, FOR EXAMPLE, CAN CAUSE A HEMOLYTIC MALARIA. 20% OF PEOPLE WHO LIVE WITHIN 100 MILES OF THE BORDER. YOU GO 150 CAN KILOMETERS, IF YOU GIVE THEM THE ANTISEIZURE DRUG TEGRETOL, THEY WILL GET A FEVER, HANDS AND FEET START PEELING. THIS IS NOT THAI PEOPLE, 20% OF THAIS OR -- IT'S PEOPLE WHO LIVE IN THAT ONE, THIS IS ALL TO SAY, WHEN WE LOOK AT RACE, IT'S JUST TOO BROAD. BUT THERE ARE DIFFERENCES AMONGST POPULATIONS. BY THE WAY, THERE'S A SICKLE CELL MUTATION FOUND IN GREECE, SOUTHERN ITALY, MIDDLE EAST AND SO FORTH. INDEED IN THE UNITED STATES, THIS IS HOW WE HAVE THESE RACIAL BLINDER, WE ALL THINK OF SICKLE CELL DISEASE AS A BLACK DISEASE. TRUTH BE TOLD, ABOUT 50,000 KIDS WILL BE BORN THIS YEAR WITH SICKLE CELL TRAIT. 8,000 OF THOSE 50,000 AMERICANS WERE SICKLE CELL TRAIT ARE WHITE PEOPLE. NOW, LOOKING AT POPULATIONS AND DIFFERENCES IN DRUG, YES, THEY DO EXIST, THEY ARE RARE BUT THEY DO EXIST. THE CANCER DRUG USED IN THE TREATMENT OF COLORECTAL CANCER, CAPECITABINE, AMERICANS TEND TO HAVE MORE SIDE EFFECTS FROM THIS DRUG COMPARED TO EUROPEANS. IT'S ACTUALLY NOT A RACE THING, IT'S AN ENVIRONMENTAL THING. IT'S THE FACT THAT THE AMERICAN DIET IS VERY HIGH IN FOLATE, AND FOLATE POTENTIATES CAPECITABINE. YOU CAN MAKE FOLATE A HARSHER DRUG BY GIVING IT ALONG WITH FOLATE. WE FREQUENTLY GIVE IT WITH LEUKOVORIN. AGAIN, POPULATION DIFFERENCES, IT'S BEEN WELL STUDIED THAT SOME OF THE TYROSINE KINASE INHIBITORS, DIFFERENT RESPONSES IN CERTAIN ASIAN POPULATIONS. PATIENTS OF ASIAN ORIGIN DO HARBOR MORE FREQUENT EGFR MUTATIONS IN CERTAIN AREAS. THIS IS AN ARGUMENT FOR LEARNING WHAT THE DRUG'S TARGET IS AND LEARNING WHAT THE DISTRIBUTION IN THE TARGET IS IN VARIOUS POPULATIONS. PERHAPS ASIAN IS THE WRONG CATEGORY, PERHAPS WE NEED TO GET A LITTLE BIT MORE GRANULAR. THIS RAISES THE ISSUE OF POPULATION DIVERSITY IN THE PATHOGENESIS OF VARIOUS DISEASES. THE IMPLICATION OF THESE FINDINGS IS THAT AREA OF GEOGRAPHIC ORIGIN MAY INDICATE DIFFERENT GENETIC BACKGROUNDS AND COMMON DISEASES THAT MAY UNFLEUNS CLINICAL OUT COME AND RESPONSE TO THERAPY. CLINICAL STUDY OF MOLECULAR TARGETED THERAPIES SHOULD INCLUDE A DIVERSE POPULATION AND SCIENTISTS SHOULD BE ON THE LOOKOUT IN THINKING ABOUT THESE THINGS. THE STUDY OF BLACK VERSUS WHITE OUTCOMES IN THE PAST IS INCREASINGLY MOVING BEYOND THE BLACK AND WHITE AND SOCIOECONOMICS. WE HAD SOMETHING CALLED THE BLACK AND WHITE STUDY. WHEN WE LOOK AT ECONOMICS, HOWEVER, I WANT YOU TO LOOK AT THE PERCENT OF PEOPLE IN THE UNITED STATES WHO LIVE UNDER THE POVERTY LEVEL. 9% OF WHITES, THAT TRANSLATE INTO 17 MILLION PEOPLE. 21% OF BLACKS TRANSLATES INTO 8 MILLION. 17% OF HISPANICS TRANSLATES INTO 10 MILLION. MANY PEOPLE DON'T REALIZE THERE ARE MORE POOR WHITES IN THE UNITED STATES THAN THERE ARE POOR BLACKS. CANCER INCIDENCE DISPARITY DUE TO DIFFERENCES IN ENVIRONMENT ARE INCREDIBLY IMPORTANT. THAT'S DIET, EXERCISE, SMOKING AND ALCOHOL USE, POLLUTION. CANCER OUTCOME DISPARITIES, ON THE OTHER HAND, ARE DUE TO DIFFERENCES IN ACCESS TO QUALITY CARE AND UTILIZATION OF AVAILABLE CARE. THEY ARE MUCH MORE INFLUENCED BY SEWS YOASH ECONOMICS. SOCIOECONOMICS. HERE WE HAVE BRITISH DATA, THEY ARE VERY GOOD AT THEIR 10-YEAR CENSUS AS DEFINING PEOPLE AS AFFLUENT AND DEPRIVED. THEY HAVE AN INDEX WHERE 1 IS VERY AFFLUENT AND 7 IS VERY DEPRIVED. THEY SHOW THE FIVE-YEAR SURVIVAL OF THE AFFLUENT FOR ALMOST EVERY CANCER, ALL THE MAJOR CANCERS, IS BETTER THAN THAT FOR THOSE WHO ARE DEPRIVED. IN THE UNITED STATE, AND THIS IS NCI INTRAMURAL DATA, PEOPLE WHO LIVE IN COUNTIES THAT HAVE PERSISTENT POVERTY HAVE A MUCH WORSE OUTCOME IN TERMS OF MORTALITY SINCE THE YEAR 2000 COMPARED TO PEOPLE WHO LIVE IN WEALTHIER COUNTIES. JUST LOOK HERE AT ALL KEAN CANCERS, THE DOTTED LINES ARE THE HIGH INCOME COUNTIES, THE SOLID LINES ARE THE WEALTHIER COUNTIES, AND THESE DECLINES ARE DECLINES IN AGE STANDARDIZED MORTALITY RATE PER 100,000. PEOPLE WHO LIVE IN THE WELFARE COUNTIES HAVE A MUCH GREATER DECLINE IN MORTALITY COMPARED TO PEOPLE WHO LIVE IN THE NON-WEALTHY COUNTIES. MORE ON THAT, AGAIN, AND I SHOULD JUST POINT OUT, I'M NOT GOING TO SPEND A LOT OF TIME ON THIS, THIS IS TRUE FOR VIRTUALLY EVERY DISEASE. NOW LOW SES AND LACK OF INSURANCE IS ASSOCIATED WITH HIGHER STAGE OF DIAGNOSIS FOR VIRTUALLY ALL CANCERS. FOR ADULTS, THE AFFORDABLE CARE ACT ORO'BAMA CARE IS ASSOCIATED WITH REDUCTION IN DISPARITIES. THERE HAVE BEEN DOCUMENTED REDUCTIONS IN STAGE OF DIAGNOSIS AND IMPROVEMENTS IN OUTCOME, BUT UNFORTUNATELY, OBAMACARE IS CAUSING AN INCREASE IN STATE BY STATE DISPARITIES AS WE LOOK AT STATES THAT HAVE IMPLEMENTED DOING BETTER THAN STATES WHO HAVE NOT IMPLEMENTED MEDICAID EXPANSION DOING WORSE. THE POOR, INCLUDING POOR WHITES, ARE MORE OFTEN PRESENT WITH DISTANT DISEASE. THEY'RE LESS LIKELY TO RECEIVE RADIATION. WHEN THEY RECEIVE RADIATION, THE QUALITY IS POOR, IN TERMS OF AIMING OF THE BEAM, POOR PEOPLE ARE MORE LIKELY TO BE TREATED WITH LOWER ENERGY OLDER RADIATION THERAPY MACHINES IN THE UNITED STATES. HERE YOU HAVE SOFT TISSUE SARCOMA, WHICH IS LARGELY A PEDIATRIC DISEASE. THOSE WHO HAVE PRIVATE INSURANCE, THEIR SURVIVAL PROBABILITY IS HERE ON THE SOLID LINE OVER TIME, THIS IS 200 MONTHS, AND THE DOTS LINE, LOW INCOME, OR WITH PUBLIC INSURANCE, SURVIVAL PROBABILITY IS MUCH LESS. SOCIOECONOMICS IS INCREDIBLY IMPORTANT. THERE'S INCREASING UNDERSTANDING OF THIS FOR CANCER CAUSATION, EVEN ITS EFFECT ON GENOMES AND BEHAVIOR. I'M GOING TO SHOW YOU SOME DATA ON WHERE SOCIOECONOMIC STATUS ACTUALLY ULTIMATELY TRANSCENDS INTO CHANGING AND HOW CANCER EXPRESSES ITSELF GENOMEICALLY. PROSTATE CANCER, EVERYONE KNOWS TWOFOLD INCREASE RISK OF DYING FROM PROSTATE CANCER FOR BLACK MEN IN THE UNITED STATES. FACTORS THAT WE KNOW ARE INVOLVED IN THIS INCLUDE INCREASED AGGRESSIVENESS OF TUMOR RELATED TO THE MED BOLG METABOLIC SYNDROME, HIGH CARBOHYDRATE DIET, MORE COMMON IN BLACKS THAN WHITES, HIGH BODY MASS INDEX. EPIGENETICS OF PROSTATE CANCER IS A FIELD OF OPPORTUNITY FOR YOUNG PEOPLE THINKING ABOUT WHAT TO PUT IN THEIR CAREER. HERE WE HAVE SOME ASSESSMENTS OF CLINICAL TRIALS. NOW THIS IS SOMEWHAT INSPIRED BY THE NIH REVITALIZATION ACT, AND THIS IS A GOOD THING, I THINK, AND WE SHOULD TAKE THIS AND CARRY THIS BALL. YOU SEE IN A NUMBER OF STUDIES WHERE THEY TOOK MULTI-INSTITUTIONAL -- THIS IS NOT CLINICAL TRIAL, THIS TOOK LARGE NUMBERS OF MEN TREATED IN A NUMBER OF INSTITUTIONS, GOOD PLACES THAT STUDY PROSTATE CANCER, THEY LOOKED AT 188 BLACK MEP COMPARED TO 1474 WHITES, WHO GOT TREATED WITH RADICAL PROS TA TECT PROSTATECTOMY AND THEY FOUND NO DIFFERENCE IN BIOCHEMICAL OUTCOME. THIS STUDY, BLACK MEN HAD BETTER SURVIVAL VERSUS WHITE MEN. AGAIN, THIS SHOWS YOU -- THIS WAS THE HAZARD RATIOS. UNADJUSTED AND IN MULTIVARIATE MODELS. BLACK MEN ACTUALLY DID SLIGHTLY BETTER WITH TREATMENT. COMPARISON OF RESPONSE TO DEFINITIVE RADIOTHERAPY FOR LOCALIZED PROSTATE CANCER IN BLACK AND WHITE MEN. HERE, A LARGER TRIAL, 1630 BLACK MEN, 7200 WHITE MEN WITH MEDIAN FOLLOW-UP OF GREATER THAN 10 YEARS, ALMOST 11 YEARS. BLACK MEN WERE LESS LIKELY TO DIE OF PROSTATE CANCER AFTER TREATMENT AND THERE'S NO SIGNIFICANT DIFFERENCE IN ALL CAUSE MORTALITY. NOW, THERE'S AN ASSOCIATION BETWEEN RACE AND RECEIPT OF DEFINITIVE TREATMENT. I THINK YOU'RE GETTING MY GIST HERE. EVEN IN PROSTATE CANCER, YES, BLACK MEN ARE MORE LIKELY TO DEVELOP IT, BUT ONCE DIAGNOSED, AT EVERY STAGE EQUAL TREATMENT YIELDS EQUAL OUTCOME, BUT THERE IS NOT EQUAL TREATMENT. THAT NEEDS TO BE A FOCUS. MUCH MORE SO THAN SUBSET ANALYSIS IN CLINICAL TRIALS NOW. NOW THERE IS RACIAL DIFFERENCES IN DEVELOPING PROSTATE CANCER. THE INCREASED RISK COULD BE -- AND THERE DOES APPEAR TO BE INCREASED RISK AMONG MEN WITH GENETIC LINKAGE TO NORTHWESTERN SUB-SAHARAN AFRICA. NOT EAST AFRICA, NOT SOUTH AFRICA, BUT NORTHWESTERN SUB-SAHARAN AFRICA. WHILE THE RACIAL DIFFERENCES IN RISK OF DEVELOPING PROSTATE CANCER, EQUAL TREATMENT YIELDS EQUAL OUTCOMES AND THERE IS NOT EQUAL TREATMENT. LET'S LOOK AT BREAST CANCER. THESE ARE THE NUMBER OF IN 2019 WHICH CALL THE LAST YEAR OF NORMAL TIME THAT I CALL COVID. THESE ARE AMERICAN CANCER SOCIETY ESTIMATES FOR DIAGNOSIS AND DEATH. THERE'S BEEN 40 TO 50% DECLINE IN RISK OF DEATH SINCE 1990. I'VE SHOWN YOU THIS ALREADY, THE BLACK/WHITE DISPARITY IS GREATER TODAY THAN IT HAS EVER BEEN, AND IT DIDN'T EXIST BEFORE WE KNEW HOW TO SCREEN AND TREAT FOR THIS. THIS IS THE BLACK/WHITE DISPARITY. IF YOU INTEGRATE ALL OF THIS, THERE'S A 40% DECLINE IN RISK OF DEATH SINCE 1990. 40% DECLINE IN RISK OF DEATH FOR THE UNITED STATES AS A WHOLE, AND THE UNITED STATES WAS VERY HOMOGENEOUS INTERESTINGLY IN THE 1980s. BUT SINCE 1988 OR SO, THESE PURPLE STATES HAVE HAD A 20 TO 29% DECLINE AND THE DARK BLUE STATES HAD A 44 TO 501% DECLINE. IT'S MOVING INTO THE RICH/PORE AND EVEN MORE SO IN THE MISSISSIPPI VERSUS MASSACHUSETTS. YOU'VE SEEN THIS BEFORE. THERE ARE SEVEN STATES WHERE BLACK/WHITE MORTALITY DIFFERENCES ARE NO LONGER STATISTICALLY SIGNIFICANT. HERE IN THE UNITED STATES TODAY, WE HAVE THE GREATEST DISPARITY OVERALL FOR BLACKS AND WHITES, BUT THERE'S SEVEN STATES WHERE BLACK/WHITE DIFFERENCES ARE NO LONGER STATISTICALLY SIGNIFICANT. INDEED THERE ARE 12 STATES WHERE WHITE WOMEN HAVE A HIGHER RISK OF BREAST CANCER DEATH COMPARED TO BLACK WOMEN WHO LIVE IN MASSACHUSETTS. AND THERE HAS HAS BEEN THIS INCREDIBLE EMPHASIS ON SCREEN, SCREEN, SCREEN. I DON'T HAVE TIME TO GO INTO IT FULLY. I JUST WANT TO POINT OUT THERE'S DATA THAT SHOW THAT A LARGER PROPORTION OF THOSE WHO DIED, THE 45,000 OF THOSE WHO DIE FROM BREAST CANCER, 21 TO 27% DIE BECAUSE THEY DON'T GET APPROPRIATE TREATMENT AFTER DIAGNOSIS. IT'S ONLY ABOUT 10% WHO DIE BECAUSE THEY DIDN'T GET SCREENED. SO I LIKE TO SAY THERE'S AN UNDEREMPHASIS ON GETTING PEOPLE ADEQUATE CARE. A SUBSTANTIAL NUMBER OF PEOPLE, BLACK, WHITE, AND POOR, DON'T GET APPROPRIATE SURGERY CHEMOTHERAPY HORMONES IN RADIATION. MARROW JOE LUN WAS ONE OF MY FELLOWS AT EMORY, AND WE PUBLISHED THAT IN ATLANTA, 7 1/2% OF BLACK WOMEN WHO GOT SCREENED AND DIAGNOSED WITH BREAST CANCER DIDN'T GET TREATED IN THE FIRST YEAR. IT'S 3%, BY THE WAY, OF WHITE WOMAN, ALL POOR, ALL DISENFRANCHISED FROM THE SYSTEM. THEY DIDN'T GET ADEQUATE TREATMENT. IN MILITARY DATABASES, BY THE WAY, THERE'S TREMENDOUS DATA THAT SHOWS THAT BLACKS AND WHITES ARE ACTUALLY GETTING CLOSER AND CLOSER TOGETHER. THE BLACK/WHITE DISPARITY OF WOMEN WHO GO TO A WALTER REED ARMY HOSPITAL IS FAR DIFFERENT FROM THAT IN THE UNITED STATES. VERY INTERESTING, A WOMAN WHOSE HUSBAND RETIRED AFTER 20 YEARS IN THE MILITARY, HER RISK OF DYING FROM BREAST CANCER, FAR LOWER THAN HER SISTER THAT MIGHT LIVE IN SOUTHWEST D.C. . THERE'S TALK ABOUT ESTROGEN RECEPTORS, TRIPLE NEGATIVE DISEASE. IT IS TRUE THAT 24% OF BLACK WOMEN AND 12% OF WHITE WOMEN IN THE U.S. HAVE TRIPLE NEGATIVE DISEASE. IN IS JUST THE AMERICAN CANCER SOCIETY'S GRAPH OF THE RACIAL DIFFERENCES IN VARIOUS TYPES OF BREAST CANCER. NOW, FEW, BY THE WAY, APPRECIATE THAT WHILE 24% OF BLACK WOMEN HAVE TRIPLE NEGATIVE DISEASE, THE BIG BLACK/WHITE DISPARITIES ARE IN TREATMENT OF ESTROGEN RECEPTOR POSITIVE NON-TRIPLE NEGATIVE DISEASE. IT'S THE 76% OF BLACKS WHO DON'T HAVE TRIPLE NEGATIVE DISEASE WHO ARE GETTING INEFFECTIVE THERAPY OR MORE LIKELY ARE GETTING INEFFECTIVE THERAPY, I SHOULD SAY, WHICH ENDS UP MEANING THAT THEY'RE MORE LIKELY TO HAVE A BAD OUTCOME. SOCIAL DEPRIVATION STUDIES IN EUROPE OVER THE LAST 25 YEARS HAVE SHOWN THAT POOR WOMEN IN EUROPE ARE MORE LIKELY TO HAVE TRIPLE NEGATIVE DISEASE. WITHOUT THE BLINDERS OF RACE IN SCOTLAND, WHERE THERE ARE VERY FEW BLACK PEOPLE, THEY REALIZE THAT POOR WOMEN, OR WOMEN WITH A HISTORY OF POVERTY, ARE MORE LIKELY TO HAVE TRIPLE NEGATIVE BREAST CANCER IN THEIR 40s AND 50s. THEY'VE BEEN ABLE TO CORRELATE IT WITH OBESITY, THEY'VE BEEN ABLE TO CORRELATE IT WITH DIETARY DIFFERENCES, ESPECIALLY WEIGHT GAIN AND HIGH CARBOHYDRATE DIET IN CHILDHOOD. INTERESTINGLY, WEIGHT GAIN FROM BIRTH UNTIL THE EARLY TEEN YEARS INCREASES RISK OF BREAST CANCER IN ONE'S 40s AND 50s AND 60s. IT HAS DO WITH THE AGE AT WHICH A WOMAN STARTS MENSTRUATING. REPRODUCTIVE PATTERNS ARE ALSO IMPORTANT. WOMEN WHO HAVE LOTS OF CHILDREN AND THEN DON'T BREASTFEED ARE AT HIGHER RISK OF TRIPLE NEGATIVE DISEASE. THESE ARE ALL SOCIOECONOMIC THINGS, AND WHEN WE LOOK AT THEM BLACK VERSUS WHITE, WE FREQUENTLY, BECAUSE OF OUR OLD WAY OF THINKING, START THINKING THIS IS BECAUSE THEY'RE BLACK. THIS IS WEIGHT GAIN FOR BLACK WOMEN VERSUS WHITE WOMEN VERSUS BLACK MEN AND WHITE MEN. YOU CAN SEE OVER THE LAST 40 YEARS OR SO INCREASING OBESITY IN EVERYONE BUT ESPECIALLY IN BLACK WOMEN. SUBSTANTIAL NUMBERS OF PEOPLE GET LESS THAN OPTIMAL CARE. WE'RE STARTING TO TALK ABOUT EQUITY AND JUSTICE. NOW LET'S TALK ABOUT NOT JUST A PAPER ON HOW IN CHICAGO THEY'VE ACTUALLY CHANGED THE NUMBERS FOR BLACK WOMEN WITHIN THE LAST 20 YEARS. IN COLORECTAL CANCER, HERE ARE THE NUMBERS. THESE ARE THE DEATH RATES, BLACK VERSUS WHITE, THE DISPARITY IS GETTING BETTER FOR BLACKS AND WHITES, AND IT'S REALLY GETTING CLOSER AND CLOSER FOR EVERYONE. HERE YOU SEE IT FOR WOMEN, HERE YOU SEE IT FOR MEN. NO DISPARITY IN THE 70s, WE LEARNED TO SCREEN AND TREAT, NOW THERE'S A DISPARITY. 50% DECLINE SINCE 1980 IN THE UNITED STATES. THE U UNITED STATES WAS VERY HOMOGENEOUS IN 1980, NOW WE'VE GOT A 12 TO 31% TEE KLEIN IN DECLINE IN T HE PURPLE STATES. A 56 TO 63% IN THE DARK BLUE STATES. AGAIN, WHAT SEPARATES MISSISSIPPI FROM MASSACHUSETTS? THIS IS JUST TO SHOW INSURANCE MATTERS. THE STAGE ONE IN RED, STAGE TWO IN BLUE, THE DIFFERENCES MEAN THAT THOSE WHO ARE UNINSURED OR GOT MEDICAID AFTER DIAGNOSIS ARE MORE LIKELY TO NOT DO WELL OVER FIVE YEARS. THIS IS FIVE YEAR SURVIVAL. AND YES, YOU'RE BETTER OFF HAVING STAGE TWO COLORECTAL CANCER WITH INSURANCE THAN STAGE ONE WITHOUT INSURANCE. KIM RHODES HAS SHOWN US, AND THIS EVEN BLEW MY MIND, THE HOSPITAL THAT YOU GO TO AND THE HOSPITAL -- IS REALLY IMPORTANT. IN CALIFORNIA, SHE WAS ABLE TO SHOW THAT AFTER COLORECTAL SURGERY, BLACKS AND HISPANICS AND POOR PEOPLE WERE LESS LIKELY TO HAVE ADEQUATE PATHOLOGY SUCH THAT BLACKS WHO WERE UNDERSTAGED WHO WERE CALLED STAGE II WERE JUST AS LIKELY TO RELAPSE AS WHITES WHO WERE CALLED STAGE III. IT'S BECAUSE THE BLACKS WERE UNDERSTAGED. KIM IS A SURGEON, SHE SAID I NOPA THOL GISTS ARE I KNOW PATHOLOGISTS ARE NOT RACIST, WHO'S GOING ON HERE? SHE WAS ABLE TO FIGURE OUT BLACKS WHO HAVE COLORECTAL CANCER, BECAUSE OF INSURANCE AND OTHER THINGS, ARE MORE LIKELY TO BE TREATED IN HOSPITAL THE, WHERE THE PATHOLOGIST HAS SIX CASES TO DEAL WITH A DAY, WHEREAS WHITES IN A HOSPITAL WHERE THE PATHOLOGIST HAS TWO CASES TO DEAL WITH A DAY. HUGE, HUGE DIFFERENCES IN QUALITY OF TREATMENT. I'M GOING TO WIND UP BY JUST NOTING THAT COLLEGE EDUCATION LOWERS RISK OF CANCER DEATH DRAMATICALLY. YOU GIVE A COLLEGE EDUCATION TO A BLACK MAN, HIS RISK OF DYING FROM CANCER GOES DOWN BELOW THAT OF THE AVERAGE WHITE MAN IN THE UNITED STATES. HERE YOU CAN SEE LESS THAN OR EQUAL COLLEGE EDUCATION, RATE OF DEATH, VERSUS COLLEGE EDUCATION. NOW, AS I LEFT THE AMERICAN CANCER SOCIETY, I CHALLENGED THE EPIDEMIOLOGISTS WHO DO THOSE ESTIMATES OF NUMBERS EVERY YEAR, HOW MANY PEOPLE WOULD DIE IF EVERYBODY HAD THE RISK OF DEATH OF A COLLEGE-EDUCATED PERSON? THERE'S NOT A NEW DRUG, NOT A NEW TREATMENT. THIS IS IF EVERYBODY GOT WHAT COLLEGE-EDUCATED PEOPLE GOT. WHAT I CAME BACK WITH IS, THERE'S 468,000 INSTEAD OF 600,000 WOULD DIE IN A GIVEN YEAR. 132,000 DEATHS WOULD BE AVERTED IF EVERYBODY GOT WHAT COLLEGE-EDUCATED PEOPLE GOT. AND THAT INCLUDES A LOW SMOKING RATE. BLACKS ARE MORE LIKELY TO SUFFER FROM DISPARITIES, BUT WHITES NUMERICALLY OUTPACE THEM. WHEN WE TALK ABOUT DISPARITIES BY STATE, THIS IS UTAH VERSUS KENTUCKY FOR DEATH RATE. WE NEED TO START THINKING ABOUT DIFFERENCES IN PREVENTION, DIFFERENCES IN SCREENING, DIFFERENCES IN DIAGNOSTICS AND TREATMENT, NOT JUST DIFFERENCES IN BIOLOGY AMONGST THE RACES, AS WE START MOVING TOWARD -- MORE TOWARD SOCIAL JUSTICE AND MORE TOWARD FIGURING OUT WHAT THE REAL PROBLEMS WITH AND OVERCOMING THE REAL DISPARITIES. THE IMPORTANCE OF RISK REDUCTION, I CANNOT OVEREMPHASIZE. WE NEED TO ALSO IDENTIFY THOSE WHO ARE MOST IN NEED, THOSE WHO NEED EDUCATION, WHO NEED CULTURAL CHANGE, THE ROLE OF MENTAL HEALTH AND OTHER THINGS, AGAIN, IDENTIFY WHO NEEDS WHAT. SOMETIMES IT WILL BE BLACKS IN BALTIMORE OR D.C. , SOMETIMES IT WILL BE WHITES IN APPALACHIA OR WHITES IN MISSISSIPPI AND THE SOUTHERN UNITED STATES. AS WE'VE MOVED BEYOND RACE, THERE'S STILL AN EMPHASIS ON POPULATION DIFFERENCES, WHICH I THINK ARE GOOD. THE EMPHASIS SHOULD CENTER ON EPIGENETICS, GENETICS AND ENVIRONMENTAL INFLUENCES THAT INFLUENCE GENETICS, AND THE EMPHASIS NEEDS TO CENTER MORE ON PROVISION OF ADEQUATE CARE. SO THANK YOU VERY MUCH. IT'S A PRIVILEGE TO BE HERE. AGAIN, DR. SCHECHTER, DR. GOTTESMAN AND DR. WANJEK, IT'S REALLY AN HONOR TO BE ABLE TO GIVE THIS TALK. >> THANK YOU, DR. BRAWLEY, FOR THE SUPERB TALK. THERE WERE SEVERAL QUESTIONS THAT I'D LIKE TO BEGIN TO RELAY TO YOU IF I MAY. >> SURE. >> ONE QUESTION WHICH SPEAKS TO THE LAST POINT YOU MAKE, IF IT'S THE QUALITY OR AMOUNT OF CARE THAT'S THE MAJOR FACTOR AMONG THE DIFFERING GROUPS, IS THERE A DIFFERENCE, FOR EXAMPLE, BETWEEN THE OUTCOME IN CANADA AND THE UNITED STATES WHERE FACTORS DUE TO COST AND AVAILABILITY OF CARE SHOULD BE LESS BECAUSE OF THE GENERALIZED HEALTH SYSTEM THAN IN THE UNITED STATES OR IN EUROPEAN COUNTRIES AS WELL? >> WELL, OVERALL OUTCOME, SO IF YOU'RE LOOKING AT THE ENTIRE POPULATION, BETTER IN CANADA THAN IN THE UNITED STATES. NOW, THAT BEING SAID, CANADA IS MUCH BETTER AT PROVIDING AVERAGE CARE TO THE AVERAGE HUMAN BEING. IF YOU HAVE AN UNUSUAL DISEASE, YOU'RE BEST OFF IN THE UNITED STATES WITH GOOD INSURANCE AND SOMEBODY LIKE OTIS BRAWLEY TO GUIDE YOU THROUGH THE SYSTEM. MUCH MORE SO THAN IN CANADA. BUT IN IF YOU HAVE AVERAGE GARDEN VARIETY ILLNESS, YOU'RE BETTER OFF IN CANADA. AND BECAUSE OF THE OBESITY ISSUE IN THE UNITED STATE VERSUS THE REST OF THE WORLD, YOU'RE LESS LIKELY TO GET SICK IN CANADA. >> OKAY. THANK YOU. A SECOND QUESTION THAT CAME IN EARLY, ONE LISTENERS ASKED WHETHER THE DIFFERENCE IN ASSUMPTIONS ABOUT YELLOW FEVER IN COLONIAL TIMES WAS RELATED TO THE FACT THAT PEOPLE UNDERSTOOD THAT YELLOW FEVER HAD COME FROM AFRICA AND THOUGHT THAT THERE WAS A DIFFERENCE IN THE -- BECAUSE OF THE ORIGIN OF THE DISEASE RATHER THAN BECAUSE OF THE NEW GENETIC U.S. SEPTEMBER IBILITIES. GENETIC SUSCEPTIBILITIES. DOES THAT CONTRIBUTE -- >> I'M NOT SURE. AT THAT TIME THERE WERE A LOT OF PEOPLE THAT THOUGHT PEOPLE COULD GIVE YELLOW FEVER TO OTHER PEOPLE, THEY DIDN'T UNDERSTAND WHAT VIRUSES WERE AT THAT TIME. KEEP IN MIND, WALTER REED, A CENTURY LATER, IN THE LATE 1800s, WOULD FIGURE OUT THAT YELLOW FEVER IS CARRIED BY A MOS. MOSQUITO. SO I'M NOT SURE WHAT THE ANSWER TO THAT IS, BUT THERE HAS ALWAYS BEEN AND I'M SURE EVEN BEFORE THE YELLOW FEVER EPIDEMIC, I CAN'T DOCUMENT IT, THIS BELIEF IN BLACK/WHITE DIFFERENCES IN BIOLOGY. >> LET ME ADD A THIRD QUESTION. MY OWN THAT I THOUGHT AFTER YOUR TUESDAY TALK AS WELL AS TODAY, YOU MENTION OFTEN THE EFFECT OF OBESITY ON CANCER INCIDENCE AND OUTCOME. DO YOU BELIEVE THAT THE OBESITY IS CAUSAL RATHER THAN A CORRELATION? IS THERE A BIOLOGICAL MECHANISM TO EXPLAIN THE LIKELY EFFECT OF OBESITY ON ANY DIFFERENT CANCERS? >> THERE ARE WEEK-LONG CONFERENCES WHERE PEOPLE ARGUE ABOUT THE MECHANISM WHERE OBESITY CAUSES CANCER. THERE'S CERTAINLY REALLY GOOD CORRELATION IN HUMANS AND THERE'S LABORATORY DATA IN ANIMALS THAT OBESE ANIMALS ARE MORE LIKELY TO HAVE CANCER. SOME OF THE THEORIES ARE OBESE PEOPLE HAVE MUCH MORE INNATE INFLAMMATION AND INFLAMMATION CAN CAUSE CANCER. OBESE PEOPLE HAVE HIGHER CIRCULATING AMOUNTS OF INSULIN, AND INSULIN IS A GROWTH FACTOR THAT HELPS BLOOD VESSELS TO GROW INTO AN ESTABLISHED TUMOR. THERE'S THOUGHT THAT PERHAPS SOME PEOPLE, BECAUSE OF OBESITY, MAY HAVE IMMUNE SYSTEMS THAT ARE IMPAIRED AND WE KNOW THAT PART OF THE WAY THAT WE PREVENT GETTING CANCER IS IMMUNE CELLS ATTACKING EARLY CANCER CELLS AND, THEREFORE, THEY CAN'T BECOME A TUMOR. I THINK THE DATA IS FAIR ENOUGH TO SAY THAT OBESITY DOES CAUSE CANCER. IT'S NOT REALLY OBESITY, IT'S A THREE-LEGGED STOOL. IT'S ENERGY IMBALANCE. TOO MANY CALORIES, NOT BURNING OFF ENOUGH CALORIES, AND STORING TOO MANY CALORIES. THE STORAGE IS JUST ONE LEG OF THE THREE LEGGED STOOL. AND INTERESTINGLY, WITHIN THE NEXT FIVE YEARS OR SO, BECAUSE SMOKING RATES IN THE UNITED STATES HAVE GONE DOWN SO DRAMATICALLY, ENERGY IMBALANCE WILL BE THE LEADING CAUSE OF CANCER IN THE UNITED STATE, AND IT ALREADY IS FOR CERTAIN SUBPOPULATIONS LIKE HISPANIC WOMEN. >> IS THE OBESITY EFFECT SIMILAR FOR MOST OF THE MAJOR DIFFERENT KINDS OF CANCERS? >> THERE ARE ABOUT 12 CANCERS THAT ARE LINKED TO OBESITY. THERE ARE 18 CANCERS, BY THE WAY, LINKED TO SMOKING, BUT THERE ARE 12 CANCERS LINKED TO OBESITY. AMONG THEM ARE SOME OF THE MAJORS. THE FIVE MAJOR CANCERS THAT EVERYBODY WORRIES ABOUT BECAUSE THEY'RE 50% OF DEATHS ARE, NOT IN ORDER, LUNG, COLON, BREAST, PROSTATE, AND PANCREAS. AND EVEN LUNG CANCER IS LINKED TO SOME DIETARY ISSUES, BUT THE OTHER FOUR ARE MORE LINKED TO OBESITY THAN AS LUNG CANCER. BUT LUNG CANCER IS LINKED TO SOME DIETARY ISSUES LIKE LOW FRUIT CONSUMPTION. >> OKAY. I CAN JUST ADD ONE FURTHER QUESTION OF MY OWN. DOES THE ASSUMPTION THAT WENT INTO THE TUSKEGEE STUDY OF GREATER RESISTANCE TO THE DISEASE AMONG THE BLACK POPULATION CHANGE AT ALL YOUR FEELING ABOUT THE ETHICAL NATURE OF THAT STUDY, EITHER AT THE BEGINNING OR AT SOME POINT IN ITS CONTINUATION, WAS THERE AN ETHICAL TRANSITION THAT OCCURRED AT SOME POINT? >> WELL, I DO THINK THERE WAS -- I THINK THERE WERE ETHICAL CHALLENGES THROUGHOUT THE ENTIRE STUDY. INFORMED DECISION-MAKING AND INFORMED CONSENT ARE CONCEPTS FROM THE 1950s. SO I CAN'T HOLD IT AGAINST THEM THAT THEY DIDN'T DO INFORMED CONSENT IN 1930, 1931. I CAN HOLD AGAINST THEM THAT THEY LIED TO PEOPLE TO GET THEM TO PARTICIPATE IN THE TRIAL. NOT TREATING PEOPLE WAS CERTAINLY VERY REASONABLE IN THE 1930s. SO I CAN'T HOLD IT AGAINST THEM THAT THEY DIDN'T GIVE PEOPLE MERCURIALS, WHICH TURNED OUT NOT TO BE HELPFUL ANYWAY AND ACTUALLY HARMFUL, BUT THERE WAS PENICILLIN IN THE 1940s, AND I CAN CRITICIZE THE PEOPLE RUNNING THE TRIAL IN THE 1940s FOR HOLDING BACK ON PENICILLIN. SO THERE WERE ALWAYS ETHICAL PROBLEMS THERE, AND THERE WAS ALWAYS A LACK OF DISRESPECT, BUT IT GOT WORSE IN THE 1940s, 50s AND 60s. AS YOU MIGHT HAVE HEARD, IT WASN'T JUST WHITE PEOPLE WHO ARE TO BLAME. THERE WERE BLACK PEOPLE WHO CONDONED THE STUDY, THERE WERE BLACK PEOPLE WHO WORK ON THE STUDY FROM THE TUSKEGEE INSTITUTE. THEY'RE ALL TO BLAME FOR THIS. INCLUDING THE LYING TO PEOPLE IN THE 1930s. THE IRONY IS THE STUDY WAS WRITTEN BY AND DESIGNED BY PEOPLE WHO LITERALLY WANTED TO PROVE THAT MY BIOLOGY IS EQUIVALENT TO YOUR BIOLOGY. THAT THERE IS NO BLACK BIOLOGY OR WHITE. THESE PEOPLE ARE TRYING TO PROVE THAT BLACK PEOPLE DESERVE SOME ATTENTION IN TERMS OF SYPHILIS, BUT THAT DOES NOT OVERCOME SOME OF THE OTHER LAPSES. >> AND IN THIS SERIES, WE'VE HAD SEVERAL LECTURES ON EUGENICS, AND I COME AWAY FROM SOME OF THE LECTURES WITH, AGAIN, THE IRONY THAT I THINK MANY OF THE PEOPLE, ESPECIALLY IN THE LATE 19TH CENTURY OR THE VERY EARLY 20TH CENTURY, THOUGHT THEY WERE DOING GOOD THINGS BY ADVOCATING GENETIC CHANGES AND THE POPULATION CONTROL OF REPRODUCTION AND THE LIKE, BUT AT SOME POINT, AGAIN, AS EUGENICS PLAYED OUT, THE TRANSITION OCCURRED THAT IT WAS NOW MORE UNETHICAL THAN ETHICAL. THERE'S A SIMILARITY IN THESE TWO ASPECTS. >> VERY MUCH SO. VERY MUCH SO. >> BUT I THINK IT'S ALMOST 5 AFTER 1:00. I THINK -- I WANT TO THANK YOU ON BEHALF OF THE NIH IN GENERAL, THE NIH OFFICE OF HISTORY IN PARTICULAR, AND WE VERY MUCH ENJOYED YOUR TALK, AND WE'LL RELAY TO YOU ANY FURTHER QUESTIONS THAT WE RECEIVE. THANK YOU. >> THANK YOU SO MUCH. IT WAS A REAL PRIVILEGE TO GIVE THIS TALK, AND IT'S WONDERFUL TO MEET YOU.