>>WE'RE GOING TO START THE FEBRUARY NIMHD DIRECTOR'S SEMINAR. IT'S A SPECIAL MONTH, BLACK HISTORY MONTH. AND IT'S ALSO CONTINUING OUR SHELTER IN PLACE. WE ARE ALL VIRTUAL. WE HAVE A SPECIAL GUEST TODAY SO I'M PLEASED ABOUT THE ABILITY TO DO THIS. TODAY'S SEMINAR WE'LL HAVE DR. BOULWARE, WHO WAS ORIGINALLY SCHEDULED IN MARCH OF 2020 JUST AS WE WERE SORT OF STOPPING ALL OF OUR TRAVEL AND HER PRESENTATION WAS POSTPONED BECAUSE OF THE PANDEMIC. SO IT'S MY PLEASURE TO PRESENT DR. EBONY BOULWARE WHO JOINS US FROM DUKE UNIVERSITY SCHOOL OF MEDICINE WHERE SHE IS CURRENTLY THE CHIEF OF THE DIVISION OF GENERAL INTERNAL MEDICINE IN THE DEPARTMENT OF MEDICINE. I WAS CHIEF AT UCSF WHEN I WAS THERE, AND THE DIRECTOR OF DUKE CLINICAL AND TRANSLATIONAL SCIENCES, WHICH IS A BIG JOB. A SCHOLAR, SHE RECEIVED HER DEGREE AND HER MEDICAL DEGREE FROM DUKE AND THEN WENT TO COMPLETE HER MEDICAL TRAINING AND RESIDENCY AND CHIEF RESIDENCY AT THE UNIVERSITY OF MARYLAND AND A RESEARCH FELLOWSHIP AT THE JOHNS HOPKINS SCHOOL OF MEDICINE. I RECALL I THINK THE FIRST TIME I MET HER WAS AT A SOCIETY OF GENERAL INTERNAL MEDICINE MEETING IN SOUTH FLORIDA, AND WE HAD JUST RECRUITED DR. NEAL POE TO COME TO UCSF AS CHIEF OF THE MEDICAL SERVICES AT THE GENERAL HOSPITAL AND HE INTRODUCED ME TO EBONY AND WE TALKED AND THEN SAID AFTERWARDS, YOU NEED TO RECRUIT HER TO YOUR DIVISION. SO I TRIED BUT I DID NOT SUCCEED. SHE IS NOW PROFESSOR OF MEDICINE AS I SAID, AND ALSO ASSOCIATE VICE CHANCELLOR FOR RESEARCH IN THE SCHOOL OF MEDICINE AT DUKE. AND SHE RUNS THEIR CPSI, WHICH IS FUNDED THROUGH THE NATIONAL CENTERED FOR ADVANCING TRANSLATIONAL SCIENCES OR NCATS AND IS THE CONTACT PRINCIPAL INVESTIGATOR FOR THE DUKE CLINICAL AND TRANSLATIONAL SCIENCE AWARD. DR. EBONY BOULWARE IS A GENERAL INTERNIST AND CLINICAL EPIDEMIOLOGIST DEVOTING HER CAREER TO STUDYING MECHANISM TO IMPROVE THE EQUITY OF HEALTH CARE AND HEALTH OUTCOMES FOR PATIENTS AND POPULATIONS WITH CHRONIC DISEASE, PARTICULARLY CHRONIC KIDNEY DISEASE AND HYPERTENSION. SHE INVESTIGATES THE INFLUENCE OF ATTITUDINAL AND ENVIRONMENTAL CONTACTS ON HEALTH OUTCOMES AS PART OF HER WORK. EBONY GAINED AN ACTIVE RESEARCH PORTFOLIO IN HER CAREER WITH FUNDINGS FROM THE NIH, PARENT CENTER OUTCOMES RESEARCH INSTITUTE, HEALTH RESOURCES ADMINISTRATION, THE AGENCY FOR HEALTH CARE RESEARCH AND QUALITY AND SEVERAL FOUNDATIONS. SHE HAS PUBLISHED OVER 130 PAPERS, MENTORED NUMEROUS STUDENTS, FELLOWS AND OTHER FACULTY IN CLINICAL RESEARCH. SHE IS AN ELECTED MEMBER OF THE AMERICAN SOCIETY OF CLINICAL INVESTIGATION AND THE NATIONAL ACADEMY OF MEDICINE. SHE FREQUENTLY ENGAGES WITH COMMUNITY MEMBERS, PATIENTS, FAMILY MEMBERS AND OTHER STAKEHOLDERS. TODAY SHE WILL TELL US ABOUT WHERE THE CLOUD MEETS THE GROUND, DEMOCRATIZING HEALTH DATA TO IMPROVE COMMUNITY HEALTH EQUITY. PLEASE WELCOME DR. EBONY BOULWARE. >> EBONY BOULWARE: THANK YOU VERY MUCH. IT'S SUCH AN HONOR FOR ME TO BE HERE AND YOU JUST TOOK ME DOWN MEMORY LANE. I COULD HAVE ENDED UP IN CALIFORNIA BUT SOMEHOW I WAS NORTH CAROLINA BOUND AND DIDN'T REALIZE IT BACK THEN. SO I'M GOING TO -- I'M GRATEFUL FOR THE OPPORTUNITY TO PRESENT HERE TO NIMHD AND I'M LOOKING FORWARD TO ENGAGING IN A DISCUSSION ABOUT THE TOPIC. I'M REALLY EXCITED TO TALK TO YOU ABOUT DEMOCRATIZING HEALTH DATA AS A WAY TO IMPROVE COMMUNITY HEALTH EQUITY. AND MY OBJECTIVES ARE GOING TO BE TO DISCUSS THE CHALLENGE OF HOW WE TRANSLATE RESEARCH FINDINGS, THE DISCOVERIES WE MAKE WITHIN ACADEMIA OFTEN TO IMPROVE COMMUNITY HEALTH EQUITY. TALK ABOUT HOW WE MIGHT LEVERAGE DATA, DEMOCRATIZATION, AS A TOOL FOR COMMUNITY HEALTH EQUITY IN A WAY FOR TRANSLATING INSIGHTS FROM WITHIN THE MEDICAL PUBLIC HEALTH ARENA INTO THE COMMUNITY AND THEN I'M GOING TO TALK ABOUT SOME NEW RESEARCH APPLICATIONS AND FUTURE DIRECTIONS I THINK THAT COULD BE VERY HELPFUL TOWARDS ADVANCING COMMUNITY HEALTH EQUITY IN THE FORM OF DATA DEMOCRATIZATION AND DATA ORIENTED STUDIES. SO, I START OFF WITH THIS SLIDE LOOKING AT THE HYPERTENSION HOSPITALIZATION RATES PER 1000 MEDICARE BENEFICIARIES FROM 2013-2015. THE DATA ARE A LITTLE DATED BUT THE SAME MAP IS PRESENT TODAY, SIX YEARS LATER. AND WHAT WE ARE SEEING IN LOOKING AT A MAP OF THE UNITED STATES AND THESE ARE COUNTY-LEVEL RATES OF HYPERTENSION, HOSPITALIZATION, IS THAT POOR HEALTH OUTCOMES AGGREGATE UNEQUALLY. IT'S EVEN WHEN WE HAVE PROVEN THERAPIES. SO HYPERTENSION IS ONE OF THE MOST AREAS IN WHICH WE HAVE A NUMBER OF TREATMENTS THAT HAVE BEEN STUDIED IN TRIAL AFTER TRIAL, NUMEROUS MEDICATIONS, NUMEROUS CLASSES OF MEDICATIONS TO TREAT HYPERTENSION. AND YET WE HAVE HISTORICALLY NOT ACHIEVED OPTIMUM RATES OF HYPERTENSION CONTROL OVER THE U.S. POPULATION IN GENERAL. WE ALSO SEE SOME ETHNIC AND RACE DISPARITIES IN HYPERTENSION CONTROL SUCH THAT ETHNIC AND RACIAL MINORITIES HAVE BEEN SHOWN TO HAVE LOWER RATES OF HYPERTENSION CONTROL COMPARED TO OTHERS. THERE IS ALSO AN INTERESTING PHENOMENON I'M SHOWING ON THIS SCREEN, WE ARE SKIING THERE THERE IS CLUSTERING OF HOSPITALIZATION RATES BY COMMUNITY. WE ARE SEEING THAT IT VARIES IF WE LOOK AT THE OVERALL MAP, WE HAVE GRADATIONS THERE WITH DARKER AREAS INDICATING GREATER RATES OF HYPERTENSION HOSPITALIZATIONS AND LIGHTER AREAS BEING LOWER RATES. SO AGGREGATION IN CERTAIN REGIONS OF THE UNITED STATES. IF WE GO DEEPER, WE ARE SEEING THERE IS COUNTY-LEVEL DIFFERENCES. COUNTIES WHERE THERE ARE DARKER AREAS OF RED AND LIGHTER AREAS OF PINK OR RED. AND THEN EVEN MORE FASCINATINGLY SO, WE SEE THERE ARE COUNTIES WHERE OFTEN THERE IS A LIGHTER AREA JUST RIGHT NEXT TO A DARKER AREA. SO THIS IS AN INTERESTING PHENOMENON OF HEALTH INEQUITY THAT IS A COMMUNITY-LEVEL HEALTH INTECH TEE WHERE SOME COMMUNITIES ARE MORE AFFECTED BY HEALTH PROBLEMS THAN OTHERS. -- INEQUITY. AND TO ACHIEVE ONE OF THE GOALS WE HAVE IN SCIENCE ARE TO IMPROVE HEALTH OVERALL AND TO ACHIEVE HEALTH EQUITY MEANING THAT ALL INVOLVES BENEFIT EQUALLY AND HAVE EQUAL BENEFITS IN HEALTH. AND I THINK THIS IS ONE OF WHAT I'M CALLING THE LAST MILE OF SCIENCE TRANSLATION. IT'S HOW DO WE, WHEN WE MAKE OUR DISCOVERIES AND WE ARE DOING OUR TRIALS AND WE ARE PRODUCING OUR SCIENTIFIC EVIDENCE, HOW DO WE GET THAT INFORMATION INTO THE HANDS OF COMMUNITIES SO WE CAN HAVE EQUITY IN HEALTH ACROSS COMMUNITIES? AND THAT HYPERTENSION EXAMPLE I THINK REALLY ADDS BECAUSE HYPERTENSION IS AN AREA WHERE WE HAVE MANY, MANY PROVEN THERAPIES. AND SO WHEN I THINK ABOUT THIS MAP, SOME OF THE QUESTIONS THAT COME TO MIND ARE WHAT FUELS COMMUNITY HEALTH INEQUITY WHEN WE ALREADY HAVE EVIDENCE-BASED TREATMENTS? AND TYPICALLY, WE THOUGHT A LOT ABOUT WHAT I CONSIDER HEALTH CARE FACTORS, THINGS ABOUT THE HEALTH CARE SECTOR. SO HOW EFFECTIVELY ARE WE DISSEMINATING THE EVIDENCE WE HAVE GENERATED? HOW WELL IS THAT GETTING OUT TO THE PUBLIC? ARE HEALTH CARE PROVIDERS KNOWLEDGEABLE ABOUT THIS EVIDENCE? DO THEY KNOW ABOUT TREATMENTS? IS THERE SOME PROBLEM WITH THE FACT THAT OUR TRIALS ARE JUST NOT THE INFORMATION IS NOT GETTING OUT THERE? THEN OFTEN PEOPLE WILL TALK ABOUT COMMUNITY HEALTH CARE PROVIDER INERTIA. MAYBE THEY KNOW ABOUT THE TREATMENT BUT THEY ARE JUST NOT TAKING IT UP OR IF THEY KNOW ABOUT IT, SOMEHOW THERE IS A PROBLEM WITH THEM GETTING THAT INTO THEIR DAILY PRACTICE. OFTEN WE MAY THINK ABOUT PATIENT PREFERENCES, MAYBE PATIENTS AREN'T TAKING MEDICATIONS. MAYBE THERE IS AN ISSUE WITH THEIR LEGALNESS, SIDE EFFECTS -- WILLINGNESS, SIDE EFFECTS, MAYBE THEY DON'T WANT TO TAKE MEDS OR BEHAVIORAL ORIENTED BARRIERS. AND THEN WE OFTEN TALK ABOUT ACCESS TO CARE AND AFFORDABILITY OF CARE. AND THESE ARE ALL REALLY IMPORTANT POTENTIAL BARRIERS TO TRANSLATION, ABSOLUTELY. AND THEY DESERVE LOTS OF FOCUS. ONE AREA WE DON'T REALLY THINK ABOUT IN LIGHT OF WHEN WE LOOK AT THIS AGGREGATION BY HEALTH, WHAT ABOUT THE COMMUNITY FACTORS? WHAT ARE LEADING TO WHY CERTAIN COMMUNITIES HAVE BETTER HEALTH THAN OTHERS? IS IT A MATTER OF SOME GEOGRAPHIC ELEMENT THAT IS RELATED TO THIS? WHAT ABOUT SOCIAL FACTORS AND THEIR AGGREGATION OR ENVIRONMENTAL FACTORS? AND I THINK WHEN WE LOOK AT COMMUNITY-LEVEL HEALTH, WE NEED TO START THINKING AT THAT MACRO LEVEL, THE FACTORS THAT INFLUENCE A COMMUNITY. WHEN WE ARE TALKING ABOUT SOCIAL ENVIRONMENTAL CONTEXT, I THINK AGAIN THERE IS ANOTHER MAP LOOKING AT NEIGHBORHOOD DEPRIVATION. THIS IS THE NEIGHBORHOOD DISVAGIN DECKS DEVELOPED BY THE KIND GROUP IN WISCONSIN. AND IT'S LOOKING AT WHERE THE RED AREAS ARE AREAS WHERE THERE IS GREATER NEIGHBORHOOD DISADVANTAGE BASED ON CENSUS BLACK DATA, I BELIEVE, AND THEN THE AREAS ARE IN BLUE, WHERE THERE IS LESS NEIGHBORHOOD DISADVANTAGE. AND SIMILARLY FASCINATINGLY ENOUGH, WE SEE A PATTERN OF NEIGHBORHOOD DISADVANTAGE THAT ARE NATIONAL IN NATURE SO WE SEE THERE IS DIFFERENT PATTERNS ACROSS THE NATION. WE SEE VARYING PATTERNS WITHIN SPECIFIC REGIONS AND THEN LOCALLY, WE SEE THAT THERE IS AGAIN AREAS OF HIGH DISADVANTAGE RIGHT NEXT TO LOW DISADVANTAGE. SO THE CONTEXT OF SOCIAL AND ENVIRONMENT ARE NOT ONLY NATIONAL BUT REGIONAL AS WELL AS LOCAL. AND SO WHAT MAKES ONE COMMUNITY HEALTHIER THAN ANOTHER? AND WHAT KINDS OF CONTEXT CONTRIBUTE TO HEALTH? IS IT THE DEMOGRAPHICS OF THE INDIVIDUALS LIVING IN A COMMUNITY? IS IT THE ECONOMY OR THINGS THAT EFFECT THE ECONOMY? ARE THERE THINGS ABOUT THE BUILT ENVIRONMENT THAT EFFECT COMMUNITY HEALTH? THE AVAILABILITY OF HEALTH CARE SERVICES? EDUCATION? HOUSING? SAFETY? WHAT ABOUT SOCIAL CAPITAL OR COHESION? THESE ARE ALL ASPECTS OR TRAITS OF COMMUNITIES BUT HOW DO THEY CONTRIBUTE TO HEALTH? AND WHEN I THINK ABOUT HEALTH INEQUITIES, WE THINK ABOUT THE INDIVIDUAL WHO SUFFERS MAYBE A DIFFERENT RATE OR INDIVIDUAL POPULATIONS THAT SUFFER DIFFERENT RATES OF DISEASE THAN ANOTHER BUT WE CAN GO BEYOND THAT WHEN WE THINK AT THE COMMUNITY LEVEL SO THAT THERE ARE THESE LAYERED AND COMPLEX DETERMINANTS OF HEALTH INEQUITIES THAT RANGE FROM THE INDIVIDUALS. SO AT THE BOTTOM, AT THE CELLULAR LEVEL, WE THINK ABOUT THE BIOLOGICAL RESPONSES AND PATHWAYS IN TERMS OF MOLECULAR PROCESSES, GENETIC PROCESSES, EPIGENETIC PROCESSES, TO PHYSIOLOGIC PROCESSES, TO HYPERTENSION OR HYPERLIPIDEMIA. THEN WE THINK ABOUT INDIVIDUALS AND THEIR OWN BEHAVIORS IN WHICH THERE ARE THESE BIOLOGICAL FACTORS LAYERED WITHIN THE INDIVIDUAL CHARACTERISTICS AND THAT INCLUDES THEIR RISK BEHAVIORS SUCH AS TOBACCO OR ALCOHOL USE, THERE ARE OTHER TYPES OF VARIOUS THEY HAVE. THEIR DEMOGRAPHICS WHICH INCLUDE THEIR AGE, OR HEALTH STATUS AND EDUCATION, RACE OR ETHNICITY. AND THEN WE, AS WE GET FURTHER DOWN AT THE COMMUNITY LEVEL, WE THINK ABOUT THE CONTEXT THAT THEY LIVE IN AGAIN, THE PHYSICAL CONTEXT. SO WHAT IS THE BUILDING QUALITY? HOW MUCH POLLUTION IS IN THE AREA WHERE AN INDIVIDUAL LIVES? HOW ABOUT THE OPEN SPACE OR PARKS? WHAT ABOUT SOCIAL NETWORKS? IS THERE A NEIGHBORHOOD THAT HAS A LOT OF COHESION OR IS THIS PERSON EMBEDDED IN A NUMBER OF COMMUNITIES THAT PROVIDE SOCIAL SUPPORT? WHAT ABOUT AT THAT LEVEL OF SOCIAL CAPITAL? ARE PEOPLE INVOLVED IN LOCAL POLITICS OF THE AREA OR ENGAGED IN SORT OF THE COLLECTIVE EFFICACY IN A SPECIFIC AREA? THEN WE THINK ABOUT INSTITUTIONS. OUR HEALTH CARE SYSTEMS, LEGAL SYSTEMS, POLITICAL SYSTEMS, AND THEN BROADER SOCIAL CONDITIONS THAT ARE IMPACTED BY POLICY SUCH AS POVERTY, MANY OF OUR CULTURAL NORMS, DISCRIMINATION, DISCRIMINATIVE PRACTICES AND POLICIES. SO THESE ARE ALL VERY LAYERED AND COMPLEX DETERMINANTS OF HEALTH INEQUITIES THAT GO FROM THE INDIVIDUAL CELLULAR LEVEL ALL THE WAY TO THE COMMUNITY. AND WHEN WE THINK ABOUT COMMUNITY-LEVEL OF THIS, HOW IS HEALTH, WHAT WE ARE SEEING HERE, SO HYPERTENSION IS A PHYSIOLOGICAL BIOLOGICAL, SOMETHING THAT WE ARE ABLE TO MEASURE IN A PERSON'S BODY. WE THEN SEE CLUSTERING OF THIS AT A LEVEL, AT A COMMUNITY LEVEL. HOW DO COMMUNITY CONTEXT SUCH AS NEIGHBORHOOD DISADVANTAGE INFLUENCE COMMUNITY HEALTH? COMPLICATED QUESTION GIVEN ALL OF THE LAYERED INFLUENCES. AND SO TO ANSWER THIS QUESTION, WE NEED NEW APPROACHES. AND THERE WAS A THINKER TANK THAT I ATTENDED SEVERAL YEARS BACK AT NHLBI WHERE THE QUESTION WAS, HOW TO REDUCE HEALTH INEQUITIES IN THE UNITED STATES. AND THERE WERE MANY PEOPLE ATTENDING THE MEETING FROM MULTIPLE SECT OPPOSITE INCLUDING MULTIPLE GOVERNMENT SECTORS -- SECTORS AND THEN FROM THE ACADEMIC SECTORS AS WELL AS OTHER SECTORS. I BELIEVE THERE WAS ALSO INDUSTRY THERE. AND THE QUESTION IS HOW DO WE BEGIN TO TACKLE THESE TYPES OF INEQUITIES NOT JUST AT THE INDIVIDUAL LEVEL BUT ALSO AT THE COMMUNITY LEVEL? AND THE ANSWER WAS, WE NEED NEW APPROACHES AND THINKING ABOUT ALL OF THE DIFFERENT FACTORS THAT EFFECT COMMUNITY HEALTH, THINGS THAT I MENTIONED LIKE BUILT ENVIRONMENT, EDUCATION-LEVEL, THESE TYPES OF THINGS, INVOLVE MULTIPLE SECTORS OF COMMUNTY. AND AREN'T DIRECTLY RELATED TO THE DELIVERY OF HEALTH CARE. WOO NEED TRANSCENTRAL MULTIDISCIPLINARY STRATEGIES TO DELIVER HEALTH IN INEQUITIES AND THEN WE NEED TO EM BRA BRACE RESEARCH TO THINK ABOUT HEALTH AND WELLNESS IN THIS CONTEXT IN MULTIPLE-LEVEL FACTORS LIKE I SHOWED, GOING FROM CELLULAR FACTORS ALL THE WAY TO MACRO SOCIAL FACTORS. ALL BEING INFLUENCES ON HEALTH AND WELLNESS. IN ORDER TO -- THEN WE NEED DIFFERENT WAYS OF BEING ABLE TO DO THE RESEARCH TO LOOK AT THIS COMPLEX MULTI-LAYERED INFLUENCES ON HEALTH. AND THAT MIGHT REQUIRE US TO HAVE NEW RESEARCH PLATFORMS THAT PROMOTE THE SYSTEM SCIENCE THINKING. WE CAN NO LONGER THINK AT THE CELLULAR LEVEL OR PHYSIOLOGICAL LEVEL. WE NEED TO THINK AT ALL OF THESE MULTIPLE LEVELS SIMULTANEOUSLY TO THINK ABOUT HOW TO BREAKDOWN SOMETHING LIKE INEQUITY WE ARE SEEING AT A COMMUNITY LEVEL. THAT MIGHT REQUIRE NEW DATA SOURCES AND NETWORKS ACROSS SECTORAL AND MULTIDISCIPLINARY STAKEHOLDERS. SO WE CAN BUILD RESEARCH CAPACITY AROUND IMPROVING COMMUNITY HEALTH. AND THE QUESTION IS, HOW? HOW DO WE DO THAT? THAT'S A BIGMOUTHFUL. AND THEN WHO IS GOING TO BE INVOLVED IN THAT? SO THEN I WANT TO TAKE IT ONE STEP FURTHERMENT ONCE WE IDENTIFY MECHANISMS FOR COMMUNITY HEALTH INEQUITY, WHO IS GOING TO BE MAKING THE CHANGE? SO I MENTIONED ALL OF THESE DIFFICULT FACTORS THAT COULD BE ASSOCIATED WITH COMMUNITY HEALTH INEQUITY FROM DEFGRAPHICS, ECONOMY, BUILT ENVIRONMENT, AVAILABILITY AND HEALTH CARE SERVICES, EDUCATION, HOUSING, SAFETY, ET CETERA AND IF WE IDENTIFY MECHANISMS AURAS PICTURES OF THESE COMMUNITY CONTEXT THAT ARE MECHANISMS FOR HEALTH INEQUITIES, WHO IS GOING TO IMPLEMENT THE INTERVENTIONS THAT ARE GOING TO CHANGE COMMUNITY HEALTH? I WOULD ARGUE THAT HEALTH CARE WILL PLAY A ROLE AND PUBLIC HEALTH WILL PLAY A ROLE BUT IT WILL REQUIRE A NUMBER OF OTHER SECTORS TO BE INVOLVED TO EFFECT HEALTH AT THE COMMUNITY LEVEL. AND THAT WOULD INCLUDE THE COMMUNITY MEMBERS THEMSELVES AND THE STRENGTHS INHERENT TO INDIVIDUAL COMMUNITIES AS WELL AS MULTIPLE ASPECTS OF GOVERNMENT AND THE SUB SECTORS WITHIN GOVERNMENT. COMMUNITY DEVELOPMENT GROUPS, NON-PROFITS, PHILANTHROPY AND AND INVESTORS, EDUCATORS AND BUSINESS. SO JUST THINKING ABOUT ALL OF THE DIFFERENT GROUPS THAT NEED TO COME TOGETHER TO IMPROVE COMMUNITY HEALTH. I WANT TO TRANSITION TO SORT OF THE MAIN FOCUS OF THIS TALK WHICH IS HEALTH CARE AS A SECTOR AND HOW HEALTH CARE, ONE WAY THAT HEALTH CARE MIGHT CONTRIBUTE TO INVESTIGATIONS TO IMPROVE COMMUNITY HEALTH EQUITY. AND THERE ARE LOTS OF WAY THAT HEALTH CARE SECTOR CAN GET INVOLVED IN THAT, INCLUDING DIRECT ENGAGEMENT WITH COMMUNITIES AND THROUGH EDUCATION, THROUGH ADVOCACY, AS A MAIN EMPLOYER OF MANY WHO LIVE IN COMMUNITIES SO THERE ARE A NUMBER OF WAYS THAT HEALTH CARE SECTORS CAN GET INVOLVED AND IMPROVE COMMUNITY HEALTH EQUITY. I WANT TO FOCUS IN ON DATA AND HOW HEALTH CARE DATA CAN BE LEVERAGED AS A COMMUNITY ASSET. AND SPECIFICALLY, THE FACT THAT WILL WHEN NOWADAYS SINCE THE MAJORITY OF HEALTH SYSTEMS ARE LEVERAGING ELECTRONIC HEALTH RECORDS, WE THEN HAVE A TROVE OF INFORMATION ON PEOPLE WHO UTILIZE HEALTH CARE THAT CAN BE USED FOR THE PURPOSES OF COMMUNITY HEALTH EQUITY. AND IF YOU THINK ABOUT IT, WHEN PEOPLE GO AND GET THEIR HEALTH CARE DATA AND EVERYBODY IS TRYING TO FIGURE OUT HOW TO USE THE DATA, HOW TO APPLY IT SO WE CAN DEVELOP MORE LEARNINGS ABOUT HEALTH AND WELLNESS OR DISEASE, AND THESE DATA CAN BE AGGREGATED SO THAT WE CAN LOOK AT COMMUNITIES OF INDIVIDUALS WHO RECEIVE HEALTH CARE WITHIN A SPECIFIC SYSTEM OR SYSTEMS OF HEALTH CARE ORGANIZATIONS AND WE CAN TAKE THAT DATA AND AGGREGATE IT TO LEARN ABOUT A COMMUNITY'S HEALTH. WE CAN QUANTIFY HEALTH INEQUITIES THAT ARE EVIDENT IN COMMUNITIES THAT SEEK HEALTH CARE AND IDENTIFY COMMUNITY HEALTH CONCERNS. THE DATA THAT WE HAVE WITHIN THESE HEALTH CARE SYSTEMS CAN BE DEMOCK TIDES AND SHARED WITH THE PUBLIC TO HELP THE PUBLIC UNDERSTAND WHAT IS HAPPENING, WHAT KIND OF HEALTH PROBLEMS ARE PEOPLE GOING TO GET HEALTH CARE FOR? AND THE DATA CAN BE USED FOR DISCOVERY AND INTERVENTIONS. AND I'M GOING TO TALK ABOUT AN EXAMPLE OF THAT THAT WE HAVE BEEN DEVELOPING OVER THE LAST SELF YEARS IN DURHAM COUNTY AT DUKE IN PARTNERSHIP WITH ANOTHER HEALTH CARE SYSTEM IN DURHAM COUNTY, A COMMUNITY-BASED HEALTH CARE SYSTEM. SO, THIS EXAMPLE IS BASED IN DURHAM COUNTY NORTH CAROLINA AND THIS IS A MAP OF NORTH CAROLINA AND I CIRCLED DIRHAM COUNTY, CENTRAL NORTH CAROLINA. NORTH CAROLINA IS A STATE OVERALL WAS RANKED BY THE UNITED HEALTH FOUNDATION AS BEING 36 OVERALL HEALTH IN THE UNITED STATES. DURHAM COUNTY IS THE 6th LARGEST COUNTY IN NORTH CAROLINA WITH ABOUT 300,000 RESIDENTS. IT'S A REASONABLY DIVERSE COUNTY WITH 14% LATINX, 38% BLACK, 42% WHITE, 6% OTHER BASED ON CENSUS DESIGNATION. AND THERE IS A FAIR AMOUNT OF SOCIOECONOMIC DIVERSITY WITH 16% OF RESIDENTS LIVING BELOW POVERTY AND 20% ABOVE. 100,000 ANNUAL INCOME. IT'S IMPORTANT TO REMEMBER THAT IN THIS PARTICULAR AREA, IT'S IN -- VERY INTERESTING BECAUSE THERE IS A LARGE DIVERSITY EVEN IN THE TOPOGRAPHY OF THE AREA RANGING FROM RURAL TO MUCH MORE URBAN IN DURHAM CITY. AND WE ARE ALSO IN THE MIDDLE OF RESEARCH TRIANGLE PARK SO THIS IS PART OF WHY WE HAVE SUCH SOCIOECONOMIC DIVERSITY IN THIS AREA. IN DURHAM COUNTY, TWO HEALTH SYSTEMS HAVE PROVIDED CARE FOR AT LEAST 85% OF THE DURHAM COUNTY RESIDENTS HISTORICALLY OVER THE PAST DECADES. AND THAT WOULD BE DUKE HEALTH, WHICH IS THE ACADEMIC HEALTH CENTER I WORK IN AND THEN LINCOLN COMMUNITY HEALTH CENTER, THE LEGAL FEDERALLY-QUALIFIED COMMUNITY HEALTH CENTER IN DURHAM. AND BOTH HEALTH SYSTEMS ARE COMMITTED TO IMPROVING COMMUNITY HEALTH AND HAVE A LONG HISTORY OF COLLABORATIVE ENGAGEMENT TOGETHER AND WITH DURHAM COUNTY STAKEHOLDERS. AND IN 2016, WHEN AROUND THE TIME WHEN DUKE HAD FULLY ESTABLISHED ITS NEW ETHIC-BASED ELECTRONIC HEALTH RECORD, LINK ON COMMUNITY HEALTH CENTER ALSO CAME INTO AGREEMENT WITH DUKE TO DEVELOP A SUBLICENSE OF EPIC ALONG WITH THE DUKE SYSTEM. SO BOTH SYSTEMS WERE USING THE SAME ELECTRONIC HEALTH RECORD PLATFORM. AND AROUND THAT TIME ONCE BOTH PROGRAMS WERE ESTABLISHED, THERE HAD BEEN DISCUSSION ABOUT A JOINT EFFORT TO LEVERAGE THE DATA FOR COMMUNITY HEALTH BENEFIT IF POSSIBLE, WHILE PROTECTING THE PRIVACY OF INDIVIDUALS LIVING IN THE COMMUNITY. SO WE STARTED A JOINT EFFORT THAT INVOLVED THE DURHAM COUNTY PUBLIC HEALTH, A NON-PROFIT COMMUNITY-BASED ORGANIZATION CALLED DATA WORKS IN DURHAM, LINCOLN COMMUNITY HEALTH CENTER, THE COMMUNITY, FEDERALLY-QUALIFIED COMMUNITY HEALTH CENTER, AND DUKE HEALTH. THE IDEA WAS TO TAKE DATA THAT WAS OBTAINED FROM PEOPLE VISITING BOTH HEALTH SYSTEMS AND TO AGGREGATE IT AT THE COMMUNITY LEVEL, DEIDENTIFY IT SO NO INDIVIDUALS DATA COULD BE EXPOSED AND THERE WAS A CAREFUL DEIDENTIFICATION PROCESS THAT WE WENT THROUGH WITH LEGAL EXPERTS. BUT AGGREGATING DATA AT THE LEFT OF THE CENSUS BLOCK WITH BREAKDOWN OF OF INFORMATION BY RACE, ETHNICITY, AGE, GENDER AND GEOGRAPHY. TO BEGIN TO UNDERSTAND COMMUNITY HEALTH AT THE LEVEL OF THE CENSUS BLOCK. AND THIS IS THE PROCESS OF WHAT HAPPENED AND I'LL SHOW YOU THE IN THE MIDDLE ARE A GROUP OF INDIVIDUALS, AND THIS IS MEANT TO REPRESENT INDIVIDUALS IN DURHAM COUNTY THAT WOULD SEEK HEALTH CARE AT DUKE HEALTH OR LINCOLN COMMUNITY HEALTH CENTER. THOSE ARE THE TWO HEALTH SYSTEMS. THEY WOULD GET THEIR HEALTH CARE AND THE DATA IS IN THE ELECTRONIC HEALTH RECORD. AT THE REQUEST OF THE COUNTY PUBLIC HEALTH IN DURHAM COUNTY, REPORTS WERE SENT, DEIDENTIFIED REPORTS WERE SENT TO DURHAM COUNTY PUBLIC HEALTH TO OBTAIN INFORMATION, AGGREGATE INFORMATION AT THE COMMUNITY LEVEL THAT SENSOR US BLOCK LEVEL, THAT A SERIES OF CONDITIONS OF INTEREST TO THE COMMUNITY THAT ARE IDENTIFIED THROUGH THE COMMUNITY BENEFITS PLANNING PROCESS. THESE REPORTS WERE VIEWED BY THE COUNTY PUBLIC HEALTH DEPARTMENT AND THEN SENT TO THIS NON-FOR-PROFIT DATA WORKS NORTH CAROLINA ORGANIZATION WHO THEN TOOK THAT INFORMATION AND COULD MAP OUT INFORMATION ON COMMUNITY-LEVEL HEALTH SO IT COULD BE PROVIDED BACK TO THE COMMUNITY AND DISSEMINATED TO STAKEHOLDERS AND MULTIPLE SECTORS FOR THINKING ABOUT YOU HO TO LEVERAGE THAT INFORMATION TO IMPROVE COMMUNITY HEALTH. AND THIS IS AN EXAMPLE OF -- THIS IS WHAT THE RESULT HAS BEEN. IT'S BEEN THE ESTABLISHMENT OR ADDITION OF HEALTH CONDITIONS TO THE DURB AM COMPASS. SO DURHAM NEIGHBORHOOD COMPASS IS BE-BASED PLATFORM YOU CAN GO TO IF YOU WANT TO ON YOUR COMPUTER. WHAT IT DOES IS DESCRIBES OR TAKES PUBLICLY-AVAILABLE DATA ON SOCIAL AND ENVIRONMENTAL DETERMINANTS OR COMMUNITY-LEVEL CHRACTERISTICS THAT REFLECT COMMUNITY ASSETS VERY SIMILAR TO THE NEIGHBORHOOD DISADVANTAGED INDEX BUT LOCAL. AND MAPS OUT THINGS LIKE CIVIC ENGAGEMENT, DEMOGRAPHICS, ECONOMIC INDICATORS, EDUCATION INDICATOR AND ENVIRONMENTAL INDICATORS ON A MAP. SO YOU CAN SEE COMMUNITY BY COMMUNITY AT THE CENSUS BLOCK LEVEL HOW ENGAGED A COMMUNITY MAY BE, WHAT THE DEMOGRAPHICS ARE, WHAT THE ECONOMIC INDICATORS ARE, ET CETERA. THE PROCESS OF THE TWO HEALTH SYSTEMS COMING TOGETHER WITH COUNTY PUBLIC HEALTH AND CONNECTING WITH THIS NOT-FOR-PROFIT WAS THAT WE WERE ABLE TO THEN ADD HEALTH CONDITIONS TO THAT. AND WE ADDED HEALTH CONDITIONS, A NUMBER OF THEM TO THAT COMPASS SO THEY CAN BE MAPPED SIMILARLY TO THE OTHER SOCIAL CHARACTERISTICS AND THE CONDITIONS THAT WE MAPPED ARE DIABETES, CHRONIC KIDNEY DISEASE, MYOCARDIAL AND I BELIEVE STROKE IS THERE. WE ALSO SENT INFORMATION OVER TO OBESITY, PRETERM BIRTH AND LOW BIRTH WEIGHT AND COLLECTED SIMILAR DATA ON A NUMBER OF OTHER CONDITIONS. AND WHAT THIS DOES IS JUXTAPOSE HEALTH CONDITIONS WITH THE SOCIAL ENVIRONMENTAL DETERMINANTS OF COMMUNITY HEALTH. SO, IN THIS FOR EXAMPLE, THIS MAP IS LOOKING AT -- WHAT CAN YOU SEE IN THE ACTUAL -- WHAT THE COMPASS WILL SHOW ARE THE CONTEXTURAL DATA. SO UP HERE ON THIS TOP RIGHT-HAND SIDE IS OUR EVICTION SUMMARY, EVICTIONS PER SQUARE MILE WHERE THE DARKER AREAS ARE AREAS WHERE THERE IS GREATER NUMBERS OF EVICTIONS VERSUS LIGHTER AREAS WITH FEWER NUMBERS AND YOU CAN SEE THAT DATA. THIS IS VIOLENT CRIMES PER SQUARE MILE ON THE BOTTOM. AND YOU CAN LOOK AT THE DATA AT A SNAPSHOT IN TIME OR OVER TIME AS WELL. WE THEN ALSO MAPPED NEXT TO THAT THE HEALTHS CONDITIONS. SO AND I THINK I HAVE AN EXAMPLE OF THAT BUT I MIGHT GO BACK TO THIS SLIDE TO SAY THIS IS A SLIDE OF THE DIABETES RATE. THIS IS A PICTURE OF WHAT THE DIABETES RATE LOOKS LIKE COMMUNITY BY COMMUNITY IN DURHAM COUNTY. AND THAT IS DATA THAT CAME FROM THE TWO HEALTH SYSTEMS. DIABETES PREVALENCE. SO THE DATA THAT ARE THERE ON SOCIAL ENVIRONMENTAL DETERMINANTS ARE BOTH NATIONAL DATA AND LOCAL. SO MANY OF THE ATLASES SUCH AS THE NEIGHBORHOOD ATLAS IN WISCONSIN DRAW FROM NATIONAL DATA SUCH AS THE CENSUS BUREAU AND THE AMERICAN COMMUNITY SURVEY BUT WHAT IS UNIQUE HERE IS WE ALSO HAVE LOCAL DATA THAT INFORMS THE LOCAL CONTEXT SPECIFICALLY SO FOR EXAMPLE, WHEN WE THINK ABOUT SPECIFIC ENGAGEMENT, ONE PROXY FOR THAT IS ELECTION PARTICIPATION SO USING DATA FROM THE DURHAM COUNTY BOARD OF ELECTIONS, WE HAVE DATA ON THAT AT THE COMMUNITY LEVEL. WE ALSO HAVE DATA ON THE ECONOMY THAT IS NOT NECESSARILY AVAILABLE AT THE NATIONAL LEVEL SUCH AS RESIDENTIAL COMMERCIAL BUILDING PERMIT VALUES WHICH COMES FROM THE DURHAM CITY COUNTY INSPECTIONS DETERMINE. LAND USE DIVERSITY WHICH COMES FROM THE COUNTY TAX ADMINISTRATION. WE HAVE DATA THAT COMES FROM THE DURHAM POLICE DEPARTMENT AND COUNTY SHERIFF. THERE IS INFORMATION ON CHILD CARE CENTERS PER SQUARE MILE FROM THE DIVISION OF CHILD CARE AND EARLY EDUCATION. AND THE CITY OF DURHAM NEIGHBORHOOD IMPROVEMENT SERVICES. THERE ARE DATA FOR EXAMPLE ON AUTOMOTIVE CODE VIOLATIONS FROM THE NEIGHBORHOOD IMPROVEMENT SERVICES, THINGS LIKE AVERAGE MONTHLY HOUSEHOLD ELECTRICITY USE IMPERVIOUS AREAS. WE ALSO HAVE DATA ON AVERAGE AGE OF DEATH FROM OUR STATE-LEVEL CENTER FOR HEALTH STATISTICS AND THEN WE ALSO HAVE NOW THE PREVALENCE OF THE HEALTH CONDITIONS OFFERED UP BY OUR HEALTH CARE SECTOR THROUGH DUKE HEALTH AND WILL LINCOLN COMMUNITY HEALTH CENTER. I THINK SIMILARLY, HOUSING, THNGS LIKE AVERAGE YEARLY CONSTRUCTION, COST BURDEN, MORTGAGE HOLDERS, RENTERS, SUMMARIES, THESE ARE THINGS THAT COME INTO IN ADDITION TO NATIONAL DATA SUCH AS HOME MORTGAGE DISCLOSURE ACT DATA AND DATA FROM THE CITY OF DURHAM AND DURHAM COUNTY ORGANIZATIONS LIKE THE TAX ADMINISTRATION AND THE SHERIFF'S DEPARTMENT. SO ADDING THIS LOCAL DATA ADDS A LOT OF CONTEXT WE MIGHT NOT ACTUALLY GET FROM USING JUST THE NATIONAL DATA AND REQUIRES GOING TO A NUMBER OF ADDITIONAL DATA SOURCES. AND I WOULD ARGUED THAT WE NEED THAT. SO WHILE IT IS VERY, VERY USEFUL TO HAVE NATIONAL MAPS OF NEIGHBORHOOD DEPRIVATION OR DISADVANTAGE, IT IS ALSO IMPORTANT TO HAVE LOCAL CONTEXT BECAUSE AS WE HAVE ALWAYS HEARD, I THINK SOME FAMOUS POLITICIAN SAID THAT ALL POLITICS IS LOCAL OR ARE LOCAL, AND IT IS REALLY TRUE THAT IN ORDER TO UNDERSTAND WHAT IS AFFECTING HEALTH IN ONE PERSON'S COMMUNITY, YOU NEED TO UNDERSTAND THE LOCAL POLICIES AND STRUCTURES AND THOSE EFFECTS ON HEALTH. SO YOU NEED THE NATIONAL AS WELL AS THE LOCAL. IN PUTTING OUT DATA THAT FOCUSES HEALTH AT THE COMMUNITY LEVEL AND THEN JUXTAPOSING IT WITH OTHER DATA ABOUT THE COMMUNITY SOCIAL ENVIRONMENTAL CONTEXT, WHAT COULD WE BE DOING? HOW CAN THAT BE HELPFUL? WE BELIEVE THAT PUTTING OUT INFORMATION ON HEALTH, PARTICULARLY HEALTH OF PEOPLE WHO ARE SEEKING OR RECEIVING HEALTH CARE SO WE HAVE INFORMATION, GRANULAR INFORMATION ON HEALTH CONDITIONS, THE SEVERITY OF HEALTH CONDITIONS AMONG THOSE WHO ARE RECEIVING ACCESS TO CARE AT THE VERY LEAST, WE CAN BEGIN TO FOSTER A COMMON UNDERSTANDING LOCALLY AMONG MULTIPLE ACCEPTABILITIORS AND STAKEHOLDERS ABOUT COMMUNITY HEALTH AND WILL INEQUITIES. OFTEN PEOPLE MAY SEE POOR HEALTH HAPPENING AROUND THEM BUT IT BRINGS IT TO LIFE WHEN YOU CAN SEE IT ON A MAP, PER SE OR YOU HAVE THE DATA IN HAND. AND I THINK THE POWER OF DATA ON HEALTH IN THE HANDS OF OTHER TYPES OF STAKEHOLDERS IS REALLY IMPORTANT TO KEEP IN MIND AS WE SEEK TO TRANSLATE WHAT WE ARE LEARNING ABOUT HEALTH CARE INTO COMMUNITY HEALTH. WE NEED TO HAVE THAT DATA IN STAKEHOLDER'S HANDS SO THEY CAN ACT. AND THEN I THINK ALSO BY GETTING IT OUT TO MULTIPLE STAKEHOLDERS, BY DEMOCRATIZING IT PUBLICLY, THEN MULTIPLE GROUPS CAN SEE IT AND MULTIPLE GROUPS ARE OFTEN WORKING ON HEALTH CONDITIONS SIMULTANEOUSLY AND MAY NOT KNOW IT. SO BY PUTTING DATA IN THE HANDS OF PEOPLE, GATHERING THEM TO TALK ABOUT COMMUNITY HEALTH ISSUES, COLLECTIVELY, YOU CAN THEN ENHANCE THE OPPORTUNITIES FOR SYNERGISTIC ACTION THROUGH LOCAL CROSS SECTIONAL COLLABORATIONS. SO, THAT IS THE PROCESS THAT WE HAVE BEEN GOING THROUGH TO GET OUR DATA OUT INTO THE HANDS OF PUBLIC STAKEHOLDERS. AND THE QUESTION IS, CAN WE USE SIMILAR PLATFORMS FOR RESEARCH? AND THE ANSWER IS, YES. WE ARE BEGINNING TO DO THAT, MANY ACROSS THE COUNTRY ARE DOING T I WANT TO SHOW EXAMPLES OF HOW WE ARE BEGINNING TO THINK ABOUT WITH REGARD TO COMMUNITY HEALTH EQUITIES AND WAYZ TO TEASE APART STRUCTURAL RACISM AND IT'S EFFECT ON COMMUNITY HEALTH. AND JUST SO THAT WE ARE ALL ON THE SAME PAGE WITH AT LEAST ONE DEFINITION OF STRUCTURAL RACE IM, MANIFESTATIONS WOULD BE MACRO LEVEL SYSTEMS, SOCIAL FORCES, INSTITUTIONS, IDEOLOGIES AND PROCESSES THAT INTERACT WITH ONE ANOTHER TO GENERATE AND REINFORCE INEQUITIES ACROSS RACIAL AND ETHNIC GROUPS. WE ARE TALKING ABOUT HEALTH INEQUITIES BUT OBVIOUSLY THERE ARE MANY INEQUITIES ACROSS RACIAL AND ETHNIC GROUPS SPECIFICALLY IN OUR YE AND HAPPENING REGIONALLY AND LOCALLY AS WELL. AND THESE INEQUITIES PERSIST OVER TIME -- AND THE RACIST SYSTEMS SOCIAL FORCES INSTITUTIONS PERSIST OVER TIME AND THEY ADAPT TO NEW SOCIO-POLITICAL CONTEXT AS THEY UNFOLD AND IMPACT POPULATION PATTERNS OF DISEASE MORE FUNDAMENTALLY THAN DO OTHER PROXIMAL FACTORS. SO CLEAN AIR AND CLEAN WATER PROBABLY ACCOUNT MUCH MORE FOR HEALTH THAN THE MANAGEMENT OF DIABETES AND HEMOGLOBIN A1C BETWEEN 6-7. THERE ARE SOME FUNDAMENTAL FACTORS THAT PREDICT OUR HEALTH THAT ARE SPECIFIC TO OUR SOCIAL AND ENVIRONMENTAL CONTEXT. THOSE THINGS. WE NEED TO THINK AT THE MACRO LEVEL WHEN WE ARE THINKING ABOUT HEALTH INEQUITIES, PARTICULARLY, RACIAL HEALTH INEQUITIES, THINKING ABOUT STRUCTURAL RACISM AS A KEY DETERMINANT OF RACIAL HEALTH INEQUITIES IS IMPORTANT. WE BEGIN TO THINK ABOUT COMMUNITY HEALTH INEQUITIES WHICH ARE RACIALLY ORIENTED OR ETHNICALLY ORIENTED AND THINKING ABOUT THE ROLE OF STRUCTURAL RACISM OR STRUCTURAL INEQUITIES AND HOW THEY MIGHT EFFECT HEALTH INEQUITIES. HERE IS AN EXAMPLE. I WANT TO JUST MAKE SURE WE ARE ALL CLEAR ON HOW A COMMUNITY-LEVEL OR A SOCIAL POLICY CAN BE A STRUCTURAL POLICY THAT PERSISTS. ONE OF THE MOST COMMON EXAMPLES OF STRUCTURAL RACISM OR POLICIES THAT RESULT IN STRUCTURAL INEQUITIES ARE THE RED LINING RESIDENTIAL POLICIES OF THE 1930s WHICH HAVE CREATED GENITIVE SYSTEMS OF INEQUALITY IN COMMUNITIES. BACK IN THE 30s THERE WAS A HOMEOWNER'S LOAN CORPORATION WHICH WAS CREATED IN RESPONSE TO THE GREAT DEPRESSION AS A WAY TO HELP STABILIZE THE HOUSING MARKET IN THE UNITED STATES AND IT WAS RESPONSIBLE FOR DEVELOPING GUIDANCE FOR REFINANCING MORTGAGES AND RESHAPING RESIDENTIAL LENDING INDUSTRY. AND AS A PART OF THE ACTIVITIES OF THE HOMEOWNER'S LOAN CORPORATION IS THIS ACTIVITY OF RED LINING AND THIS IS A MAP OF BALTIMORE, MARYLAND IN 1937 WHEN YOU CAN SEE RED LINING WAS DONE. IN THESE MAPS THE RED AREAS WOULD BE CONSIDERED AREAS OF HIGH RISK WHERE IT WAS -- WHERE LOANING MORTGAGES WOULD BE CONSIDERED HIGHER RISK LESS DESIRABLE. THE GREEN AREAS ARE SLIGHTLY MORE DESIRABLE AND THE BLUE CONSIDERED TO BE THE MOST DESIRABLE. AND WHEN YOU LOOK AT THE POLICIES, IT'S REALLY QUITE STRIKING HOW EXPLICIT THEY ARE THAT THE MORE BLACKS THAT WOULD BE IN A PARTICULAR AREA THAT AREA WOULD BE RED LINED. AND IT LITERALLY, MANY OF THE POLICIES, SOME 200 U.S. CITIES THAT WERE RED LINED IN THE SAME MANNER AND IF YOU LOOK AT THE DESCRIPTIONS OF THOSE RED LINED AREAS IT WOULD SAY, HIGH RISK, MANY BLACKS IN THIS AREA AND THEN THE NEXT YELLOW AREA MIGHT SAY, FEWER BLACKS, SLIGHTLY LESS RISKY. SO THAT KIND OF EXPLICIT LANGUAGE AROUND HOUSING AND RESIDENTIAL SEGREGATION. WHEN WE HAVE THIS KIND OF STRUCTURAL RACIST POLICY THAT GOES IN PLACE, THAT RESULTS IN RESIDENTIAL SEGREGATION BY RACE, WHAT HAPPENS IS THAT THERE ARE WHOLE CASCADING SET OF EVENTS THAT EFFECT THE VIBRANCY, HEALTH OF A COMMUNITY, INCLUDING -- IF YOU SAY IN AREAS LESS DESIRABLE THEN THERE IS A LACK OF FINANCIAL INVESTMENT. THAT LEADS TO HISTORICALLY LOWER INCOME FAMILIES BEING ONLY BEING ABLE TO WANTING TO LIVE THERE OR BEING ABLE TO LIVE THERE. THEN, AS A RESULT OF A LOWER TAX BASIS, HAVE YOU FEWER HIGH-QUALITY EDUCATIONAL RESOURCES. RELATED TO THAT THE INDIVIDUALS WHO HAVE POORER QUALITY EDUCATION HAVE WORSE EMPLOYMENT OPPORTUNITIES. WHICH THEN LEADS TO MORE POVERTY OR LESS BUILDUP WITHIN FAMILIES. THOSE LIVING IN THAT AREA HAVE LESS SOCIAL CAPITAL TO ENSURE A CLEAN AND HEALTHY ENVIRONMENT. AND THERE IS WORSE HOUSING CONDITIONS THAN LEADS AGAIN TO RESIDENTIAL SEGREGATION BY RACE. SO THESE ARE STRUCTURAL INEQUITIES THAT ARE MEDIATED AT THE COMMUNITY LEVEL THAT RELATE TO COMMUNITIES HEALTH AND ARE LIKELY ALSO RELATED TO THAT SOCIAL AND ENVIRONMENTAL CONTEXT IN WHICH INDIVIDUALS PHYSICAL HEALTH ARE EMBEDDED. AND SOY AS I'M SAYING, WHEN WE DEPRIVE A COMMUNITY OF RESOURCES AND OPPORTUNITIES, WE END UP HAVING -- SO IF YOU LIMIT CLEAN AIR, CLEAN WATER, TRANSPORTATION, FINANCIAL INVESTMENT, HOUSING, EDUCATION AND EMPLOYMENT, YOU ARE THEREFORE -- THESE ARE GOING TO BE RELATED TO ILLNESS PROMOTING LIVING CONDITIONS, POVERTY, FOOD AND HOUSING INSECURITY, TRAUMA, VIOLENCE AND INCARCERATION, POOR ACCESS TO HEALTH CARE, SUBOPTIMAL HEALTH CARE AND LOW HEALTH LITERACY. THESE ARE ALL IN SOME FORM HAVE BEEN RELATED TO POOR HEALTH. AT THE COMMUNITY LEVEL ARE WHERE THESE ENVIRONMENTAL CONTEXT IS DIRECTLY RELATED TO THESE FACTORS. SO, UNTIL DURHAM, MY COLLABORATORS AND I, PARTICULARLY MY COLLABORATOR, DR. [ INAUDIBLE ] IS LOOKING AT HOW STRUCTURAL ASPECTS, STRUCTURAL CHARACTERISTICS OF THE COMMUNITY THAT MAY REFLECT STRUCTURAL RACISM ARE ASSOCIATED WITH COMMUNITY HEALTH IN TERMS OF COMMUNITY PREVALENCE OF CHRONIC KIDNEY DISEASE. SO THIS AGAIN IS A MAP OF DURHAM, NORTH CAROLINA, AND THIS IS A MAP OF THE COUNTY-LEVEL OR CENSUS BLOCK LEVEL, COMMUNITY BY COMMUNITY, AND THIS IS THE BLACK OR AFRICAN-AMERICANS IN THE POPULATION OF EACH COMMUNITY PORTION SO THE DARKER AREAS HAVE MORE PROPORTION OF BLACK INDIVIDUALS AND THE LESS BLUE HAS LOWER PROPORTION OF BLACK INDIVIDUALS. AND THEN ON THE RIGHT-HAND SIDE, WE HAVE THE PREVALENCE OF CHRONIC KIDNEY DISEASE COMMUNITY BY COMMUNITY AT THE CENSUS BLOCK LEVEL. AND I'M JUST POINTING OUT PART OF THIS AREA WAS RED LINED AS PART OF THE POLICIES THAT I WAS TALKING ABOUT BEFORE. AND SO WHAT WE ARE LOOKING AT IS TO SEE IF THERE IS A CONNECTION BETWEEN SOME OF THESE COMMUNITY-LEVEL FACTORS THAT MIGHT REFLECT STRUCTURAL RACISM AND THE PREVALENCE OF DISEASE AT THE CENSUS BLOCK LEVEL? AND SO SOME OF THE CONSTRUCTS THAT WE BELIEVE MAY REFLECT ELEMENTS OF STRUCTURAL RACISM INCLUDE EVICTIONS, WHICH WOULD BE A REFLECTION OF HOUSING AND ECONOMIC STABILITY, AGAIN RELATED TO THAT CONCEPT OF THE RED LINING. MEDIAN HOUSEHOLD INCOME REFLECTING WEALTH AND OPPORTUNITY OR A LACK OF WEALTH AND OPPORTUNITY AS A RESULT OF STRUCTURAL POLICIES. COMMUTE TIMES WHICH WOULD REPRESENT ACCESS TO ESSENTIAL SERVICES. IMPERVIOUS AREAS REFLECTS THE BUILT ENVIRONMENT AND HOW MUCH CONCRETE WATER RUNOFF THERE IS IN AN AREA. ELECTION PARTICIPATION SUCH AS POLITICAL DISENFRANCHISEMENT OR THE HOW MUCH ARE COMMUNITIES PRIORITIES REFLECTED IN THE POLICIES. OR NOT? AND VIOLENT CRIMES REFLECTING ACCESS CRIMINALIZATION OR LACK OF SAFETY WITHIN A PARTICULAR COMMUNITY. AND WE HAVE DONE SOME -- WHERE THIS WORK IS ONGOING, WE HAVE BEEN LOOKING AT THE ELEMENTS OF STRUCTURAL RACISM OR THESE CHARACTERISTICS OF A COMMUNITY THAT MIGHT REFLECT STRUCTURAL RACISM AND HOW THEY MIGHT BE RELATED TO THE PREVALENCE OF CHRONIC KIDNEY DISEASE IN A PARTICULAR CENSUS BLOCK. SO, FOR EXAMPLE, VIOLENT CRIMES PER SQUARE MILE IN LOOKING AT THE PREVALENCE OF ENVIRONMENT CRIMES PER SQUARE MILE AMONG HIGH PREVALENCE CHRONIC -- COMMUNITIES WITH HIGH CKD PREVALENCE VERSUS THOSE WITH LOW CKD PREVALENCE OR LEVEL TO EVICTIONS PER SQUARE MILE AND THOSE WITH HIGH OR LOWER CKD PREVALENCE. THESE ARE THE FACTORS. WE FOUND THERE ARE FACTORS THAT SOME OF THESE ELEMENTS OF A COMMUNITY CHARACTERISTICS OF A COMMUNITY THAT REFLECT STRUCTURAL RACISM THAT ARE ASSOCIATED WITH CKD PREVALENCE INCLUDING VIOLENT VITAMINS PER SQUARE MILE, COMMUTE TIMES, ELECTION PARTICIPATION AND HOUSES HOLD INCOME AND WE ARE CONTINUING -- THESE WERE PRELIMINARY DATA WE PRESENTED PREVIOUSLY AND NOW ELABORATING ON THESE THERE ARE MEW IN-DEPTH EVALUATIONS. SO WHEN WE WERE DUELING THIS KIND OF RESEARCH, ONE QUESTION IS, WHY IS THIS VALUABLE? EARLIER ON IN MY CAREER, I DISTINCTLY REMEMBER DOING DISPARITIES WORK AND WE WERE VERY MUCH FOCUSED ON DISPARITIES AND HEALTH AT THE INDIVIDUAL LEVEL AND WE WOULD GET TO SOMETHING LIKE, OKAY, WELL, THE PROBLEM IS -- AND MAYBE IT'S POVERTY. THEN WE SAY WHO CAN DEAL WITH THAT? TAT'S JUST OUTSIDE OF OUR REALM. AND IT IS TRUE THAT IT IS OUTSIDE OF THE REALM NECESSARILY OF THE -- THAT THE PREDICTORS OR THE THINGS THAT CAUSE POVERTY ARE OUTSIDE OF THE REALM OF HEALTH CARE AND SCIENCE, PER SE. HOWEVER, WE ARE PART OF A MULTISECTORAL GROUP OF STAKEHOLDERS IN HEALTH. AND SO, I THINK THAT THE VALUE OF THIS KIND OF WORK LOOKING AT WHERE WE ARE TRYING TO DRAW INSIGHT AROUND SOCIAL CONTEXT AND HEALTH ARE TO HELP IDENTIFY THE MACRO ENVIRONMENTAL MECHANISMS THAT CAN BE TARGETED FOR INTERVENTIONS. RATHER THAN THROWING UP OUR HANDS, WE MIGHT SAY, OKAY, POLICIES RELATED TO THE CRIMINALIZATION OF SPECIFIC INDIVIDUALS ARE ALSO RELATED TO HEALTH INEQUITIES. LET'S THINK ABOUT HOW WE ARE DEVELOPING OUR POLICIES AROUND VIOLENTED CRIMES. SIMILARLY, MAYBE EDUCATIONAL POLICIES ARE RELATED TO THE HEALTH OF OUR COMMUNITY AND LET'S THINK ABOUT HOW WE IMPROVE ACCESS TO EDUCATION THROUGH OUR POLICIES. IN ORDER TO DO THAT, WE NEED SOME KIND OF SCIENTIFIC PLATFORM WHEREBY WE ARE ABLE TO IDENTIFY THE MECHANISMS FOR THESE SOCIAL CONTEXT ACTING ON HEALTH. THE OTHER WAY THAT I THINK THESE TYPES OF RESEARCH ARE USEFUL IS IN FACILITATING THE CROSS SECTORAL INSIGHTS I TALKED ABOUT AT THE BEGINNING WHEN WE WERE TALKING ABOUT DEMOCRATIZING DATA. WHEN WE TALK ABOUT DEVELOPING INTERVENTIONS FOR THESE MACRO ENVIRONMENTAL MECHANISMS ON STRUCTURAL INTECHITIES AND RACIST POLICIES, IT REQUIRES MULTIPLE SECTORS TO WORK IN TANDEM TO ADDRESS THOSE. WE MIGHT NEED POLICY CHANGE, BUSINESS PRACTICES TO CHANGE, FOR EXAMPLE LENDING PRACTICES, ET CETERA. SO WE NEED THOSE CROSS SECTORAL INSIGHTS TO TARGET THESE BIG MAC ROW-LEVEL MECHANISMS FOR HEALTH INEQUITIES. AND THEN I THINK IT PROVIDES THAT FOUNDATIONAL FRAMEWORK THROUGH WE CAN VIEW THE HEALTH OF INDIVIDUALS. SO INCREASINGLY WE ARE SEEING HEALTH SYSTEM BEGIN TO COLLECT INFORMATION ON THE SOCIAL AND ENVIRONMENTAL DETERMINANTS OF HEALTH AT THE INDIVIDUAL LEVEL. AND THAT IS JUST VERY IMPORTANT BECAUSE IT PROVIDES A LENSE FOR WHAT IS HAPPENING NOT JUST WITHIN THAT PERSON'S BODY BUT OUTSIDE OF THAT PERSON'S BODY THAT ARE AFFECTING THEIR HEALTH. I WANT TO JUST TALK ABOUT ANOTHER LAYER THAT WE ARE WORKING ON AT DUKE AND PARTICULARLY LED BY -- THINKING ABOUT NOT JUST THOSE MICRO-- MACRO ENVIRONMENTS BUT THE MICROENVIRONMENTS THAT ARE WITHIN COMMUNITIES. SO, IN THIS EXAMPLE HE IS VERY MUCH INTERESTED IN LOOKING AT WHAT SORT OF COMMUNITY-LEVEL FACTORS MIGHT BE ASSOCIATED WITH HIGH CKD FLISK A COMMUNITY? IF A COMMUNITY HAS HIGH RATES OF CHRONIC KIDNEY DISEASE, ARE THERE THINGS THAT ARE HAPPENING INSIDE THAT COMMUNITY THAT ARE RELATED TO THAT? SHE SPECIFICALLY LOOKING AT RETAIL OUTLETS AND HOW LOW-COST HIGH POTENCY NON STEROIDALS WHICH ARE DAMAGING KIDNEYS ARE MARKETED TOWARDS INDIVIDUALS IN SPECIFIC COMMUNITIES. SO I DON'T KNOW MANY OF YOU MAY HAVE HEARD OF PRODUCT SUCH AS BC OR GOODY POWDER. THESE ARE LOCAL-COST NON STEROIDAL MEDICATIONS OFTEN USED FOR PAIN OR HEADACHES. AND BUT THEY ARE ALSO HIGH POTENCY. AND THESE ANECDOTALLY MAY BE SOLD IN LOWER INCOME NEIGHBORHOODS BECAUSE OF THEIR LOW COST MARKETING IN NEIGHBORHOODS WHERE PEOPLE CAN AFFORD THEM. AND SO, SHE IS BEGINNING TO LOOK AT -- AND LOOKING WITHIN STORES WITHIN SPECIFIC NEIGHBORHOODS SO LOOKING AT WHAT IS BEING MARKETED TO INDIVIDUALS FOR PAIN MANAGEMENT WITHIN LOW CKD NEIGHBORHOODS WITH LOW CHRONIC KIDNEY DISEASE PREVALENCE VERSUS HIGH CHRONIC KIDNEY DISEASE PREVALENCE AND LOOKING AT HOW ARE THESE PARTICULAR LOW-COST HIGH POTENCY NON STEROIDALS DAMAGING TO KIDNEY HEALTH, BEING MARKETED TO INDIVIDUALS IN SPECIFIC COMMUNITIES. AND SHE IS ALSO LOOKING AT OTHER TYPES OF FACTORS THAT MIGHT BE MARKETED TOWARDS PEOPLE IN SPECIFIC COMMUNITIES PARTICULARLY LOW-INCOME COMMUNITIES SUCH AS HIGH PHOSPHATE FOODS THAT ARE AS A RESULT OF PRESERVATIVES OR TOBACCO. AND SO, LOOKING AT HOW THINGS ARE MARKETED AND SOLD AND HOW THAT IS RELATED TO COMMUNITY PREVALENCE OR CHRONIC KIDNEY DISEASE. AND ONE OF THE THINGS THAT SHE HAS BEGUN TO EXPLORE EVEN THE KINDS OF RETAIL OUTLETS THAT ARE IN PARTICULAR COMMUNITIES SO AGAIN THIS IS A MAP OF DURHAM COUNTY AND SHE HAS BEGUN TO LOOK IN SEEING WHICH OF THE RETAIL OUTLETS SELL BEER, WINE OR LIQUOR, GROCERS, PHARMACIES, CONVENIENCE STORES, TOBACCO AND BAIT. AND SOMETIMES IN A LOCAL ENVIRONMENT, PARTICULARLY WITHIN SOMEONE'S BLOCK OR TWO, THERE MAY BE NO GROCERY STORE AND MAYBE A CONVENIENCE STORE IS ALL THAT ONE HAS TO GET THINGS LIKE THINGS THAT CAN CONTROL PAIN. THESE ARE THINGS THAT COULD INFLUENCE THE ENVIRONMENT THAT ALSO COULD BE INFLUENCING HEALTH. SO AGAIN, AS IN THE BEGINNING, I TALKED ABOUT THIS IS THE LAST MILE OF TRANSLATION BECAUSE THE BIGGER PICTURE IS THAT WE HAVE OFTEN TREATMENTS FOR CONDITIONS OR RISK FACTORS FOR CONDITIONS. SO I USE THAT EXAMPLE OF HYPERTENSION AND THEN HOW ARE WE GOING TO GET THESE INSIGHTS TRANSLATED INTO COMMUNITY HEALTH? AGAIN, IT'S NOT GOING TO BE JUST SCIENTISTS AND MEDICAL PRACTITIONERS. IT WILL INCLUDE GOVERNMENT OFFICIALS AND POLICY ADVOCATES WHO WILL CHANGE POLICIES AND SERVICES, BUSINESS LEADERS WHO WILL BE CHANGING THEIR PRACTICES, HEALTH CARE PROVIDERS AS WELL CHANGING THEIR PRACTICES, COMMUNITY-BASED ORGANIZATIONS WHO CAN RESPOND TO THESE TYPES OF DATA BY PROVIDING RESOURCES AND ENHANCING COMMUNITY SUPPORT, INDIVIDUAL RESIDENTS [ TECHNICAL DIFFICULTIES ] THE QUESTION IS, WHAT OTHER TYPES OF DATA COULD BE APPLIED? I SHOWED YOU THAT LOCAL CONTEXTURAL DATA AND THE CENSUS DATA BUT COULD WE ALSO USE MARKETING AND LOCAL WEATHER OR TRAFFIC DATA, DATA FROM COMMUNITY MEDIA OUTLETS OR SOCIAL MEDIA OR LOCAL HEALTH CARE PROVIDER DATA THAT IS COMING FROM OUTSIDE OF THESE? LIKE WE HAVE TWO BIGGER HEALTH SYSTEM BUT NOW CVS, WALGREENS AND A NUMBER OF COMMERCIAL CHAINS ARE PROVIDING TARGET HEALTH CARE. CAN THOSE BE BROUGHT IN? AND WHAT ABOUT INFORMATION FROM LOCAL MERGE SEE SAFETY SERVICES, CRIMINAL JUSTICE ET CETERA? AND THEN I JUST BRIEFLY TOUCHED ON ANOTHER PROMISING NATIONAL DATA RESOURCE THAT I THINK CAN CREATE A BACKBONE FOR THIS TYPE OF WORK IF WE WANT TO LOOK AT SOCIAL AND ENVIRONMENTAL DETERMINANTS OF HEALTH AT A NATIONAL LEVEL, NATIONAL COVID COHORT COLLABORATIVE N3C, WHICH IS IT NOW BEING USED TO STUDY COVID BUT COULD BE USED TO STUDY ANY CONDITION FOR WHICH INDIVIDUALS ARE SEEKING HEALTH CARE. THIS IS AN EFFORT THAT IS SUPPORTIVE THROUGH NCATS, THE NATIONAL CENTER FOR ADVANCING TRANSLATIONAL SCIENCES TO BRING TOGETHER HEALTH RECORD SYSTEMS FROM ACROSS THE COUNTRY. STARTED OFF WITH THE 60+ CTSA HEALTH SYSTEM ASSOCIATED WITH THAT BUT GOES BEYOND THAT AS WELL TO BRING ALL OF THEIR ELECTRONIC HEALTH RECORD DATA INTO THE CLOUD AND THEN TRANSFORM THEM INTO A SINGLE ONTOLOGY SO SHAY CAN BE ANALYZED BY THOSE ASKING SPECIFIC RESEARCH QUESTIONS OF THE HEALTH SYSTEM DATA. YOU CAN IMAGINE HOW POWERFUL IT WOULD BE TO LINK THAT TO DATA ON SOCIAL AND ENVIRONMENTAL DETERMINANTS OF HEALTH TO ASK QUESTIONS NATIONALLY, REGIONALLY AND LOCALLY ABOUT HOW THE LINKS BETWEEN THESE SOCIALITY FACTORS AND CONTEXT AND COMMUNITY-LEVEL HEALTH. SO, SOME OF THE POSSIBILITIES WOULD BE AGAIN THINKING ABOUT GENERATING EVIDENCE TO ISOLATE TARGETS. I THINK THE UPSTREAM MANIFESTATIONS OF STRUCTURAL RACISM, BY THIS I MEAN AGAIN, LET'S LOOK AT WHAT ARE THE DIFFERENT CONTEXT THAT EFFECT COMMUNITIES HEALTH AND HOW THEY ARE ASSOCIATED WITH THE HEALTH OF -- AND HOW THESE FACTORS LIKE POLICIES, STRUCTURES, ACTIVELY INFLUENCE COMMUNITIES AND INDIVIDUALS LIVING IN THE COMMUNITIES PHYSICAL HEALTH. AND THINKING ABOUT ALSO HOW WE CAN LOOK AT THINGS OVER TIME. SO ONE THING I WAS TALKING ABOUT WHERE IN THEA IN DURHAM, WE ARE UPDATING REPORTS TO THE COMMUNITY EVERY YEAR. THAT ALLOWS TO YOU TRACK WHETHER COMMUNITY HEALTH IS IMPROVING OR WORSENING OR STAYING THE SAME OVER TIME. THAT IS VERY IMPORTANT BECAUSE WHEN WE ARE DOING INTERVENTIONS, WE WANT TO KNOW IF THEY ARE WORKING. WE DON'T WANT TO FEEL GOOD ABOUT THEM, WE WANT TO KNOW IF WHAT WE ARE DOING HAS AN IMPACT. THE OPPORTUNITY TO TRACK COMMUNITY HEALTH OVER TIME AND LOOK AND SEE THE IMPACT, SPECIFIC INTERVENTIONS OR FURTHER TO TRACK THE COLLECTIVE IMPACT OF MULTIPLE EFFORTS. SO OFTEN MULTIPLE STAKEHOLDERS ARE DOING THINGS TO IMPROVE DIABETES CARE, FOR EXAMPLE, ONE SECTOR MAY BE DOING DIABETES EDUCATION AND OUTREACH, ANOTHER MAY BE TREATING INDIVIDUALS WITH DIABETES, ANOTHER PERHAPS PUBLIC HEALTH LOOKING AT HOW TO PREVENT. WHAT IS THE COLLECTIVE IMPACT OF THOSE EFFORTS OVER TIME? THESE ARE THE POSSIBILITIES THAT UTILIZING DATA IN THIS WAY TO LOOK AT COMMUNITY HEALTH COULD BE USEFUL. ONE THING THAT WE ARE ALSO TRYING TO DO AT DUKE IN PARTICULAR, IS TO BUILD OUT THIS VISION SO THAT WE DO PROVIDE ANNUAL UPDATES ON HEALTH TO THE COMMUNITY AND THAT GOES INTO OUR MAPPING. AND I ALSO MENTIONED WE ARE BEGINNING TO DEVELOP THIS DATASET. AND THERE IN ADDITION TO LINKING THE DATA TO OUR ELECTRONIC HEALTH RECORD FOR INVESTIGATORS TO USE, WE WANT TO ALSO ENGAGE COMMUNITY STAKEHOLDERS AND SOCIAL SCIENTISTS WHO CAN HELP MORE TRADITIONALLY BIOMEDICALLY ORIENTED RESEARCHERS, UNDERSTAND THE CONTEXT WITH WHICH THE QUESTIONS THEY ARE ASKING ARE BEING ASKED. SO WE WANT TO KNOW IF A CERTAIN TYPE OF POLICY IS ASSOCIATED WITH HEALTH. IT WOULD BE USEFUL TO ENGAGE COMMUNITY STAKEHOLDERS WHO LIVE IN THE AREA TO GET THEIR INSIGHTS ON THAT RESEARCH QUESTION OR SOCIAL SCIENTISTS WHO MAY HAVE A SENSE OF HISTORICAL OR BROADER CONTEXT AROUND THOSE QUESTIONS. SO GATHERING THOSE TOGETHER WITH INVESTIGATORS. ALSO, WE ARE DEVELOPING SOME COLLABORATIVE EVIDENCE TO ACTION PILOTS THAT INVOLVE COMMUNITY MEMBERS WITH RESEARCHERS AT DUKE TO SPARK IDEAS AROUND COMMUNITY ACTION AND WE LIKE TO HAVE THOSE BE LINKED TO COMMUNITY HEALTH PRIORITIES BUT THIS MAPPING, THIS DATA DEMOCRATIZATION EFFORT BEING ONE WAY TO HELP COMMUNITY MEMBERS BE AWARE OF THE HEALTH CONDITIONS AND BEING ABLE TO WORK WITH INTERESTED RESEARCHERS AND VICE VERSA TO HAVE IDEAS THAT COULD SPARK INTERVENTIONS THAT COULD LEAD TO COMMUNITY ACTION OR CHANGES IN RESEARCH AND POLICY. AND THEN ULTIMATELY OUR GOAL IS TO TRACK SUSTAINED UPTAKE OF EFFECTIVE INTERVENTIONS IN THE COMMUNITY. SO I WANTED TO HARKEN BACK TO THAT THINK TANK THAT I ATTENDED AT NHLBI WHERE AN IDEA WAS WHAT DO WE NEED TO LOOK AT COMMUNITY HEALTH INEQUITIES. AND I THINK THAT MANY OF THE THINGS THAT WE NEED TO BEGIN TO SPARK THAT NEW ERA OF RESEARCH WE HAVE. SO, IN USING EFFORTS LIKE DEMOCRATIZING DATA OR LEVERAGING OUR DATA AS A COMMUNITY ASSET, LINKING IT TO DATA ON SOCIAL AND ENVIRONMENTAL CONTEXT, WE ARE USING CREATIVE TRANSSECTORAL MULTIDISCIPLINARY STRATEGIES BECAUSE WE ARE PULLING IN DATA FROM MULTISECTORS AND EMBRACING RESEARCH THEMES THAT THINK ABOUT THINGS AT MULTIPLE LEVELS. WHAT IS HAPPENING IN OUR COMMUNITY AND WHAT IS HAPPENING IN THE STORIES IN MY COMMUNITY AND HOW DOES THAT RELATE TO MY INDIVIDUAL HEALTH AS SOMEBODY WHO LIVES IN THE COMMUNITY? IT IS FUNDAMENTALLY A SYSTEM SCIENCE APPROACH BECAUSE WE ARE THINKING MACRO TO MICROAND THE MULTIPLE SECTORS AND WE NEED TO REFINE HOW WE THINK ABOUT SYSTEM SCIENCE IN THIS CONTEXT. NEW DATA SOURCES, OF COURSE, AND THEN REALLY THE POWER IN THIS IS GOING TO BE HOW WE LEVERAGE NETWORKS ACROSS SECTORAL AND MULTIDISCIPLINARY STAKEHOLDERS. WE ARE BEGINNING TO DEVELOP THE TOOLS TO DOT WORK, THE REAL TRANSLATION IS IN GETTING THE OUTPUT INTO THE STAKEHOLDERS THAT ARE GOING TO MAKE THE CHANGE AT THE END OF THE DAY. THAT IS WHERE THE BIG PAYOFF IS. SO I'M AT THE END OF MY REMARKS. I WANT TO SUMMARIZE TO SAY THAT COMMUNITY HEALTH EQUITY RESEARCH REQUIRES A UNIQUE LENSE AND NEW APPROACH. WE NEED TO START THINKING ABOUT THESE MULTIPLE LAYERS OF SIMULTANEOUS INFLUENCES ON HEALTH AND HOW THEY ACT IN A COORDINATED AND AGGREGATED FASHION. I BELIEVE THAT THE HEALTH SYSTEM AND COMMUNITY CROSS SECTORAL DATA ARE CRITICAL AND SHOULD BE JOINTLY LEVERAGED TOL DRIVE AS A WAY OF INFORMING, TRACKING- AND MEASURING HEALTH. I THINK PUTTING DATA INTO THE HANDS OF COMMUNITY STAKEHOLDERS AND RESEARCHERS SIMULTANEOUS LIE IS IMPORTANT NOT ONLY TO PA SILLITATE SYNERGIES BUT ALSO TO PROMOTE EFFECTIVE TRANSLATION OF INTERVENTIONS INTO IMPROVED HEALTH OUTCOMES AND HEALTH EQUITY. AND I THINK WE NEED A NEXT GENERATION OF RESEARCH THAT IS FUNDED TO REALLY LOOK AT HOW TO BEGIN TO LEVERAGE THESE NEW RESOURCES TO IMPROVE COMMUNITY HEALTH EQUITY. AND I JUST WANT TO MENTION AS I'M CLOSING, THAT THIS KIND OF WORK INVOLVED A LOT OF DIFFERENT COLLABORATORS BOTH INSIDE DUKE AND OUTSIDE OF DUKE, NOT ALL OF THE DIFFERENT LOGOS ARE HERE BUT THIS IS HIGHLY COLLABORATIVE WORK AND SO I WANT TO MAKE NOTE OF THAT AND THANK THE COLLABORATORS. SO WITH THAT, I SAY THANK YOU AND HAPPY TO HAVE A DISCUSSION. >> WONDERFUL. THANK YOU, SO MUCH FOR A GREAT TALK. WE HAVE A NUMBER OF QUESTIONS BUT I WANT TO START WITH A COMMENT. WHEN YOU WERE VERY FIRST BEGINNING WHEN YOU TALKED ABOUT HYPERTENSION AND THE MAP, WHICH I THINK WAS FROM A FEW YEARS AGO, IT STRUCK ME THAT THERE WERE CERTAIN GEOGRAPHIC DIFFERENCES IN THAT ON THE WEST COAST AND THE UPPER MIDWEST THE OUTCOMES WERE BETTER. AND HAVING BEEN A WEST TO EAST MIGRANT NOW INTO MY 6th YEAR, I HAVE NOTICED THE ORGANIZATION OF HEALTH CARE MAKES A BIG DIFFERENCE. AND THERE IS PREDOMINANCE OF THE MANTRA OF THE ACCOUNTABLE CARE ORGANIZATION AND THE STAFF MODEL HMO INITIATED BY KAISER AND OTHERS, MOUNTAIN HEALTH AND OTHERS THAT HAS SORT OF COVERED THAT AREA. AND I THINK THERE IS OTHER ANALYSIS YOU'RE PROBABLY FAMILIAR WITH THAT SHOW THE SAME THING WITH BLOOD PRESSURE CONTROL NOT BEING DIFFERENT BY RACE OR SOCIOECONOMIC STATUS IN THE WEST BUT IT IS ELSEWHERE. SO YOU DIDN'T MENTION HEALTH CARE ORGANIZATIONS. YOU WANT TO COMMENT ON THAT IN THE GLOBAL OF ALL OF THIS? >> SO I DID PUT IT UP AS A CONSIDERATION AND I FOCUSED ON THE COMMUNITY CONTEXT BUT CLEARLY THE TYPE OF HEALTH CARE AND THE ACCESS TO HEALTH CARE DELIVERY ARE IMPORTANT. AND LIKELY IF WE HAD UNIVERSAL ACCESS TO HEALTH CARE, THAT WAS COORDINATED WHERE PEOPLE COULD GET ACCESS TO HIGH QUALITY CARE, THERE ARE A NUMBER OF STUDY AFTER STUDIES SHOWING WHEN THERE IS EQUAL ACCESS THAT WE GET EQUAL OUTCOMES. THAT'S ANOTHER KEY EQUITY INDICATOR. I THINK WHAT IS REALLY FASCINATING IS TO THINK ABOUT HOW OUR NATION IS SET UP, EACH STATE HAS ITS OWN RULES ABOUT HOW HEALTH CARE AND EVEN IS DELIVERED. AND THAT REALLY HAS A HUGE IMPACT ON HOW COMMUNITIES THINK ABOUT HEALTH. AND I REMEMBER WHEN I MOVED FROM MARYLAND TO NORTH CAROLINA, VERY DIFFERENT. NORTH CAROLINA WAS A STATE TA DIDN'T DO MEDICAID EXPANSION IMMEDIATELY AND THE CONVERSATIONS YOU HEARD IN THE HEALTH CARE DELIVERY SPACE WERE DIFFERENT FROM WHERE THERE WAS A PLACE WHERE THERE WAS EXPANSION. AND THEY HAD ALSO SOME EXPERIMENTAL MODELS OF HEALTH CARE DELIVERY IN MARYLAND THAT ARE UNIQUE. BUT I THINK THAT IT IS VERY FSCINATING AND IT POINTS TO THAT MACRO LEVEL OF POLICY AND HOW IT REALLY HAS AN EFFECT ON COMMUNITY HEALTH. >> I'M GOING TO READ A COUPLE OF THE QUESTIONS THAT HAVE COME IN WITH TOO HARD BIASES. HOW DO WE ENSURE THE DATA SOURCES PULLED FOR SIMILARINAL CISION AREN'T IN THEMSELVES INHERENTLY BIASED? IMAGINE HEALTH UTILIZATION SERVICES RESEARCH MAY BE TIGHTLY LINKED TO EMPLOYMENT AND INSURANCE COVERAGE. HOW TO ENSURE THE OUTPUTS AND ASSUMPTIONS BEHIND RELATED MODELING THAT RESULT FROM USE OF THOSE DATA CAN ACCOUNT FOR THIS IN THE ANALYSIS. >> EBONY BOULWARE: WHAT I WILL SAY ABOUT THAT IS GARBAGE IN AND GARBAGE OUT. THE QUALITY OF THE DATA THAT WE USE ARE CRITICALLY IMPORTANT TO MAKING ANY SORT OF REASONABLE VALID INFERENCES. AND THAT IS ONE OF THE KEY THREATS THAT WE HAVE. I MYSELF HAVE HAD A HEALTHY AMOUNT OF SKEPTICISM. WHEN PEOPLE ARE SO EXCITED TO GET THE THE DATA. WE HAVE THE DATA AND NOW WE CAN ANALYZE. BUT HOW ARE THOSE DATA CONSTRUCTED? WHO ARE THEY COLLECTED ON? ARE THEY COLLECTED EQUITABLY? WE CAN DRAW IN PROPER INFERENCES BY MAKING ASSUMPTIONS BASED ON THE DATA WE HAVE OR DON'T HAVE. I THINK THERE HAVE BEEN SOME PRETTY WIDELY PUBLICIZED EXAMPLES OF WHERE ARTIFICIAL INTELLIGENCE ARE BEING USED TO PREDICT HEALTH OUTCOMES AND THOUGH THE DATASETS THEY ARE TRAINED ON DON'T HAVE DIVERSE POPULATIONS IN THEM. SO THEY ARE TRAINED ON NON DIVERSE POPULATIONS AND MAY MAKE ASSUMPTIONS ABOUT RISK, DISEASE RISK, BASED ON FAULTY ASSUMPTIONS THAT GO INTO THE ACTUAL DATA THAT IS BEING USED FOR THE PREDICTION THAT IS BEING SOUGHT. THERE ARE A NUMBER OF EXAMPLES OF THAT. SO AGAIN, HOW DO WE -- SO THAT IS A THREAT. IT'S A THREAT. HOW DO WE ENSURE THAT? WE ARE GOING TO HAVE TO BECOME CAREFUL ABOUT HOW WE DECIDE OR BEGIN TO COLLECT THESE DATA USING MORE PRESCRIBED WAYS OF DESCRIBING THINGS. BEING CLEAR WHEN WE ARE -- I THINK THE ISSUE OF BEING CLEAR WHEN WE ARE TALKING ABOUT A SOCIAL CONSTRUCT VERSUS A BIOMEDICAL OR BIOLOGICAL CONSTRUCT. RACE IS A TYPICAL THING. I DON'T WANT TO GET OFF INTO A WHOLE SIDE DISCUSSION ABOUT THIS BUT WE HAVE A PROBLEM IN WHICH RACE IS OFTEN CONFLATED WITH BIOLOGY IN SCIENCE AND MEDICINE AND THAT CREATES A TREMENDOUS AMOUNT OF IMPRECISION AND BIAS IN THE WAY WE ARE THINKING ABOUT THE INFERENCES WE ARE MAKING. SO WE NEED CLARITY WHEN WE SAY WE ARE COLLECTING DATA AND THAT IS REALLY IMPORTANT WHEN WE ARE SPEAKING, NOT JUST AT THE INDIVIDUAL LEVEL BUT ALSO AT THE COMMUNITY LEVEL BECAUSE WE DON'T WANT TO CONFLATE CONSTRUCTS THAT DON'T REFLECT THE RIGHT CONSTRUCTS. SO WE NEED TO BE VERY CAREFUL ABOUT THAT. I HOPE THAT ANSWERED THAT. >> THAT WAS GREAT. AND IN FACT, I WOULD ADD THAT STANDARDIZATION -- I THINK YOU WERE GOING THERE -- OF HOW YOU COLLECT DATA IS REALLY CRITICAL. AND WE HAVE BEEN TRYING TO PROMOTE THAT AT NIMHD AND THROUGHOUT NIH AS A CONSEQUENCE OF THE PANDEMIC THROUGH COMMON DATA ELEMENTS. HERE IS ANOTHER QUESTION. I THINK THEY ARE BOTH FROM THE SAME PERSON BUT THERE IS A TREMENDOUS DISPARITY IN THE RATES ACQUISITION OF CERTAIN INFECTIOUS DISEASES. HOW CAN THE DUKE COMP PASS DATA WORKS PLATFORM BE USED AS A MODEL TO HELP ADDRESS THIS BY PROVIDING DATA TO IMPROVE PREVENTION PROGRAMS FOR FOR EXAMPLE, HIV, HEPATITIS C AND OTHERS? AND BETTER INCLUSION OF KEY POPULATIONS INCLUDING COMMUNITIES OF COLOR. IN DID NOT SEE INFERS DISEASE ON YOUR SLIDE. CANNOT COVER IT ALL. -- INFECTIOUS DISEASE. >> WE HAVEN'T BEGUN TO COVER ALL THE OPPORTUNITIES FOR PREVENTION AND OPPORTUNITIES TO IMPROVE HEALTH EQUITY. CLEARLY THIS TYPE OF A TOOL CAN BE USED TO IDENTIFY GROUPS THAT MAY BE OR COMMUNITIES THAT MAY BE AT INCREASED RISK FOR WHATEVER REASON OF CONDITIONS INCLUDING INFECTIOUS DISEASE CONDITIONS. AND I THINK WE HAVE BEGUN TO SEE THAT THERE HAS BEEN MAPPING OF CONDITIONS IN THE COVID ERA, FOR EXAMPLE, I KNOW WITHIN OUR DEPARTMENT OF PUBLIC HEALTH IN DURHAM COUNTY, THERE ARE EFFORTS TO IDENTIFY WHERE OUR INFECTION RATES INCREASING MORE RAPIDLY CAN WE GET RESOURCES TO THOSE COMMUNITIES INCLUDING IN TERMS OF EDUCATION AND GETTING TESTING ET CETERA OUT TO THESE COMMUNITIES. SO I THINK INCREASING WE ARE SEEING AT THE COMMUNITY LEVEL, DATA LOOKS AT USING THESE TYPES OF DATA CAN BE HELPFUL. WHAT IS CHALLENGING IS BECOMING NIMBLE ABOUT IT. I CAN TELL YOU THAT IT HAS TAKEN US YEARS TO GET TO THE POINT WHERE WE WERE ABLE TO GET THIS MANY HEALTH CONDITIONS TO THE COMMUNITY. WE ARE GAINING SKILL WITH IT NOW BUT THE TIME IT TOOK TO GET APPROVALS FOR THIS TYPE OF A TOOL FOR PEOPLE TO FEEL COMFORTABLE WITH THE DEMOCRATIZATION, I THINK THERE IS STILL SOME STEPS TO GO WITH THAT. AND THAT IS BEYOND OUR HEALTH SYSTEM ACROSS THE NATION. THE MORE COMFORTABLE WE CAN GET WITH GETTING HEALTH INFORMATION OUT THERE THE BETTER IT WILL BE. WITH THE N3C COVID COLLABORATIVE THAT IS HAPPENING THROUGH NCATS, THAT WILL BE MAKE A HUGE STEP TOWARDS THIS BUT WE ARE TAKING ALL THE ELECTRONIC HEALTH RECORDS ACROSS THE NATION AND BEGINNING TO USE THEM IN THIS WAY. WE WILL BECOME MORE QUICK AND NIMBLE WITH HOW TO LEVERAGE THIS KIND OF INFORMATION FOR SURVEILLANCE AND PREVENTION EFFORTS AND EDUCATION, ET CETERA. >> THAT IS CORRECT AND I MUST SAY THAT MY CAUTIOUSNESS WITH SOMETHING LIKE THAT IS, HOW MANY DIFFERENT WAYS DO EACH SYSTEM HAVE OF ASKING THE QUESTIONS THAT WE ARE INTERESTED IN, NOT THE BIOMEDICAL ONES, NOT WEIGHING SOMEONE OR GETTING THEIR A1C OR MEASURING BLOOD PRESSURE, BUT ACTUALLY ASKING ABOUT THE SOCIOECONOMIC STATUS WHICH IS ALMOST NEVER DONE IN A STANDARDIZED WAY OTHER THAN UNLESS YOU IMPUTEIT DATA BESIDES THEIR ADDRESS, WHICH IS AN ANSWER BUT THAT WOULD BE A WAY OUT. HERE IS ANOTHER QUESTION FOR YOU. GIVEN THAT STATES ARE IN CONTROL INSTEAD OF NATIONWIDE HEALTH REGULATIONS, WHAT ARE SOME OF THE FACTORS THAT PROHIBIT EVERYONE FROM MIGRATING TO THOSE STATES THAT DO OPTIMAL HEALTH CARE DELIVERY? >> I THINK THIS IS THE TIME IN OUR COUNTRY WHERE WE NEED TO RECKON WITH THE AVAILABILITY OF HEALTH CARE SERVICES. HEALTH SYSTEMS ARE COLLAPSING. RESPONDING TO MARKET PRESSURES. LESS AND LESS AVAILABILITY. YOU'RE CREATING DESERTS OF HEALTH CARE ESSENTIALLY. AND WE NEED TO THINK ABOUT HOW WE INVEST IN AREAS GEOGRAPHICALLY TO ENSURE THERE CAN BE HEALTH EQUITY. CLEARLY IF YOU'RE NOT EVEN IN VESTING, YOU'RE JUST NOT GOING TO HAVE IT. SO I DON'T KNOW IF I CAN ANSWER THAT OTHER THAN TO SAY WE CAN'T ALL AFFORD TO MOVE TO ONE OF THE AREAS WHERE THERE IS BETTER HEALTH CARE COVERAGE OR LIVE THERE. BUT WE SHOULD BEGIN TO DEMAND MORE UNIFORMITY AROUND ACCESS TO HEALTH CARE, I BELIEVE. >> AND WE COULDN'T AGREE MORE. AND I THINK THAT NOT JUST ACCESS, WHICH IS A BIG FIRST STEP, BUT ALSO A PLACE AND CLINICIAN AND COORDINATION, WHICH REALLY MAKE A DIFFERENCE ULTIMATELY. SO A FOLLOW-UP IS HAVE THE TWO HEALTH SYSTEM, DUKE AND LINCOLN, MADE ANY CHANGES TO CLINICAL PRACTICES BASED ON THE DATA RECEIVED FROM OTHER SECTORS? AND JUST TO CLARIFY, I'M ASSUMING THAT BOTH DUKE AND LINCOLN ARE NETWORKS, NOT JUST SINGE SITES. LINCOLN IS PROBABLY A NETWORK OF COMMUNITY CLINICS? >> IT'S A PART OF A NETWORK OF COMMUNITY CLINICS. IT'S JUST ONE IN OUR CLOSEST PROXIMITY. WE HAVEN'T -- DUKE AND LINCOLN ARE VERY CLOSE TO ONE ANOTHER AND HAVE A LONG TERM HISTORY OF COLLABORATION IN CLINICAL CARE. SO THERE IS A LOT OF BACK-AND-FORTH. WE HAVEN'T HAD -- I HAVEN'T YET PERSONALLY SEEN AN INSTANCE WHERE THE COMPASS HAS BEEN USED TO GUIDE TA CARE BUT THAT IS THE VISION. IDEALLY WE WILL BE UTILIZING TOOLS TO HELP GUIDE CARE MODELS, COLLABORATIVE EFFORTS TO IMPROVE COMMUNITY HEALTH. I THINK WE ARE MOVING IN THAT DIRECTION. AGAIN, THIS IS SORT OF THE EARLY INSTANCE BUT THOSE ARE THE TYPES OF PRACTICAL APPLICATIONS I THINK ARE WORTHY OF THIS KIND OF A MODEL. >> AND I COULD SPECK LATE FOR A SECOND AND SAY, IF YOU HAVE A MAP, AND I LOVE THESE MAPS, AND YOU IDENTIFY HOTSPOTS OF A CONDITION THAT YOU KNOW CAN BE MANAGED BETTER, SUCH AS HYPERTENSION OR DIABETES OR SCREENABLE CANCERS, THEN THE ORGANIZED HEALTH CARE SYSTEM COULD SAY, WHAT IS GOING ON THERE? WHAT CAN WE DO TO IMPROVE THAT? AND OF COURSE AS YOU SET THESE U, IT TAKES TIME TO BEGIN TO DO THESE THINGS AND THEN TAKES TIME FOR AN ACTION TO BE DEVELOPED AND TO HAVE EFFECT. SO I DEFINITELY SEE THE POTENTIAL OF THIS KIND OF APPROACH. >> YES. I ALSO, AGAIN, ONE OF THE THINGS THAT VERY MUCH EXCITES ME ABOUT IT IS THE IDEA OF TRACKING OUTCOMES OVER TIME. WHERE YOU CAN SEE WHAT WE ARE DOING MAKING A DIFFERENCE. AND THAT MIGHT BE HARD TO DO BUT IT CAN BE A BENCHMARK YOU HAVE FOR POLICY CHANGE. WE ARE GOING TO MAKE THIS CHANGE AT A MACRO LEVEL. WE ARE GOING TO LOOK IN TWO OR THREE YEARS AND SEE IF X METRIC CHANGED. I THINK THAT IS AN OPPORTUNITY THAT IS EXCITING. >> WE HAVE AN OPPORTUNITY WITH COVID, RIGHT? IF TWEE GET ENOUGH VACCINATIONS AND ENOUGH PEOPLE DOING BEHAVIORAL MITIGATION, WE SHOULD SEE THOSE RATES DROP. SO ONE FINAL QUESTION BUT ONE QUESTION HERE, WHAT DO YOU THINK, WHAT ROLE SHOULD CAN OR SHOULD NIH TAKE IN PROMOTING THIS KIND OF MULTISECT ORAL RESEARCH? >> I THINK NIH SHOULD TAKE IT ON WHOLEHEARTEDLY. WE HAD A PRE-SESSION -- I WAS TALKING TO A GROUP PRIOR TO THIS AND TALKING ABOUT THE NEED FOR US TO REALLY THINK ABOUT HOW WE ARE FUNDING WORK TO IMPROVE HEALTH AND HEALTH EQUITY. WE NEED THIS KIND -- AND I THINK THAT IS THE IDEA THAT WAS BEHIND THE NHLBI UNCLE TANK. THE REALITIES IS WE ARE RECOGNIZING THERE ARE MULTILAYERED INFLUENCES ON HEALTH AND WHILE WE STILL NEED TO MAKE DISCOVERY AT THE PHYSIOLOGICAL LEVEL, THE CELLULAR LEVEL, THE BIOLOGICAL LEVEL, WE ALSO NEED TO LOOK AT THESE MACRO DETERMINANTS OF HEALTH. AND IF WE TRULY ARE DEVOTED TO IMPROVING HEALTH AND HEALTH EQUITY, WE HAVE TO PUT INVESTMENT IN LOOKING AT MULTIPLE LAYERS OF DETERMINANTS. I THINK IT IS CRITICALLY IMPORTANT AND I ALSO THINK NO OTHER BETTER SITUATION THAN COVID TO DEMONSTRATE WHY WE NEED THAT. IT WAS NO SHOCK WHEN WE SAW THESE MARKED HEALTH INEQUITIES AMONG HISPANIC AND BLACK POPULATIONS AND OTHER POPULATIONS WHO HAD BEEN HISTORICALLY DISENFRANCHISED AND IT CLEARLY LAYS OPEN THE LINK BETWEEN SOCIALITY AND ENVIRONMENTAL CONTEXT AND HEALTH. AND WE INDIVIDUAL TO BEGIN TO, AS SCIENTISTS, APPLY OUR INTELLECTUAL CAPACITY TO CONTRIBUTE TO THE EFFORT TO IMPROVE THE EQUITY NEEDS. >> WELL SAID. WE'LL SEE WHAT WE CAN DO. AND THE FINAL COMMENTS YOU OR FROM ANYONE? ANY OTHER QUESTIONS? IT DOESN'T LOOK LIKE I HAVE MORE QUESTIONS. >> I WANT TO THANK THE OPPORTUNITY. I AM HOPEFUL THAT EFFORTS LIKE THIS ARE GOING TO PICK UP AROUND THE COUNTRY. I THINK THESE ARE -- THIS IS AN EARLY EXAMPLE BUT CLEARLY THIS CAN GO MUCH BROADER AND SO I'M EXCITED ABOUT THAT. AND I'M EXCITED TO COLLABORATE WITH ANY GROUPS THAT ARE INTERESTED IN COLLABORATING WITH US ON THESE EFFORTS. >> THANK YOU VERY MUCH FOR TAKING THE TIME TO BE WITH US THIS AFTERNOON, EBONY. IT WAS REALLY A DELIGHT TO HEAR THIS PRESENTATION AND HEAR YOUR THOUGHTS ON THESE CRITICAL ISSUES THAT WE ARE ALL DISCUSSING THEM AS WELL AT NIH, AS YOU CAN IMAGINE AND WE'LL CONSIDER. THANK YOU VERY MUCH.