WELCOME TO THE 2021 NURSING RESEARCH ROUNDTABLE. I'M REALLY LOOKING FORWARD TO HEARING FROM ALL OUR DISTINGUISHED SPEAKERS AND MEMBER OF THE ROUNDTABLE. IN ADDITION, I'M VERY HAPPY TO SAY THAT FOR THE FIRST TIME, THIS ROUNDTABLE IS BEING LIVE STREAMED TO THE PUBLIC THROUGH THE NIH VIDEOCAST SITE. IT'S GREAT SO MANY OTHERS WILL BE ABLE TO HEAR OUR DISCUSSION. I WANT TO EXPRESS MY APPRECIATION TO THE WESTERN INSTITUTE OF NURSING, WIN, FOR CO-SPONSORING THE MEETING. IT WAS PLANNED BY JANE LASSITER AND OTHERS FROM NINR. I'D LIKE TO RECOGNIZE OTHER MEMBERS OF THE TEAM WHO MADE THIS EVENT POSSIBLE. MR.NATHAN BROWN, AND MS. BRONTE WASHINGTON, AND I WOULD LIKE TO SINCERELY THANK MY DISTINGUISHED COLLEAGUE FOR JOINING US TODAY, DR. ELISEO PEREZ-STABLE. WE'RE LOOKING FORWARD TO HEARING YOUR THOUGHTS. PURPOSE OF THE MEETING IS TO PROVIDE A REGULAR FORM OF COMMUNICATION ABOUT NURSE REG SEARCH AND SERVE AS A CATALYST FOR BRINGING TOGETHER THE NURSING COMMUNITY AND ORGANIZATIONS THAT PROMOTE NURSING, RESEARCH, AND ADVANCEMENT OF SCIENCE. THIS YEAR'S THEME IS NURSING RESEARCH OF THE FUTURE, TO EXPLORE HEALTH INEQUITIES, AND SOCIAL DETERMINANTS OF HEALTH. COVID IS THE LATEST HEALTH CONDITION TO APPEAR ON THE LANDSCAPE FOR WHICH LARGE INEQUITIES HAVE EMERGED. IDENTIFY STRATEGIES TO ADDRESS SOCIAL DETERMINANTS OF HEALTH AND ADVANCE HEALTH EQUITY, I BELIEVE, ARE AREAS IN WHICH NURSING SCIENCE CAN MAKE A DIFFERENCE IN PEOPLE'S LIVES AND HAVE A MAJOR IMPACT. I'LL HAVE MORE TO SAY IN MY REMARKS TOMORROW BUT THESE ARE AREAS WHICH I THINK NINR AND NURSING SCIENCE MUST BE LEADERS. THESE DISCUSSIONS WILL FOCUS ON HOW BIG DATA MIGHT REDUCE DISPARITIES. THANK YOU FOR JOINING US. I'D LIKE TO INTRODUCE OUR PARTNER FOR THIS YEAR'S EVENT. DR. JANE HANSON LASSITER IS PRESIDENT OF THE WESTERN INSTITUTE OF NURSING. SHE LEADS THE BOARD OF GOVERNORS TO PROMOTE DIVERSITY, EQUITY AND INCLUSION WITHIN THE ORGANIZATION. IMPORTANTLY, THE BOARD HAS FORMED A TASK FORCE TO EXAMINE, IDENTIFY, AND ELIMINATE STRUCTURAL RACISM AND OTHER RELATED CHALLENGES IN THE PROFESSION. DR. LASSITER IS THE DEAN AND PROFESSOR IN THE COLLEGE OF NURSING AT BRIGHAM YOUNG UNIVERSITY IN UTAH, WHERE SHE PREVIOUSLY SERVED AS ASSOCIATE DEAN OF GRADUATE STUDIES. AS DEAN, SHE SEEKS TO UNIFY FACULTY AND STAFF AROUND GOAL OF LIFTING WHERE WE STAND, TO CONTINUOUSLY IMPROVE THE COLLEGE. DR. LASSITER IS ALSO THE PAST PRESIDENT OF THE INTERNATIONAL FAMILY NURSING ASSOCIATION, AS PRESIDENT OF THAT ASSOCIATION SHE ADVOCATED FOR MIGRANT AND REFUGEE FAMILIES IN OFFICIAL STATEMENTS ADDRESSING ATROCITIES, RESEARCH FOCUSES ON CHILDHOOD OBESITY, INCLUDING NATIVE HAWAIIAN AND PACIFIC ISLANDER FAMILIARS. >> THANK YOU. IT IS MY PLEASURE TO REPRESENT THE WESTERN INSTITUTE OF NURSING AT THE 2021 NATIONAL NURSING RESEARCH ROUNDTABLE, DIVISION OF THE WESTERN INSTITUTE -- THE VISION IS ALL PEOPLE WILL HAVE THE OPPORTUNITY TO ACHEER -- ACHIEVE BEST HEALTH AND WELL BEING, A ALIGN WITH USING CLINICAL BIG DATA TO EXPLORE HEALTH INEQUITIES AND SOCIAL DETERMINANTS OF HEALTH. OUR WIN LEADERSHIP HAS ENJOYED COLLABORATING WITH DR. EVAN BRIAN, DR. REBECCA RUZULI, NATHAN BROWN AND BRONTE WILLIAMS WASHINGTON TO PLAN THIS EVENT. I LOOK FORWARD TO LEARNING WITH YOU FROM THESE EXPERTS INVITED TO PRESENT. I HOPE YOUR ATTENDANCE WILL BE REWARDED WITH NEW INSIGHTS FOR FUTURE EXPLORATION AND APPLICATION. IT'S NOW MY PLEASURE TO INTRODUCE YOU TO DR. ELISEO PEREZ-STABLE, DIRECTOR OF THE NATIONAL INSTITUTE OF HEALTH, NATIONAL INSTITUTE ON MINORITY HEALTH AND HEALTH DISPARITIES, WHICH SEEKS TO ADVANCE THE SCIENCE OF MINORITY HEALTH AND PUBLIC DISPARITIES RESEARCH THROUGH RESEARCH, TRAINING, RESEARCH CAPACITY DEVELOPMENT, PUBLIC EDUCATION, AND INFORMATION DISSEMINATION. DR. PEREZ-STABLE PRACTICED GENERAL INTERNAL MEDICINE FOR 37 YEARS AT THE UNIVERSITY OF CALIFORNIA, SAN FRANCISCO, BEFORE MOVING TO THE NIH IN SEPTEMBER 2015. HE WAS A PROFESSOR OF MEDICINE THE UCSF AND CHIEF OF THE DIVISION OF GENERAL INTERNAL MEDICINE FOR 17 YEARS. HIS RESEARCH INTERESTS INCLUDE IMPROVING THE HEALTH OF RACIAL AND ETHNIC MINORITIES AND UNDERSERVED POPULATIONS, ADVANCING PATIENT-CENTERED CARE, IMPROVING CROSS-CULTURAL COMMUNICATION SKILLS AMONG CLINICIANS, AND PROMOTING DIVERSITY IN THE BIOMEDICAL RESEARCH WORKFORCE. FOR MORE THAN 30 YEARS DR. PEREZ-STABLE LED RESEARCH ON LATINO SMOKING CESSATION AND TOBACCO CONTROL POLICY IN THE UNITED STATES, AND LATIN AMERICA. ADDRESSING CLINICAL AND PREVENTION ISSUES IN CANCER SCREENING AND MENTORING 70 MINORITY INVESTIGATORS, PUBLISHED 300 PEER-REVIEWED ARTICLES, ELECTED TO NATIONAL ACADEMY OF MEDICINE IN 2001. PLEASE JOIN ME IN WELCOMING DR. PEREZ-STABLE. >> THANK YOU, DR. LASSITER. THANK YOU, SHANNON, FOR MAKING THIS HAPPEN AND TO PROMOTE IT IN SUCH AN EFFECTIVE WAY THROUGH VIDEOCAST, READING BROADER POPULATIONS. I WANT TO EXPRESS MY GRATITUDE OF DR. LASSITER AT NIH, PROVIDING A NEW ENERGY ON THESE TOPICS AND I LOOK FORWARD TO WORKING TOGETHER ON MANY TOPICS THAT PROVIDE SYNERGY BETWEEN NATIONAL INSTITUTE OF MINORITY HEALTH AND HEALTH DISPARITIES AND NATIONAL INSTITUTE ON NURSING RESEARCH. I DIDN'T REALLY WANT TO SPEND THE TIME PRESENTING A POWERPOINT AND TALKING ABOUT THE KIND OF THINGS, I KNOW DR. GALEA WILL SPEAK, HE'S MAGNIFICENT AND I LOOK FORWARD TO HIS PRESENTATION, BUT I WANT TO SHARE BASIC PRINCIPLES WHERE WE CAN OVERLAP AND LINK NOT JUST TO BIG DATA BUT HEALTH CARE DATA. FIRST, FAMILIARITY THAT OUR INSTITUTES, POPULATIONS WITH HEALTH DISPARITIES, HAVE BEEN DEFINED BY LEGISLATION IN OUR FOUNDING OF THE CENTER, IN THE YEAR 2000, IT WAS STIPULATED THAT FEDERAL GOVERNMENT DEFINED RACIAL ETHNIC AUTHORITIES BY THE OFFICE OF CENSUS AND MANAGEMENT AND BUDGET, ALL MINORITIES, INDEPENDENT OF THEIR OUTCOMES. SECOND, ALL POOR PEOPLE, REGARDLESS OF THEIR RACE/ETHNICITY, AND WE USE THE TERM LESS PRIVILEGED SOCIOECONOMIC STATUS IN REFERENCE TO THEM. THIRD UNDERSERVED RURAL RESIDENTS. RURALITY IS ASSOCIATED CAN CHALLENGES, UNDERSERVED THAT WE SHALL NOT TARGETING FOLKS IN JACKSON HOLE, WYOMING, BUT OTHER POPULATIONS. THIS OF COURSE CAPTURES OFTEN RACIAL AND ETHNIC MINORITIES DEPENDING ON PART OF THE COUNTRY. IN 2016 DECLARED SEXUAL AND GENDER MINORITIES WERE ALSO A POPULATION WITH HEALTH DISPARITIES FOR NIH RESEARCH PURPOSES AND I THINK THIS WAS A MOVE IN THE RIGHT DIRECTION. THERE IS AN OFFICE OF RESEARCH ON SEXUAL AND GENDER MINORITY RESEARCH AT NIH, IN THE OFFICE OF THE DIRECTOR, AND WE WORK CLOSELY WITH THEM. I THINK THERE'S POTENTIAL SYNERGY. NOW, IN MY VIEW, THIS OPENS THE DOOR FOR DOING NON-HIV-RELATED RESEARCH IN THIS SPACE, THERE'S BEEN MODEST WORK DONE IN FOR EXAMPLE SUBSTANCE USE, SOME MENTAL HEALTH, AND HIV RISK AREAS, IN SEXUAL AND GENDER MINORITIES, BUT NOT AS MUCH ON THE INTERSECTIONALITY ISSUES THAT COME UP OTHER OTHER FACTORS, MUCH LESS IS KNOWN BECAUSE PEOPLE HAVE NOT ASKED. ONE ADVANCES MADE, WE'VE BEEN ABLE TO ADD IN TWO OF THE NATIONAL HEART LUNG BLOOD INSTITUTE COHORTS THE QUESTIONS TO IDENTIFY ONE'S SEXUAL ORIENTATION AS WELL AS GENDER IDENTITY, THEY MAY NOT BE PERFECT, STILL WORK ON DEVELOPING AND PERFECTING THEM. WE EMBRACE IN THESE FOUR CATEGORIES OF POPULATIONS THE IDEA THAT SOCIAL DISADVANTAGE EXISTS IN ALL OF THESE POPULATIONS, BECAUSE THEY HAVE ALL BEEN SUBJECT TO DISCRIMINATION OR RACISM AND ALL UNDERSERVED IN HEALTH CARE. I THINK THAT UNIFIES SOME OF THE CONCEPTS WE'RE INTERESTED IN. EVERYONE IS FAMILIAR WITH THE CENSUS CATEGORIES OF RACE/ETHNICITY, THERE ARE MANY PROBLEMS, I WON'T BELABOR THAT POINT. THE CENSUS DID TRY TO CHANGE IT FOR 2020, THAT WAS NOT APPROVED BY THE ADMINISTRATION AT THE TIME. THE ONE CHANGE THAT THEY WERE ABLE TO GET THROUGH RESPONDING AS BEING WHITE OR AFRICAN AMERICAN OR BLACK RACE WERE ASKED TO PROVIDE THEIR NATIONAL ORIGIN BACKGROUND, SOMETHING THAT'S BEEN ASKED OF OTHER GROUPS FOR AT LEAST DATING BACK TO BEFORE THE YEAR 2000. I'LL BE INTERESTED TO SEE HOW MANY RESPOND TO MORE THAN ONE RACE, IT SHOULD GO UP. IT DIDN'T CHANGE MUCH BETWEEN THE YEAR 2000 AND 2010. AND THEN THE LATINO OR HISPANICS REMAINED THE ONLY ETHNIC GROUP RECOGNIZED BY THE CENSUS. WE KNOW RACE AS A SELF REPORTED SOCIAL CONSTRUCT, THAT'S WHAT IT IS, IT'S WORTH REPEATING BECAUSE I DO -- PEOPLE ARE STILL TRYING TO MAKE IT A BIOLOGICAL CONSTRUCT AND IT IS NOT, PREDICTS SO MUCH, IT'S IMPERATIVE TO MEASURE IN A RELIABLE WAY, THE SAME WAY ACROSS THE RESEARCH ENTERPRISE THE NIH SUPPORTS, IN CLINICAL CARE, IN CLINICAL TRIALS, PEOPLE DON'T OFTEN ASK THIS QUESTION IN A SYSTEMATIC WAY. THE GAP IN LIFE EXPECTANCY CAN VARY FROM -- PRE-COVID, 3 TO 4URES IN ONE DIRECTION OR THE OTHER. FOR ASIANS, AS A GROUP, AGAIN CDC HAS NOT PUBLISHED NATIONAL ESTIMATES. LOTS OF INDIRECT OTHER DATA THAT WOULD SUPPORT THAT. THE FACT -- THE SOCIAL DETERMINANT THAT IS LEAST EMPHASIZED IN ALL OF THIS RESEARCH IS SOCIOECONOMIC STATUS. IT IS TO ME, FROM MY CLINICAL LIFE, BEFORE NIH, SOBERING TO REMEMBER HOW OFTEN RESIDENTS WERE NOT AWARE OF WHO THEY WERE TAKING CARE OF, IN TERMS OF THEIR SOCIOECONOMIC STATUS. THIS MATTERS SO MUCH TO HOW WE COMMUNICATE, THE KIND OF LANGUAGE OR JARGON OR NON-JARGON THAT WE EMPHASIZE, CULTURAL ISSUES AND RESPECT THAT NEEDS TO BE SHOWN IN DIFFERENT WAYS. WHEN WE LOOK AT THE NATIONAL DATA ABOUT SOCIOECONOMIC STATUS WE SEE A GRADIENT AS ROBUST AS BLOOD PRESSURE OR SMOKING IN TERMS OF PREDICTING MORBIDITY AND MORTALITY. A RESEARCH ASSOCIATE, A POSTDOC, DID A VERY ELEGANT ANALYSIS OF NATIONAL DATA SHOWING THAT FOR ADULTS 40 TO 64, HEART DISEASE IS ACTUALLY NOT DECREASED AT ALL IN THE LAST 20 YEARS. IF THEY ARE IN THE BOTTOM 20 PERCENTILE OF INCOME. WHILE FOR THE TOP 50%, THE STEADY IMPROVEMENT IN OUTCOMES, CARDIOVASCULAR OUTCOMES, INCLUDING DECREASE IN HEART ATTACKS, DECREASE IN HEART FAILURE, ANGINA, AND OF COURSE MORTALITY ARE CLEAR AND HAVE CONTINUED EVEN THOUGH THEY ARE PLATEAUING IN THE LAST FEW YEARS NATIONALLY BUT WE'RE NOT MAKING THIS AN EQUAL BENEFIT ACROSS THE POPULATION, AND IT IS OFTEN MORE DRIVEN BY SOCIAL CLASS THAN IT IS BY OTHER FACTORS. I THINK IN OUR PERSPECTIVE AT NIMHD WE SEE THESE AS OUR TWO PILLARS OF RESEARCH, RACE/ETHNICITY AS A SELF IDENTIFIED SOCIAL CONSTRUCT THAT MEANS SO MUCH MORE THAN THE BOX YOU CHECK AND THE SOCIOECONOMIC STATUS WHICH YOU CAN MEASURE THROUGH A VARIETY OF WAYS, SIMPLEST WAY FOR CLINICAL RESEARCH MAY BE YEARS OF FORMAL EDUCATION BUT OF COURSE THE DEFINITIVE WAY TO TRY TO GET A SENSE OR ASCERTAINMENT OF WEALTH WHICH IS NOT SIMPLE, EVEN ANNUAL INCOME IS OFTEN NOT DISCLOSED BY THE INDIVIDUALS. NIMHD HAS DEVELOPED A FRAMEWORK JUST TO PROVIDE A ROADMAP, A GUIDE FOR INVESTIGATORS TO THINK ABOUT THEIR RESEARCH. YOU CAN EASILY FIND IT ON THE WEB. WE'VE PUBLISHED IT. THINK ABOUT DIFFERENT LEVELS OF INFLUENCE AS WELL AS DOMAINS OF INFLUENCE, HOW THIS AFFECTS YOUR DIFFERENT OUTCOMES. I WOULD CHALLENGE THE FIELD, MOST OF OUR RESEARCH REMAINS IN THAT INDIVIDUAL COLUMN WHERE WE'RE COMFORTABLE ASKING ABOUT BEHAVIOR OR MEASURING BIOLOGICAL BIOMARKERS OR LOOKING AT INDIVIDUAL PERSPECTIVES ON THE PHYSICAL ENVIRONMENT FOR THE SOCIAL CULTURAL ENVIRONMENT AND HOW THE INDIVIDUAL IS CARED FOR IN THE HEALTH CARE SYSTEM. PARTICULARLY AMONG THOSE WITH CHRONIC DISEASES. AND THAT MUCH LESS HAS BEEN DONE AT THE COMMUNITY LEVEL OR THE SOCIETAL LEVEL, AND THAT THIS IS AN AREA OF RESEARCH THAT WE NEED TO MOVE INTO. SO, I WILL PAUSE AND BE HAPPY TO COMMENT ON OTHER ISSUES, AND MAKE THIS MORE CONVERSATIONAL UNTIL DR. GA LLEA HAS JOINED US. I SEE HE'S HERE. WELCOME. >> DOES ANYONE HAVE QUESTIONS FOR ELISEO? >> THERE'S A TON OF STUFF WE COULD TALK ABOUT. >> I KNOW. >> COVID. >> AND I KNOW SANDRA WILL ADDRESS INEQUITIES. >> CAN I MAKE SURE THE SLIDES OPEN UP? >> ABSOLUTELY. >> OKAY. >> I DON'T THINK SHANNON PLANNED THIS MEETING TO BE TIMED WITH THE DISCUSSION THAT WAS PUBLIC LAST FRIDAYTY ADVISORY COMMITTEE FOR THE DIRECTOR BUT THIS AUDIENCE REALLY SHOULD BE VERY ENTHUSED ABOUT THE DIRECTION NIH IS TAKING IN THIS TO ADDRESS ISSUES AROUND STRUCTURAL RACISM. I WOULD ARGUE WE HAVE A CONCEPT WE APPROVED IN OUR NIMHD COUNCIL LAST FALL, WORKING ITS WAY THROUGH THE SYSTEM. IT WAS DELAYED FOR I THINK EXTERNAL REASONS INITIALLY BUT NOW WE'RE REALLY BUILDING MOMENTUM WITH INSTITUTE SUPPORT ACROSS THE AGENCY, AND WE'RE VERY PLEASED WITH THE RESPONSE OF MY COLLEAGUES ON THIS FACTOR. AND SO THIS WILL BE THE -- THE FUNDING WILL BE IN FISCAL YEAR 22, ANNOUNCEMENT IN THE NOT TOO DISTANT FUTURE. THIS IS REALLY CRITICAL FOR HEALTHCARE SETTINGS. ONE OF THE AREAS WHERE WE CAN ADDRESS SOME OF THESE CONCERNS IN RESEARCH, UNDERSTAND, HOW CAN WE PROVIDE MORE EQUITABLE HEALTH CARE, ACCESSIBLE, COMPREHENSIVE CONTINUITY, AND I THINK THAT PARTNERSHIP OF CLINICAL TEAMS WHETHER THEY BE PHYSICIANS, NURSE PRACTITIONERS, PAS, RNS, MEDICAL ASSISTANCE, THE WHOLE EFFORT ON DOING THIS CREATING QUESTIONED AS AN IMPORTANT METRIC, I THINK, IS REALLY AN OPPORTUNITY TO ADDRESS THIS. IT'S ONE OF THE AREAS I THINK THAT COULD BE ADDRESSED IN THIS STRUCTURAL SENSE, SINCE THERE IS EVIDENCE WHERE THAT HAS BEEN A CHALLENGE AND BARRIER. >> ELISEO, THIS IS SHANITA HUGHES ALBERT. >> GOOD TO SEE YOU. >> GAD TO BE HERE. I APPRECIATED YOUR COMMENTS AND WAS JUST WONDERING IF YOU COULD PROVIDE COMMENTS ABOUT, YOU KNOW, WHAT WE SHOULD BE THINKING IN TERMS OF HOW WE MEASURE STRUCTURAL RACISM. I THINK THAT'S AN IMPORTANT SORT OF DIRECTION IN WHICH THE FIELD -- ALL FIELDS ARE GOING. AND I WAS READING A PAPER WHERE AN INVESTIGATOR AT THE UNIVERSITY OF MINNESOTA DID A SYSTEMATIC REVIEW, AND WHAT HER REVIEW DEMONSTRATED IS THAT MOST OF THE WORK WAS IN THE SPACE OF STRUCTURAL RACISM, FOCUSED ON MEASURES OF INTERPERSONAL DISCRIMINATION. AS YOU TALKED ABOUT THE NIMHD FRAMEWORK, WHICH I THINK IS CRITICALLY IMPORTANT FOR HELPING US THINK ABOUT WHERE AND HOW OUR RESEARCH FITS WITHIN THE SPACE OF MINORITY HEALTH AND HEALTH EQUITY, THEY ARE NOT I DON'T THINK ROBUST, EQUALLY ACCESSIBLE MEASURES OF STRUCTURAL RACISM THAT COULD BE INCLUDED WITHIN A STUDY DESIGN. OTHER THAN THIS INDIVIDUAL LEVEL. SO I WONDERED IF YOU COULD -- IF YOU THOUGHT ABOUT THAT, IF YOU HAVE THOUGHTS, IF YOU HAVE ANY THOUGHTS AT THIS MOMENT. >> THANK YOU FOR THAT QUESTION. JUST TO MAKE CLEAR, WE'RE NOT TALKING ABOUT INTERPERSONAL RACISM AT ALL IN THINKING ABOUT STRUCTURAL. THAT'S WHERE 95% OF THE RESEARCH HAS BEEN. REALLY GREAT WORK, GOOD MEASURES ARE AVAILABLE. AND ASSOCIATIONS IN THE PATHWAY, PARTICULARLY AROUND MENTAL HEALTH SYMPTOMS, BEHAVIORAL ISSUES IN ADOLESCENTS AND SUBSTANCE USE ARE QUITE EXTENSIVE. SOME EVIDENCE ON OTHER FACTORS RELATED TO CHRONIC DISEASE, PARTICULARLY CARDIOVASCULAR, LESS SO ON SOME OTHERS. I'D LIKE TO CONCEPTUALIZE THAT AS CHRONIC STRESS BUT IT'S CUMULATIVE, YOU GET EXPOSED EARLY IN LIFE TO RACISM AND YOU CONTINUE TO EXPERIENCE IT, AND YOU JUST GET USED TO IT. WHEN 50% OF AFRICAN AMERICANS AND 35% OF LATINOS SAY THAT IN THE PAST 30 DAYS THEY EXPERIENCED SOME DISCRIMINATION RELATED TO THEIR RACE OR ETHNICITY, YOU KNOW THIS IS A PROBLEM. THIS IS NOT LIFETIME. THIS IS THE LAST 30 DAYS. HEALTH CARE DOES BETTER, AS WE SHOULD, BUT THIS IS I THINK AN ISSUE. I DON'T KNOW THE ANSWER TO YOUR QUESTION, IT'S I DON'T KNOW. MOST PEOPLE HAVE LOOKED AT THE OUTCOMES AND USED THE CONCEPT OF STRUCTURAL RACISM TO EXPLAIN IT. THE ANCHOR FROM WHAT I'VE READ AND WHAT I'VE LEARNED ABOUT ALL THIS IS THE POLICY OF REDLINING, RESIDENTIAL SEGREGATION. BUT IT IS MORE THAN THAT. IT'S A WHOLE SET OF POLICIES THAT PERPETUATE DIFFERENCES, THAT CREATE THIS CULTURE OF INFERIORITY IN SOME GROUPS, AND PERPETUATES POWER IN SOME OTHER GROUPS. AND THIS HAPPENS AT ALL LEVELS, YOU COULD SAY AT A SOCIETAL LEVEL, NATIONAL LEVEL OR LOCAL LEVEL. BUT IT ALSO HAPPENS AT AN INSTITUTIONAL LEVEL. AND ORGANIZATIONAL LEVEL. SO FOR YEARS I HAD WONDERED WHETHER THIS CONSTRUCT, THIS CONCEPT OF RACISM WAS A RESEARCH CONCEPT WE COULD STUDY, MEASURE, FIGURE OUT HOW TO INTERVENE, OR ORGANIZATIONAL CONCEPT THAT NEEDED OTHER APPROACHES. AND I COME TO CONCLUDE WE CAN OPERATIONALIZE IT AS A RESEARCH CONSTRUCT, BUT I'M NOT SURE THAT I CAN GIVE YOU A FORMULA TO SAY HERE IS HOW YOU MEASURE IT. I KNOW THAT SOME OF WHAT SANDRA IS GOING TO SAY IS GOING TO ADDRESS SOME OF THESE THINGS, THESE ISSUES, BUT WE HOPE, WE HOPE, THAT WITH THE FUNDING OPPORTUNITY ANNOUNCEMENT THAT WE WILL HAVE WE WILL GET REALLY SMART PEOPLE LIKE YOU TO APPLY AND BE FUNDED AND BE ABLE TO HELP US MOVE THIS FIELD FORWARD. WE WANT INTERVENTIONS. THIS IS NOT A MYTHOLOGICAL CALL. SOME OBSERVATIONAL WORK NEEDS TO BE DONE BUT I THINK THE FIELD IS READY AND EAGER TO SEE HOW CAN WE MAKE CHANGES IN THIS. WE KNOW IT'S NOT GOING TO BE EASY AND QUICK. BUT IF ANYTHING, THE PANDEMIC HAS REVEALED THE STRUCTURAL INEQUITIES IN OUR SOCIETY THAT MADE THEM ACUTE, YOU KNOW. AND REALLY SHONE LIGHT ON INEQUITIES, THAT HAS LED TO -- WE MAY HAVE STARTED DOWN THIS PATH EARLIER, PRE-COVID, IT'S ACCELERATED THE ENERGY AND PASSION THAT WENT INTO DEVELOPING THIS. >> SHANNON, DO YOU WANT TO TAKE A CRACK AT THE QUESTION? >> NO, YEAH, I'M SO EXCITED ABOUT THAT FOA. THANK YOU, ELISEO, FOR TAKING THE LEAD ON THAT, ALL OF NIMHD. YOU'VE GOTTEN SUPPORT ACROSS NIH, THESE EXACTLY THE TIMES OF QUESTIONS, THESE TOUGH QUESTIONS, RIGHT? ABOUT UNDERSTANDING THE HEALTH EFFECTS OF STRUCTURAL RACISM AND HOW WE SOLVE THESE ISSUES IS UNDERLYING THAT FUNDING ANNOUNCEMENT. WE'RE HOPE TO SUPPORT IT, AND LOOKING FORWARD TO WORKING WITH ELISEO AND NIMHD IN TERMS OF ADVANCING THAT AREA OF SCIENCE. SO IT'S A GREAT QUESTION. WITH THAT I'LL THANK ELISEO FOR JOINING US TODAY AND FOR HIS COMMENTS AND FOR HIS LEADERSHIP IN THIS CRITICAL AREA OF MINORITY HEALTH AND HEALTH INEQUITIES AND HE'S DOING AN AMAZING WORK ACROSS NIH. SO I'M GLAD TO JOIN HIM AT NIH. SO WITH THAT, I WILL INTRODUCE OUR KEYNOTE SPEAKER. IT'S REALLY MY PLEASURE TO INTRODUCE DR. SANDRA GALLEA, A PHYSICIAN, EPIDEMIOLOGIST, AUTHOR, DEAN AND ROBERT A KNOX PROFESSOR AT BOSTON UNIVERSITY SCHOOL OF PUBLIC HEALTH. HE PREVIOUSLY HELD ACADEMIC AND LEADERSHIP POSITIONS AT COLUMBIA UNIVERSITY, UNIVERSITY OF MICHIGAN, AND NEW YORK ACADEMY OF MEDICINE. HE PUBLISHED EXTENSIVELY IN THE PEER REVIEWED LITERATURE AND IS A REGULAR CONTRIBUTOR TO A RANGE OF PUBLIC MEDIA, ABOUT THE SOCIAL CAUSES OF HEALTH, MENTAL HEALTH, CONSEQUENCES OF TRAUMA. HE'S BEEN LISTED AS ONE OF THE MOST WIDELY CITED SCHOLARS IN SOCIAL SCIENCES. CHAIR OF THE BOARD OF ASSOCIATION OF SCHOOLS AND PROGRAMS OF PUBLIC HEALTH, PAST PRESIDENT OF THE SOCIETY FOR EPIDEMIOLOGIC RESEARCH, AND OF THE INTERDISCIPLINARY ASSOCIATION FOR POPULATION HEALTH SCIENCE. HE'S ELECTED MEMBER OF THE NATIONAL ACADEMY OF MEDICINE. DR. GALLEA RECEIVED SEVERAL LIFETIME ACHIEVEMENT AWARDS, MEDICAL DEGREE FROM UNIVERSITY OF TORONTO, GRADUATE DEGREES FROM HARVARD UNIVERSITY AND COLUMBIA UNIVERSITY, HONORARY DOCTORATE FROM UNIVERSITY OF GLASGOW. PLEASE JOIN ME IN WELCOMING DR. GALLEA. >> THANK YOU FOR THE KIND INTRODUCTION, IT'S WONDERFUL TO FOLLOW DR. PEREZ-STABLE. WHAT I WAS ASKED TO DO IS TO TALK ABOUT POPULATION HEALTH BROADLY. YOU WERE TALKING ABOUT HEALTH INEQUITIES BUT I WANT TO TAKE A STEP BACK AND TALK ABOUT WHAT WE MEAN, WHAT IS THIS THING, IN SOME RESPECTS IT'S AN EXPRESSION THAT SEEMS BANAL. WE UNDERSTAND POPULATION HEALTH BUT I'M HERE TO SAY HOW DO WE THINK ABOUT POPULATION HEALTH AND WHAT DOES IT MEAN TO THINK ABOUT POPULATION HEALTH AND UNDERSTANDING HELPS US IDENTIFY METHODS THAT WE NEED AND APPROACHES WE NEED TO ADVANCE OUR SCHOLARSHIP. SO, LET ME SHARE MY SLIDES. CAN YOU SEE THAT? >> YES. >> IN MY VOICE AND SLIDES MISMATCH PLEASE JUMP IN AND WE'LL SWITCH MODALITY. LET ME START WITH SORT OF POPULATIONS, I COULD DO AN HOUR-LONG ABOUT POPULATION HEALTH RIGHT NOW ESPECIALLY IN THE TIME OF COVID. I WON'T DO THAT BUT WANTED TO SET THE STAGE FOR RECOGNIZING THAT POPULATION HEALTH IN THE U.S. IS TROUBLED. IT WAS TROUBLED BEFORE COVID. IT'S MORE TROUBLED NOW POST-COVID. THIS IS THE ONE SLIDE SUMMARY OF OUR TROUBLES WITH POPULATION HEALTH. LIFE EXPECTANCY ON Y-AXIS, SPENDING ON HEALTH ON THE X-AXIS. YOU SEE COUNTRIES, SPEND MORE, GO IN THE DIRECTION. WE SPEND MORE AND GET LESS. ANY OF YOU WHO DO PEDIATRIC STUFF, CHILDREN FAILING TO THRIVE FALLING OFF THE CURVE. I WOULD ASK YOU THIS QUESTION, ALL OF ON YOU THIS WALL. NAME ONE OTHER SECTOR, ONE OTHER SECTOR, WHERE WE SPEND MORE AND GET LESS COMPARED TO OTHER COUNTRIES. THERE IS NOT A SECTOR. LET ME MAKE IT PERSONAL. IF I TOLD THAT YOU OUR iPHONES WERE MORE EXPENSIVE THAN ANY OTHER HIGH INCOME COUNTRY BUT THEY ARE SLOWER AND HOLD LESS DATA, WOULD YOU BUY AN iPHONE? THE ANSWER IS NO. AND THAT IS TRUE AND HAS BEEN TRUE FOR A LONG TIME. WE SOMEHOW ACCEPT IT, THAT THAT'S OKAY WITH HEALTH. I SUPPOSE I ARGUE IT'S NOT OKAY. WE SHOULD NOT ACCEPT THAT. WE SHOULD EXPECT MORE OF OUR HEALTH. THERE'S MANY REASONS. I COULD DO A SEPARATE TALK ABOUT HOW WE OFTEN MISS SOME KEY ELEMENTS BUT I WANT TO SAY RECOGNIZING THIS PICTURE, HOW DO WE UNDERSTAND POPULATION HEALTH SO WE CAN DO BETTER SCHOLARSHIP AND IN YOUR CAPACITY AT NINR SHEPHERD BETTER SCHOLARSHIP AND PARTNERSHIP WITH NIMHD AND OTHER INSTITUTES. THIS IS COVID, BECAUSE -- I'M NOT TALKING EXPLICITLY ABOUT COVID, I'LL WEAVE IN COVID HERE AND THERE. THIS LOOKS AT LIFE EXPECTANCY IN THE CONTEXT OF WHAT'S ANTICIPATED IN THE CONTEXT OF COVID, WHITE POPULATIONS ARE THE GRAY, LATINO BLUE, AND BLACK POPULATIONS ARE ORANGE. YOU SEE THERE'S BEEN A NARROWING BUT STILL A BLACK/WHITE DIFFERENCE IN LIFE EXPECTANCY, NOW A DRAMATIC DROP IN LIFE EXPECTANCY AROUND BLACK POPULATIONS, .2, .1 IN WHITE POPULATION, .5 OR .6 IN BLACK POPULATIONS. POPULATION HEALTH WAS NOT GOING GREAT, LESS GREAT AFTER COVID. IN A SEPARATE PRESENTATION, I MAKE THE ARGUMENT THAT WHAT HAPPENED IN COVID WAS A DIRECT RESULT OF WHAT WAS HAPPENING BEFORE COVID. WHAT WAS HAPPENING BEFORE WAS WHY OUR HEALTH DID SO POORLY IN THE CONTEXT OF COVID, A COMPELLING STORY TO BE TOLD THERE. IT'S FINE. I'M JUST TELLING YOU BY WAY OF FRAMING. MY INTEREST HERE TODAY IS TO SAY OKAY UNDERSTANDING THESE CHALLENGES HOW DO WE THINK ABOUT POPULATION HEALTH, PRINCIPLES TO GUIDE, THAT FITS IN WELL WITH WHAT YOU'RE DOING IN THE NEXT COUPLE DAYS OF YOUR DEEP THINKING. UNDERSTANDING POPULATION HEALTH, LET'S MOVE ON TO THAT. WHAT IS POPULATION HEALTH? THIS IS A CLASSIC DEFINITION, HEALTH OUTCOMES OF GROUPS OF INDIVIDUALS INCLUDING DISTRIBUTION IN THE GROUP. IT'S A SIMPLE DEFINITION, AN IMPORTANT DEFINITION BECAUSE IT'S HEALTH OUTCOMES OF A GROUP OF INDIVIDUALS, AND DISTRIBUTION WITHIN THE GROUP, POPULATION HEALTH IS ABOUT OVERALL HEALTH, ALSO HEALTH EQUITY. HEALTH EQUITY IS INEX-TRICKABLE. WE WANT TO UNDERSTAND AND INTERVENE. OUR JOB IS TO UNDERSTAND BOTH TO NARROW EQUITY GAPS. THAT HAS REAL IMPLICATIONS FOR POPULATION HEALTH, WHAT WE DO AND SCHOLARSHIP. JUST GRAPHICALLY IF YOU THINK OF THIS AS A POPULATION, WITHIN THE POPULATION YOU HAVE A CERTAIN NUMBER OF PERSONS IN A POPULATION NOT AS WELL AS OTHERS. THE GOAL OF POPULATION HEALTH IS WHEREVER THOSE PERSONS ARE IN THE POPULATION TO MAKE THEM BETTER. THAT IS THE GOAL OF POPULATION HEALTH TO DEAL WITH THE WHOLE POPULATION SO PEOPLE OVERALL ARE BETTER. POPULATION HEALTH IS DIFFERENT THAN CLINICAL CARE, CARE THAT FOCUSES ON ALREADY SIX SUBGROUPS, IN THE CORP.ER, THAT'S NOT MEANT TO SAY ONE IS BETTER. SIMPLY SAYS THESE ARE DIFFERENT APPROACHES. IF WE'RE SERIOUS ABOUT NARROWING HEALTH GAPS WE NEED TO THINK ABOUT WHOLE POPULATIONS. SO, FOUR PRINCIPLES, DERIVES FROM WORK THAT I DID, MY COLLEAGUE KATHERINE McKEES. I'LL FOCUS ON FOUR TODAY THAT REALLY ARE IMPORTANT TO HELP THINK ABOUT POPULATION HEALTH, SCHOLARSHIP AND POPULATION HEALTH AND HOW SCHOLARSHIP CAN GUIDE US. NUMBER 1, THE HEALTH OF POPULATIONS IS NOT BINARY. POPULATION HEALTH IS CONTINUOUS. THAT MEANS IT'S NOT JUST PEOPLE WITH DISEASE, IT MEANS PEOPLE HAVE BURDENS SYMPTOMS, WELL OR NOT WELL, FULL SPECTRUM OF WELL OR NOT WELL, AN IMPORTANT DISTINCTION WITH IMPLICATIONS FOR HOW WE DO SCIENCE AND THINK ABOUT INTERVENTIONS. TO SHOW THIS ILLUSTRATIVELY, POPULATION BMI, BODY MASS INDEX. IT'S FLAWED IN MANY WAYS AS A MEASUREMENT BUT RECOGNIZING IT IS ASSOCIATED WITH WHOLE HOST OF POOR HEALTH CONDITIONS, WE CAN THINK OF USING CUTOUTS AROUND BODY MASS INDEX, OVER 30 YOU'RE AT HIGH RISK. OR WE CAN LOOK AT THE WHOLE DISTRIBUTION OF BODY MASS INDEX ACROSS THE POPULATION. GRATIFIED RIGHT NOW PUBLIC CONVERSATION TO SEE SHIFTS AWAY FROM RECOGNIZING SOME CUTOFFS PARTICULARLY BODY MASS INDEX OF OBESITY BECOME STIGMATIZING AND SIMPLIFYING HOW WE THINK ABOUT OUR HEALTH. THAT REFLECTS WE SHOULD BE THINKING AS A CONTINUUM, OUR BODY MASS INDEX, WEIGHT, HEIGHT, A CONTINUUM AND WHEN WE THINK ABOUT CONTINUUM HOW IT EXPANDS YOUR THINKING. NOW I'M SHOWING YOU NHANES DATA, COLLECTED BETWEEN 1976 AND 1980, 40 YEARS AGO, AND NHANES DATA 15 YEARS AGO. YOU SEE THE CURVE IN THAT 40 YEARS AGO IS DIFFERENT THAN THE CURVE WAS 15 YEARS AGO? THE WHOLE SHAPE OF WEIGHT IN A POPULATION HAS SHIFTED IN THE PAST 40 YEARS, DRAMATICALLY DIFFERENT STATEMENT THAN SAYING LET ME HAVE THE LINE OF OBESITY, LET ME COUNT HOW MANY PEOPLE ARE QUOTE/UNQUOTE OBESE NOW THAN 40 YEARS AGO. THE UNDERLYING SHIFT IN THE POPULATION CURVE MAKES US SAY WHAT'S GOING ON, WHAT DOES THIS MEAN FOR HEALTH AND HEALTH OF POPULATIONS? IT HAS IMPLICATIONS FOR HOW WE UNDERSTAND THE TRADITIONAL RISK FACTORS THAT WE THINK OF WHEN WE THINK ABOUT OUR HEALTH. YOU ALL HAVE HEARD ABOUT -- WE KNOW CHOLESTEROL, HIGH CHOLESTEROL, IS ASSOCIATED WITH POOR HEALTH, THERE'S NOTHING SURPRISING ABOUT THAT. THAT CAME FROM THE FRAMINGHAM STUDY, BOSTON UNIVERSITY, WHERE I AM. WHERE DOES THAT COME FROM? WELL, THAT OBSERVATION, OBSERVATION ABOUT CHOLESTEROL BEING ASSOCIATED WITH POOR HEALTH COMES FROM THESE GRAPHS, REAL DATA. THE SOLID BLACK LINE ARE PEOPLE WITHOUT HEART DISEASE, DOTTED BLACK LINE ARE PEOPLE WITH HEART DISEASE. WHAT DO YOU SEE? WHAT YOU SEE IS THE TWO WITH ALMOST OVERLAPPING. SO CHOLESTEROL, PEOPLE WITH HEART DISEASE, PEOPLE WITHOUT HEART DISEASE, YOU KNOW CHOLESTEROL IS A RISK FACTOR FOR HEART DISEASE. HOW IS IT THESE TWO LINES ARE ALMOST OVERLAPPING? WHEN WE SAY IT'S A RISK FACTOR WE'RE SEEING THIS, WE'RE DRAWING A LINE. DRAWING A LINE AT A CERTAIN CUTOFF AND COUNTING PEOPLE UNDER THE CURVES, PEOPLE WITH HEART DISEASE, HIGH CHOLESTEROL, HIGH IS OVER THE LINE, PEOPLE WITHOUT HEART DISEASE WITH HIGH CHOLESTEROL, PEOPLE WITHOUT HEART DISEASE, WITH HIGH CHOLESTEROL, WITH THAT BECOMES A TABLE OVER HERE ON THE RIGHT, THE BREAD AND BUTTER OF EPIDEMIOLOGY. THAT GIVES RISK FACTOR, ONCE YOU HAVE THAT, THAT BECOMES SOMETHING WE CALL A RISK. BUT THE REASON I'M TELLING YOU THIS IS BECAUSE HOUR TABULATION OF CHOLESTEROL RISK, OBESITY RISK, THAT HAS ALL SORTS OF IMPLICATIONS, STIGMA AROUND OBESITY, LEAVING THAT ASIDE HOW WE DO OUR BILLING, SCHOLARSHIP, AND THAT BELIES A MORE FUNDAMENTAL OBSERVATION OF POPULATION HEALTH THAT THERE IS A FULL DISTRIBUTION, FULL DISTRIBUTION OF HEALTH AND AXES OF WELLNESS ACROSS POPULATIONS, THAT FULL DISTRIBUTION CHANGES OVER TIME AS SOCIAL CONDITIONS AND SOCIAL FORCES CHANGE AROUND OVER TIME. IF WE'RE TO THINK OF POPULATION HEALTH WE SHOULD THINK ABOUT THESE FULL DISTRIBUTIONS. JUST IN TERMS OF THE RISKS AND POPULATION AND CURVES, THE RISKS WE SEE IN PUBLICATIONS YOU NEED AN EXTRAORDINARILY HIGH RISK TO BE ABLE TO DISTINGUISH POPULATION CURVES. THIS IS FROM A PAPER THAT SHOWS YOU NEED OBSERVATION OF 350, THE BOTTOM RIGHT, TO HAVE WHAT WE CALL CURVE SEPARATION WHERE A RISK FACTORS TELLS YOU WHO IS MORE LIKELY TO GET DISEASE, WHY MANY RISK FACTORS ARE TERRIBLE PREDICTORS. RISK FACTOR PARADIGM, WE ALL KNOW, ALL OF US IN SCHOLARSHIP, FOCUS ON THE RISK FACTOR PARADIGM. IT'S TERRIBLE AT DISTINGUISHING POPULATIONS OF PEOPLE WITH AND WITHOUT DISEASE, FUNDAMENTALLY, BECAUSE THERE'S A FULL UNDERLYING DISTRIBUTION OF DISEASE WHEN WE THINK ABOUT HEALTH OF POPULATIONS. PRINCIPLE 2, CRITICAL TO THINK ABOUT UBIQUITOUS CAUSES. I TELL THE STORY OF THE GOLDFISH, IF THEY ARE SURROUNDED BY WATER ALL THE TIME, CAN YOU DO ALL YOU WANT TO GIVE THEM THE BEST GOLDFISH DOCTOR AND GOLDFISH PILLS, TELL THEM TO EXERCISE BUT IF YOU DON'T CHANGE THE WATER THE GOLDFISH WILL NEVER BE HEALTHY. THE WATER IS UBIQUITOUS IN THE CONTEXT OF GOLDFISH. FOSTER WALLACE TELLS THE STORY WITH THE YOUNG FISH AND OLD FISH, THE OLD FISH SAYS TO THE YOUNG FISH HOW'S THE WATER, THE YOUNG FISH SAY WHAT'S WATER? IT'S EVERYWHERE AROUND THEM, OF COURSE. WE NEED TO THINK ABOUT FORCES AROUND US THAT HELP SHAPE HEALTH OF POPULATION AND DISTRIBUTION OF HEALTH IN POPULATIONS. BEFORE THIS WHEN HAVING A CONVERSATION WITH ELISEO, STRUCTURAL RACISM, IT'S A PERFECT EXAMPLE OF SOMETHING IN THE WATER, SOMETHING THAT DR. PEZER STABLE WAS TALKING ABOUT HARD TO DEFINE. WE CAN COME UP WITH A DEFINITION BUT ULTIMATELY THE DIFFICULTY IT'S EVERYWHERE, BUILT INTO THE INFRASTRUCTURE, BUILT INTO THE ECOSYSTEM IN WHICH WE LIVE, THAT MEANS IT INFLUENCES EVERYTHING AND EVERYBODY AND HEALTH OF EVERYTHING AND EVERYBODY. MORE CONCRETE EXAMPLE, FOR EXAMPLE WHEN WE -- A CRACK BABY EPIDEMIC 30 YEARS AGO WHICH HAD BECOME A REAL BIG FOCUS OF ATTENTION, SUBJECT OF A LOT OF NIH FUNDING. AT THE TIME, THERE WAS A LOT OF WORRY THESE BABIES WERE BORN WITH MOTHERHOOD USED GESTATIONAL COCAINE WOULD BE VERY DAMAGED. STUDIES WERE DONE WHICH SHOWED THAT WASN'T THE CASE IN THE MEDIUM TERM. THIS IS THE PEABODY VOCABULARY TEST FOR BABIES IN THE GRAY WERE BORN WITH MOMS WITH GESTATIONAL COCAINE COMPOSURE AND WHITE WITHOUT. WHAT DID IT HAVE TO DO WITH? IT WAS POVERTY. THESE BABIES WERE BORN IN POVERTY. ENVIRONMENTAL STIMULATION WHAT GOES WITH POVERTY WAS ULTIMATELY AFFECTING THESE BABIES' LIVES. THINKING ABOUT UBIQUITOUS EXPOSURES, OFTEN IS A WAY FOR US, WE OFTEN FORGET THAT. WE FORGET THAT THERE ARE FORCES LARGER AND MORE OBVIOUS IN FRONT OF US. THE MOM WAS USING COCAINE DURING GESTATION BUT THE ISSUE IS THE LARGER CONTEXT IN WHICH THE BABY IS BORN. DO WE MAKE THAT MASS TAKE NOW? MISTAKE NOW? WE DO IT ALL THE TIME. OUR FOCUS IS HOW WE SHOULD EXERCISE, EAT BETTER, WE AS INDIVIDUALS. WHAT IS UBIQUITOUS EXPOSURE? CHANGE IN NUMBER OF CALORIES. A BAGEL 20 YEARS AGO HAD 140, TODAY 250. THIS IS AN NIH AUDIENCE, FRENCH FRIES WERE 100 CALORIES, NOW 600. THOSE DWARF THE IMPACT OF EXERCISE OR WHAT I EAT. WE CAN'T FORGET THAT CAN POPULATION HEALTH. POOR FOOD ENVIRONMENT, AVAILABILITY OF FOOD, POOR EDUCATION, EDUCATION THAT SETS PEOPLE'S PATH IN TERMS OF THEIR DIETARY CHOICES. SO PRINCIPLE 2, THINK ABOUT UBIQUITOUS FORCES IF YOU'RE TRYING TO IMPROVE POPULATION HEALTH. NUMBER 1, NOT JUST CAN WE KEEP PEOPLING FROM CROSSING A THRESHOLD OR MEETING A BMI BUT UNDERSTANDING FULLNESS OF PEOPLE'S LIVES, AND FULLNESS OF HEALTH IS SET BY THE FULL SET OF DETERMINANTS UBIQUITOUS AROUND US. THIRD PRINCIPLE IS CO-OCCURRING CAUSES. SO, WE TEND TO THINK AND BECAUSE WE'RE HUMAN, THIS IS A HUMAN THING, WE DO IT ALL THE TIME, I DO IT ALL THE TIME, WE TRY TO ISOLATE INDIVIDUAL CAUSES, THINK OF WHAT'S THE ONE THING THAT IS IMPORTANT. AND EVERY TIME I DO TALKS, SOMEBODY SAYS TELL ME THE ONE THING THAT REALLY MATTERS. I STOP ANSWERING. I DON'T KNOW THAT THERE IS ONE THING. SIMILARLY THERE'S NO ONE THING THAT CAUSES THINGS BY ITSELF. I WANT TO ILLUSTRATE THIS BY STICKING WITH OBESITY AS AN EXAMPLE, TALKING ABOUT GENES AND ABOUT HOW MUCH OBESITY IS DETERMINED BY GENES. HERE IS MY QUESTION. THIS IS A EASIER DONE IN PERSON. I WILL ASK YOU TO DO IT IN YOUR HEAD. RECOGNIZING, RECOGNIZING THAT THE GENES MATTER FOR OUR BODY WEIGHT, BUT RECOGNIZING ENVIRONMENTAL FORCES ALSO MATTER, RECOGNIZING THE WHO MATTER, OKAY? GENES MATTER, ENVIRONMENT MATTERS. WHAT PERCENT OF RISK FOR OBESITY COMES FROM YOUR GENES, RECOGNIZING BOTH MATTER AND I'M GOING TO CHALLENGE YOU TO WRITE DOWN THE ANSWER, OR AT LEAST HOLD YOURSELF ACCOUNTABLE FOR THE ANSWER WHEN I SHOW YOU THE ANSWER. GENES MATTER. ENVIRONMENT MATTERS. WHAT PERCENT IS DUE TO YOUR GENES? I'M PAUSING TO GIVE YOU TIME TO THINK AND WRITE DOWN YOUR ANSWER. LET'S NOW DO THE MATH. LET'S START WITH POPULATION. THIS IS POPULATION, GRAY UNDIFFERENTIATED PEOPLE. PEOPLE WHO ARE MORE BLACK HERE HAVE A GENE FOR OBESITY. NOW, THERE IS NO SINGLE GENE FOR OBESITY, THIS IS AN EXAMPLE JUST TO ILLUSTRATE THE POINT. BUT SAY THERE IS ONE GENE, JUST ONE SIMPLE GENE. PEOPLE IN GREEN ARE ENVIRONMENT, IN OBESE-GENIC ENVIRONMENT MORE LIKELY TO MAKE PEOPLE DISEASE. RED ARE PEOPLE WHO BECOME OBESE, WHO THEN BECOME OBESE. AND IN ORDER TO BECOME RED, YOU NEED A COMBINATION OF THE GENE AND ENVIRONMENT. THEY BOTH MATTER. I'M INSERTING RANDOM RED PEOPLE TO SHOW YOU AND MAKE THE MATH WORK. LET'S TAKE EXAMPLE 1. THOSE ARE THE GENES, AND NOW I'VE PUT EVERYBODY IN AN OBESEOGENIC ENVIRONMENT. BLACK PLUS RED, NOW THEY BECOME OBESE. WHAT PERCENT LINKED TO GENE? EVERYBODY, THE THE PART WHICH IS THE POPULATION IS 100%. EVERYBODY IN THE BLACK HAD THE GENE ACTUALLY BECAME OBESE. THAT'S SCENARIO ONE. SCENARIO TWO, SAME PATTERN OF PEOPLE IN THE BLACK WHO HAVE THE GENE. DIFFERENT ENVIRONMENT. GREEN IS NOW DIFFERENT. ONLY A COUPLE OF THE PEOPLE WITH THE GENE IN THE BLACK ARE ACTUALLY NOW DOTTED. WELL, THOSE ARE GOING TO BECOME RED. THEY BECOME OBESE. BECAUSE THE BLACK AND GREEN BECOMES RED. LOOK AT THE PEOPLE IN THE BLACK WHO DID NOT BECOME OBESE. BECAUSE THEY DIDN'T HAVE THE GREEN ENVIRONMENT. SO RELATIVE RISK IS NOW 1.7, POPULATION WITH RISK IS 40%. POPULATION WITH RISK CHANGED DRAMATICALLY, NOT BECAUSE THE GENE CHANGED BUT THE ENVIRONMENT CHANGED. THE ANSWER TO THE QUESTION THAT I ASK YOU, WHAT PERCENT OF RISK FOR OBESITY IS DETERMINED BY YOUR GENES HAS TO BE "I DON'T KNOW" UNTIL YOU TELL ME ABOUT THE ENVIRONMENT. AFTERWARDS WHEN I STOP SHARING I WOULD LIKE YOU TO RAISE YOUR HAND, THOSE WHO GOT THE ANSWER CORRECT. BECAUSE IT'S A HARD ANSWER TO GET CORRECT. NOW, I DIDN'T FOOL YOU. I TOLD YOU THAT GENES MATTER AND ENVIRONMENT MATTERS. I TOLD YOU THAT. BUT DESPITE THAT WE ALWAYS THINK THAT WE CAN SOMEHOW CONTROL FOR ONE AND ISOLATE THE OTHER. IT'S SIMPLY MATHEMATICALLY WRONG. CO-OCCURRING CAUSES, GENE ASSOCIATION CANNOT BE UNDERSTOOD IF WE DON'T UNDERSTAND THE OTHER ENVIRONMENTAL FACTORS AROUND US. THAT'S TRUE ALL THE TIME. THIS IS, FOR EXAMPLE, BODY MASS INDEX BY GENOTYPE. YOU SEE PHYSICAL ACTIVITY ON THE X-AXIS, BMI ON Y-AXIS, RELATIONSHIP BETWEEN PHYSICAL ACTIVITY AND BMI CHANGES DEPENDING ON GENE, CLASSIC GENE/ENVIRONMENT INTERACTION. ISOLATING CAUSES IS A MISTAKE. WE NEED TO THINK ABOUT CAUSES HAPPENING TOGETHER THAT ULTIMATELY ARE WHAT PRODUCES THE HEALTH OF POPULATIONS. THAT BY THE WAY IS WHY IT IS SO DIFFICULT FOR US TO PREDICT HEALTH IN INDIVIDUALS BY FOCUSING ON INDIVIDUAL RISK. FOR EXAMPLE, I'LL SHOW YOU THIS. DIABETES, THERE'S A LOT OF CORRELATION, RISK OF DIABETES ON Y-AXIS, HIGHER GENOTYPE MORE MORE INCIDENCE OF DIABETES. I WONDER WHAT MY GENOTYPE SCORE IS BECAUSE I WANT TO KNOW. BUT TAKE THE SAME DATA AND SHOW THEM A DIFFERENT WAY. THERE ARE TWO LINES. BLACK LINE IS PEOPLE WITH DIABETES, GRAY WITHOUT DIABETES. NOTICE HOW THE TWO CURVES ARE ON TOP OF EACH OTHER DESPITE GENOTYPE SCORE. ULTIMATELY, THESE OBSERVATIONS OF INDIVIDUAL RISK FACTOR AND POPULATION TELL US LITTLE ABOUT WHAT'S HAPPENING AT THE INDIVIDUAL LEVEL BECAUSE YOU NEED TO UNDERSTAND MULTIPLE RISK FACTORS TO UNDERSTAND THE HEALTH OF POPULATIONS. GOING BACK MY POINTS, UNDERRING YOUR UNDERRING YOUR UNDERRING UBIQUITOUS FORCES IS IMPORTANT. WHY YOU CAN'T UNDERSTAND HOW STRUCTURAL RACISM AND OTHER FORCES AFFECT DIABETES, YES/NO, BUT ULTIMATELY SHOULD BE UNDERSTAND TO UNDERSTANDING THE FULL EXPRESSION OF PEOPLE'S GLUCOSE METABOLISM BECAUSE THERE'S PROBABLY FULL SET OF RANGES OF THAT, IF WE'RE TO UNDERSTAND HEALTH POPULATION. THAT'S THE THIRD PRINCIPLE. THE FOURTH IS HEALTH EQUITY. THAT WE CANNOT UNDERSTAND HEALTH OF POPULATIONS WITHOUT HEALTH EQUITY. YOU ALL KNOW DATA ON HEALTH EQUITY. BUT TO REFRESH OUR THINKING, THERE'S WIDENING OVER TIME AND WIDENING HEALTH GAPS OVER TIME. THIS LOOKS AT A COHORT BORN IN 1930 ON THE LEFT, 1960 ON THE RIGHT. THIS GOES FROM POORER TO RICHER QUINTILE. THE GROUP IN 1960 THERE'S A 12-YEAR DIFFERENCE. OUR HEALTH GAPS IS CHANGING. I CAN SHOW YOU THIS IN MANY GRAPHS. THIS IS LIFE EXPECTANCY FOR WOMEN WHICH HAS ONLY INCREASED FOR THE RICHEST 20%, NOT AT ALL FOR WOMEN IN THE POORER 80%, ONLY INCREASED FOR THE RICHER 20%. SO NOW WE GET THIS NOTION OF HOW DO YOU ACHIEVE HEALTH EQUITY? I SAID AT THE BEGINNING OUR THINKING ABOUT POPULATION HEALTH HAS TO BE AROUND IMPROVING OVERALL HEALTH BUT NARROWING HEALTH GAPS. I BET WHEN I SAY THAT YOU'RE NODDING, THAT'S FINE. BUT IS THAT POSSIBLE, AND IS IT EASY TO IMPROVE HEALTH OF POPULATIONS AND NARROW HEALTH GAPS AT THE SAME TIME. THERE'S A TENSION WE'RE NOT WILLING TO ADMIT, COVID TIMES HIGHLIGHTED THIS. AN EXAMPLE, COMPOSING HAVE YOU POPULATION OF TOP, NO INTERVENTION, 50, ANY HEALTH UNIT YOU WANT TO THINK OF, A GROUP WITH 50, AND GROUP WITH 25. YOU SAY I'M GOING TO DO AN INTERVENTION, GIVE EVERYBODY ONE NEW POSITIVE HEALTH FOR EVERY 50 UNITS. WELL, 50 BECOMES 51. 25 BECOMES 25.5. SUPPOSING I ADD 10 FOR EVERY 50. 50 BECOMES 60. 25 BECOMES 30. WHAT AM I DOING BY ADDING MORE HEALTH? I'M WIDENING THE HEALTH GAP. ACTUALLY WIDENING THE HEALTH GAP. LET ME SHOW ANOTHER EXAMPLE. TWO POPULATIONS ARE EQUAL, BOTH THE SAME, BUT THEN SUPPOSE I DO AN INTERVENTION WHERE ONE GROUP GAINS MORE. YOU'RE SAYING IT'S NICE, THEORETICAL. HOW ABOUT IN COVID TIMES? WELL, HAS THERE EVER BEEN A BETTER EXAMPLE THAN VACCINATION? WE CAN PROBABLY ACHIEVE MORE VACCINATION IF WE VACCINATE ONLY HIGH SES GROUPS AND VERY QUICKLY. SHOULD WE DO THAT? OR SHOULD WE SACRIFICE EFFICIENCY FOR THE SAKE OF MAINTAINING EQUITY IN VACCINATION? IN THE CONTEXT OF COVID THERE'S A BENEFIT TO ALL MORE PEOPLE VACCINATED. I'M RAISING THIS TO MAKE THE POINT THESE ARE DIFFICULT DECISIONS AND IF WE'RE SERIOUS ABOUT POPULATION HEALTH SCHOLARSHIP AND ACTION, WE NEED TO GRAPPLE, BE HONEST, RECOGNIZE THESE ARE COMPLEX ISSUES. I WANT TO LEAVE TIME FOR QUESTIONS AND TALK ABOUT METHODS. HOW DO YOU DEAL WITH ALL THIS COMPLEX IF COMPLEXITY? I'VE WRITTEN A FAIR ABOUT IT, I WANT TO GIVE YOU ILLUSTRATION, NOT TO SAY IT'S THE ONLY APPROACH BUT IT'S A WAY FOR US TO THINK ABOUT THE COMPLEXITY OF HEALTH OF POPULATIONS. SO, THIS IS A POPULATION, RIGHT? WHAT I SHOWED YOU BEFORE. AND DETERMINISTIC METHODS ASSUME A POPULATION LOOKS LIKE THIS, EVERY SINGLE PERSON IN YOUR POPULATION IS A PERSON WHO LOOKS THE SAME AND IS BLUE AND HAS THE SAME SHAPE AND ALL THAT. THAT'S EXACTLY WHAT IT LOOKS LIKE. IT'S NOT REALLY TRUE. POPULATIONS ARE HETEROGENEOUS, DIFFERENT SHAPES, SIZES, GENDERS, NON-LINEAR DYNAMICS. WE KNOW EACH OTHER, INTERACT, CHANGES OUR BEHAVIOR. WHAT YOU DO CHANGES WHAT I DO. WHAT I DO MIGHT CHANGE WHAT YOU DO. SOMETIMES THINGS HAPPEN BECAUSE THEY HAPPEN. AS A RESULT, WE AS A CROWD HAVE A TOTALLY DIFFERENT SET OF BEHAVIORS. POPULATION IS A HETEROGENEOUS GROUP OF PEOPLE, BY DEFINITION A COMPLEX SYSTEM. I'LL GO BACK TO OBESITY FROM THE FORSYTHE MODEL THAT TRIED TO MAP OUT ALL THE DETERMINANTS OF OBESITY. YOU HAVE SOMETHING VERY COMPLICATED LIKE THIS. IF WE WANT TO UNDERSTAND WE SHOULD UNDERSTAND THE ECOSYSTEM SO WE DON'T MAKE MISTAKES OF OVERSIMPLIFYING AND RESULTING IN SOMETHING NOT USEFUL. WHEN WE UNDERSTAND CAUSES WE THINK OF THEM AS COUNTER-FACTUAL, A FUNDAMENTAL PRINCIPLE OF CAUSAL THINKING, THIS WOMAN IS WALKING ON A BOARDWALK, HAPPY, AND ALL WE'RE TRYING TO DO IS SAY SAME WOMAN, SAFE EVERYTHING, SAME BOARDWALK, WALKS UNDER A GRAY CLOUD, NOW SHE'S SAD. AH, WELL, THE ONLY THING THAT CHANGED IS THE GRAY CLOUD, THEREFORE THE GRAY CLOUD CAUSE THE HER SADNESS. THERE'S NO THING AS THE SAME UNIVERSE, SAME EVERYTHING, WHERE THE SAME WOMAN WAS SO ISOLATED THE IMPACTS OF THE GRAY CLOUD OF THE SADNESS. WE TALK ABOUT THE RANDOMIZED CONTROL TRIAL, POPULATION OF INTEREST, CIRCLE RIGHT HERE. YOU TAKE THE POPULATION AND DIVIDE IT. SOME YOU GIVE TREATMENT, SOME CONTROL. GRAY CLOUD, NO GRAY CLOUD. YOU SEE DISEASE. CERTAIN PROPORTION GETS DISEASE, IS THERE A CAUSE? THAT IS ONE TYPE OF STUDY. THAT IS OFTEN CALLED THE GOLD STANDARD, SHOULDN'T BE CALLED THAT. YOU HAVE OBSERVATIONAL STUDIES, TAKE DIFFERENT POPULATIONS, TAKE POPULATION, STRATIFY. SOME PEOPLE EXPOSED, SOME PEOPLE NOT EXPOSED. EXPOSED WHICH IS GRAY, SOME GET DISEASE, WHICH IS RED. THAT'S OBSERVATIONAL STUDIES. IT USED TO BE EASY TO SAY THEY ARE NOT AS GOOD AS RANDOMIZED STUDIES WHICH IS NOT THE CASE. ALL THESE STUDIES HAVE STRENGTH, WEAKNESS, THEY ALL HAVE DIFFERENT THINGS THEY CAN GIVE US. THEN YOU HAVE MORE MODELING TYPE STUDIES WHERE YOU CAN SIMULATE POPULATIONS, CREATE TREATMENT POPULATIONS, CONTROL POPULATIONS, CREATING COUNTER-FACTUAL AND, AGAIN, LOOKING AT DISEASE DISTRIBUTION, YES OR NO. ALL I'M DOING IS TRYING TO SET THE STAGE FOR YOUR THINKING, SET THE STAGE FOR THINKING ABOUT BROAD SET OF DETERMINANTS UNDERSTANDING THEM WITHIN THE PRINCIPLES OF POPULATION HEALTH AND THAT'S WHAT YOU NEED TO UNDERSTAND TO THINK ABOUT THE HEALTH OF POPULATIONS AND THINK ABOUT HOW THE HEALTH OF POPULATIONS ULTIMATELY CAN BECOME PRACTICAL INTERVENTIONS. ONE OF MY FAVORITES, ATTRIBUTED TO ALBERT EINSTEIN, EVERYTHING SHOULD BE SHOULD BE MADE AS SIMPLE AS POSSIBLE BUT NOT SIMPLER. MY FIELD IS PUBLIC HEALTH, PUBLIC HEALTH THERE IS THIS FOUNDING MYTHOLOGY, THAT JOHN SNOW WHO IS THE MAN WHO YOU SEE OVER HERE REMOVED THE PUMP HANDLE THAT STOPPED CHOLERAIC WATER AND STOPPED THE EPIDEMIC IN LONDON. HE MADE CONTRIBUTIONS TO MAPPING DISEASE BUT HERE IS THE REAL EPIDEMIC. THAT WAS THE EPIDEMIC OF CHOLERA WHICH WE ALL THINK ABOUT EPIDEMIC CURVES ALL THE TIME. THE PUMP WAS CLOSED. TELL ME IF JOHN SNOW INTERVENTION MADE DIFFERENCE? THE ANSWER IS IT DID NOT. EVEN FOUNDING MYTHOLOGY OF OUR FIELDS RESTS ON THESE SIMPLIFICATIONS THAT ARE BELIED BY DEEPER THINKING, DEEPER UNDERSTANDING OF POPULATION HEALTH. I'LL CONCLUDE WITH THE BIG PICTURE, THAT IF WE'RE SERIOUS ABOUT POPULATION HEALTH WE SHOULD THINK ABOUT FULL SET OF DETERMINANTS UNDERSTANDING PRINCIPLES THAT THEY ACT TOGETHER, INFLUENCE HEALTH, MULTIPLE DIMENSIONALITY, SOME ARE UBIQUITOUS AND ULTIMATELY THEY RESULT IN CHANGES IN HEALTH IN POPULATIONS AND EQUITY IN POPULATIONS, ALL THIS REQUIRES SERIOUS THOUGHT. IT'S HELPFUL TO THINK OF POPULATION HEALTH THROUGH THE LIFE COURSE, LIFE COURSE WHERE YOU HAVE OLDER AGE, DEVELOPMENT OF POOR HEALTH, ACROSS PRENATAL, ADOLESCENCE, OLDER, ACCUMULATE VARIETY OF FACTORS THAT ULTIMATELY AFFECT YOUR HEALTH, MOTHER'S NUTRITION, EXPOSURE TO VIOLENCE, SOCIAL ISOLATION OLDER IN LIFE, LIFE COURSE, SOCIAL ECOLOGICAL PERSPECTIVES, MULTI-LEVEL PERSPECTIVES WHERE YOU HAVE GENETIC FACTORS INFLUENCED BY INDIVIDUAL RISKS, NEIGHBORHOODS, INSTITUTIONS, SOCIAL AND ECONOMIC POLICIES. ALL OF THAT TOGETHER FUNDAMENTALLY ULTIMATELY INTERSECT WAS LIFE COURSE TO SHAPE THE HEALTH OF POPULATIONS. SO CONCLUDING, I TALKED IN MY TITLE OF MY TALK ABOUT DETERMINANTS. I PUT SOCIAL IN BRACKETS BECAUSE SOCIAL DETERMINANTS, A HOT THING TO TALK ABOUT BUT FUNDAMENTALLY WE SHOULD BE THINKING ABOUT THE FULL SET OF DETERMINANTS, ACROSS LIFE COURSE, AND ACROSS SOCIAL AND ECOLOGICAL LEVELS, AND HOW THEY INTERSECT TOGETHER TO CREATE HEALTH OF POPULATIONS, FULL SPECTRUM OF HEALTH AND POPULATIONS, HOW THESE FORCES HAPPEN TOGETHER AND HOW THEY ULTIMATELY INFLUENCE WHERE WE ACT. AND A COMMISSION WHICH I'M LEADING, HEALTH DETERMINANTS DATA AND DECISION MAKING COMMISSION TRYING TO THINK ABOUT POPULATION HEALTH, HOW DATA WESTBOUND USED TO INFORM SOCIAL DETERMINANTS AND HOW THAT CAN HELP US MAKE BETTER DECISIONS, ABOUT SCHOLARSHIP AND WHAT SOCIETY SHOULD DO TO NARROW HEALTH GAPS. IT'S A PRIVILEGE TO BE HERE. THANK YOU FOR HAVING ME. I WILL STOP SHARING SO THAT WE CAN ASK QUESTIONS AND HAVE A CONVERSATION. THANK YOU. >> THANK YOU SO MUCH, SANDRO, EVERY TIME I HEAR YOU SPEAK I LEARNING SOMETHING, MANY THINGS. I APPRECIATE YOU JOINING US TODAY. THERE ARE MULTIPLE WAYS TO ENGAGE IN THE CONVERSATION AND ASK QUESTIONS IF YOU'RE ON ZOOM YOU CAN FEEL FREE TO ADD THEM TO CHAT. YOU CAN RAISE YOUR HAND OR UNMUTE YOURSELF. SO I CAN SEE YOU. AND STOP TALKING. I'LL SEE IF ANYONE WANTS TO JUMP IN FIRST. ALL RIGHT. SO, I'M GOING TO TAKE THE LIBERTY OF ASKING THE FIRST QUESTION. SO, THE LIFE COURSE PERSPECTIVE THAT YOU MENTIONED, I WAS HOPING YOU COULD COMMENT A LITTLE BIT ABOUT -- IF WE'RE RECOGNIZING THE IMPORTANCE OF THINKING OF THE LIFE COURSE WHAT ARE IMPLICATIONS FOR INTERVENTIONS, IF WE THINK ABOUT THE LIFE COURSES IS IMPORTANT AND THEN DOES IT MATTER IF WE LAYER AN INDIVIDUAL HEALTH OR POPULATION HEALTH IN TERMS OF HOW WE THINK ABOUT THOSE INTERVENTIONS? >> IT'S A GREAT QUESTION. THE CHALLENGE THINKING ABOUT LIFE COURSE IS THAT THERE'S A LOT OF THINGS TO THINK ABOUT. AND FUNDAMENTALLY LIFE COURSE RESULTS IN CONCATENATED LINKED FORCES, IN CRITICAL PERIODS, RESULTS IN DISCONTINUITIES, GROWTH SPURTS AND THINGS LIKE THAT. I DO THINK THAT IT IS IMPORTANT TO THINK OF THE FULL SET OF FORCES ACROSS THE LIFE COURSE SO THAT WE DON'T MAKE THE MISTAKE OF SAYING WE HAVE A PERSON AND THEIR DETERMINANTS OF THEIR HEALTH ARE WHAT THEY PRESENT WITH TODAY. YOU HAVE A -- IF YOU HAVE A PATIENT, I'M USING THE WORD PATIENT INTENTIONALLY, I'VE NOT USED THAT IN MY PRESSURE PRESENTATION, I TALKED ABOUT PERSONS. IF THE PATIENT IN FRONT OF YOU HAS ARTHRITIS IN THE HIP AND TYPE 2 DIABETES, IF YOU SEE THAT, IF ONE SEES THAT, AS SIMPLY THE PRODUCT OF THE HERE AND NOW TODAY YOU'RE GOING TO BE ASKING ONLY WHAT IS IT ABOUT TODAY THAT THAT PERSON IS DOING SO YOU CAN INTERVENE THROUGH THERAPEUTICS OR SURGERY. IF ONE UNDERSTANDS THAT PERSON IS WHO THEY ARE IN FRONT OF YOU BECAUSE OF THE PRODUCT OF THE CONDITIONS AND CIRCUMSTANCES OF THEIR LIFE, THAT NOW PUTS YOU IN A VERY DIFFERENT SPACE TO THINK ABOUT WHAT INTERVENTIONS YOU SHOULD BE DOING. AND THAT IS A TOTALLY DIFFERENT WAY OF THINKING, AND I WAS EXCITED TO BE INVITED TO SPEAK TO NINR BECAUSE IT ALWAYS STRUCK ME THAT THIS SHOULD BE NATURAL FOR NIINR TO GRAPPLE WITH. YOU HAVE THE POTENTIAL TO HELP THINK BEYOND THE PATIENT TO THE PERSON. SO, I'M USING THOSE WORDS INTENTIONALLY. WE SLIP FROM PERSON TO PATIENT WHEN WE SEE ONLY THE DISEASES IN CROSS-SECTION. WE GO TO PERSON WHEN WE RECOGNIZE THAT THE PERSON IS NESTED IN THEIR LIFE COURSE AND FULL SET OF INFLUENCES THAT INFLUENCE THEIR FULL EXPRESSION OF WHO THEY ARE INCLUDING THEIR HEALTH. >> THANKS. THAT'S HELPFUL. I DON'T WANT TO MISS ANYONE. FEEL FREE TO UNMUTE YOURSELF IF YOU WANT TO JUMP IN. ALL RIGHT. SO, YOU TALKED ABOUT STRUCTURAL RACISM BEING IN THE WATER, PART OF THE WATER, IN WHICH -- THAT WE ALL EXPERIENCE. SO, CAN YOU TALK ABOUT MORE GIVEN YOUR PRESENTATION, AS YOU THINK ABOUT INTERVENTIONS TO TACKLE STRUCTURAL RACISM, WHAT DO YOU SEE AS THE IMPLICATIONS OF IT BEING IN THE WATER? >> WELL, IT'S NOT ONE THING. DR. PEREZ-STABLE IS MUCH MORE EXPERT IN THIS THAN I AM. IT SIMPLY MEANS THAT YOU BUILT INTO THE SYSTEM AROUND US ELEMENTS THAT PRIVILEGE ONE GROUP OVER ANOTHER. THOSE ELEMENTS CAN BE AN EMPLOYMENT, THEY CAN BE IN OUR CAPACITY TO GET HOMES, IN CAPACITY TO PUT OUR CHILDREN IN SCHOOLS, IN OUR LIKELIHOOD OF GETTING SELECTED FOR SCHOLARSHIPS IN SCHOOL THAT ADVANCE US. THOSE ARE ALL FORMS OF STRUCTURAL RACISM WHICH TRYING TO TEASE THE WORD APART, IT IS FUNDAMENTALLY BIASES TOWARDS ONE GROUP OR ANOTHER IN CONTEXT OF RACISM, PREDICATED ON THE IDENTITY OF RACE, RIGHT? BUT MAKES ONE GROUP THAT GIVES ONE GROUP MORE OPPORTUNITY THAN ANOTHER GROUP. THAT'S FUNDAMENTALLY WHAT THAT MEANS. INTERVENTIONS DEPENDS ON WHAT THE FORCES ARE. I DON'T THINK THERE'S ONE FORCE. THERE'S A WHOLE RANGE OF FORCES LIKE ARE THERE EMPLOYMENT FORCES? ARE THERE EDUCATIONAL FORCES? IS IT MORE OR LESS LIKELY THAT PEOPLE BASED ON DIMENSION OF IDENTITY OF RACE ARE GOING TO GET TRACKED INTO PROFESSIONS MORE LUCRATIVE, IF THAT'S THE CASE WE SHOULD TACKLE SHOWS FORCES. IS IT THE CASE THERE ARE PARTICULAR FORCES THAT MEAN THAT PEOPLE ARE MORE LIKELY TO RECEIVE LET'S SAY BETTER MEDICAL CARE, BECAUSE OF THE ONE DIMENSIONAL IDENTITY OF THEIR RACE. IF THAT'S THE CASE WE SHOULD ALSO WORK ON FIXING THOSE FORCES. FUNDAMENTALLY THIS THING IN THE WATER, SYSTEMIC RACISM IS A SET OF FORCES AND DIFFERENT DIMENSIONS. THERE'S NO ONE SOLUTION. IT'S A SET OF MANY SOLUTIONS AND DIMENSIONS OF OUR LAWS. >> THANKS. I'M GOING TO CONTINUE WITH THE QUESTIONS THAT I RECEIVED BY E-MAIL. IF YOU WANT TO JUMP IN AGAIN FEEL FREE TO UNMUTE YOURSELF. >> I SEE A HAND RAISED. >> OH GOOD. I'M SORRY I CAN'T SEE THAT. JUMP IN PLEASE. >> HI. THANK YOU SO MUCH. IT'S REALLY APPRECIATED HEARING YOU SPEAK. I'M (INDISCERNIBLE) FROM (INDISCERNIBLE) UNIVERSITY. SO MUCH OF WHAT SEEMS TO UNDERLIE HEALTH INEQUITIES IS ROOTED IN POVERTY AND INCOME EQUALITY. AS HEALTH CARE PROVIDERS AND RESEARCHERS, MANY IN THE HEALTH CARE FIELDS, IN ACADEMIC HEALTH CARE SETTINGS, HOW CAN WE THINK ABOUT OUR RESEARCH AND HOW IT MIGHT INFLUENCE UNDERLYING POLICIES THAT ARE RELATED TO MORE OF AN ECONOMIC SLANT? >> YEAH, NO, IT'S AN EXCELLENT QUESTION. I THINK ALL OUR RESEARCH NEEDS TO BE COGNIZANT OF ALL THE OTHER FORCES AROUND US THAT SHAPE WHAT WE'RE LOOKING AT. IT DOESN'T MEAN THAT YOU AND I NEED TO BY OURSELVES SOLVE EVERYTHING, RIGHT? IT DOESN'T MEAN THAT. IT SIMPLY MEANS WE NEED TO BE AWARE OF WHAT IS HAPPENING AND WHY IT'S HAPPENING. SO, LET ME TAKE AN EXAMPLE. I'VE DONE A LOT OF WORK ON TRAUMA, FOR EXAMPLE. TRAUMA AND HOW THAT AFFECTS MENTAL HEALTH. FOR ANY GIVEN PAPER I THINK IT'S PERFECTLY, I THINK, PERFECTLY REASONABLE TO PUBLISH A PAPER ABOUT THAT TRAUMATIC EVENT, TRAUMA X EQUALS HEALTH CONDITION Y. A SIMPLE PAPER. I HAVE A RESPONSIBILITY TO RECOGNIZE THAT TRAUMA X MAY BE DIFFERENTLY DISTRIBUTED AMONG PEOPLE OF HIGHER VERSUS LOWER SOCIOECONOMIC POSITION BECAUSE YOU ARE MORE LIKELY TO HAVE TRAUMA X IF YOU HAVE FEWER SOCIOECONOMIC RESOURCES AND I THINK IT'S MY RESPONSIBILITY TO RECOGNIZE AND TO MAKE THAT CLEAR IN MY FINDINGS AND PERHAPS TRYING TO PUSH RESEARCH IN THAT AS WELL. SO, I THINK ONE OF THE CHALLENGES IN SPEAKING AND PRESENTING THE WAY I HAVE IS THAT IT BECOMES TEMPTATION TO SAY YOU'RE SAYING EVERYTHING MATTERS FOR EVERYTHING. OKAY. I GET THAT. I REALLY DO. SO I DON'T WANT TO DISCOURAGE US FROM SAYING THERE'S ROOM FOR FOCUSED WORK BUT FOCUSED QUESTIONS, PLEASE, I DON'T WANT TO -- THAT'S WHAT SCIENCE DOES. REMEMBER ALBERT EINSTEIN QUOTE, AS SIMPLE AS CAN BE BUT NOT SIMPLER? AS LONG AS WE RECOGNIZE IT'S WITHIN A LARGER SPECTRUM. I DIDN'T ASK YOU TO RAISE YOUR HAND HOW MANY GOT THE THE QUESTION RIGHT, THE QUESTION OF OBESITY. RAISE YOUR HAND IF YOU DID. HERE'S THE FUNNY THING. I'VE PRESENTED THAT A COUPLE DOZEN TIMES, ALMOST EVERY TIME IN MY MIND I ASK THE QUESTION, I GIVE MYSELF AN ANSWER IN A PERCENT IN MY MIND. IT'S THE MOST RIDICULOUS THING. WE'RE SO PROGRAMMED TO THINK THAT WAY. IT'S QUITE AMAZING. I'M SAYING THAT'S HOW WE THINK. THAT'S OKAY. IF YOU WANT TO THINK ABOUT POPULATION HEALTH, ABOUT BEYOND PATIENT TO PERSON, YOU NEWED -- YOU NEED TO THINK ABOUT PRINCIPLES WHERE YOU CAN PUT THESE PEACES -- PIECES TOGETHER TO COME UP WITH USEFUL SCHOLARSHIP. >> SO I DO HAVE SOME IN CHAT, IF I DON'T SEE ANOTHER HAND. SORRY, APPARENTLY I'M BAD AT RECOGNIZING THE HANDS THAT COME UP. SO ONE OF THE QUESTIONS THAT HAS COME THROUGH IS ASKING FOR YOUR THOUGHTS, SANDRO, HOW WE CAN AS CLINICIANS AND RESEARCHERS HELP GENERATE PUBLIC OR PRIVATE INVESTMENT IN SOCIAL DETERMINANTS OF HEALTH. >> IT'S GREAT QUESTION. SO THIS GOES A LITTLE BIT TO WHAT I SAID AT THE END. THERE'S OBVIOUSLY IMPLICATION FOR SOCIAL DETERMINANTS OF HEALTH BUT I'M TRYING TO DROP THE WORD "SOCIAL" BECAUSE ULTIMATELY ALL THE DETERMINANTS OF HEALTH, DETERMINANTS OF HEALTH CROSS LEVELS OF INFLUENCE, CROSS THE LIFE COURSE, AT THE INDIVIDUAL LEVEL, AT THE NETWORK LEVEL, GROUP LEVEL OF WHERE WE LIVE, LEVEL OF POLICY. THESE ARE ALL DETERMINANTS. SO, I THINK OUR JOB, AND I HOPE YOU DON'T MIND I'M PRESUMING OUR COLLECTIVELY, IS TO PUSH FORWARD THE SCIENCE THAT MAKES IT CLEAR THAT OUR HEALTH AS PERSONS IS INEXTRICABLE FROM WHERE WE LIVE WORK AND PLAY, EAT AND DRINK, ALL THOSE ARE DETERMINANTS OF HEALTH. THE MORE WE PUSH THAT ARGUMENT, THE MORE WE CAN PUSH FOR POLICY INVESTMENT IN THE DETERMINANTS OF HEALTH. >> ANOTHER QUESTION IN THE CHAT, CONSIDERING THERE IS SLOW UPTAKE ON POLICIES TO RECOGNIZE RACISM AS A HEALTH CRISIS, HOW DO YOU SEE SUCH INTERVENTIONS CHANGING TO INFLUENCE POLICIES? >> YEAH, THAT GETS A LITTLE BIT AT THE ROLE OF SCIENCE AND I THINK THE ROLE OF SCIENCE AND SCHOLARSHIP IS -- IT'S ABOUT BEARING WITNESS, ABOUT BEARING WITNESS. I THINK IF YOU SEE RACISM AS A FORCE THAT IS AFFECTING HEALTH AND UBIQUITOUS FORCE THEN I THINK WE HAVE A JOB TO DO TO DO THE SCIENCE THAT ILLUSTRATES. I THINK THAT WILL SLOWLY TURN THE TIDE. IT'S HARD TO RECOGNIZE. IT TAKES TIME TO CHANGE PEOPLE'S MIND. TAKES TIME FOR THESE THINGS TO PENETRATE. PERHAPS I FORGET HOW MUCH I CAN BE IN ROOMS LIKE THIS HAVING THIS CONVERSATION, THINGS THAT SEEM TO BE OBVIOUS, LEAVE THIS ROOM AND TALK TO SOMEBODY, LIKE REAL PEOPLE, WHAT ARE YOU TALKING ABOUT? WHAT ARE YOU TALKING ABOUT? SO IT TAKES TIME FOR THESE IDEAS TO GET OUT THERE. I THINK IT'S REALLY ABOUT LABELING THE CHALLENGES, DOING THE SCHOLARSHIP, DOING THE -- YOU KNOW, WE SHOULD BE CAREFUL ABOUT -- THIS IS A SPACE FOR SCIENTISTS, WHICH HELPS CHANGE THE CONVERSATION, DIFFERENT THAN ROLE OF ADVOCACY AND ADVOCATES. SCIENTISTS CAN BECOME ADVOCATES, TO BEAR WITNESS AND SHOW THE SCIENCE THAT SHOWS HOW FORCES SHAPE IT. REBECCA HAS HER HAND UP? >> SO THANK YOU FOR THAT WONDERFUL TALK. I WANTED TO ASK YOU ABOUT RESTRICTED ENVIRONMENT WHICH HAVE YOU QUESTIONS ABOUT, THE HEALTH CARE ENVIRONMENT. I ASK YOU IF YOU HAVE THOUGHTS OR SEEN STUDIES OR CONSIDERED THE HEALTH CARE FACE THAT IT PRESENTS. IN OTHER WORDS, THE MIX OF WORKERS, THE WHO IS MEDIATING THE HEALTH CARE AND ACCESS TO HEALTH CARE. THINKING ABOUT NOT ONLY THE TRADITIONAL PROVIDERS BUT ALSO ALL THE OTHER KINDS OF PROVIDERS AND THEIR IMPACT. >> YEAH. YEAH, IT'S -- IF I MAY TRY TO ANSWER BY WAY OF METAPHOR, YOU KNOW, I WOULD -- I'VE USED THE METAPHOR OFTEN OF THE SOCCER TEAM, TWO KIDS PLAYING SOCCER, YOU'RE TRYING TO WIN AT SOCCER. IF NOBODY SCORES A GOAL YOU'RE NEVER GOING TO LOSE, RIGHT? YOU CAN SAY IF I HAD THE WORLD'S BEST GOALIE I'M GOING TO WIN BECAUSE SHE'S GOING TO KEEP THE BALL OUT. ANYBODY THAT PLAYED SOCCER, YOU KNOW THE NET IS PRETTY BIG. THE GOALIE IS GOING TO LET A BALL IN IF IT COMES AT HER FAST ENOUGH. TO WIN YOU NEED NOT JUST A GOOD GOALIE BUT OTHER TEN PLAYERS GOOD. I THINK HEALTH CARE IS LIKE THAT. HAVE YOU THE CLINICIAN, THE GOALIE. YOU WANT A GOOD CLINICIAN, REALLY GOOD CLINICIAN, IS SOMETHING IS WRONG WITH YOUR HEART YOU WANT A GOOD CLINICIAN TO OPERATE ON YOUR HEART. THE GOALIE BY THEMSELVES IS NOT GOING TO WENT GAME. YOU NEED THE OTHER ASPECTS TO ACTUALLY CREATE THE CONDITIONS FOR PERSONS TO BE HEALTHY AND STOP BEING PATIENTS. LIKE YOU'RE A PATIENT IN FRONT OF THE GOAL BUT REALLY YOU NEED TO BE A PERSON WITH THE OTHER TEN PLAYERS MOVING YOU AWAY FROM THE GOAL. SO NOW I REALIZE WE CAN TALK ABOUT IT, THERE'S LONG HISTORY OF STRUCTURAL INEQUITIES AND HIERARCHIES WITHIN HEALTH CARE SYSTEMS THAT ELEVATE THE GOALIE OVER EVERYBODY ELSE. I GET THAT. THAT, TO ME, IS A MISGUIDED REPRESENTATION OF THE FACT YOU NEED A FULL TEAM TO KEEP PERSONS IN POPULATIONS HEALTHY SO TO KEEP US ALL FROM BEING PATIENTS. RAISE YOUR HAND, HOW MANY PEOPLE HERE WOULD RATHER BE A PATIENT VERSUS A PERSON? NONE OF US WOULD. WE ALL WOULD LIKE TO BE PERSONS, NOT PATIENTS, RIGHT? IT'S ABSURD TO BE WITHIN OUR SYSTEMS PRIVILEGING THE PATIENT-NESS RATHER THAN THE PERSON-NESS. YOU THINK ABOUT PERSON-NESS, ALL THE OTHER PLAYERS WITHIN SYSTEMS THAT MAKE US ALL PERSONS. I'M GIVING YOU A METAPHORICAL ANSWER BUT I'M NOT SURE HOW TO ANSWER, WE NEED TO MOVE BEYOND THIS NARROW PATIENT/CLINICIAN CENTRIC APPROACH TO THINK ABOUT A MORE PERSON-CENTERED APPROACH THAN BY DEFINITION HAS TO EXTEND TO FULL RANGE OF DETERMINANTS, ACROSS MULTIPLE LEVELS, APPLYING PRINCIPLES AND LENSES OF LOOKING LIKE THE ONES I DESCRIBED. >> THANK YOU, DR. GALEA. I WANTED TO ASK YOU ABOUT THE CONCEPT OF PRECISION CARE AND THIS PRECISION HEALTH, SCIENCE OF PRECISION HEALTH. HOW DO YOU SEE -- IS THERE A ROLE FOR PRECISION HEALTH IN POPULATION HEALTH? >> YEAH, YEAH, GREAT QUESTION. MY HONEST ANSWER, SURE, AS LONG AS IT DOESN'T TAKE AWAY ALL OUR ENERGY. I THINK LIKE A BIG FAN OF SCIENCE AND DISCOVERY SCIENCE, PRECISION HEALTH, PRECISION MEDICINE, HAS HELPED US ADVANCE A LOT OF IDEAS THAT MIGHT END UP HAVING POSITIVE THERAPEUTIC AND DIAGNOSTICALITY. BUT IF THAT'S ALL WE DO, AND WE IGNORE ALL THE OTHER PRINCIPLES THAT GENERATE HEALTHY POPULATIONS WE'LL BE BARRELING DEEPER INTO PRECISELY HELPING PATIENTS, I'M NOT MORE INTERESTED IN KEEPING PERSONS FROM BECOMING PATIENTS. IT'S NOT AN EITHER/OR ARGUMENT. SOMETIMES I FEEL LIKE MY WRITING MAY BE MISUNDERSTOOD AS EITHER/OR ARGUMENT. THERE'S BEEN TERRIFIC WORK, REALLY INTERESTING WORK, THE UMBRELLA OF PRECISION HEALTH, PRECISION MEDICINE, ANY NUMBER OF LABELS BUT FUND MEN FUNDAMENTALLY TO BE DIAGNOSTIC AND THERAPEUTIC. I WANT GOOD GOALIES BUT NOT TO THE EXCLUSION. >> THANK YOU. >> THANK YOU. >> COULD YOU TALK MORE ABOUT THE CONCEPT OF PRECISION POPULATION HEALTH AND WHAT YOU AND YOUR COLLEAGUES HAVE MEANT BY THAT AND HOW YOU SEE THAT AS BENEFICIAL IN TERMS OF THINKING ABOUT HOW TO ADVANCE POPULATION HEALTH OR, YOU KNOW, ADVANCE HEALTH EQUITY? >> YEAH. NO, I -- PRECISION POPULATION HEALTH BY DEFINITION IS EFFORTS TO BETTER TARGET INTERVENTIONS FOR POPULATIONS AT THE RIGHT TIME AND RIGHT CASE, WHICH I WOULD ARGUE IS WHAT ONE TRIES WITH POPULATION HEALTH ALL THE TIME. DID I A DEBATE. I'M NOT SURE I FEEL STRONGLY TO BE COMPLETELY CANDID. I'M NOT CONVINCED IT'S HURTFUL, I'M AGNOSTIC. FUNDAMENTALLY I THINK EVERYTHING I DISCUSS TODAY ABOUT POPULATION HEALTH YOU COULD CALL IT PRECISION POPULATION HEALTH. I TALKED ABOUT BEING CAREFUL ABOUT DESCRIBING HEALTH PROPERLY AS A FULL EXPRESSION OF HEALTH, NOT JUST DICHOTOMY OF DISEASE AND NON-DISEASE. I TALK ABOUT MULTIPLE DETERMINANTS OF HEALTH SO YOU CAN THINK ABOUT THEM TOGETHER. I TALK ABOUT SOME BEING UBIQUITOUS AND HEALTH AND HEALTH FOR DIFFERENT GROUPS, TRYING TO PRECISELY CHARACTERIZE THE HEALTH OF POPULATIONS, RIGHT? SO IS THAT PRECISION POPULATION HEALTH? MAYBE. I'M NOT SURE. I'M AMBIVALENT ABOUT IT. >> THANKS. ANOTHER QUESTION IN THE CHAT, I STRUGGLE TO DIFFERENTIATE THE INFLUENCE OF RACE AND SES ON HEALTH OUTCOMES. SES SEEMS TORE MORE INFLUENTIAL AS RACE IS A SOCIAL CONSTRUCT BECOMES LESS MEANINGFUL. YOUR THOUGHTS ABOUT THE ISSUE? >> IT'S QUESTION IS THINKING OF RACE AS SOCIAL CONSTRUCT? TRY PARSING THE QUESTION AGAIN FOR ME. >> YEAH, LET ME REPEAT IT AND THEN IF THE PERSON WHO ASKED IT WANTS TO CHAT ME A LITTLE MORE SPECIFICS I CAN TRY AND EXPLAIN. SO, THE QUESTION, YOU KNOW, THE PERSON IS STRUGGLING TO DIFFERENTIATE THE EFFECTS OF RACE AND SES ON HEALTH OUTCOMES. THEY ARE OBSERVING THAT SES SEEMS TO BE A MORE INFLUENTIAL, RACE AS A SOCIAL CONSTRUCT BECOMES LESS MEANINGFUL. >> I SEE. I SEE. I THINK I GET IT NOW. YEAH, IT'S A TERRIFIC QUESTION. WHAT I'VE WRITTEN ABOUT THIS, WHAT I PRESENT ABOUT THIS, I TALK ABOUT DIVIDES, HEALTH DIVIDES SOCIOECONOMIC AND RACIAL AXIS. I SHOW THEY BOTH MATTER, BOTH INDEPENDENTLY AND JOINTLY. BUT FUNDAMENTALLY, WE HAVE TO BE CAREFUL ABOUT THINKING OF RACE OR ETHNICITY AS IN AND OF ITSELF A DETERMINANT. THAT GETS US TO A RACIAL ESSENTIALISM ARGUMENT. LIKE WE KNOW, I MEAN IN SO FAR AS MY SKIN TONE AND YOUR SKIN TONE, EVERYBODY'S SKIN TONE IS SLIGHTLY DIFFERENT, WE KNOW IT'S GENETICALLY NEGLIGIBLE. THERE'S SOME HEALTH LINKED, THAT HAPPENS TO BE LINKED TO GENES, SKIN TONE, BUT VERY LITTLE, RIGHT? FUNDAMENTALLY WE SEE RACIAL DIFFERENCES. REAL SOCIAL AND ECONOMIC DIFFERENCES, DIFFERENCES IN CULTURE AND AND HOW WE INTERACT WITH EACH OTHER BECAUSE OF THAT ONE THING, RACE. WE HAVE TO BE CAREFUL. YOU'LL READ ABOUT IT, SAYING, THESE ARE FORCES THAT MATTER FOR THE RACE ABOVE SOCIOECONOMIC. FOR EXAMPLE WE KNOW THAT IF YOU HAVE A GRADUATE DEGREE, AND YOU'RE BLACK AMERICAN, YOU HAVE WORSE HEALTH THAN GRADUATE DEGREE WITH WHITE AMERICAN. OH, THERE'S MORE TO RACE THAN SOCIOECONOMICS. YES, BUT WHAT'S MORE IS OTHER SOCIAL EXPERIENCES, OVER THE LIFE COURSE, ACROSS LEVELS. YOU KNOW, THIS IS GOING TO SOUND POLYANNISH. LIKE A UNICORN THING. ALLOW ME FOR A SECOND. IN A HUNDRED YEARS AFTER WE'RE LONG GONE SORRY TO SAY THE WORLD MAY HAVE GONE BEYOND THINKING OF RACE. IT'S NOT ABOUT RACE. IT'S ABOUT THE EXPRESSIONS OF INTERSECTION OF THE WORLD WITH US BECAUSE OF WHATEVER RACIAL IDENTITY IS. AND THAT WILL BE A BETTER WORLD. WE'LL GET THERE BUT IT'S GOING TO TAKE A LONG TIME TO GET THERE. >> GREAT. >> ARE YOU JUMPING IN? >> I WAS GOING TO EXPLAIN MY QUESTION BETTER BUT I THINK DR. GALEA GOT IT PERFECTLY. IT'S SUCH A STRUGGLE. I THINK IN A HUNDRED YEARS YOU'RE RIGHT, WE WON'T HAVE THESE QUESTIONS ABOUT RACE. THAT WILL BE A GOOD THING. SO THANK YOU. >> THAT MEANS WE'RE STRUGGLING WITH THEM FOR -- >> A LOT. >> ALL OF MY AND YOUR PROFESSIONAL LIFE, I HATE TO SAY IT. >> THANK YOU. >> THANK YOU. SUSAN OLDE FROM NURSING INSTITUTE. SO, I WAS -- I'M AP CARD CARRYING GENETICIST, I SPENT MANY YEARS TRYING TO FIGURE OUT HOW TO DO BETTER SORT OF UNDERSTANDING OF THE ROLE IN GENES AND ENVIRONMENT. AND IT'S NOT REALLY EASY TO SEPARATE THOSE AT ALL. I SPENT MANY YEARS TRYING TO FIGURE OUT HYPERTENSION, RIGHT, FOR HOW TO FIND THE GENES. AND IT'S NOT POSSIBLE IN SEPARATING OUT THE ENVIRONMENT. HOW DOE -- DO YOU SUGGEST WE USE, THE QUESTION CAME UP ABOUT PRECISION MEDICINE, HOW DO WE USE OTHER KNOWLEDGE OF THE GENOME HELPING US THINK ABOUT LOOKING AT HEALTH AND INEQUITIES IN THE EXAMPLES THAT YOU'VE GIVEN IN THE FOOD DESERTS AND OBESITY AND ACCESS TO HEALTH CARE? HOW DO WE THINK ABOUT -- >> YEAH, YEAH. NO, IT'S A GREAT QUESTION, AFTER ALL. I SUPPOSE WHAT I COME TO IS THAT A LOT OF THE WORK WE DO, OF COURSE IT'S VERY DIFFICULT, WHAT YOU DO, IN GENOMICS, ENVIRONMENT, GENETIC, THAT DEPENDS ON A PARTICULAR SET OF METHODS LIMITED FOR DOING SUCH A THING. I'M NOT SURE HOW TO DO IT. I HAVE NO ANSWER. BUT OTHER THAN TO SAY THE FACT THAT YOU'RE ASKING THE QUESTION IS THE RIGHT THING FOR US TO DO. AND THAT OVER TIME WE'RE GOING TO GET MORE SOPHISTICATED. THE GENE-ENVIRONMENT INTERACTION, SIMPLE TERM, FIRST OF ALL THEY MERGED 20 YEARS AGO. NUMBER TWO WE KNOW THEY ARE LIMITED IN WHAT GENE ENVIRONMENT DIRECTION, YOU'RE TAKING A SNIP, ENVIRONMENT REDUCED TO BINARY VALUE, LIMITED. WE HAVEN'T COME THAT FAR BUT 30 YEARS AGO WEREN'T DOING THAT EITHER. ALL I'M SAYING, I HAVE TOLERANCE FOR SLOW PACE OF PROGRESS AS WE AND SCIENCE FIGURE THIS OUT. AND THERE IS GENETIC CONTRIBUTION TO EVERYTHING ABOUT US. EVERYTHING ABOUT OUR HEALTH. NONE OF THIS EVER DIMINISHES THE IMPORTANCE OF GENES AND MOLECULES. IT SAYS WE NEED TO THINK ABOUT THAT WITHIN A FUEL SET OF OTHER FORCES. HOW TO COMBINE THAT IS A WHOLE SET OF QUESTIONS, WHOLE SET OF QUESTIONS ABOUT HOW WE CAN BRING THESE CONCEPTS INTO THE METHODS. I THINK I'VE GIVEN YOU ABSOLUTELY NO ANSWER, I APOLOGIZE. >> A FOLLOW-UP, TRYING TO THINK ABOUT EVEN -- WE'VE GOTTEN FAIRLY GOOD AT MEASURING GENES. I'M NOT SURE WE'RE VERY GOOD AT MEASURING ENVIRONMENT. >> NO, WE ARE ORDERS OF MAGNITUDE BETTER AT MEASURING GENES THAN ENVIRONMENT. ABSOLUTELY. >> THAT'S ONE OF THE THINGS THAT SORT OF CAN THE NURSING INSTITUTE AS WE GO FORWARD IN RESEARCH THINKING ABOUT LOOKING AT COMMUNITIES, WHAT IS IT WE WANT TO MEASURE, WHAT OUTCOMES ARE WE LOOKING FOR? AND THEN UNDERSTANDING SORT OF THE GENETIC VARIANT UNDER THAT PERHAPS BUT IT IS COMPLEX AS YOU LAID OUT IN YOUR TALK. >> ABSOLUTELY. GEORGE? >> YES, HI. THANK YOU. I HAVE A QUESTION, RESOURCES WHEN WE DO RESEARCH, HAVE INTERVENTIONS, OUR RESOURCES ARE LIMITED, LIMITS WHAT WE CAN DO, HOW FAR WE CAN CARRY OUR INTERVENTIONS OUT. AND HOW DO YOU SEE ARTIFICIAL INTELLIGENCE AND MACHINE LEARNING BEING USED FOR POPULATION HEALTH? >> YEAH, IT'S A GOOD QUESTION. I DON'T KNOW. YOU'RE ASKING ME QUESTIONS I DON'T KNOW, SHOWING LIMITS OF MY KNOWLEDGE, ABUNDANCE OF MY IGNORANCE. BECAUSE I THINK WE'RE AT THE BEGINNING OF ACTUALLY THINKING ABOUT THOSE METHODS. I THINK OUR TEAM HAS DONE A BUNCH OF THINGS WITH MACHINE LEARNING. I'M AS YET UNCONVINCEDITS ADDED VERY MUCH. I THINK OUR A.I. METHODS ARE MORE POTENTIAL, MORE BROADLY, IN TERMS OF GETTING AT MORE PRECISE UNDERSTANDING OF INTERACTION BETWEEN FORCES AND DETERMINATION OF RISK. THEY ARE EMERGING. I LIKE THE EVOLUTION. IT'S IMPORTANT TO PUSH THEM FORWARD AS LONG AS WE DON'T MAKE THE MISTAKE THINKING THE METHOD IS THE ANSWER. METHOD IS JUST A TOOL TO GET AT THE ANSWER. I THINK WE SHOULD PUSH FORWARD NEW METHODS, ABSOLUTELY. >> THANK YOU. >> I HOPE I'M NOT MISSING A HAND. APPARENTLY I'M BLIND TO THESE HANDS. SO, I HAVE RECENTLY BECOME MORE FAMILIAR WITH SOCIAL CARE, I'VE ALSO HEARD -- AND I KNOW SOME OUR SPEAKERS WHO JOINED US FOR THE ROUNDTABLE HAVE EXPERTISE AND EXPERIENCE IN THIS AREA. I'M JUST INTERESTED IN YOUR REACTIONS. SOME HAVE COMMENTED WE NEED TO BE CAREFUL. I'M WONDERING IF YOU HAVE ANY THOUGHTS, IF YOU, YOU KNOW, WHAT YOUR PERSPECTIVE IS ON SOCIAL CARE AND ITS PROMISE MOVING FORWARD. >> HMM. YEAH, IT'S A GREAT QUESTION. I THINK IN SO FAR AS SOCIAL CARE BROADENS OUR LENS BEYOND THINKING OF INDIVIDUALS AS PATIENTS WITH NARROW CURATIVE NEEDS, I THINK IT IS A STEP IN THE RIGHT DIRECTION. A STEP IN THE RIGHT DIRECTION THINKING MORE HOLISTICALLY ABOUT THE FULL RANGE OF DETERMINANTS THAT ULTIMATELY CREATE HEALTH IN POPULATIONS. I THINK BEYOND THAT, THE DEVIL BECOMES IN THE DETAILS ABOUT EXACTLY WHAT WE MEAN BY SOCIAL CARE AND WHAT THE SCOPING OF IT IS AND WHAT WE'RE ASKING OF IT TO DO. BUT FUNDAMENTALLY IN SO FAR AS IT'S REPRESENTING AN EFFORT TO THINK MORE BROADLY ABOUT THE DETERMINATION OF HEALTH I THINK IT'S A STEP IN THE RIGHT DIRECTION. >> GREAT. WOULD YOU TELL US A LITTLE BIT MORE ABOUT THE 3D COMMISSION YOU MENTIONED AT THE END OF YOUR TALK SO WE CAN LEARN MORE ABOUT THAT? >> YEAH, YOU CAN TAKE A LOOK. IT'S A GLOBAL COMMISSION THAT WAS PUT TOGETHER BY ROCKEFELLER FOUNDATION WHICH I HAVE THE PRIVILEGE OF CHAIRING, THE REPORT WILL BE COMING OUT TOWARDS THE END OF THIS YEAR ABOUT TRYING TO ETCH OUT THE STATE OF THIS KNOWLEDGE IN SOCIAL DETERMINANTS, AND HOW DATA SHOULD BE APPLIED TOWARDS MEASURING SOCIAL DETERMINANTS BETTER CHARACTERIZING HEALTH TO MAKE BETTER DECISIONS, REALLY AIMING TO CREATE A BIT OF A TEMPLATE FOR PEOPLE INTERESTED IN SOCIAL DETERMINANTS IN PARTICULAR AND HOW TO MEASURE THEM USING SORT OF WITH SOME KEY PRINCIPLES, USING STATE OF THE SCIENCE DATA. THAT'S WHAT WE'RE TRYING TO DO. >> ALL RIGHT. ANY OTHER QUESTIONS? I KNOW IT'S GETTING LATE IN THE DAY TOO. OH, GREAT, SOMEONE -- FOR FOLKS PUT IT IN THE CHAT, THANK YOU, MARCELLA. ANY OTHER COMMENTS? GREAT. SANDRO, I CAN'T THANK YOU ENOUGH FOR JOINING US TODAY. YOU KNOW, IT'S REALLY -- I LEARNED A LOT. I'M SURE EVERYONE ELSE DID AS WELL. YEAH, I SEE COMMENTS, PRIVATELY AND PUBLICLY, WONDERFUL PRESENTATION. SO THANK YOU. SO WE'RE GRATEFUL FOR THE THOUGHTS AND QUESTIONS PEOPLE SHARED AND AS WELL AS TO THOSE WHO JOINED ON VIDEOCAST, LOOKING FORWARD TO AN EXCITING AND THOUGHT-PROVOKING DAY TOMORROW TO MOVE THE NEED TOLL ADDRESS POPULATION HEALTH AND USE CLINICAL BIG DATA TO SCORE SOCIAL DETERMINANTS OF HEALTH AND HEALTH CARE. WE'LL SEE YOU TOMORROW AT 11 A.M. EASTERN, HAVE A GREAT EVENING, EVERYONE. THANK YOU SO MUCH, DR. GALEA.