>> GOOD AFTERNOON.
MY NAME IS DAVID MURRAY, I AM
THE ASSOCIATE DIRECTOR FOR
PREVENTION AT NIH AND THE
DIRECTOR OF THE OFFICE OF
DISEASE PREVENTION.
I'M PLEASED TO WELCOME YOU TO
THE 2024 ROBERT S. GORDON JR.
LECTURE IN EPIDEMIOLOGY.
THIS IS PART OF THE NIH
DIRECTOR'S WEDNESDAY AFTERNOON
LECTURE SERIES, WHICH IS I
GENERALLY DESCRIBE AS THE MOST
IMPORTANT LECTURE SERIESOT
CAMPUS.
THE GORDON LECTURE IS AWARDED
EACH YEAR TO A TESTIFY WHO MADE
HUGE CONTRIBUTIONS TO THE FIELD
OF RESEARCH OR TRAINING IN
EPIDEMIOLOGY OR IN THE CONDUCT
OF CLINICAL TRIALS.
THE SPEAKER SELECTION IS
COORDINATED BY THE OFFICE OF DEC
PREVENTION AND THIS IS THE
29th YEAR THAT ODP HAS
SPONSORED THE GORDON LECTURE.
THE LECTURE WAS ESTABLISHED IN
TRIBUTE ROBERT S. GORDON JR. FOR
HIS DEDICATION TO THE FIELD OF
EPIDEMIOLOGY AND HIS
DISTINGUISHED SERVICE TO NIH.
OVER THE COURSE OF 30 YEARS,
DR. GORDON SERVED IN NUMEROUS
SENIOR LEADERSHIP POSITIONS,
INCLUDING SPECIAL ASSISTANT TO
THE DIRECTOR, AND CHIEF ADVISOR
FOR CLINICAL PRACTICES AND
RESEARCH.
DR. GORDON WAS AN EARLY
ORGANIZER OF EFFORTS TO ADDRESS
THE EMERGING PROBLEM OF HIV/AIDS
AND IT BECAME A KEY COORDINATOR
OF AIDS RESEARCH AT NIH.
BEFORE WE GET STARTED, I HAVE A
FEW HOUSEKEEPING ITEMS.
THE CME CODE FOR TODAY IS 50125.
I WILL REPEAT THAT IN A MOMENT.
IF YOU HAVE QUESTIONS DURING
TODAY'S TALK AND YOU'RE WATCHING
ONLINE, PLEASE SUBMIT THEM VIA
THE VIDEOCAST WEBSITE.
YOU CAN DO SO BY CLICKINGOT WORD
SEND LIVE FEEDBACK.
THIS FEATURE IS JUST BELOW THE
VIDEO DISPLAY FOR THE LECTURE.
THOSE OF YOU WHO ARE IN THE ROOM
WITH US, WE WILL OPEN THE
MICROPHONES FOR QUESTIONS AT THE
END OF THE LECTURE AND ALL YOU
HAVE TO DO IS STEP UP TO 1 OF
THE 2 MICROPHONES AND WE'LL CALL
ON YOU.
WE'LL OPEN THE FLOOR TO
QUESTIONS AT THE END OF THE
LECTURE.
PLEASE FEEL FREE TO SUBMIT
QUESTIONS ANY TIME, YOU DON'T
HAVE TO WAIT UNTIL THE END.
A VIDEO RECORKING OF THIS
LECTURE WILL BE POSTED ON OUR
WEBSITE, PREVENTION.NIH.GOV IN
APPROXIMATELY 2 WEEKS, IT WILL
ALSO BE AVAILABLE ON THE NIH
VIDEOCAST WEBSITE.
AGAIN THE CME CODE FOR TODAY IS
50125.
TODAY'S SPEAKER IS DR. LEONARD
EDGDE, HE IS THE PROFESS
OVERLAPPING OF MILWAUKEE
COMMUNITY CHAIR OF HEALTH AND
RESEARCH AT THE MEDICAL COLLEGE
OF WISCONSIN, HE'S ALSO CHIEF OF
THE MEDICAL CENTER AND DIRECTOR
FOR CENTER FOR ADVANCING
POPULATION SCIENCE MUCH AS A
NATIONALLY RECOGNIZED HEALTH
DISPARITIES RESEARCH FOCUSES ON
DEVELOPING AND TESTING
INNOVATIVE INTERVENTIONS TO
REDUCE AND/OR ELIMINATE HELT
DISPARITIES RELATED TO RACE
ETHNICITY, SOCIOECONOMIC STATUS
AND GEOGRAPHIC LOCATION FOR
CHRONIC MEDICAL AND MENTAL
HEALTH CONDITIONS.
DR. CERTAINLY--CERTAINLY GEDE IS
THE WIN AREY OF 5 NIH CLINICAL
AWARDS, NOT MANY PEOPLE CAN SAY,
AND HE HAS PUBLISHED MORE THAN
450 MANUSCRIPTS AT THE PROVIDER
AND SYSTEM LEVEL INFLUENCE
OUTCOMES, HIS WORK ALSO EXAMINED
THE IMPACT OF SOCIAL RACISM,
SOCIAL DETERMINANTS OF HEALTH
AND SOCIAL RISK ON HEALTH
OUTCOMES, EFFECTIVE RESEARCH ON
TELEHEALTH AND TELEMEDICINE AS
DELIVERING CLINICAL CARE AND
IMPROVED UNDERSTANDING OF THE
ROLE OF BEHAVIORIAL ECONOMEC ON
HEALTH AND HEALTH OUTCOMES WITH
INDIVIDUALS WITH CHRONIC
DISEASE.
HADIS PRESENTATION IS TITLED
ADDRESSING HELT DISPARITY ANDS
DIABETES.
INTERSECTION OF STRUCTURAL
RACISM, SOCIAL DETERMINANTS AND
RACIAL ETHNIC DISPARITIES,
PLEASE JOIN ME IN WELCOMING THE
2024 ROBERT S. GORDON JR.
LECTURE RECIPIENT DR. LEONARD
EGEDE.
>> THANK YOU.
IT'S DEFINITELY AN HONOR TO BE
HERE AND REEVE THIS AWARD BUT
ALSO TO GIVE THIS PRESENTATION
AND I USUALLY LIKE TO START OFF
MY PRESENTATION BY GIVING
CONTEXT, SO I'M AN IMMIGRANT,
MOVED HERE IN 1995 TO THE UNITED
STATES AND I REALLY LOVE THIS
COUNTRY.
I HAVE HAD A LOT OF BENEFIT FROM
BEING HERE BUT ALSO JUST
WATCHING OVER THE YEARS, I'VE
SEEN A LOT OF GAPS IN WHAT WE
COULD BE AS A SOCIETY, SO I COME
FROM THIS PERSPECTIVE OF
[INDISCERNIBLE], SO IT'S NOT ALL
BAD, BUT THERE ARE THINGS WE CAN
DO TO GET BETTER.
THAT IS THE CONTEXT I HAVE TO
GIVE, I HAVE NO DISCLOSURES AND
REALLY THE GOAL OF THIS TALK IS
TO FOCUS ON SOME OF THE NATIONAL
DATA RELATED TO DISPARITIES IN
THE SCARE TO DEFINE HEALTH
DISPARITIES AND DISCLOSE THE
INTERSECTION OF STRUCTURAL
RACISM AND HEALTH AND HEALTH
DISPARITIES AND THEN DISCUSS
EMERGING INTERVENTIONS TO
DISCUSS DETERMINANTS AND REDUCE
DISPARITIES IN CLINICAL OUTCOMES
FOR DIABETES.
I HAVE STUDIED DIABETES MY WHOLE
CAREER, BUT I FOUND DIABETES TO
BE A VERY GOOD MARKER FOR A LOT
OF THE WORK THAT WE ACTUALLY DO
BECAUSE IT'S VERY PREVALENT.
BIOLODGE IIC MEASURES ARE EASY
TO TRACK BUT ALSO HAVE YOU A LOT
OF SOCIAL FACTORS THAT DRIVE THE
OUTCOME SO VERY GOOD FOR US TO
WORK IN THAT SPACE.
SO I WANT TO GO BRIEFLY OVER
DIABETES, THOSE ARE WHO ARE NOT
FAMILIAR WITH DIABETES, SO YOU
LOOK AT PREVALENCE, YOU KNOW
ALMOST 15% OF THE U.S.
POPULATION HAVE DIABETES.
IN THE AREAS, WE USED TO TALK
ABOUT UNDIAGNOSED DIABETES AND
THOSE NUMBERS ARE GETTING LESS
AND LESS AS WE DO BETTER WORK AT
TRACKING, BUT AGAIN, YOU HAVE
STILL ABOUT 33% OF INDIVIDUAL
WHO IS ARE UNDIAGNOSED, BUT WITH
WE LOOK AT DIABETES BY RACE, YOU
SEE THERE ARE DIFFERENCES BY
RACIAL GROUPS.
AND SO RACIAL AND ETHNICITY, IF
YOU LOOK AT WHITE, NONHISPANIC
IT'S ABOUT 14% AND YOU LOOK AT
BLACK NONHISPANIC ABOUT 17 AND
HALF%, ASIAN NONHISPANIC ALMOST
10%, AND HISPANIC BY 16%, SO YOU
SEE GAPS IN PREVALENCE OF
DISEASE BY RACE.
SO NOW I JUST WANT TO TALK ABOUT
WHAT IS HOW DISPARITIES AND SOME
LANGUAGE THAT'S REALLY IMPORTANT
TO GRIND US AND SO NOW MOST NOW
ARE FAMILIAR WITH THE RISK AS A
SOCIAL CONSTRUCT.
WHEN I WAS IN TRAINING WE TREAT
RACE AS BIOLOGY AND WE ALL
RECOGNIZE THAD THERE WAS A VERY
BIG DIFFERENCE SEEING IT AS A
SOCIAL CONSTRUCT AS SEEING IT AS
A BIOLOGICAL CONSTRUCT SO THESE
ARE VERY IMPORTANT FOR US TO LAY
THE FOUNDATION FOR THE TALK.
BUT THE OTHER THING THAT'S ALSO
IMPORTANT IS ETHNICITY, WE TALK
ABOUT RACE ETHNICITY AS IF THAT
MAKES IT BETTER, IF YOU LOOK AT
ETHNICITY, IF YOU LOOK AT
HISPANIC, IT INCLUDING
400 MILLION PEOPLE FROM MANY
DIFFERENT ETHNIC GROUPS IN MORE
THAN 20 DIFFERENT COUNTRY, SO IF
YOU ARE LUMPING PEOPLE TOGETHER,
WITH SOMEWHAT VARIABILITY, IT
REALLY BEGS THE QUESTION, WHAT
ARE YOU ACTUALLY MEASURING BUT
THIS IS THE BEST MEASURE WE HAVE
RIGHT NOW SO WE HAVE TO FIND
WAYS TO MAKE THIS WORK AND THIS
IS PART OF WHAT THIS
CONVERSATION, AND WHAT IS
CULTURE AND HOW DOES IT PLAY OUT
AND MANY THINGS WE'RE DRIEBING,
ARE ACTUALLY CONNECTED TO OUR
CULTURE AND CULTURE OF VALUES,
SO AGAIN, JUST SEPARATE THOSE
TERMS AS WE GO FORWARD.
THE NEXT THING IS, WHAT DO WE
MEAN BY DISPARITIES, DIFFERENCES
AND DISCRIMINATION, BECAUSE
EVERYBODY ASSUMES THE ONLY SAME
THING BUT WE'RE VERY DIFFERENT.
SO IF YOU LOOK AT THIS, THIS IS
A SLIDE THAT'S ACTUALLY VERY
HELPFUL IN HELPING UNDERSTAND
WHAT DOES IT REALLY MEAN, SO
WHEN YOU TAKE 2 GROUPS,
NONMINORITY AND MINORITY GROUP
AND THERE'S SOMETHING THAT'S
DIFFERENT, LET'S SAY PREVALENCE
OF DISEASE, ALL YOU CAN SAY AT
THAT POINT IS JUST A DIFFERENCE,
AND DIFFERENCES DO NOT REALLY
MEAN ANYTHING AND YOU BEGIN TO
DELVE INTO WHAT ARE THE
DIFFERENCES DUE TO.
SO WHEN THE DIFFERENCE IS DUE TO
CLINICALLY APPROPRIATENESS AND
PATIENT PREFERENCES, THEN,
THAT'S A DIFFERENCE AND IT'S
ACTUALLY NOT BAD BECAUSE NOT
GOOD, ONCE IT BECOMES TIED TO
THE OPERATIONAL HEALTHCARE
SYSTEM AND LEGAL AND REGULATORY
CLIMATE THEY START TO TALK ABOUT
DISPARITY AND WHEN YOU HAVE
DISCRIMINATION, BIAS AND
PREJUDICE TERIO TYPING
UNCERTAINTY THEN THAT IS
DISCRIMINATION.
SO DISCRIMINATION AND DISPARITY
ARE 1 CATEGORY, DIFFERENCES
EXPLAINS EVERYTHING.
SO WHENEVER YOU SEE A DIFFERENCE
BETWEEN DIFFERENT GROUPS, THE
FIRST QUESTION IS THIS DIFFERENT
DUE TO APPROPRIATENESS, IS IT
CLINICALLY APPROPRIATE FOR THAT
TO EXIST, IT THAT'S THE CASE,
THEN IT'S JUST DIFFERENCE, BUT
WHEN YOU DRILL DOWN TO BIASES
AND THINGS LIKE THAT, YOU START
TALKING ABOUT DISCRIMINATION,
IT'S REALLY IMPORTANT BECAUSE
MANY TIMES WE USE THE
TERMINOLOGY AS IF THEY'RE ALL
INTERCHANGEABLE AND WE ACTUALLY
THEN DO NOT CLARIFY WHAT WE MEAN
WITH SOME OF THESE TERMS.
SO NOW I WANT TO GO OVER--I
SHOWED YOU DETERMINE NABTS OF
HEALTH WHICH IS THE FIRST TIME
WE TARTED WORKING ON SOCIAL
DETERMINANTS WAS WITH MY Ph.D.
STUDENTS IN 2010 AND AT THAT
TIME WE WERE JUST ANY PHASE OF
SOCIAL DETERMINANTS, WE ACTUALLY
DIDN'T HAVE GOOD MEASURES AND
NOW WE HAVE ALL THESE GREAT
MEASURES SO WHAT
[INDISCERNIBLE].
THE W. H. O. DEFINES SOCIAL
DETERMINANTS AS THE CONDITIONS
WE ARE BORN, GROW, WALK AND AGE,
AND THESE CIRCUMSTANCES ARE
SHAPED BY THE DISTRIBUTION OF
MONEY, POWER AND RESOURCES AT A
GLOBAL, NATIONAL AND LOCAL
LEVELS.
SO I THINK BEING ABLE TO
UNDERSTAND THESE DIFFERENCES
ALLOW US TO CALL AND BE VERY
CLEAR WHAT WE MEAN WHEN WE SAY,
WHEN WE USE THE WORD SOCIAL
DETERMINE NABTS, PEOPLE SAY, I'M
MEASURING SOCIAL DETERMINANTS,
AND THEN MY QUESTION IS WHAT ARE
YOU MEASURING?
YOU NEED TO BE VERY CLEAR WHAT
YOU ARE MEASURING, SO THIS IS A
CLEAR FRAMEWORK FROM THE W. H.
O. TO DEFINE HOW WE THINK ABOUT
THE FRAMEWORK, THE CDC FRAMEWORK
BUT THIS IS THE FRAMEWORK WE USE
BECAUSE IT'S A VERY--IT'S A
GREAT ORGANIZING FRAMEWORK FOR
SOME OF THESE ISSUES, SO IF YOU
LOOK AT--IF YOU GO FROM MY RIGHT
TO YOUR LEFT, YOU GO PRACTICES
IMPACT AT AN INDIVIDUAL LEVEL,
YOU GO BACKWARDS, YOU SEE
MATERIALISTIC CIRCUMSTANCES,
BEHAVIORS, PSYCHOSOCIAL FACTORS,
YOU HAVE THE HEALTH SYSTEM, YOU
GO BACKWARDS YOU LOOK AT
ECONOMIC SPOGZ, SOCIAL CLASS,
EDUCATIONAL OCCUPATIONAL INCOME
AND THE--BUT GO EVEN FURTHER
BACK, YOU START SEEING THINGS,
GOVERNMENTS, MACROAND
MICROPOLICIES, SO WE SPEN A LOT
OF TIME AT THE INDIVIDUAL LEVEL
AND WE DON'T PAY ATTENTION TO
DEFINE THE ORGANIZATION FACTORS
THAT DRIVE THE DIFFERENCES.
SO THE MORE I'VE DONE THIS WORK
NOW, I FOUND A SPEND A LOT OF
TIME IN THE FIRST DECADE OF MY
CAREER JUST TO FOCUS ON THE
INDIVIDUAL LEVEL.
I REALIZE YOU DO ALL THESE
INTERVENTIONS AND THESE FACTORS
CAN YOU EXPLAIN, SO NOW I MOVE
BACKWARDS AND WE ASK OURSELVES
HOW DO YOU HAVE IMPACT AT THAT
NEXT LEVEL.
SO I'M JUST GOING TO SHOW WITH
YOU SOME OF THE WORK YOU'VE DONE
OVER TIME.
WE'VE HAD A VERY GOOD TEAM AND I
REALLY BELIEVE IN WORKING IN
TEAMS AND HAVE HAD MENTEES WHERE
THEY CONTRIBUTED ALL THIS WORK,
AND MANY OF THIS PRESENTING THE
Ph.D. WORK OR SOME OF MY
MENTEES, VERY EARLY ON IN THEIR
CAREER, SO THIS IS 1 STUDY WE
DID WHERE WE TOOK ABOUT 650
INDIVIDUALS WITH TYPE 2 DIABETES
AND WE DID A VERY DETAILED ARK
ASSESSESMENT OF SOCIAL
DETERMINANTS OF HEALTH FACTORS
OR IF WE BROUGHT THEM INTO
PSYCHOSOCIAL BUILT ENVIRONMENT
AND MULTIPLE ASPECTS AND I
REMEMBER THAT STUDY BECAUSE
DR. WALKER AND IT WAS 1 OF THE
INDIVIDUALS, RECRUITING PATIENTS
WITH THE UNIVERSITY FROM THE VA,
FROM THE COMMUNITY, AND THE
SURVEYS WERE REALLY LONG.
WE HAD 70 PAGES JUST TO CAPTURE
ALL THIS INFORMATION BUT WHAT WE
ALMS WANTED TO DO WAS GO BEYOND
REGULAR REGRESSION, YOU KNOW CAN
QUESTIONS USING A LITTLE BIT
MORE SOPHISTICATED APPROACH,
SHOWING STRUCTURAL MODELING
WHERE YOU COULD LOOK AT PATH,
WHAT IS THE PATHWAY FOR THIS AND
WHAT WE ACTUALLY FOUND VERY
QUICKLY IS THAT IN THIS CONCEPT
OF FRAMEWORK, YOU COULD SEE THE
DRIVERS OF GLYCEMIC CONTROL AND
HOW PROCESSES OF CARE ACCESS TO
CARE, AND SELF-CARE ACTUALLY
PLAY THE ROLE, BUT THEN THIS
FACTOR, THIS PSYCHOSOCIAL FACTOR
ACTUALLY HAD DIRECT EFFECT.
ASK SO THIS IS 1 OF THE STUDIES
THAT BEGAN OR RAISE THE REQUESTY
THAT SOCIAL FACTORS WERE
ACTUALLY IMPORTANT BECAUSE WHEN
I WAS TRAINING, I WAS TOLD IT
WAS ALL ABOUT BIOLOGY, YOU KNOW,
JUST TAKE YOUR MEDICATIONS AND
THINGS WILL GO WELL, WE BEGIN TO
SO NOW, IT'S MORE THAN JUST THE
MEDICATIONS, IT'S ENVIRONMENT,
ALL THESE OTHER FACTORS, HOW
DOES DEPRESSION PLAY A ROLE,
SOCIAL SUPPORT, SO WE BEGIN TO
DEMON TRAIT THAT THIS FACTORS
ACTUALLY ARE INDEPENDENT OF OUR
USUAL PATHWAYS AND THIS IS 1 OF
THE FITTER STUDIES THAT SHOWED
THAT.
--FIRST STUDIES THAT SHOWED
THAT.
ONE OF MY OTHER MENTEES D
R. DAWSON, WAS LOOKING AT
DISCROSS EXAMINEINATION, AT THAT
TIME WE KNOW THERE WAS
DISCRIMINATION, IT IMPACTS YOU
BUT HOW DOES IT DO IT.
WHAT IS THE MECHANISM IN THIS IS
WITH THE METHODOLOGY, WE
IDENTIFIED AND HYPOTHESIZED THAT
DISCRIMINATION WOULD IMPACT
STRESS AND THAT STRESS WOULD
IMPACT SELF-CARE AND YOUR
GLYCEMIC CONTROL AND THAT'S WHAT
WE FOUND IN THE STUDY BUT WHAT
WE ACTUALLY FOUND WAS THAT
SOCIAL SUPPORT BUFFERED THAT
RELATIONSHIP, SO THE PEOPLE HAD
GOOD STRONG SOCIAL SUPPORT
ACTUALLY DID BETTER AND THE
SOCIAL COHESION, NEIGHBORHOOD
COHESION ALSO MADE IT DIFFERENT.
SO TRESES WAS 1 OF THE PATHWAYS,
WAS STRESS ALSO HARD, WITH 2
PATHWAYS 1 THROUGH SELF-CARE AND
THE OTHER DIRECTLY ON GLYCEMIC
CONTROL.
SO AGAIN, RACING QUESTIONS ABOUT
HOW DO WE BEGIN TO FACTOR--HOW
DOES DISCRIMINATION LEAD TO POOR
OUTCOMES AND SOME OF THESE
PATHWAYS WE WILL ACTUALLY STUDY
AND THEN I HAD A STUDENT NOW
WHO'S IN MEDICAL SCHOOL NOW WHO
WAS LOOKING AT THIS AND THE NEXT
QUESTION WAS LET'S LOOK AT
MENTAL HEALTH AND AGAIN VERY
SIMILAR PATHWAY, AND WHAT WE
FOUND WAS THAT STRESS ACTUALLY
LED TO POOR MENTAL HEALTH, SO
NOT JUST POOR PHYSICAL HEALTH
BUT POOR MENTAL HEALTH BUT
SOCIAL SUPPORT, MITIGATED THAT
EFFECT AND ACTUALLY BUFFERED
SOME OF THAT EFFECT, SO AGAIN,
SHOWING THAT YOU IN PEOPLE WITH
DIABETES, SOME OF THESE FACTORS
ACTUALLY PLAYED A ROLE.
AND THEN NEXT, WE BEGUN TO LOOK
AT WAS LOOKING AT FOOD
INSECURITY ANSWERS SO DR. WALKER
IS AN ASSOCIATE PROFESSOR, HE
HAS AN RO-1 LOOKING AT SOME OF
THESE AREAS BUT AT THAT TIME,
SHE IS A DOCTORATE STUDENT AND
ASKED THE QUESTION HOW DOES FOOD
INSECURITY AFFECT DIABETES
CONTROL.
IN THAT ERA EVERYTHING WAS ABOUT
SELF-CARE AND WHAT THIS STUDY
ACTUALLY SHOWED WAS THAT FOOD
INSECURITY WAS ASSOCIATE WIDE
FATALISM, SUICIDE, DEPRESSION,
STREASES, AND HAD AN IPT GREATER
PACT ON A1C, AND SOME OF THOSE
WERE DIRECT PATHWAY ANDS OTHERS
WERE INDREK THROUGH SELF-CARE,
SO THIS WAS 1 OF THE FIRST
TODAYS TO DEMON TRAIT THE FOOD
INSECURITY HAD DIRECT CONTROL
THAT WAS INDEPENDENT OF
SELF-CARE AND AGAIN RAISING THE
QUESTION, WHAT DO WE ACTUALLY DO
IN AND THEN THE LAST STUDY,
TURNS OUT SON WAS DOING A SUMMER
PROGRAM WITH US SO HE PICKED UP
THIS PROGEC, IT WAS SOMETHING OF
INTEREST TO HIM, NEIGHBORHOOD
FACTORS AND THE QUESTION WAS HOW
DO NEIGHBORHOOD FACTORS REALLY
IMPACT GLYCEMIC CONTROL IN
INDIVIDUALS WITH DIABETES.
AS YOU CAN SEE, WE HYPOTHESIZED
AT THAT TIME THAT VIOLENCE,
DISCRIMINATION AND CRIME IN THE
NEIGHBORHOOD WOULD LEAD TO
STRESS AND STRESS WAS AFFECT THE
SELF-EFFICACY, [INDISCERNIBLE]
SELF-MANAGEMENT AND GLYCEMIC
CONTROL AND ALL THOSE PATHWAYS
ARE ACTUALLY VALIDATED.
SO YOU CAN SEE, WE HAVE VIOLENCE
IN THE COMMUNITY, STRESS LEVELS
ARE VERY HIGH, DISCRIMINATION
LEVELS ARE VERY HIGH, CRIME,
TRESES IS HIGH, STRESS LEAVES TO
POOR SELF-EFFICACY AND POOR
SELF-CARE AND POOR SELF-CARE TO
GLYCEMIC CONTROL BUT THEN HAVE
YOU ALL OF THIS INDIRECT
PATHWAYS FROM CRIME TO
SELF-EFFICACY, SO AGAIN, RAISING
THE IDEA THAT WE NEED TO START
THINKING ABOUT NEIGHBORHOODS AND
THE NEIGHBORHOODS ACTUALLY
MATTER AND IF WE WANT TO GET
GOOD CONTROL, WE NEED TO PAY
ATTENTION TO WHAT THOSE THINGS
ARE.
SO WE DID ALL THIS STUDIES VERY
EARLY ON FOR THE FIRST COUPLE OF
YEARS, AND THEN WE REALIZE, WELL
YOU, NOW WE HAVE THESE PATHWAYS,
WHAT DO WEB CONNECTED DO, HOW DO
YOU ADDRESS THIS ISSUE, SO THIS
COINCIDED ABOUT THE TIME ALL
THIS WORK WAS DONE WHEN I WAS IN
CHARLESTON, THE MEDICAL
UNIVERSITY OF SOUTH CAROLINA ASK
WE MOVED TO MILWAUKEE AND WE'RE
FACE WIDE A PROBLEM, ALL THE
TIME WE'RE IN SOUTH CAROLINA,
MOST OF THE WORK WAS ABOUT RURAL
MINORITIES AND THEN WE CAME TO
MILWAUKEE AND IT WAS ABOUT OTHER
CHALLENGES.
SO WE SPENT THE FIRST 2 YEARS
DOING A LOT OF DEEP WORK IN THE
COMMUNITY, WE DID ABOUT 350
FOCUS GROUPS, WE STICK WITH THE
INTERVIEWS, WE'RE ASKING
QUESTIONS ABOUT AND THE GOAL WAS
TO ASK THE QUESTION, GIVEN WHAT
WE KNOW, WHAT TYPES OF
INTERVENTIONS WOULD ACTUALLY
WORK IN THIS ENVIRONMENT, I SAID
THE VERY FIRST STUDY GOT FUNDED
CAME OUT OF CONVERSATIONS WITH
COMMUNITY MEMBERS AND WE'RE
ASKING A QUESTION, WE ACTUALLY
AT THE SENIOR CENTER AND THE
WOMEN SAID, YOU KNOW OUR REAL
PROBLEM IS SOCIAL ISOLATION AND
WE DON'T HAVE, YOU
KNOW--WOULDN'T IT BE NICE IF
SOMEONE COULD COME FROM YOUR
TEAM AND EDUCATE US ABOUT
DIABETES SO WE DON'T HAVE TO
COME TO THE HOSPITAL AND THEN WE
COULD GET A TEAM TOGETHER AND
THAT WOULD REALLY ALLOW US TO
HIT THE COMMUNITY.
SO WE KIND OF THOUGHT IT
THROUGH, DID THE STUDY, WROTE
THE GRAND TO NIDDK AND GOT IT
FUNDED AND THIS STUDY IS JUST
FINISHING UP NOW, WE RANDOMIZED
ABOUT 2 HELPED INDIVIDUALS,
ORIGINALLY THE PLAN WAS TO
RANDOMIZE A DISCIPLINARY SIGN,
AND TAKING 30 SENIOR CENTERS AND
RANDOMIZING PEOPLE BY TRUSTEESS
BUT WHEN THE PANDEMIC HIT WE HAD
TO CONVERT THIS TO ONE-ON-ONE
INTERVENTIONS AND CHANGES, SO
WE'RE AT THE POINT WHERE WE'RE
DOING THE INITIAL ANALYSIS TO
SEE--THE IDEA WAS IF WE COULD
TAKE PEOPLE AND PROVIDE THEM
WITH NOT JUST DIABETES
EDUCATION, BUT SOCIAL NEEDS, YOU
KNOW, HOUSING, TRANSPORTATION,
AND ASSESSING WHAT COULD WE DO
TO HELP YOU, THE GOAL OF THIS
WAS NOT TO FIX THE SOCIAL NEEDS,
IT WAS TO HELP THEM FIND
RESOURCES, WHAT'S OUT IN THE
COMMUNITY, WHAT BEING YOU
ACTUALLY DO AND DOING THAT
TOGETHER WITH DIABETES
MEDICATION TO SEE IF IT HAD AN
IMPACT ON CLINICAL OUTCOMES.
AND WE USE SOMETHING CALLED
BEHAVIOR ACTIVATION WHICH IS A
PSYCHOSOCIAL APPROACH THAT
ALLOWS YOU TO INCREASE ACTIVITY,
REALLY HELP PEOPLE VIEW
RESILIENCE AS A WAY TO USE HAD
AS AN ISHT VENTION AND THIS
PEPPING SOME RESULTS NOW.
THE NEXT 1 THAT CAME ABOUT WAS
WE WERE DOING SOME OF THIS
AGAIN, WE WENT TO THE FOOD
PANTRY AND HAVING THIS
CONVERSATION ABOUT HOW DO YOU
DEAL WITH FOOD, AND THE PEOPLE
SAID, WELL, YOU KNOW, PEOPLE
COME IN AND ASK US TO GO TO YOU
KNOW FARMER'S MARKET, PEOPLE
LIKE US DON'T ANY TO FARMER'S
MARKET, IT DOESN'T REALLY WORK
FOR US EMPLOY WELL WHAT WOULD
WORK FOR YOU EMPLOY WOULDN'T IT
BE NICE IF SOMEONE COULD DELIVER
STOP CONTROLLER OF BANKS, AND
SOMEONE SAID STOP CONTROLLER OF
BANKS MAY NOT BE ENOUGH, WHAT
ABOUT VOUCHERS.
AND SOMEONE SAID WHAT IF YOU DID
BOTH, CAN YOU DO BOTH?
I SAID WE CAN DO ANYTHING YOU
WANT US TO DO, JUST TELL US WHAT
YOU THINK WILL WORK, WE WILL
FEBRUARY OUT THE SCIENCE.
SO WE SAT DOWN AND CAME DOWN
WITH THE 2 BY 2 DESIGN WHERE WE
QUOM PAIRED 1 GROUP GOT
DIABETES, EVERYBODY GOT DIABETES
MEDICATION, THE 1 GROUP GOT THE
BOXES MAILED TO THEM, THE THIRD
GROUP GOT VOUCHERS AND THE
FOURTH GROUP GOT BOTH, ABOUT
HALF OF EACH.
AND WE ACTUALLY DID THIS AND WE
RANDOMIZED PEOPLE AND WE
PARTNERED WITH THE HUNGER TASK
FORCE TO PROVIDE THE STOCK BOXES
SO WE DIDN'T HAVE TO PAY FOR
THEM BECAUSE THIS IS SOMETHING
THAT THE GOVERNMENT PROVIDES AS
PART OF USDA SUPPORT FOR FOOD.
AND WE RANDOMIZE THIS
INDIVIDUALS AND THE FIRST THING
WE REALIZE, HALFWAY INTO THE
STUDY WAS THE PEOPLE, COMMUNITY
MEMBERS BEGAN TO SAY, YOU KNOW,
THESE BOXES ARE TOO HEAVY, IT'S
NOT CONVENIENT, AND I DON'T
REALLY LIKE WHAT'S IN THE BOX.
BECAUSE 1 OF THE THINGS I
BELIEVE IN BEFORE I ASK PEOPLE
TO DO SOMETHING, I WANT TO MAKE
SURE I'M COMFORTABLE, SO I TOOK
THE TOCK BOX HOME AT THE VERY
BEGINNING OF THE STUDY AND I
TRIED TO EAT WHAT WAS IN THE BOX
AND NO 1 IN MY HOUSE WOULD EAT
IT.
[LAUGHTER]
THE CEREAL WASN'T REALLY GOOD,
THE CHEESE WASN'T--THEN I
REALIZED WHAT WAS GOING IN THE
BOXES WAS REALLY NOT IERK DEAL
SO THEN I SAID DO PEOPLE, WE
WILL FINISH THIS STUDY AND LEARN
FROM THIS FEEDBACK AND
INCORPORATE IT INTO THE NEXT
STUDIES THAT WE DID EMPLOY SO
THIS IS FINISHING UP AND
[INDISCERNIBLE] IS ADA GRANT, WE
USED THAT TO DO AN INTERVENTION
WHERE SHE'S TESTING DIFFERENT
APPROACH, SO WE NOW HAVE A
BETTER SENSE THAT THIS BOX
DOESN'T WORK AND PEOPLE TELLING
US WHAT WE WANT BECAUSE I DON'T
WANT THE STIGMA OF SHOWING UP
WITH A VOUCHER, WHY CAN'T I GET
A CARD AND NOBODY CAN TELL
WHAT'S IN IT SO WE'RE FOURTH
APPEARANCE GIVING PEOPLE CARDS
AND SO NOW THEY GO TO THE
GROCERY TORE AND SHOP WITHOUT
HAVING TO FEEL LIKE EVERYBODY
KNOWS THAT YOU ARE FOOD INSECURE
OR GETTING A WIC CARD OR THINGS
LIKE THAT.
SO THIS STUDY IS NOW, JUST
FINISHED UP IN THAT ANALYSIS SO
THIS IS ALL WRAPPING UP YOU KNOW
5 YEAR STUDIES THAT ARE JUST
WRAPPING UP, THE FED STUDY WAS
INTERESTING BECAUSE THIS
WAS--WITH WHEN WE WERE IN CHARLS
TON, WE WERE TRYING TO FIGURE
OUT HOW TO MOTIVATE PEOPLE TO
GET BEHAVIOR CHANGE.
AND WE HAD DONE A COUPLE OF
STUDIES, IS AS YOU REALIZE WHEN
YOU LEARN MORE FROM FIELD
STUDIES, DIFFERENT STUDIES THAT
SUCCEED, SO THEN WE COME UP TO
RO-1S AND WE GOT RESULTS THAT
WERE NOT INCONCLUSIVE ABOUT
EDUCATION AND SO, IN DISCUSSING,
I SAID, YOU KNOW, THAT WAS ABOUT
THE TIME WHEN BEHAVIORIAL
ECONOMICS WAS COMING UP, SO I
SAID LET'S DO PILOTS TOEE IF
GIVING PEOPLE FINANCIAL
INCENTIVES CAN MAKE A DIFFERENCE
WE DID A PILOT AND IT DROPPED
ALMOST 3%.
AND IRB THOUGHT HOW AND
EEIVETTUALRY TRANSITION TO
MOTIVATION SO WE RAPPED ORDER OF
MICRONSIZE PEOPLE TO THIS
DESIGN, AND I WANTED TO TEST, WE
HAD ALREADY TESTED THE HOME
MONITORING INTERVENTION AND THE
GOAL WAS TO LAYER THIS INCENTIVE
ON TOP OF THE HOME INTERVENTION,
SO PLUS STRUCTURAL INCENTIVE AND
AS WAY QUESTION WAS STRATIFIED
BY RISK BECAUSE THE QUESTION WAS
IT APPEARS FINANCIAL INCENTIVES
MAY ACTUALLY FUNCTION
DIFFERENTLY BY RACIAL GROUP AND
WE DIDN'T HAVE THAT INFORMATION
SO WE STRATIFIED BY RACE AND SO
WE HAD WHITE, BLACK AND
HISPANIC, THE OTHER THING WE
SAID IS WHAT WOULD HAPPEN IF WE
STUDY INTERVENTION, DO WE REALLY
HAVE PEOPLE CONVERTING FROM
INTRINSIC TO EXTRINSIC SO WE
FOLLOWED THEM FOR 6 MONTHS, SO
THAT STUDY IS PROBABLY THE LONG
OAST RANDOMIZED PROGRAM AND
LARGEST WE'VE DONE TO DATE AND
WE JUST FINISHED THE 18 MONTH
PHASE RIGHT NOW AND SOME OF THE
STUDIES SUGGEST THAT THE
INCENTIVES ACTUALLY WORK AND TRY
TO SEE WHAT ARE THE RISKS
ASSOCIATED RESPOND DIFFERENTLY
TO INCENTIVES IN EMERGING ITS OF
HOW THIS IS ACTUALLY DONE.
SO THIS IS SPENDING RESULTS
RIGHT NOW, BUT WE'RE ALMOST
READY TO DO ANALYSIS.
AND THEN, OR AT THE END WHEN WE
FINISHING THIS, GEORGE FLOYD,
THE DEATH OF GEORGE FLOYD, THE
CONVERSATION ABOUT THIS AND WE
GET TO THE POINT WHERE WE SAID
THIS LEVEL OF INTERVENTIONS ARE
NOT ADDRESSING THIS UPSTREAM
FACTORS, AND SO, WE ACTUALLY
BEGUN TO LOOK AT THIS W. H. O.
FRAMEWORK AND WE SAID OKAY,
THERE'S THIS WHOLE SOCIALIO
ECONOMIC AND POLITICAL CONTEXT
THAT IS TYPICALLY NOT TALKED
ABOUT.
HOW DO WE ADDRESS THIS?
AND SO I WANT TO WALK YOU
THROUGH THE CONCEPT OF
STRUCTURAL RACISM, STRUCTURAL
INEQUALITIES AND SOME OF THE
WORK WE'VE DONE THERE AND WHAT
WE'VE ACTUALLY FOUND IN OUR
RESEARCH.
SO THESE ARE 2 DEFINITIONS THAT
MOST PEOPLE WIDELY ACCEPTED
RIGHT NOW IN TERMS OF DEFINITION
STRUCTURAL RACISM, 1 IS TO TURN
IT TO WAYS IN WHICH SOCIETIES
FOSTER DISCRIMINATION THROUGH
MUTUAL REINFORCING EQUITY
SYSTEMS THAT IN TURN ENFORCE
DISCRIMINATORY PLEEFS AND
RESOURCES AND THE SECOND IS
ORGANIZE SYSTEMS THAT CAUSE
AVOIDABLE AND UNFAIR
INEQUALITIES IN POWER,
RESOURCES, CAPACITIES AND
OPPORTUNITIES ACROSS RACIAL OR
ETHNIC GROUPS.
NOW, WE USE STRUCTURAL
INEQUALITIES AS THE OVERALL
FRAMEWORK, AND THE INEQUALITIES
ARE ARE TIED TIED--ARE TIED TOE
AND STRUCTURAL RACE.
BUT THERE ARE 2 CONCEPTS, THIS
IS FROM THE WORK OF RICHARD
ROSTIN, THE THIS IS NOT
OFFICIALLY SAIRCHGZED, THE
RESULT OF PRIVATE PREVENTIVE
FERENCE OR INDIVIDUAL CHOICE,
NOT A RESULT OF LAW OR
GOVERNMENT POLICY, WHEREAS THE
YOURY IS SANKED BY A LAW OF
PUBLIC POLICY, PRIVATE-PREJUDICE
[INDISCERNIBLE] AND IT'S NOT
REINFORCED THROUGH JUDICIAL
DECISIONS [INDISCERNIBLE] SO
THIS IS THE CONCEPT OF YOU CALL
IT TRUCTURE, THESE ARE THINGS
THAT ARE EMBEDDED IN OUR SOCIETY
IN SYSTEMS AND THE SYSTEMS HAVE
THE WAY OF ACTUALLY PERPETRATING
THEMSELVES.
SO WHEN PEOPLE SAY, WELL, LET
THE PAST BE THE PAST.
IT'S REALLY NOT TRUE BECAUSE THE
PAST INFLUENCES THE PRESENT.
IF YOU UNDERSTAND LAW, THAT ALL
THESE DECISIONS ARE BASED ON
PROUD DECISIONS, SO IF YOU DON'T
INVEST IN THESE DECISIONS, THEN
YOU WILL CONTINUE FORWARD THE
INYESTERDAYS.
SO HERE ARE EXAMPLES OF SOCIAL
INJUSTICES, HOUSING AND
RESIDENTIAL SEGREGATION, AND
EDUCATION, RICH SYSTEMS ARE
BETTER THAN POOR NEIGHBORHOODS,
OR VALUES, WHERE PEOPLE WERE
KILLED OR POLICE KILLINGS HAPPEN
AND WHEN NOTHING IS ACTUALLY
DONE AS PART OF TRYING TO BRING
ABOUT CHANGE, MASS INCARCERATION
THIS, IS GETTING BETTER NOW BUT
WE HAD A TIME WHEN ABOUT 37% OF
AFRICAN-AMERICAN MEN WITHOUT A
HIGH SCHOOL DIPLOMA WERE
INCARCERATED.
THEN THE JUDICIAL SYSTEM,
DEPENDING HOW RICH OR WEALTHY
YOU ARE, YOU CAN EXPUNGE YOUR
RECORDINGS IF YOU ARE NOT THAT
WEALTHY, YOU CAN'T.
BUT ALSO IN TERMS OF
DIFFERENTIAL RACE, AND THEN ALSO
ACCUMULATION OF WEALTH, WHEN YOU
HAVE GENERATIONS WHO OWN HOMES
YOU CREATE A WEALTH GAP THAT IS
PRESENT TO THIS DAY, IF YOU LOOK
AT SOCIETY TODAY ABOUT 85% OF
THE WEALTH, IS IN WHITE HOUSE
HOLDS AND ABOUT 4.2% IN AFRICAN
AMERICAN HOUSEHOLDS AND 3% IN
LATIN O OR HISPANIC HOUSEHOLDS
SO YOU SEE DIFFERENTIAL WEALTH
AND WEALTH IS VERY DIFFERENT
FROM INCOME BECAUSE INCOME IS
ESSENTIAL TO WHAT YOU MAKE NOW
EMPLOY WEGHT IS CUMULATIVE AND
IT IS WHAT IS IN YOUR FAMILY AND
WHAT YOU HAVE OVER TIME.
SO NOW I WANT TO SWITCH GEARS
AND TALK ABOUT SOME OF OUR WORK.
SO WHEN WE GOT ON THIS PATH, WE
SAID OKAY, WHAT DO WE DO TO
CREATE MEANINGFUL RESEARCH THAT
WOULD HELP US UNDERSTAND ISSUES,
BUT ALSO THAT WILL ACTUALLY GET
PEOPLE, ISHT VENTION JUST AS WE
DID WITH SOCIAL DETERMINANTS, WE
DID THE INSHALL PATHWAYS AND WE
SAID HERE ARE THE TARGETS SO
HERE WE ARE DOING WORK NOW, THE
VERY FIRST STUDY WE DID WAS
PUBLISHED IN DIABETES IN 2022
WITH MY--3 OF MENTEES AND THE
IDEA WAS TO LOOK AT RED LINING
AND PRESENTING DIABETES
MORTALITY IN YEARS OF LIFE LOST.
WHAT WAS FASCINATING ABOUT THIS
IS THAT MANY PEOPLE MAY NOT BE
FAMILIAR WITH, BUT RED LINING IS
THE PREVIOUS LEGAL PRACTICE OF
SYSTEMATICALLY DENYING CREDIT
ACCESS TO THOSE IN CERTAIN
NEIGHBORHOODS.
IT WAS LATER PROHIB THORS
EDUCATIONALLED BY THE FEDERAL
HOUSING IN 1968, IT'S ILLEGAL
TODAY, SO WHAT DID THE RED
LINING DID, THEY HAD WHAT
HOMEOWNERS LONE CORPORATION AND
THEY GRADED NEIGHBORHOODS BASED
ON WHAT THEY THOUGHT ABOUT
VIABILITY, SO A WAS CONSIDERED
BEST, COLORED GREEN.
B, WAS STILL DESIRABLE, COLORED
BLUE, C, WAS DECLINING COLORED
YELLOW AND DWAS HAZARDOUS, IT
WAS COLORED RED.
IF YOU WERE RED, YOU DIDN'T GET
RESOURCES, YOU COULDN'T BUILD,
BUY, INVEST IN THOSE
NEIGHBORHOODS.
SO, THIS IS THE CONCEPT OF RED
LINING, AND SO, CITIES THAT HAVE
THOSE RED LINING MAPS, ACTUALLY
SEE THAT MOST OF THE
MARGINALIZED NEIGHBORHOODS ARE
IN THOSE RED ZONES TODAY, NOW
THERE'S OVERLAP BUT TILL ABOUT
THE SAME.
SO WHAT WE WANTED TO DO WAS ASK
THE QUESTION, WAS THE
RELATIONSHIP BETWEEN RED LINING
AND [INDISCERNIBLE] MORTALITY
AND YEARS OF LIFE LOST FOR
PEOPLE WITH DIABETES AND WE USE
MULTIPLE DATA SETS AND 1 OF THE
THINGS BECAUSE OF MY BACKGROUND
IN TRAINING HEALTH SERVICES, WE
WERE ABLE TO WORK WITH NATIONAL
DATA, LIKE DATA, SMALL DATA,
THIS WAS DATA FROM--AT THE TIME
WHEN WE DID THIS WORK, THERE WAS
ONLY 1 COUNTY IN WASHINGTON THAT
HAD ENOUGH DATA TO ALLOW US TO
DO THIS ANALYSIS AND THAT WAS
FROM SEATTLE.
SOPHISTICATEDY WE TOOK THE HOT
MAP FROM THE CITY OF SEATTLE AND
WE USED INFORMATION FROM THE
CENSUS BURRO AND WE CAME UP WITH
109 CENSUS TRACKS AND FOLLOW
OUTCOMES.
WE WANTED TO FOLLOW THEM FROM
1990 TO 2014.
SO THIS IS WHAT WE FOUND.
SOT THE FIRST PANEL IS 1990, THE
SECOND PANEL IS 2014, THE TOP IS
DEATH AND THE OTHER IS YEARS OF
LIFE LOST.
AND WHAT YOU SEE IT'S ALMOST A
LINEAR RELATIONSHIP BETWEEN
[INDISCERNIBLE] GREEN, SO 1 IS
GREEN AND 4 IS [INDISCERNIBLE].
BUT WHAT WAS MORE CONCERNING FOR
US WAS NOT JUST THE FACT WE
ARE--WE KNEW THIS IS WHAT WE
WERE GOING TO FIND IN EMERGING
ITS OF THIS SPECIFICATION, IT
WAS PERSISTENCE, SO YOU LOOK AT
1990 AND 2014, THE EFFECTS ARE
STILL VERY SIMILAR, WHAT THIS IS
SAYING IS THAT WHAT ALL OF THOSE
CENTER FOR EXCELLENCE ON AGINGS
THAT WE HAD IN 1960S ARE STILL
CARRYING FORWARD TODAY AND WE'RE
HAVING SOME OF THOSE EEIVETS SO
AGAIN, THIS IS SOMETHING THAT
REALLY GOT US THINKING ABOUT,
OKAY, NOW, IF THIS IS TRUE, THEN
WHAT ELSE DO WE NEED TO ACTUALLY
PAY ATTENTION TO.
SO THE NEXT STUDY WE DID, WAS A
STUDY WHERE WE WERE TRYING TO
UNDERSTAND WHAT'S BEEN DONE IN
THE LITERATURE AND SO WE DID THE
SCOPING REVIEW, LOOKING AT
STRUCTURAL RACISM AS AN UPSTREAM
SOCIAL DETERMINANT OF HEALTH AND
I'M NOT GOING TO GO INTO THIS,
THIS IS THE ABSTRACT BOOK, WHAT
WE WANTED TO ACTUALLY DO WAS TO
ACTUALLY TAKE THE LITERATURE
USING THE W. H. O. MODEL AND ASK
THE QUESTION, THOSE UPTREME
FACTORS WHAT'S BEEN DONE IN THE
LITERATURE, HOW MANY STUDIES, SO
WE DID RESEARCH OF MED LINE, AND
WE ACTUALLY LOOKED AT ALL
ARTICLES PUBLISHED FROM THE
BEGINNING OF THE DATABASE TO
JULY OF 2022, AND WE USE THIS
FRAMEWORK, THE W. H. O.
FRAMEWORK THAT CLASSIFIES
STUDIES AND THEN WE HAVE--WE
FOUND A TOTAL FOR THE STUDIES
THAT WE ACTUALLY IDENTIFIED AND
AND THAT WE REALLY NAARE O DOWN
TO 54, WE HAD THAT INFORMATION
AND ULTIMATELY WE'RE DOWN TO 10
STUDIES TO ACTUALLY HAVE ANY
KIND OF MEASURABLE RELATIONSHIP.
AND WHAT CAN WE FIND, 1 POSITIVE
WORK IN THAT SPACE BUT 2 FOR
THOSE STUDIES THAT ACTUALLY HAD
DATA THERE WAS A VERY STRONG
RELATIONSHIP BETWEEN STRUCTURAL
RACISM, AND POOR DIABETES
OUTCOMES AND MORTALITY, SO,
AGAIN, SUGGESTING THAT THERE WAS
SOMETHING GOING ON, SO, IT WAS
POOR CLINICAL OUTCOMES, MORE
[INDISCERNIBLE] BEHAVIORS, LOWER
STANDARDS OF CARE, HIGHER
MORTALITY AND MORE YEARS OF LIFE
LOST.
BUT THE MAIN ISSUE TO DATE IS
THERE ARE NO PATHWAYS.
WE CAN'T CREATE INTERVENTIONS
WITHOUT UNDERSTANDING THE
MECHANISM AND THE PATHWAYS, AND
SO WE THEN STARTED AND THIS WAS
2023, WE SAT DOWN AND WE SAID
HOW DO WE ANSWER THIS QUESTION?
AT THIS LEVEL, YOU NEED DATA,
NOT AT THE INDIVIDUAL LEVEL,
MORE ABOUT CENSUS TRACK, SO WE
DECIDED TO DO THIS LAST STUDY
THAT JUST GOT PUBLISHED THIS
YEAR, AND LOOKING AT HISTORIC
LIKE IMPACT OF STRUCTURAL RACISM
AND DIABETES, PREVALENCE OR
NATIONAL [INDISCERNIBLE] OF U.S.
ADULTS.
SO WHAT DID WE DO?
WE USE RED LINE AS A SURROGATE
AND RED LINING IS NOT STRUCTURAL
RACISM, IT'S AN EXPRESSION OF
STRUCTURAL RACISM.
SO IT'S NOT--IT'S 1 OF THE
MEASURES WE HAVE, IT'S NOT THE
BEST MEASURE BUT IT GIVES US
SOME SENSE OF WHAT'S GOING ON,
AND I WANTED TO INVESTIGATE THE
DIRECT OR INDIRECT RELATIONSHIPS
BETWEEN RED LINING AND
PREVALENCE OF DIABETES.
FOR THOSE OF COURSE WE DO
INTERVENTIONS, WE'RE NOT
SATISFIED WITH FINDING RESULTS,
WE WANT TO FIND THE PLANETARY
MODELS, HOW DO WE FIX THIS, SO
WE'RE CONDITIONALLINGA THE THIS
WITH THE MIND SET OF WHAT
UNMUTABLE FACTORS, WHAT ARE
POLICIES THAT COULD ACTUALLY BE
CHANGED AND WHAT WOULD THAT LOOK
LIKE?
SO WE TOOK DATA FROM VERY
SIMILAR TO WHAT WE DID, CDC
PLACES DATA FOR PREVALENCE,
[INDISCERNIBLE] MAPPING
INEQUALITY PROJECT AND THEN WE
ACTUALLY USED A REALLY NICE WORK
THAT HAS BEEN PUT TOGETHER
LOOKING AT CONCEPTUAL FRAMEWORK
AND WE HAVE DONE THAT WORK IN
EMERGING ITS OF CONCEPTUAL
FRAMEWORK AND THEN ADJUSTED FOR
THE CENSUS POPULATION BASED ON
CENSUS DATA.
SO WE'RE AT ABOUT ALMOST 9600
TRACKS ACROSS THE UNITED STATES
AND WE USE THIS WHOLE
METHODOLOGY FOR USING WHOLE
GRADE BECAUSE WHEN YOU HAVE
OVERLAP, OF HISTORIC GRADE
VERSUS NEW DATA, WE ACTUALLY
SIGN AGGREGATE SCORE, SO IF YOU
ARE 1 PLUS 2, WE TAKE EVERY DAY,
BECAUSE 1 PBT 5 SO THAT ALLOWS
US TO ACCOUNT FOR OVERLAP, YOU
KNOW IF YOU ARE RED, BEFORE NOW,
YOU ARE KIND OF GREEN, WHAT DOES
THAT REALLY MEAN AND WE'RE ABLE
TO DO THAT CONFIDENT.
AND WE USEDDED MODELING AS A
METHODOLOGY FOR DOING THIS, BUT
I WANT TO TALK TO YOU ABOUT HOW
WE GOT TO THE FRAMEWORK, SO WHEN
WE'RE IN WISCONSIN, I GOT SOME
FUNDING FROM ADVANCED HELGTD
CARE WISCONSIN FOUNDATION AND
THEY GAVE US ALMOST $3 MILLION
TO LOOK AT DATA IN THE INNER
CITY OF MILWAUKEE, 10 ZIP CODES
SO WE DID A DEEP DIVE INTO THE
ZIP CODES, WE DID 30 FOCUS
GROUPS, 60 INTERVIEWS,
INTERVIEWED ABOUT 50 COMMUNITY
MEMBERS AND LEADERS AND DID A
BREW OF INDIVIDUALS, VERY DEEP
STUDY OF CLINICAL RISKS AND
OUTCOMES ACROSS THE BOARD AND
WHEN WE GOT DONE, IT WAS A MIXED
METHOD, WE WERE TRYING TO
UNDERSTAND WHAT DRIVES THESE
DIFFERENCES FROM THE COMMUNITY
PERSPECTIVE, PLUS WHAT WE HAVE
ACTUALLY FOUND AND THIS IS A
PAPER WE PUBLISHED ABOUT THE
CONCEPTUAL FRAMEWORK AND WE
ACTUAL LYE ARGUED THAT
STRUCTURAL RACISM EXPRESSED AS
RED LINING LED TO
DISCRIMINATION, HIGH
INCARCERATION RATE, POVERTY,
RESIDENTIAL SEGREGATION, HOUSING
INSTABILITY, FOOD INSECURITY,
LOWER EICATIONAL ACTIVITY
APPROXIMATE UNEMPLOYMENT AND
THIS LED TO POOR HEALTH AND THIS
ABILITY AND WE INTRODUCED THE
CONCEPT OF HUMAN CAPITAL,
BECAUSE SICK PEOPLE DO NOT
CONTRIBUTE TO SOCIETY.
SO YOU ACTUALLY HAVE A
[INDISCERNIBLE] WHEN PEOPLE ARE
SICK AND WHEN PEOPLE ARE NOT
DOING VERY WELL, SO WE PUBLISHED
THIS IN 2021 AS A FRAME WOR WORK
FOR HOW TO ADDRESS THIS SO WE
USE THAT SAME FRAMEWORK NOW FOR
THIS PARTICULAR PAPER, I SAID
WHAT WE DID WAS WE ACTUALLY
ASKED THE QUESTION, I DON'T
DIRECT AND INDIRECT REP
RELATIONSHIPS BETWEEN RED LINES
AND SOME OF THESE FACTORS.
AND WHAT YOU CAN SEE IS THAT ALL
OF THEM, RED LINING WAS HIGH
ENCORSERATION, HIGH POVERTY,
HIGH DISCRIMINATION, SUBSTANCE
USE DISORDER, HOUSING,
UNEMPLOYMENT, FOOD ACCESS, AND
THOSE FACTORS LED TO INCREASED
DIABETES PREVALENCE AND THERE
WAS A [INDISCERNIBLE] TO RED
LINING TO DIABETES PREVALENCE.
SO WHY IS THIS IMPORTANT?
THIS GIVES US ACTIONABLE
TARGETS.
YOU CAN SEE IF YOU WANT TO DO
SOMETHING HERE YOU CAN FOCUS ON
THE STRESS OF THE ASSOCIATION,
AND BASED ON WHAT CAN BE MUTABLE
AT THE POPULATION LEVEL BECAUSE
THIS IS NOT INDIVIDUAL LEVEL,
THIS IS REALLY IF YOU TOOK YOUR
ZIP CODE WHAT COULD YOU DO WITH
YOUR ZIP CODE LEVEL.
SO WHAT ARE WE DOING NOW?
WE'RE NOW AT A POINT WHERE WE'RE
ASKING OURSELVES, OKAY, WE HAVE
SOME OF THIS GENERAL SENSE, BUT
WHAT WE REALLY DO AND WHAT IS
THE NEXT--SO WE HAVE 2 RO-1S
RIGHT NOW, THE MULTIPLE PI
WHICHON OF MY MENTEES AND THE
FIRST 1 IS LOOKING AT STRUCTURAL
RACISM AND DISPARITIES IN SOCIAL
RISK, HUMAN CAPITAL, HEGHT CARE
RESOURCES AND OUTCOMES, I WILL
CALL IT MULTILEVEL ANALYSIS OF
PATHWAYS AND POLICY LEVELS,
WE'RE PARTICULAR ABOUT NOT JUST
SHOWING RELATIONSHIPS, WE'RE
ASKING OURSELVES THE QUESTION,
SO THIS IS THE 5 YEAR RO-1
FUNDED BY NIMHD, TO LOOK AT
USING NATIONAL DATA, AND
TRACKING ALL OF THIS MEASURES,
AND LOOK AT THE RELATIONSHIP,
SOME OF WHICH WE ALREADY KNOW
AND SOME IS LOOK AT DIRECT AND
INDIRECT EFFECTS AND THEN THE
THIRD IS TO LOOK AT POLICIES,
WHAT ARE THE POLICIES THAT ARE
ACTUALLY ABLE, AT THE FEDERAL,
STATE AND REGIONAL GOVERNMENTS
THAT CAN BE USED TO REDUCE
VULNERABLES AND FINALLY TO
ENGAGE STAKEHOLDERS, I WANT TO
BE ABLE TO GET PEOPLE TO
PRIORITIZE THIS ON THE DATA AND
SAY WHAT ARE THE TOP 3-5
INTERVENTIONS THAT REALLY MAKE A
DIFFERENCE FROM THE RIGHT KEY
STAKEHOLDER SO WE CAN HAVE A
BLUEPRINT FOR PEOPLE GOING
FORWARD.
SO THIS STUDY IS ONGOING, WE'RE
IN THE SECOND YEAR OF THIS.
WE'RE ECTOMYOSIN KLF-TWOING DATA
NOW.
THE DATA IS HUMONGOUS AND AND
WE'RE TRYING TO PUT IT TOGETHER.
BUT THE SECOND IS A GRANT, A
GRANT WITH INDIVIDUALS, WHERE
WE'RE LOOKING AT STRUCTURAL
RACISM AND CLINICAL CLOSURES AND
COMMUNITY ACCESS AND HEALTH
OUTCOMES, AGAIN THIS IS A VERY
DIFFERENT PERSPECTIVE AND SAYING
WE'RE LOOKINGA THE THESE FACTORS
CAN AND HOW IF YOU LOOK AT MOST
VIERPTS YOU HAVE ABSENCE OF
HEALTHCARE AND THE PANDEMIC MADE
IT WORSE SO OUR GOAL IS TO LOOK
AT THE STRUCTURAL RACISM AND
PROPENSITY FOR HOSPITAL CLINIC
CLOSURES, SO ARE WE DISINVESTING
IN COMMUNITIES THAT ACTUALLY
HAVE YOU KNOW THAT ARE FORMALLY
RED LINE AND WHAT DOES THAT DO
WHEN ENVIRONMENT, MOST OF THOSE
ARE THE HIGHEST IN THE RARE, YOU
TAKE ARK WAY YOB CORPSS, FROM
OPPORTUNITIES SO ALL OF THIS
CREATES A CASCADING EFFECT IN
E-PRESCRIBING ITS OF
NEIGHBORHOOD AND WE WANT TO LOOK
AT THE ABILITY OF THE RISK OF
CLOSURE SO CAN WE ANTICIPATE
HOSPITALS THAT ARE ABOUT TO
CLOSE CLINIC, CLOSE THAT
ENVIRONMENTS AND MITIGATE THOSE
CLOSURES BEFORE THEY ACTUALLY
HAPPEN.
AND FEIGNALLY AGAINST THE
ENIMAIJMENT, WE CAN USE, YOU
KNOW POLICIES IDENTIFIED TO
IDENTIFY STRATEGIES TO REALLY
HELP US ADDRESS FUTURE IMPACT
AND FOR MOST OF MY RESEARCH, AND
WE CAN'T DO SOMETHING ABOUT, IT
NOT ENOUGH TO TELL SOMEONE YOUR
PROBLEM, YOU NEED TO GIVE
SOLUTIONS GOING FORWARD.
SO IN CONCLUSION I THINK I AM
DOING WELL IN TERMS OF TIME.
SO IN CONCLUSION, SOCIAL
DETERMINANTS OF HEALTH ARE KEY
DRIVERS OF POOR DIABETES
OUTCOMES, THIS IS PRETTY MUCH
CONCLUSIVE THAT WE KNOW AND IT'S
BEEN WELL DOCUMENTED AND IT'S A
STRONG DRIVER OF POOR DIABETES
OUTCOMES.
I THINK THIS IS THE PART THAT
SOMETIME SYSTEM MISSING WHERE
SOCIAL DETERMINE NABTS AND WE
DON'T PAY ATTENTION TO THE
UPSTREAM FACTORS AND WE ARE
TRYING TO MAKE PEOPLE AWARE THAT
THE UPSTREAM FACTORS AND THAT
RED LINING HAS A DREK AND
INDIRECT RELATIONSHIP WITH
DIABETES PREVALENCE AND THE KEY
OF THIS FOR RESEARCH SHOULD BE
TO IDENTIFY DIRECT AND INDIRECT
PATHWAYS AND IDENTIFY
INTERVENTIONS, WHAT CAN BE DONE
AND WE BELIEVE TAKEN--THEY
POLICY INTERVENTIONS ARE NEEDED
TO ADDRESS UPSTREAM STRUCTURAL
RACISM TO IMPROVE DIABETES
OUTCOMES.
THANK YOU.
[ APPLAUSE ]
>> THANK YOU.
WE HAVE 2 MICROPHONES IN THE
AISLES, SO I WOULD ENCOURAGE
MEMBERS OF THE AUDIENCE TO STEP
UP TO A MICROPHONE IF YOU HAVE A
QUESTION.
BE HAPPY TO LET YOU ASK YOUR
QUESTION AND GET AN ANSWER.
SO PLEASE.
>> HELLO, MY NAME'S REBECCA
[INDISCERNIBLE] I'M AT NIAID.
THANK YOU SO MUCH FOR WILL
EXCELLENT TALKOT OVERRUE OF THE
HISTORY OF CURRENT EFFECT OF
STRUCTURAL RACISM.
IN TERMS OF INTERVENTIONS, YOU
MENTIONED THAT AN INTERVENTION
COULD BE STAKEHOLDERS TRYING TO
PREVENTION THE CLOSURE OF
COMMUNITY HOSPITALS AND AREAS, I
AM CURIOUS WHETHER YOU'VE HAD
SUCCESS WITH THAT, OR KNOW OF
SUCCESS WITH THAT, EITHER IN
WHERE YOU WERE BEFORE, I THINK
YOU SAID SOUTH CAROLINA OR WE'RE
IN WISCONSIN, AND I HAD A SECOND
QUESTION.
>> OKAY, SO, THE STRATEGIES NOW
WE ACTUALLY HAD A SIMILAR
SITUATION THAT JUST HAPPEN
INDEED WISCONSIN WHERE 1 OF THE
INNER CITY HOSPITALS WAS ABOUT
TO BE CLOSED AND FROM A BUSINESS
STAND POINT IT MADE SENSE FOR
THE HEALTH SYSTEM, THAT
PARTICULAR HEALTH SYSTEM TO
CLOSE DOWN BUT THE COMMUNITY
ROSE UP AND SAID THIS IS ABOUT
THE ONLY HOSPITAL WE HAVE, IF
YOU CLOSE IT DOWN, PEOPLE WILL
NOT HAVE ACCESS BECAUSE OF
COMMUNITY ACTIVISM, THE HOSPITAL
IS STILL OPEN SO PEOPLE CAME
TOGETHER AND IT BECAME VERY
CLEAR THAT BECAUSE SOMETIMES, WE
MAKING THESE DECISIONS, PEOPLE
ARE NOT MAKING DECISIONS BASED
ON WHAT IS THE IMPACT TO THE
COMMUNITY AND THIS GROUP GOT
TOGETHER AND PROVIDED EVIDENT
ISSUES THE COMPROMISE WAS WE
WILL MOVE PROGRAMS THAT ARE NOT
VIABLE AND WE WILL KEEP OTHERS
AND THAT ALLOWED THEM TO KEEP
THAT HOSPITAL OPEN.
NTHAT WAS GREAT.
THAT WAS IN WISCONSIN IN.
>> YES.
>> OKAY, SECOND QUESTION RELATES
TO FOOD DESERT ANDS YOUR FIRST
STUDY, WE WERE LOOKING AT
INTERVENTIONS RELATED TO SENDING
BOXES OF FOOD OR GIVING
VOUCHERS, I KNOW IN THE SOCIAL
EPILITERATURE THERE'S A LOT OF
DISCUSSION OF A FOOD DESSERS,
I'M CURIOUS IN THOSE
NEIGHBORHOODS ARE THEY FOOD--ARE
YOU SENDING BOXES OF FOOD
BECAUSE OF SENIOR CITIZEN CAN'T
GET OUT TO THE GROCERY STORE,
WHATEVER OR ARE THEY IN FOOD
DESERTS OR IS IT A LITTLE BIT OF
BOTH NIT'S A LITTLE BIT OF BOTH.
SO HAVE YOU THE SITUATION WHERE
SOME NEIGHBOR HOODS IT WOULD
TAKE YOU A BUS ROUTE ALMOST 2
HOURS TO GET TO THE NEAREST
GROCERY STORE, AND THEN IN OTHER
AREAS, THESE ARE OTHER
INDIVIDUALS AS WELL, THEY DON'T
FEEL SAFE GOING AROUND AND THEN
MANY OF THEM ACTUALLY DO NOT
HAVE TRANSPORTATION SO GETTING
ARK ROUND BECOMES CHALLENGING TO
DO THAT BUT WHAT'S ALSO
IMPORTANT IS THAT IF YOU LOOK AT
MOST OF THESE NEIGHBORHOODS,
RIGHT, YOU HAVE CORNER STORES,
WHERE THE FOOD IS NOT FRESH,
IT'S REALLY NOT, SO THEY REALLY
DON'T, YOU MAY HAVE MANAGE IN
YOUR NAIB HERE HOOD, BUT MOSTLY
SHOPPING AND SO COMMUNITY
MEMBERS ARE SAYING IS THIS IS
FOCUS ON THE HEALTHY AND WE
ACTUALLY--THE MORE WE EDUCATE
IT, THE MORE WE REALIZE THIS IS
NO GOOD FOR US, SO HOW DO WE GET
TO HEALTHY FOOD OR HOW DO WE GET
ACCESS TO THOSE HEALTHY OPTIONS
NGREAT.
I WISH YOU SUCCESS IN THESE
STUDIES AND INTERVENTIONS.
>> THANK YOU.
>> HI, ROLAND'S OFFICE OF
INTRAMURAL RESEARCH.
SO BOTH LOW SOCIOECONOMIC STATUS
OR NUMERACY WERE ASSOCIATE WIDE
POOR GLYCEMIC CONTROL, HAVE YOU
LOOKED AT FINANCIAL LITERACY AS
AN EDUCATION TO INTERVENTION?
>> YOU ARE RIGHT ON TARGET.
SO 1 OF THE THINGS WE DO AFTER
EVERY STUDY WE DO, WE DO FOCUS
GROUPS AT THE END OF THE STUDY
REALLY TO UNDERSTAND WHAT WORK
OR DIDN'T WORK AND WHAT COULD WE
LEARN FROM IT BEYOND THE
COMPONENT AND 1 THING IS COMING
UP NOW IS THE DESIRE TO HAVE A
LITERACY EDUCATION EMPLOY NOW
WHAT WE ARE REALIZING IS, WHEN
YOU CALL IT FINANCIAL LITERACY,
COMMUNITY MEMBERS THINK YOU'RE
TRYING TO MANAGE THEIR FINANCES
SO YOU HAVE TO CREATE A
TERMINOLOGY THAT ALLOWS THEM TO
FEEL COMFORTABLE, WITH MANY OF
THEM ASKING AND SOME OF OUR
FOCUS GROUPS A WOMAN SAID NO 1
TOLL ME ABOUT CREDIT.
YOU KNOW?
THEY KEEP OFFERING YOU THESE
CREDIT CARDS AND THEN YOU SEE
YOUR CREDIT SCORES GO DOWN, SO
WHY OFFER THEM IF IT'S GOING TO
DING YOUR CREDIT.
SO GOING THROUGH THE EXPLANATION
OF UNDERSTANDING, WHAT DOES IT
EVEN MEAN TO HAVE, WHAT IS
CREDIT, WHAT DO CREDIT CARDS DO,
THEN ISSUES AROUND THIS AS
SIMPLE AS BUDGETING IN HOW MUCH
DO YOU ACTUALLY SPEND, SO
PARTICIPANTS SAID, I DIDN'T
REALIZE YOU KNOW HOW MUCH THESE
THINGS ACTUALLY COST UNTIL I
REALLY GOT HERE BECAUSE THE
QUESTION WE WERE CATEGORY WAS,
SO HOW DO YOU KNOW AND WHO
EDUCATES YOU, AND THAT'S PART OF
WHAT WE NEED TO ACTUALLY BEGIN
TO DOE, SO IT'S REALLY VERY
CUSTOMIZED SO PEOPLE IT WOULD
VARY, WE WILL HAVE TO CREATE
MENUS SO PEOPLE CAN PICK AND
CHOOSE WHAT THEY NEED TO KNOW IN
TERMS OF FINANCIAL LITERACY.
>> THANK YOU.
NOTHER QUESTIONS IN THE ROOM?
NJANE [INDISCERNIBLE] DIRECTOR
OF OBSSR HERE AT NIH.
GREAT TALK, I LOVE LOOKING AT
WIDER BROADER STRUCTURAL FACTORS
AS THE CLINICAL PSYCHEICOLOGYIST
TO LOOK AT THE INDIVIDUAL
FACTORS BUT IT'S HARDER WHEN YOU
LOOK AT THESE BIGGER PROBLEMS TO
ADDRESS, AND YOU SAID, I THINK
CORRECTLY THAT THE NEXT STEP IS
KIND OF POLICY CHANGES TO LOOK
AT THESE THINGS, THERE'S NO
INDIVIDUAL COUNSELING, AND TALK
TO A PERSON AND SOLVE RACISM,
ANY WHYEDS FROM ALL THIS GREAT
WORK YOU'VE DONE SO FAR ON WHERE
THESE POLICY CHANGES MIGHT BE
THE MOST EFFECTIVE?
>> YES, SO WE HAVE ACTUALLY
PLAYED AROUND WITH USING DATA,
RIGHT, TO DO--SO IN 1 OF MY
MENTEES IS OUR COLLABORATOR NOW
IS THE HEALTHY [INDISCERNIBLE]
WHO IS VERY WELL TRAINED IN
THIS, DIFFERENCE IN DIFFERENCE
WHEN YOU LOOK AT POLICY
INTERVENTION AND YOU CHOOSE
CONTROLS, SO 1 EXAMPLE IS
MEDICAID ADOPG SO IF YOU THINK
ABOUT THE LOW HANGING FRUIT.
WE KNOW THAT ACCESS IS A BIG
DRIVER, IT DOESN'T MATTER WHAT
[INDISCERNIBLE] ON THE SPECTRUM
YOU ARE, RIGHT OR LEFT, IT
DOESN'T REALLY MATTER, PEOPLE
ARE PEOPLE, THEY NEED ACCESS TO
HEALTHCARE, HOW WE GET IT IS A
POLITICAL DEBATE BUT THE KEY
ISSUES WE KNOW ARE ACCESS
IMPROVES OUTCOMES.
SO WE ACTUALLY TESTED, SO 1 OF
THE GREATEST DRIVERS OF
BANKRUPTY IS HEALTHCARE, SO IF
YOU DON'T HAVE INSURANCE, MANY
OF YOU MAY NOT KNOW THIS, WHEN
YOU HAVE INSURANCE, THERE'S
WHAT'S CALLED THE PRENEGOTIATED
RATE.
SO IF YOU GO TO THE HOSPITAL FOR
2 DAYS, 3 DAYS AND CHAI CHARGE
YOU 50,000, YOUR INSURANCE
NEGOTIATES THAT RATE DOWN AND
MAYBE YOU PAY 20,000, OF THAT
20,000 YOUR COPAYMENT MAY HAVE
500, WHEN YOU DON'T HAVE
INSURANCE YOU PAY THE FULL
PRICE, SO THEY CHARGE YOU 50,000
AND HAY CHARGE IT YOU.
YOU CAN'T PRENEGOTIATE.
SO THOSE ARE HIT WITH A BILL FOR
50,000, IT'S PROBABLY BECAUSE
YOU DON'T HAVE THE RESOURCES TO
HAVE THAT SO THOSE INDIVIDUALS
ARE HIT AND WE'VE SHOWN THAT
THOSE CATASTROPHIC EXPENDITURES
ARE HIGHER IN MINORITY
COMMUNITIES AND INSURANCE OF 1
OF THOSE RATES, AND WE'VE ALSO
SHOWN THAT MEDICAID ADOPTION IF
YOU LOOK AT COMMUNITIES ARE
MEDICAID EVIKS RATES, AND
JUDGMENTS ARE LOWER AND WHAT DID
THAT MEAN, PEOPLE ARE
PRIORITIZING WHAT TO SPEND MONEY
ON.
SO IF I HAVE A CHOICE, BECAUSE
HEALTHCARE YOU CAN'T CHOOSE, IF
YOU'RE SICK, YOU ARE SICK.
SO PEOPLE ARE USING THEIR
RESOURCES TO PAY FOR HEALTHCARE
AND AS A RESULT YOU CAN'T PAY
FOR HOUSING.
SO IF YOU HAVE TO CREATE ACCESS
TO HEGHT CARE, YOU DECREASE
THOSE, WE DEMON TRAITED THIS IN
STUDIES.
SO THESE ARE EXAMPLES OF THINGS
THAT ACTUALLY MAKE SENSE IN
TERPS OF VERY LOGICAL
[INDISCERNIBLE] WITH THESE
ISSUES.
>> ONE OF THE DIFFICULTIES OF
COURSE IS THAT'S A VERY RATIONAL
ARGUMENT AND THE WORLD ISN'T
ALWAYS VERY RATIONAL.
>> POLITICS.
>> THE QUESTION WE GOT FROM
DR. [INDISCERNIBLE] ABOUT POLICY
INTERVENTIONS, POLICY
INTERVENTIONS ARE TOUGH FOR NIH
TO SUPPORT AS AN INTERVENTION
APPROACH TO TRY TO IMPROVE SOME
HEALTH CONDITION, THOSE ARE
POLITICAL PROCESSES AND IT CAN
BE CHALLENGING TO GET A GRANT
FUNDED IF YOU ARE GOING TO GO
OUT AND TRY TO DO POLITICAL WORK
NYEAH, SO I THINK THAT'S THE
VERY, VERY IMPORTANT POINT.
SO WHAT WE TRY TO FOCUS ON IS
NOT THE POLITICS, IT IS THE
HEALTH OUTCOME.
NIH FUNDS RESEARCH THAT IMPROVES
HEALTH, AND SO WE HAVE FOCUSED
ON ON--EVEN WHEN WE DO FINANCIAL
INCENTIVES, WE'RE NOT GIVING
PEOPLE PEOPLE MONEY FOR THE SAKE
OF GIVING THEM MONEY, WE'RE
ACTUALLY ASKING MOW DO WE CHANGE
BEHAVIOR TO IMPROVE SCIENTIFIC
OUTCOME.
SO THAT'S THE QUESTION, BUT IF
WE ARE SAYING COME OUT AND
GIVING PEOPLE MONEY TO FEEL
BETTER, THAT'S NOT A SCIENTIFIC
QUESTION.
SO HOW THESE STUDIES ARE FRAMED,
THE NCTS FRONTIER IS HOW DO WE
FRAME TODAYS THAT GET RESULTS
THAT IMPROVE HELT AND NOW WITHIN
THIS PERVIEW OF SCIENTIFIC
INQUIRY.
NEVEN THAT KIND OF INTERVENTION
IS A HOT POTATO, WE HAVE SEVERAL
STATES NOW THAT ARE PASSING LAWS
THAT FORGID COMMUNITIES FROM
PASSING OUT MONEY, WITHOUT A
WORK REQUIREMENT NBUT I THINK
THAT IS IMPORTANT TO RECOGNIZE
THAT PHILOSOPHICALLY, DEPENDING
ON WHERE YOU STAND, I THINK
GIVING MONEY WITHOUT--WE USE
WHAT WE CALL CONDITIONAL CASH
TRANSFER, THE CONDITION IS THAT
IT'S A HEALTH COMPONENT TO IT,
SO IT'S CONDITIONAL ON YOU
ATTENDING CLASSES, CONDITIONAL
ON YOU IMPROVING OUTCOMES,
EATING BETTER, THOSE CONDITIONAL
TRANSFERS ARE LOGICAL AND
THEY'RE TIED TO HEALTH OUTCOME,
WHERE YOU MEASURE, I THINK WHERE
POLITICIAN ANDS THE COMMUNITY OF
THOSE INDIVIDUALS, IT GIVES
PEOPLE, FROM ECONOMIC THEORY, IF
YOU FLOOD THE MARKET WITH MONEY,
YOU WILL CAUSE INFLATION, IT'S A
PROCESS, RIGHT?
SO I THINK WHAT PEOPLE ARE
WORRIED ABOUT IS HOW DO YOU DO
THIS WITHOUT IT FEELING LIKE
YOU'RE JUST GIVING PEOPLE MONEY
AND THAT'S WHERE THAT TENSION
COMING IN.
BECAUSE NO 1 IS ARGUING ABOUT SO
IF YOU GIVE PEOPLE MONEY TO BUY
STRIPS SO THEY CAN CHECK THEIR
DIABETES, IT'S LOGICAL, IT'S
TIED TO AN END POINT.
IT'S WHEN YOU GIVE MONEY AND SAY
NO 1 DITION, DO WHATEVER YOU
WANT WITH IT AND YOU KNOW THAT
IS--THAT'S VIABLE, BUT WE THINK
IT'S A VIABLE OPTION BUT WE
THINK FROM FUNDING NIH FUNDED, I
THINK THOSE ARE ISSUES MAY NOT
BE EASY FOR NIERK H.
NNEXT QUESTION.
NHI, I'M RENE AND I'M A POST DOC
IN THE NEUROLOGICAL DISORDERS
AND STROKE BRANCH AND MY
RESEARCH HAS BEEN FOCUSAD I LOT
ON EPIDEMIOLOGY RELATING TO
STROKE AND SOCIAL DETERMINANTS
OF HEALTH.
SO I REALLY ENJOYED THIS, MY
QUESTION OVERLAPS WITH A LOT OF
OTHER QUESTIONS TO THE POLICY
INTERVENTIONS BUT ALSO I'M
CURIOUS ABOUT IN TERMS OF
INTRINSIC MOTIVATION IN THESE
FOCUS GROUPS WHEN YOU'RE SEEING
PEOPLE GIVING DIFFERENT OPTIONS
WHETHER IT'S FOOD OR EDUCATION
AND THINGS THAT WILL HELP THEM
CHANGE THEIR HEALTH, DO YOU
NOTICE THAT PEOPLE TEND TO
GRAVITATE TOWARDS 1 OR THE
RECOLLECT IN LIKE I'M WONDERING
WHAT KIND OF INTERVENTIONS WOULD
HAVE THE MOST SUCCESS IN TERMS
OF GIVING PEOPLE RESOURCES OR
EDUCATING THEM TO MAKE BETTER
CHOICES IN TERMS OF THE
LONGEVITY OF THE SITUATION.
>> YEAH, SO WE HAVE THE MENTEE
RIGHT NOW WHO HAS A FRANT
LOOKING AT BASIC INCOME
SUPPLEMENTATION, RIGHT?
AND SO THE WHYED WHYED--IDEA FT
STUDY AND FUNDS FOR NIDDK, WHAT
THEY SAID WAS FOR THAT
PARTICULAR K-GRANT WE WILL FUND
THE SCIENCE AND YOU FIND OTHER
RESOURCES FOR THE INCOME
COMPONENT.
SO WE ACTUALLY USED, WE KIND OF
PUT OUR RESOURCES TOGETHER AND
WE TESTED IN THAT STUDY WAS WE
LOOKED AT CONDITIONAL AND
UNCONDITIONAL CASH TRANSFER AND
WHAT WOULD HAPPEN WITH
RANDOMIZED PEOPLE AND WE
FOLLOWED THEM AND EACH PERSON
GOT EDUCATION, WHAT WE FOUND FOR
A LOT OF--NOW FOCUS GROUP, THE
STUDY JUST FINISHING UP RIGHT
NOW, THE FOCUS GROUPS, THE
PARTICIPANT SAID THE EDUCATIONAL
WAS VERY HELPFUL, THAT YOU KNOW
I KNOW THE MONEY IS HELPFUL BUT
THE MOST IMPORTANT FROM THEN WAS
EDUCATION, SO WE BELIEVE THAT
AND WHEN WE ACTUALLY LOOKEDDA AT
THAT, WE WERE GIVING OUT THE
CONDITION WAS, WE'VE GOT ACCESS
TO THE GIVING BANK CARDS BUT
ACCESS TO THE STATEMENT, WE WENT
IN AND ANALYZED WHAT ARE THEY
DOING WITH THE MONEY.
RIGHT?
PEOPLE ARE PAYING RENT.
TRANSPORTATION.
THEY'RE BEING MEDICATION,
THEY'RE BUYING STRIPS SORE
THEY'RE USING THEIR FUNDS FOR
THE THINGS THAT THEY COULD BT DO
OTHERWISE THAT'S TIED TO HEALTH.
BUT WHAT MANY OF THEM ACTUALLY
SAID TO US WAS THEY SAID,
BECAUSE OF THE INCENTIVE, I CAME
IN, BUT THE EDUCATIONALLY,
REALLY, REALLY HELPED ME SO I
THINK IT'S REALLY ABOUT, SO WE
THEN HAVE SOME OTHER MENTEES WHO
ARE WORKING ON SOCIAL NEEDS, SO
HAVE YOU SOCIAL NEEDS
NAVIGATION, YOU HAVE SOCIAL
NEEDS EDUCATION, AND THEN HAVE
YOU SOCIAL NEEDS INTERVENTION O
PROVIDE SPECIAL NEEDS AND ALL OF
THEM HAVE RESULTS, IT JUST
DEPENDS ON WHAT YOU ARE
COMPORTABLE WITH, WHAT RESOURCES
HAVE YOU AND OW MUCH.
SO FOR EXAMPLE, WE KNOW THAT
TELLING PEOPLE ABOUT SOCIAL
NEEDS IS NOT ENOUGH, RIGHT?
SO JUST SAYING, HERE.
BUT WHAT HELPS A SOCIAL NEEDS
RESOLUTION, HOW CAN RESOLUTION
HAPPEN, 1 IS TO SEND THEM TO
EXISTING RESOURCES.
WE HAVE ALL THESE GOVERNMENTAL
PROGRAMS THAT ALREADY EXIST, CAN
YOU HELP PEOPLE WITH THAT BUT
YOU'RE NOT PART OF THAT, THEN
YOU CAN ALSO HAVE PEOPLE WHO
HELP THEM SO FOR XCH, INSURANCE,
HELPING THEM ARK PLIE FOR AID AS
IS A HUGE DIFFERENCE.
SO JUST THINKING ABOUT HEALTH
RESEARCH FROM THE STANDPOINT OF
HOW DO WE CREATE A REALISTIC
APPROACH TO SOME OF THESE
PROGRAMS, AS OPPOSE TO THESE
SILOS, WHERE WE DO THIS AND SO
WE HAVE YOU, IT WAS HOUSING
INSECURE, PROBABLY ANYTHING TO
HAVE TRANSPORTATION PROBLEMS, SO
RATHER THAN JUST SAYING HEY, I
ONLY DO HOUSING, CAN WE CREATE A
WHOLISTIC PROGRAM THAT THEN
PLOTS PEOPLE TO WHAT THEY NEED.
>> GREAT.
THANK YOU NHI, GREAT TALK.
I'M SOFY DRAW, I'M VISITING NIH,
I'M A RESEARCHER FROM BAYLOR
COLLEGE OF MEDICINE DOWN IN
HOUSTON, I LOVE WHAT YOU SAID IN
THE STUDY, YOU DID, TELL US WHAT
WORKS ABOUT WE WILL FIGURE OUT
THE SCIENCE AND YOU TALKED ABOUT
RACE BEING A BIOLOGICAL
CONSTRUCK, AND FROM THE WORK
NOW, YOU NO LONG BELIEVE THAT
AND DOING ALL THIS FANTASTIC
EFFORT TO REDUCE THE BURDENS OF
STRUCTURAL RACISM, I'M WONDERING
WHAT THE PIVOT POINT WAS FOR YOU
AND WHAT DROVE YOU INTO THIS
LINE OF WORK ESPECIALLY COMING
FROM MY POSITIONALLITY OF TEXAS
WHERE OUR LEGISLATORS ARE TRYING
TO MAKE SURE THAT IS NOT TAUGHT
IN COOLS NOW, I WOULD LOVE TO
HEAR YOUR YOWRN TOW GIVE THIS
TALK TODAY, IT'S A LONG
QUESTION.
GIVE ME THE SHORT VERSION.
>> YES, I WILL GIVE YOU VERY,
VERY SHORT.
SO I THINK COMING FROM NIGERIA
MY FIRST STOP WAS IN BALTIMORE,
I WAS A RESIDENT IN BALTIMORE
AND I WAS WALK WORKING THE
CLINIC IN DOWN TOWN BALTIMORE
AND I WAS SURPRISED.
I DID NOT EXPECT TO SEE, I COULD
UNDERSTAND A DEVELOPING COUNTRY
HAVING DIFFICULTY BUT THIS I SAW
IN BALTIMORE, I SAID TO MYSELF,
I CAN'T BELIEVE THIS IS
HAPPENING IN AMERICA.
IT WAS SHOCKING TO ME, SO, AND
THEN AT THAT TIME, DIABETES OR
SOMETHING ELSE, I WAS KIND OF
REALLY FASCINATED BY, SO IT WAS
FOR ME, THE COMBINATION OF THE
EXPERIENCE AND THE DIABETES, SO
FOR ME WAS A NATURAL AND THEN I
HAVE SOMEONE WHO INVESTED IN ME,
YOU KNOW, A DIVISION CHIEF WHO
SAID, MY FIRST JOB SAID WE WILL
GIVE YOU FACULTY POSITION AND WE
WILL ALLOW YOU TO DO MASTERS OF
CLINICAL RESEARCH AND GET YOUR
FELLOWSHIP TRAINING SO I DID
THAT AND THAT JUST CHANGED MY
TRANSLATIONAL RESEARCH YECTRY
BUT I THINK IT'S REALLY A
FUNCTION OF THAT EXPOSURE AND I
REALIZE AND SO FOR MY
[INDISCERNIBLE] I WAS FUNDED BY
HRQ TO GIVE KUDOS TO HRQ FOR
FUNDING ME AT THE TIME WHEN
HEALTH SERVICES WAS PRETTY MUCH
UNKNOWN BUT 1 MIGHT HAVE MENTORS
WAS A SOCIOLOGIST, AND THE OTHER
WAS A PSYCHEICOLOGYIST SO I HAD
PEOPLE FROM NONMEDICAL AND I HAD
AN ENDOCRINOLOGIST THAT WAS MY
DIABETES PERSON BUT THAT
EXPOSURE GOT ME THINKING ABOUT
SO MANY ASPECTS THAT ARE NOT
TAUGHT IN MEDICAL SCHOOL AND I
THOUGHT--1 OF THEM WAS A
STATISTICIAN, SO I MET MENTORS
AND THAT CHANGED MY
TRAJECTORY.
>> WE HAVE ALMOST 400 PEOPLE
ONLINE, WE SHOULD GIVE THEM A
CHANCE TO ASK A QUESTION.
NOKAY, WHAT SUGGESTIONS DO YOU
HAVE FOR RESEARCHERS LOOKING AT
FEMALE DIABETES, ALREADY
SCREENING FOR DIABETES IN
PREGNANCY BUT LOOKING AT BLOOD
SUGAR ISSUES IN POLYCYSTIC
OVARIAN DISEASE AND CONDITIONS
THAT LOOK LIKE PC O S.
>> YES.
SO A BIG ISSUE RIGHT NOW IS
GUESTATIONAL DIABETES.
THIS IS MORE PROBLEMATIC BECAUSE
AS WE HAVE--HIGHLY PREVALENT IN
THE MINORITY COMMUNITIES AND
THEY HAVE LONG-TERM IMPACT WITH
THE RISK OF DEVELOPING TYPE 2
DIABETES AND ALSO IMPACT ON
INFANT.
SO THERE ARE GROUPS OF
INDIVIDUAL WHO IS--I DON'T DO
WORK IN THAT SPACE BUT I KNOW
THERE'S A LOT OF ADADVANCEMENT
IN SCIENCE IN TERMS OF SCREENING
AND DETECTION AND IN TREATMENT,
SO MOST PROGRAMS ACTUALLY USED
FOR DPUNISHING P DIABETES
PREVENTION, WORK IN WOMEN WITH
GUESTATIONAL DIABETES, SO THIS
WOULD BE DIET AND PHYSICAL
ACTIVITY AND HELPING PEOPLE GET
SCREENS.
>> THANK YOU.
I WANT TO THANK DR. EGEDE, FOR A
TERRIFIC PRESENTATION, I WANT TO
THANK THE AUDIENCE FOR GOOD
QUESTIONS, A LIVELY DISCUSSION.
AS I MENTIONED EARLIER, WE WILL
BE POSTING THE RECORDING OF
TODAY'S PRESENTATION ON OUR
WEBSITE PREVENTION.NIH .GOV IN
THE NEXT FEW WEEKS AND IT WILL
BE AVAILABLE ON THE NIH
VIDEOCAST SITE.
I WANT TO THANK EVERYONE FOR
JOINING TODAY'S LECTURE, FOR
THOSE WHO ARE HERE IN LIP SET,
PLEASE JOIN US OUTSIDE THE
AUDITORIUM FOR A BRIEF RECEPTION
AND TO THOSE ONLINE, IF YOU WERE
HERE, YOU COULD BE PART OF THE
RECEPTION AND HANG OUT WITH OUR
SPEAKER.
SO I WOULD ENCOURAGE YOU TO COME
IN PERSON NEXT TIME, HELP US
FILL THE ROOM.
YOU ALSO HAVE A BETTER CRACK AT
ASKING QUESTIONS IF YOU ARE IN
THE ROOM.
FINALLY, THE CME CODE, I'VE BEEN
ASKED TO REPEAT, 50125.
THANK YOU VERY MUCH.
[ APPLAUSE ]