WELCOME TO THE WEDNESDAY AFTERNOON LECTURE WITH A PRESENTATION TODAY BY DR. SANDRA GALLIA I'M GLAD YOU ARE JOINING US ON THIS SNOWY, RAINY AFTERNOON TO LISTEN TO WHAT I THINK WILL BE A VERY THOUGHTFUL AND RELEVANT PRESENTATION FROM OUR SPEAKER. SO, DR. GALLIA IS PROFESSOR AND DEAN AT THE BOSTON UNIVERSITY SCHOOL OF PUBLIC-HEALTH. HAS UNDERGRADUATE TRAINING AT THE UNIVERSITY OF TORONTO AND MD AT THE UNIVERSITY OF TORONTO MEDICAL SCHOOL AND MASTER OF PUBLIC-HEALTH AT HARVARD AND DOCTOR OF PUBLIC-HEALTH AT COLOMBIA. HE HAS HAD MEDICAL TRAINING IN EMERGENCY MEDICINE AND HIS ACADEMICS CAREER HAS TOUCHED ON OFFICESEVERAL INSTITUTIONS INCLUDING THE COLOMBIA UNIVERSITY FOLKS, THE UNIVERSITY OF MICHIGAN COLOMBIA AGAIN AND AT BOSTON UNIVERSITY SCHOOL OF PUBLIC-HEALTH. HE HAS RECEIVED A NUMBER OF IMPORTANT HONORS INTERESTED BY TIME MAGAZINE TO BE ONE OF THE EPIDEMIOLOGY INNOVATORS. HE HAS SERVED ON THE ADVISORY COUNCIL FOR THE NATIONAL INSTITUTE OF MINORITY HEALTH AND HEALTH DISPARITIES, FOR WHICH WE ARE GRATEFUL, THANK YOU FOR THAT WILLINGNESS TO HELP US WITH GUIDING O OUR OWN RESEARCH. HE HAS FOCUSED ON THE INTERSECTION OF SOCIAL AND PSYCHIATRIC EPIDEMIOLOGY AND PARTICULARLY ON THE BEHAVIORAL HEALTH CONSEQUENCES OF TRAUMA. WE ARE ALL GOING THROUGH TRAUMA IN 2020 AND SO THAT BACKGROUND FITS RATHER WELL FOR WHAT HE IS GOING TO TALK TO US ABOUT TODAY. HIS TITLE IS "THE CONTAGION NEXT TIME." UNDERLINE SOCIOECONOMIC AND RACIAL DIVIDES IN OUR RISK FROM COVID-19 AND FUTURE PANDEMICS. WITH THAT INTRODUCTION, PLEASE JOIN ME IN WELCOMING OUR SPEAKER, DR. SANDRO GALIA. >> THANK YOU, DR. COLLINS FOR THAT KIND INTRODUCTION. THANK YOU FOR ACTUALLY SAYING MY LAST NAME PERFECTLY, THE WAY MY MOTHER WOULD SAY IT WHICH IS QUITE UNUSUAL. AND THANK YOU ALL THE COLLEAGUES AND FRIENDS WHO I ENJOYED BEING ON COUNCIL FOR NIMHD. AS DR. COLLINS MENTIONED I'M GOING TO TALK ABOUT THE CONTAGION NEXT TIME AND THE COVID MOMENT. THERE SAY MOMENT THAT'S VERY MUCH ON ALL OUR MINDS AND I'M GOING TO MAKE A CASE FOR WHY THE COVID MOMENT CANNOT BE SEEN WITHOUT THE SOCIAL DIVIDE LENS AND ABOUT DIVIDE AND HEALTH HAVEs AND HAVE NOT AND WHY IT MATTERS AND THIS MOMENT AND I'M GOING TO TRY TO DO THAT IN 40 TO 45 MINUTES TO LEAVE TIME FOR QUESTIONS. I'M GOING TO MAKE 10 POINTS IN THIS TALK. COVID-19 IS A REAL TRIUMPH BIOMEDICAL SCIENCE AND SPEAKING HERE AT NIH, IT SEEMS THAT NOT ONLY IMPORTANT TO SAY THAT BUT IT'S IMPORTANT TO ELEVATE THE ROLE THAT THE WORK OF THIS COMMUNITY AND BY OWE MEDICAL SCIENTISTS AT NIH AND THROUGHOUT THE COUNTRY AND WORLD HAS PLAYED THIS ENORMOUS ROLE IN THE CONTEXT OF COVID-19. I'LL START BY MAKING THAT CASE AS A RECENT PAPER FROM DR. HOR OWE WITS AT NYU LOOKING AT COVID MORTALITY AND THE GRAY BAR IS THE MISSION OF THE NYU SYSTEM FOR COVID BUT WHAT MATTERS HERE IS THE OUR LIGHT BLUE BARS. IT'S A DROP IN MORTALITY AFTER THE FIRST CASES OF COVID IN MARCH AND APRIL. THE PAPER A TRIBUTES TO THE DROP IN MORTALITY FROM COVID TO IMPROVE CLINICAL EXPERIENCE, GREG USE OF PHARMACOLOGICAL TREATMENT AND STEROIDS AND BETTER CLINICAL CARE, THINGS LIKE PRONING, PRONING OF PATIENTS AND POTENTIALLY LOWER VIRAL, THESE ARE MASK-WEARING. ALL OF THIS, TO MY MIND, IS THE REALM OF SCIENTIFIC DISCOVERY AND SHOWS HOW SCIENCE WAS ABLE TO GUIDE OUR HANDLING OF THIS UNPRECEDENTED, PREVIOUSLY UNKNOWN DISEASE AT LEAST IN THIS FORM. AND RESULT IN REALLY A DROP OF MORTALITY IN JUST A FEW MONTHS. IT'S HARD TO WRAP OUR BRAIN AROUND THAT AND IT'S HARD TO THINK ABOUT IT AS A BIG DEAL BECAUSE WE'LL ALL BEEN IMMERSED IN COVID FOR THE PAST YEAR BUT IT'S A BIG DEAL. IN A SHORT PERIOD OF TIME, FAR FEWER PEOPLE WERE DYING FROM COVID, LARGELY BECAUSE OF THE WORK OF BIOMEDICAL SCIENCE AND THE TRIUMPH IS THIS. VACCINATION DATA. WE KNOW THAT WE HAVE TWO VACCINES THAT ARE BEING APPROVED WITH EUAs AND FROM PFIZER AND MODERNA. THEY'RE GOING TO BE TRANSFORMATIVE AND CHANGE THE WORLD AND HOW WE LIVE IN 2020 BUT WHAT IS MOST REMARKABLE IS HOW THESE VACCINES HAVE DEFIED ALL PREVIOUSLY EXPERIENCES WITH VACCINES. THIS IS A SIMPLE GRAPH FROM THE WELCOME TRUST SHOWING THE TYPICAL VACCINE DEVELOPMENT COURSE, WHICH IS TYPICALLY ABOUT 10 YEARS AND LEAVING THE COST ASIDE FOR A SECOND BUT THE PREVIOUS FASTEST VACCINE THAT WE HAD DELIVERED WAS FOUR YEARS IN THE CASE OF MUMPS AND NOW WE'VE DONE THIS IN SIX TO EIGHT MONTHS, WHICH IS EXTRAORDINARY. EVEN MORE EXTRAORDINARY IS THIS COMES FROM THE NEW TECHNOLOGY. MRN TECHNOLOGY AND A PAPER ABOUT 10 YEARS WHICH SAYS MRNA PRESENTS A VACCINE AND WILL BE THE GAME-CHANGING VACCINE TECHNOLOGY PLATFORM. WHICH I LIKE BECAUSE IF THERE WAS A PREDICTION THAT HAS COME TRUE FOR HUMANITY IT'S THIS CON CONTEXT. IT'S IMPORTANT WE SEE COVID-19. IT'S REALLY HARD TO SEE IT THAT WAY IN THIS MOMENT IN TIME BECAUSE WE'RE ALL SO IMMERSED IN IT AND IT HAS TRANSFORMED OUR LIVES. REALLY IT DOES REPRESENT THE TRIUMPH BIOMEDICAL RESEARCH AND I THINK AND HOPE THAT IT POSITIONS US ALL WELL IN THE SCIENTIFIC COMMUNITY, WELL TO THEN BUILD ON THIS TOWARDS EVER GREATER BETTER SCHOLARSHIP TO IMPROVE OUR HEALTH AND TO GET US READY FOR WHAT I'M CALLING THE CONTAGION NEXT TIME. SO STARTING WITH THE TALE OF TRIUMPH, IS THERE A PROBLEM? WHAT IS THE CHALLENGE ABOUT COVID-19? WHY IS IT IT HAS DOMINATED OUR THINKING SO MUCH AND WHY IS IT THAT I SUSPECT NO ONE REALLY IN THE ROOM, IF I MAY USE THE ZOOM AS THE WORD ROOM, REALLY FEELS LIKE IT HAS BEEN A TRIUMPH. I THINK TO THINK ABOUT WHY IT HAS BEEN A PROBLEM, WE NEED TO UNDER HEALTH. WE NEED TO GO BACK TO BASIC AND SAY HOW DO WE UNDERSTAND HEALTH. I REALIZE THERE'S AN ARROGANCE IN A STATEMENT GIVEN I'M TALKING IN THE NATIONAL INSTITUTE OF HEALTH. I WANT TO STRUCTURE OUR THINKING ABOUT HEALTH AND TO SAY WHAT IS IT ULTIMATELY THAT GENERATES HEALTH? AND TO MAKE THAT CASE, I WANT TO MAKE THE CASE BY SHARING A STORY OF THIS GENTLEMAN HERE FOR THOSE OF YOU WHO ARE BLUES' FANS HE IS WILLIE JOHNSON ONE OF THE GREATS OF THE BLUES AND BLIND BILLY JOHNSON WAS BORN IN TEXAS AT THE TURN OF THE 20th CENTURY. HE WAS BORN CITE SIGHTED BUT HE LOST HIS EYESIGHT WHEN HE WAS CHILD IN A DOMESTIC VIOLENCE INCIDENT. HE GREW UP POOR AND BLIND AND BLACK IN TEXAS IN THE BEGINNING OF THE 20th CENTURY. HE GOT MARRIED AND HE WAS LIVING IN A SMALL HOUSE AND THAT HOUSE BURNED DOWN AND BECAUSE HE DIDN'T HAVE MONEY, THEY WENT BACK TO LIVING IN THE BURNT OUTHOUSE. WHEN HE WAS IN HIS 40s, THIS IS IN THE 1940s IN TEXAS HE DEVELOPED MALARIA. IT WAS NOT SO UNCOMMON, TEXAS AND MALARIA AND MANY PEOPLE HERE KNOW THE CDC WAS INITIALLY STARTED IN NO SMALL PART TO HELP CONTROL MALARIA IN THE SOUTHERN STATES. HIS WIFE TOOK HIM TO HOSPITAL AND HE WAS TURNED AWAY FROM HOSPITAL. IT'S NOT CLEAR IF HE WAS TURNED AWAY BECAUSE HE WAS POOR, BLACK OR BLIND? AND THEN HE DIED. SO THE REASON I TELL THAT STORY IS TO ASK WHAT KILLED BLIND BILLY JOHNSON? WELL, WHAT KILLED BLIND BILLY JOHNSON WAS MALARIA. HAD HE RECEIVED TREATMENT FROM MALARIA, HAD HE RECEIVED THE COLOR O'QUINN, HE ACTUALLY WOULD HAVE LIVED. THE REASON I TELL THAT STORY, IS BECAUSE IT'S OBVIOUS TO EVERYBODY LISTENING THAT IT WASN'T JUST MALARIA THAT KILLED BLIND BILLY JOHNSON IT WAS ALSO DOMESTIC VIOLENCE AND RACISM AND HOMELESSNESS AND POVERTY AND POOR ACCESS TO CARE. ALL OF THOSE FORCES KILLED BLIND BILLY JOHNSON. HAD IT NOT KILLED HIM THE DAY IT KILLED HIM, SOMETHING ELSE WAS GOING TO KILL HIM THE NEXT DAY. WHEN I TELL THAT STORY, ALL PEOPLE LISTENING TO THE STORY THINK THE FORCES THAT SHAPE BLIND BILLY JOHNSON'S HEALTH WERE NOT JUST MALARIA BUT ALL THESE OTHER FORCES AROUND HIM AS WELL. THEY ALL ULTIMATELY PRODUCED HIS HEALTH. AND AS A RESULT, THOSE OF US WHO ARE INTERESTED IN HEALTH, NEED TO CONCERN OURSELVES WITH THE FULL SET OF FORCES. WE NEED TO GENERATE SCHOLARSHIP THAT UNDERSTANDS THIS FORCES AND WE NEED TO MAKE SURE THAT WE THINK ABOUT INTERVENTIONS AND APPROACHES THAT DEAL WITH THIS FULL SET OF FORCES. THINKING THIS SCHEMATICALLY, THIS IS FROM THE CLINICAL SYSTEMS IMPROVEMENT INSTITUTE AND WHAT IS IT THAT CAUSE HEALTH? THIS IS REALLY THE STORY TOLD IN THE FOR OF A CARTOON. THEY ALL COME UP WITH PERCENTAGE OF ILLNESS THAT CAUSE HEALTH AND I'M SO NOT FUSSED ABOUT THESE PERCENTAGES AND I WOULD WARD US AWAY FROM GETTING TOO HUNG UP BUT FUNDAMENTALLY, HEALTH IS CAUSED BY HEALTHCARE, BY THE DISEASE THEMSELVES AND ALSO BY HEALTH BEHAVIOR. DIET, SEXUAL ACTIVITY, ALCOHOL, WHICH OUR JOBS, EDUCATION, SOCIAL SUPPORTS, INCOME, COMMUNITY. ALL OF THESE FORCES FUNDAMENTAL LOFUNDAMENTALLY SHAPE US. THE QUESTION IS, DO WE UNDERSTAND THIS AND DO WE INVEST ACCORDINGLY? IF THIS IS CORRECT, IS HOW WE DEAL WITH HEALTH COMMENSURATE WITH WHAT SHAPES HEALTH? I WOULD ARGUE IT'S NOT THE CASE. ON THE LEFT IS AGAIN A STYLIZED CARTOON, THE SAME CARTOON I SHOWED YOU BEFORE AND THE SAME PERCENTAGE I SHOWED YOU BEFORE AND IT'S ENVIRONMENT, MEDICINE, HEALTH AND BEHAVIOR AND WHAT CAUSES HEALTH AND ON THE RIGHT IS WHAT WE SPEND OUR MONEY ON. AND WE SPEND OUR MONEY OVERWHELMINGLY ON THE MEDICAL SIDE OF THE HEALTH. EFFECTIVELY, WE SPEND ALL OUR MONEY ON MALARIA. IF WE, MALARIA BY WAY OF METAPHOR. IF WE SAW BLIND BILLY JOHNSON'S CASE AS A CASE OF MALARIA, WE WOULD SPEND OUR MONEY CORRECTLY. IF WE CAN FIX MALARIA ONLY AND WE TAKE EVERYTHING ELSE WE'RE DOING THE RIGHT TIME. 90% OF OUR EXPENDITURES ARE REAM' ABOUT THE TREATMENT SIDE OF THE HOUSE AND IT'S 90% OF A LOT OF MONEY AND THIS IS A GROWNISH LOIN AND I DON'T KNOW WHAT COLOR THIS IS IT SHOWS OUR HEALTH EXPENDITURES AND SOME OF THE OTHER COLORFUL LINES OF COUNTRIES AND EVERYBODY SPENDS MORE ON HEALTH. WE'RE SPENDING MORE AND MORE FASTER THAN EVERYBODY ELSE. IT'S OUR RATE OF CHANGES FASTER THAN EVERYBODY ELSE SO WE'RE SPENDING MORE AND MORE ON HEALTH AND MORE ON THE ASPECT OF MALARIA AND JUST TO MAKE THAT CASE, IS BLUE IS SPENDING IN HEATH CARE AND DARK PLUMAS AND AS DR. COLLINS IN SERVING HIS DEAN IN BOSTON IT MEANS I'M SITUATED IN MASSACHUSETTS AND MASSACHUSETTS IS CONSIDERED ITSELF ONE OF THE MOST PROGRESSIVE OF STATES AND I GET THE STOCK TO SOMETHING LIKE IT AND SAYS WELL, THAT MAY BE THE CASE ALL OVER THE COUNTRY OR MAYBE IN SOUTHERN STATES BUT IT'S NOT THE CASE IN A PLACE LIKE MASSACHUSETTS WHERE WE'RE PROGRESSIVE AND OPEN MINDED SO I LOOKED AT MASSACHUSETTS BUDGET AND THIS IS SPENDING OF 15-YEAR PERIOD IN MASSACHUSETTS AND YOU SEE 100% INCREASE IN HEALTHCARE IN THE MALARIA TREATMENT SIDE OF THE HOUSE AND MORE THE SAME LIKE TRANSPORTATION, HOUSING, PRIMARY SECOND EDUCATION, MENTAL HEALTH, HIGHER EDUCATION AND EARLY CHILDHOOD CARE AND PUBLIC-HEALTH AND ALL OF THAT STAYING THE SAME AND GOING TO AND THESE NUMBERS ARE TRUE EVERYWHERE. THEY ARE TRUE EVERYWHERE. AND WE HAVE PAID THE PRICE FOR THEM AND WE AS A COUNTRY PAY THE PRICE FOR THAT AND I COULD GO ON AND ON TO SHOW YOU DATA BUT JUST BY WAY OF SAM AR EYE SUMMARIZING IT, WE'RE THE RED LINE OR THE OTHER COUNTRIES ARE COLORFUL LINES, WE BROADLY LEAVE FIVE YEARS ON THE STABLE IN THE CONTEXT OF LIFE EXPECTANCY. WE CHOSE TO DIE FOUR TO FIVE YEARS SOONER THAN OTHER COUNTRIES. ONE CAN MAKE AN ARGUMENT THAT RATIONAL PEOPLE CAN CHOSE TO HAVE LOWER LIFE EXPECTANCY BECAUSE WE CHOSE OTHER VALUES. I ARGUE WE DO NOT CONSCIOUSLY CHOSE THAT BECAUSE WE DO NOT ENGAGE INTELLECTUALLY AND HONESTLY WITH THE TRADE OFFS THAT WE ARE MAKING AND LEAVING ON THE TABLE. OF COURSE, HOPEFULLY YOU ARE CONNECTING THE DOTS TOGETHER. WE'RE TALKING ABOUT COVID AND THESE UNDERLYING FORCES AND HOW THEY RELATE TO COVID AND I STARTED OFF BY SAYING, THAT COVID IS A BIOMEDICAL RESEARCH BECAUSE WE ARE ACTUALLY HAVING VACCINE AND TREATMENT FOR COVID SO IN THE CONTEXT OF BLIND BILLY JOHNSON IT'S RESEARCH AS MALARIA BUT I'M HERE TO ILLUSTRATE HOW THE OTHER FORCES ARE INTER LOCK ABLE AND IT DOESN'T MATTER HOW GOOD WE ARE AT TREATING MALARIA IT'S NEVER ENOUGH AND TREATING THE FORCES AROUND COVID AND THE OTHER FORCES AROUND US HOLD US BACK AND STRUCTURE FUNDAMENTALLY OUR HEALTH OUTCOMES DUE TO THE DISEASE AROUND US. FUNDAMENTALLY WE CANNOT GET AWAY FROM THE ROLE OF FORCES LIKE EDUCATION, NUTRITION, PARKS, OPPORTUNITIES FOR RECREATION, POVERTY AND INCOME. HOUSING, ISOLATION, LONELINESS AND FORCES LIKE THE ENVIRONMENT. THESE FORCES ALL NEED TO BE KEPT IN MIND IF WE ARE TO THINK ABOUT HOW WE CREATE HEALTHIER POPULATIONS AND I WOULD ARGUE THAT IN THE CONTEXT OF A TALK AT THE NATIONAL INSTITUTE OF HEALTH, WE SHOULD BE THINKING ABOUT HEALTH AND ALL THE FORCES THAT GENERATE HEALTH. PERHAPS MY ONE FAVORITE NOT SLIDE, WHICH CAPTURES THE DISCREPANCY IN OUR COUNTRY BETWEEN HOUR SPENDING AND WHAT WE ACHIEVE IS THIS SLIDE. THE X AXIS LOOKS AT OUR SPENDING AND THE Y IS LIFE EXPECTANCY AND YOU SPEND MORE AND YOU GET MORE LIFE EXPECTANCY IT'S SEEMS RATIONAL. WE SPEND MORE AND WE SORT OF FALL OFF THE CURVE. WE'RE LIKE A CLASSIC GROWTH CURVE FOR CHILDREN WHO DO DEVELOPMENTAL TYPE WORK WHERE WE ESSENTIALLY ARE FAILING TO THRIVE WHERE WE FALL OFF THE CURVE AND FUNDAMENTALLY, IT'S BECAUSE WE UNDER INVEST IN THE FORCES THAT GENERATE HEALTH THAT ARE NOT THE CLINICAL THERAPEUTIC FORCES THAT ARE IMPORTANT BUT REALLY JUST ONE PART OF THE PUZZLE. THAT'S BY WAY OF BACKGROUND. NOW, COMPOUNDING THIS, IT'S THE FACT THAT THESE FORCES ARE MALL DISTRIBUTED. COMPOUNDING THIS IS THE FACT THAT THE FORCES I'M TALKING ABOUT TO GENERATE HEALTH ARE DISTRIBUTED IN WAYS THAT ARE UNEVEN, BROADLY ALONG TO AXIS AND ALONG SOCIOECONOMIC AXIS AND AS THEY'RE MALL DISTRIBUTED WHAT WE SAW IN COVID WAS IN MANY RESPECTS NOTHING NEW AND IT WAS A DRAMATIC EXPRESSION OF WHAT WAS THERE BEFORE AND WHAT HAD BEEN THERE FOR DECADES AND ELEVATED FOR ALL TO SEE THESE UNDERLYING DIVIDES IN HOW THE RESOURCES THAT GENERATE HEALTH ARE DISTRIBUTED. LET ME START WITH THE OBVIOUS. PERHAPS THE MOST OBVIOUS IS INCOME. I'LL START WITH INCOME. WHAT THIS LOOKS AT IS INCOME BY QUINN TILE IN THE COUNTRY AND YOU SEE THE INCOME OF THE RICHEST QUINNTILE HAS GROWN OVER THE PAST 30 YEARS, 40 YEARS WHICH YOU WANTED TO GROW. INCOME FOR EVERYONE ELSE AND THE POOREST 80% ESSENTIAL LOW HAS NOT BUDGED THAT MUCH. I SAY THAT AND I SAY ISN'T IT EXTRAORDINARY AND IT'S EXTRAORDINARY BECAUSE TO HAVE 80% OF THE COUNTRY NOT BUDGE IN WHAT IS THE FUNDAMENTAL RESOURCE THAT GENERATES OUR WELL-BEING IS REALLY QUITE REMARKABLE EX TO ILLUSTRATE THIS DIVIDE BETWEEN THE 20% AND 80% AND I'M COMING BACK TO THAT BECAUSE THIS DIVIDE TO MY MIND -- THEY ARE DEEPLY INTERTWINED, IT'S IMPOSSIBLE TO SEPARATE THEM. THIS LOOKS AT WEEKLY EARNINGS BY DEGREE AND BY RACE AND I WANT TO SHOW YOU THIS IS PEOPLE WITH BACHELOR DEGREES OF PEOPLE WHO ARE WHITE AND BLACK, TO SHOW THAT THE GAP, THE AMAZING GAP THAT IS BUILT IN THE TWO WAGES BY RACE COMPARING WHITE ASK BLACK AND IF I WERE TO JUST TAKE THE INCOME AGAIN, THIS IS WHITE AND BLACK FAMILIES OVER ALL THE GAP IN INCOME PALES WITH THE GAP IN WEALTH, THAT'S ON THE RIGHT. THE GAP IN WEALTH, WHICH IS ESSENTIALLY 10 FOLD BETWEEN WHITE FAMILIES AND BLACK FAMILIES, WHICH OF COURSE UNDERLIES AND IS A PATTERN REFLECTION OF THE LONG-TIME MARGINALIZATION OF MINORITY, AMERICANS BLACK AMERICANS, WHO HAVE LONG NOT HAD ACCESS TO WEALTH AND TO RESOURCES AND IF ONE BUYS THE STORY, THAT FUNDAMENTALLY THESE RESOURCES ARE PREDICTABLE OF HEALTH, THAT'S TO GENERATE HEALTH. IN OTHER WORDS, IF YOU UNDERSTAND AND INTUITIVELY UNDERSTAND THE BLIND BILLY JOHNSON STORY IS IMPORTANT IN OUR UNDERSTANDING OF HEALTH, YOU REALIZE WE'RE STRUCTURING THE WORLD WHERE THOSE RESOURCES THAT GENERATE HEALTH ARE MALL DISTRIBUTE AND WHERE ONE GROUP, IN THIS CASE BLACK AMERICANS, ARE A TREMENDOUSLY GREATER RISK OF POOR HEALTH SIMPLY BECAUSE THEY DON'T HAVE THESE RESOURCES. THIS IS ACTUALLY PATTERN AT ALL LEVELS. I WANT TO SHOW YOU THE WORTH. HOUSEHOLD NET WORTH WHICH IS ESSENTIALLY WEALTH BY RACE AND EDUCATION AND THE LEFT IS WHITE AND BLACK IS RED AND YOU SEE AT ALL LEVELS OF POST COLLEGE, COLLEGE, SOME COLLEGE, THE WHITE-BLACK WEALTH GAP IS LARGE AND IT'S ABOUT FIVE FOLD THE DIFFERENCE BETWEEN WEALTH GAP AND WHITE VERSUS BLACK AND DIFFERENT LEVELS OF COLLEGE AND THIS IS BY DIFFERENT LEVELS OF HOUSEHOLD INCOMES. DIFFERENT LEVELS OF INCOME YOU HAVE DIFFERENT WEALTH. INCOME OF MORE THAN $121,000, YOU HAVE A THREE AND A HALF FOLD INCREASE BETWEEN WHITE AND BLACK WEALTH. NOW WHAT IS AMAZING ABOUT THIS IS YES, IF IT'S AMAZING IT EXISTS AN AND IT EXISTS AND IT'S GETTING WORSE. THIS IS LOOKING AT 1983 AND 2016. THIS IS ALL WEALTH IN THE COUNTRY AND THIS IS A LITTLE BIT DOWN BETWEEN OVER THE PAST 40-YEAR PERIOD. LOOK AT WHITE GOING UP AND BLACK ESSENTIALLY GOING DOWN AND LATIN EX. I FEEL ANYBODY WHO IS INTERESTED AT HEALTH AT THIS POINT, HAS TO SAY TO THEMSELVES, YOU EITHER HAVE TO SAY I DON'T BELIEVE THE BLIND BILLY JOHNSON STORY, YOU HAVE TO SAY THAT IS NONSENSE. ALL WE SHOULD DO IS FOCUS ON MALARIA. OR, IF YOU DON'T SEE THAT, AND IT'S A DISCUSSION WE CAN HAVE. WE CAN HAVE THAT DISCUSSION. IF YOU DON'T SAY THAT, YOU THEN HAVE TO SAY THESE OTHER FOURSES MATTER AND THEY MATTER AND THEY'RE SO DIVIDED IT SETS US UP FOR FAILURE. IF THOSE RESOURCES ARE MALL DISTRIBUTED, DIFFERENT GROUPS HAVE WORSE HEALTH. A LOT THE MALL DISTRIBUTION GOES BACK CENTURIES AND IT GOES BACK TO FORCES LIKE SLAVERY. THIS EX F. I IS IS A MAP OF SLAVELY BEING AREAS WHERE THERE WERE MORE BLACK SLAVES AND THAT ULTIMATELY SET UP A HISTORY OF THIS DISSEN FRANCHISE WHICH WAS RESOURCES THAT PERSISTED THIS VERY DAY. SLAVERY SET UP PATTERNS OF RED LINING, RED LINING THROUGH DISCRIMINATION ABOUT PEOPLE WITH DIFFERENT RACIAL GROUPS COULD LIVE AND A PICTURE OF DETROIT SHOWING THE RED AREAS WHERE THE HOMEOWNERS WHICH WAS A FEDERAL CORPORATION THAT WAS IRONICALLY ENOUGH ESTABLISHED TO HELP PEOPLE BUY HOMES AND THEY TOOK IT UPON THEMSELVES TO CREATE RED LINES SO SHOW LEN DERS AREAS WHERE THEY SHOULD NOT LEND WHERE MINORITY RESIDENTS AND THAT HAS RESULTED IN THE PATTERNS THAT WE HAVE TODAY. FOR EXAMPLE, PATTERNS OF SEGREGATION. THIS IS DETROIT, EIGHT-MILE ROAD IS IN THE MIDDLE. I SPENT TIME IN MICHIGAN AND THIS IS FROM A STUDY WHICH TOOK PEOPLE FROM THE CENSUS, INDIVIDUALS, GREEN DOTS, BLUE DOTS, WHITE AND BLACK AMERICANS SHOWING THIS SEGREGATION, RIGHT. YOU CROSS EIGHT-MILE ROAD AN EIGHT-MILE RO AD AND IT GOES WHITE-BLACK. IT'S PATTERN ON OUR HISTORICAL LEGACY OF DISSEN FRANCHISING PARTICULAR GROUPS. NOW, THAT MAY BE INTERESTING, PERHAPS, AND IT MAY ALSO BE INTERESTING SORT OF SOCIO LOGICALLY. IT'S NOT UNREASONABLE TO SAY IT'S NICE BUT WE'RE SHALL INSTITUTES OF HEALTH AND IT MAY BE INTERESTING AND IMPORTANT FOR HOW WE STRUCTURE SOCIETY, IT DOESN'T REALLY MATTER TO US SO MUCH UNLESS IT AFFECTS HEALTH. SO, REALLY THE QUESTION IS, WHAT ARE THE HEALTH DIVIDES THAT ARE SOCIAL DIVIDE. WE CARE ABOUT HEALTH. DOES THIS MAP ON TO OUR HEALTH? THE ANSWER IS YES, IT DOES. YES, IT DOES. WE CAN START AT SIMPLE THINGS LIKE LIFE EXPECTANCY. THIS IS WHITE AND BLACK SHOWING THE PERSISTENT ALTHOUGH SLIGHTLY NARROWING FOUR-YEAR INCREASE AND ALTHOUGH IN THE CONTEXT OF COVID IT'S REVERSING. LET ME GO BACK TO THE PICTURE OF SLAVERY. THIS IS THE SAME MAP OF SLAVERY ONLY IT'S RENDERED IN GIS. YOU SEE THE SAME DENSITY IN THE SAME AREA AND THAT MAPS DIRECTLY ON THE SOUTHERN U.S. AND THE LEGACY OF SLAVERY IN RESPECT CAST A LONG SHADOW AND MAPS ON TO HIGHER DENSITY TODAY. I COULD GO ON AND ON. I COULD SHOW YOU MORTALITY RATES BY BLACK VERSUS WHITE AND DIFFERENT AGES AND YOUNG AGES AND MIDDLE AGES AND OLDER AGES AND DIFFERENT PATTERNS OF RISK FACTOR AND HIGHER FROM A BLACK AMERICAN AND YOUNG AND MIDDLE AGES AND HIGH BLOOD PRESSURE AND DIABETES. AND I COULD ACTUALLY TIE THE VARIOUS PICTURES OF MARGINAL MARGINALIZATION AND THE MIDDLE IS THE 2008 RECESSION WHERE AREAS ARE RED LOIN THERE'S MORE FORECAST AND UNDER WRITE IS POOR HEALTH AND THE YEARS THAT ARE ON THE RIGHT THAT ARE DARKER ARE THE AREAS FORECAST WHICH IS THE AREAS WHERE IT WAS RED LINING DECADES AGO. SHOWING THE LONG FOOTPRINT OF THIS MALL DISTRIBUTION OF RESOURCES. LET ME GO BACK TO INCOME FOR A SECOND. REMEMBER I SHOWED YOU 80% AND 20% POPULATION HAS HIGHER INCOME AND THE HIGHER INCOME ALSO IS THE 20% OF POPULATION WITH BETTER HEALTH AND INCREASINGLY BETTER HEALTH. THESE ARE A VARIETY OF HEART DISEASE METRICS. LOOKING AT THE BLUE IS THE RICHEST 20% AND THE ORANGE IS THE POOREST 80% AND WHAT YOU SEE IS LOWER CHF, HEART ATTACK, STROKE ET CETERA AMONG 20% TO VERSUS 80%. IT MAY NOT SURPRISE YOU BUT WHAT THIS IS SURPRISING THAT THE GAP IS WIDENING AND LOOK AT THE PREVALENCE FOR 80% VERSUS 20% AND HEART ATTACK 840 80%. IT'S WIDENING ALONG ALL RISK FACTORS FOR HEART DISEASE. THE YELL SEW THE GROWN AND THE 20% AND THE 80% AND THIS IS 20 YEARS AGO. THERE WAS A GAP 20 YEARS AGO AND THERE'S A WIDER GAP NOW AND IT'S GROWING AND YUCKIN CONSTRUCTING PATTERNS. THE 20% AND 840 80% IS 25%. I WANT TO SHOW YOU ONE SLIDE AND THEY HAPPEN TOGETHER AND AT THE SAME TIME. I THINK THIS GRAPH BRINGS THEM TOGETHER AND IT BRINGS UP THIS IS ACROSS THE COUNTRY AND THIS IS MORE INCOME BY CENSUS TRACT. LET'S TAKE PREVALENCE OF ASTHMA AND I WANT YOU TO SEE HERE, AS YOU HAVE MORE MINUTE YOU CAN DRAW A LINE TO THE CLOUD OF CENSUS AND IT GOES DOWN THIS WEEK WHICH MEANS THE HIGHER INCOME LESS ASTHMA AND IT'S NOT SURPRISING AND WHAT THIS GRAFT DOES IS COLORS IN A TRACK PURPOSE, BY BLACK POPULATION AND THE BLACK CENSUS TRACKS ARE THOSE THAT ARE CLUSTERED WITH LOWER INCOME HIGH PREVALENCE OF ASTHMA SO THERE ARE RACIAL DIVIDES AND THEY COME TOGETHER TO CREATE A PATTERN OF LIMITED ACCESS TO RESOURCES THAT ULTIMATELY GENERATE HELP THAT ARE LINKED TO THE ACTUAL PATH OF PHYSIOLOGY THAT RESULTS IN DISEASES LIKE MALARIA OR COVID. SO LET'S MOVE TO THE MOVE MOMENT SO WE'RE LIVING THE COVID MOMENT. THIS IS THE MAP OF WHERE WE ARE IN COVID. THIS IS THE MAP OF THE CURVE. COVID HAS RESULTED IN EFFORTS AT MITIGATION. THIS IS A PICTURE OF TIME SQUARE. I LIVED SEVERAL YEARS LIVING IN NEW YORK CITY. AND THOSE EFFORTS AND MITIGATION HAVE RESULTED IN ECONOMIC CONSEQUENCES AND THIS IS THE DROP IN EMPLOYMENT AMONG AMERICANS WITH DROPPED EMPLOYMENT THE LOWEST LEVEL WE'VE HAD SINCE 1975 FROM LABOR DEPARTMENT DATA. THESE PATTERNS OF MITIGATION, THE RESULTS OF THIS MITIGATION HAS DID NOT UNEVEN AND IT SHOULDN'T BE SURPRISING AT THIS POINT THAT THOSE PATTERNS OF MITIGATION REFLECT THE UNDERLINE PATTERNS OF RESOURCES HAVE AND HAVE NOTs AND THEY HAVE SHAPED OUR HEALTH. THIS LOOKS AT SHARE OF UNEMPLOYMENT AND WHAT YOU SEE SCHEER OVER ALL, OUR UNEMPLOYMENT FOR HIGH WAGES, THAT'S ESSENTIALLY ALL OF US ON THE SCOPE, REALLY HASN'T GONE DOWN ANYMORE AND IT'S BACK TO NORMAL BUT YOU LOOK AT LOW WAGES WORKERS AND IT'S STILL 20% LOWER THAN IT WAS. I CAN SHOW YOU THE SAME THING BY RACE. THIS LOOKS AT WHITE AMERICANS OVER ALL HAVE RECOVERED MORE THAN HALF THEIR JOBS AND BLACK AMERICANS HAVE RECOVERED ONLY ABOUT A THIRD OF THEIR JOBS. THE LOSS OF RESOURCE THAT'S ALREADY DISTRIBUTED IS NOW BEING DEEPENED BY THE RESULT TO THE COVID PANDEMIC. AND OF COURSE, THAT IS ALSO LINKED TO RACE AND ACROSS ALL LEVELS OF EDUCATION ATTAINMENT THIS LOOKS AT UNEMPLOYMENT, BLACK, LATINO AND WHITE SHOWING THAT LOOK AT HIGH SCHOOL DIPLOMA THAT THERE'S HIGHER UNEMPLOYMENT FOR ALL THOSE GROUPS AND WHAT IS MORE HEARTBREAKING IS IT DIDN'T HAVE TO BE LIKE THIS AND IT HASN'T BEEN LIKE THIS IN HIGHER PRE SESSION AND IN 2001 AND 2008 AND WHAT YOU SEE IS THE DIFFERENT JOB LOSS AND THE CORONAVIRUS, LOOK AT 2008, IT WAS SOME STRATIFICATION BUT LOOK AT CORONAVIRUS. THE HIGHEST EARNING 25% VERSUS LOWEST LEARNING. THE STRATIFICATION THAT FOLLOWED THE COVID RECESSION. SO THIS IS A MOMENT IN TIME, THAT HAS LAID BEAR THESE UNDERLYING INEQUITIES AND ELEVATED THEM TO OUR CONSCIOUSNESS AND ALL OF US IN HEALTH AND ALL OVER THE WORLD SHOULD BE AWARE OF THIS AND OF COURSE IT'S NOT A SURPRISE THAT WHILE WE'RE GOING TO THE NATIONAL TRAUMA OF COVID, THE NATIONAL TRAUMA TO USE DR. COLLINS' WORD OF THE ECONOMIC CONSEQUENCES OF COVID WE ARE GOING THROUGH TOGETHER OF THE MOST PROFOUND CIVIL UNREST IN 50 YEARS DRIVEN BY RACIAL CONCERNS. OF COURSE ALL OF THIS EMERGED AFTER THE KILLING OF AN ARMED BLACK MAN AND WOMAN BUT REALLY IT WASN'T ONLY ABOUT THAT. IT WAS THE UNDERLYING CONDITIONS THAT HAVE BEEN SO SOCIALLY STRATIFIED THAT COVID MADE IT SO UNCLEAR. LET'S GO TO COVID. LET'S GO TO HOW THE BLIND BILLY JOHNSON STORY TRANSLATED PRE DIRECTLY TO A TIME OF COVID. ABOUT 50,000 BLACK AMERICANS HAVE DIED FROM COVID TO DATE. SOME PLAQUE AMERICANS HAVE ABOUT 1% OF THE U.S. POPULATION AND 19% OF DEATHS WERE RACIST QUANTIFIED. BLACK AMERICANS BUY TWO TIMES THE RATE OF WHITE AMERICANS. THERE ARE HIGHER DEATH AMERICAN LATINO, NATIVE HAWAIIAN AND I'M JUST FOCUSING ON BLACK AMERICANS FOR THE SAKE OF SIMPLICITY IN THIS TALK. WHAT I FIND MOST REMARKABLE THAN ASSUMING COVID HAPPENED, ASSUMING COVID HAPPENED, BUT, JUST MAKING THE SIMPLE SUCH, 20,000 BLACK AMERICANS WOULD BE ALIVE. IT'S NOT SAYING THERE'S NO COVID, THEY'RE SAYING THERE'S STILL COVID JUST EVERYBODY DIES AT THE SAME RATE. WE STILL HAVE 20,000 BLACK PEOPLE AND 10,00 10,000 10,000 LATINO PEOP LE ALIVE. IT'S IMPORTANT TO BREAK IT DOWN. WHAT DO WE MEAN BY DEATH AND COVID? WHAT DO WE MEAN BY COVID IN PARTICULAR GROUPS AND HOW IS THAT LINKED TO THE UNDERLYING PATTERNS OF OF LOSS OF SOCIOECONOMIC CONDITIONS THAT CREATE HEALTH THAT I'M TALKING ABOUT BEFORE. I'M GOING TO ADDRESS IT BY LOOKING AT THIS GRAPH. THEY ALL BEHAVE THE SAME WAY. LET'S FOCUS ON DISTRICT OF COLOMBIA WHICH IS WHERE YOU ARE AND BLACK VERSUS WHITE AND THROW GRAPHS AND THE BLUE GRAPH IS THE PERCENTAGE OF THE POPULATION AND THE ORANGE GRAPH IS COVID AND THE GRAY IS PERCENT OF COVID DEATHS. WHAT YOU SEE AMONG BLACKS IS, MORE COVID CASES THAN THERE ARE POPULATION AND MORE DEATHS THAN THERE IS COVID CASES. CONVERSELY AMONG WHITE, FEWER VASES THAN THE POPULATION AND FEWER DEATHS THAN CASES. WHAT DOES THAT MEAN? THAT MEANS THAT THERE ARE TWO SETS OF RISK FACTORS. RISK FACTORS TO TAKE US FROM BEING IN A POPULATION TO GETTING COVID AND THERE ARE RISK FACTORS THAT GO FROM GETTING COVID TOLL DYING FROM COVID. AND THE TWO SETS OF RISK FACTORS ARE COINCIDING OF GREATER DEATH COMPARED TO BLACK AND WHITE AMERICANS. THAT MATTERS TO US UNDERSTANDING ABOUT WHAT ARE THE FORCES AROUND ALL OF US THAT GENERATE GREATER RISK FOR GETTING THE DISEASE AND WHEN YOU GET THE DISEASE, TO HAVE MORE SEVERE OUTCOMES. SO I WANT TO GET IN THAT. BEFORE I DO, I JUST WANT TO PAUSE FOR A SECOND AND SAY, WHILE I'M HERE TALKING ABOUT THE U.S. AND I'M TALKING ABOUT THE U.S. BECAUSE THE NATIONAL INSTITUTE OF HEALTH WE ARE IN THIS COUNTRY AND IT'S OUR COUNTRY THAT WE ARE FOCUSING ON IS APPROPRIATE BUT THIS PATTERNING, THIS PATTERNING OF DISADVANTAGED BECOMES PATTERNING BY HEALTH IS NOT UNIQUE TO US. IT'S AS FUNDAMENTAL A LAW OF POPULATION HEALTH SCIENCE AS ARE RULES ABOUT BLOOD PRESSURE AND CHOLESTEROL ASSOCIATED WITH HEART DISEASE. THIS COMES FROM THE U.K. IT LOOKS AT THE FIRST WAVE. THIS IS THE CLASSIC EPIDEMIC CURVE AND SEE THE NUMBER OF COVID CASES, THEY SEPARATE BY QUINN TILE. EVERYBODY BEHAVES THE SAME WAY. IT'S IN CASES SIMILARLY IN DEATHS. SAME THING EXACTLY. LOWEST QUINTILE, BEST QUINTILE. THIS IS A UNIVERSAL ON -- OUR COUNTRIES PREDICT A RELATIONSHIP TO THESE UNDERLYING CONDITIONS AND IT'S ONE WE HAVE A RESPONSIBLE TO ADDRESS. SO, LET'S BRING IT ALL TOGETHER. LET ME TALK ABOUT HEALTH HAVE AND HAVE NOTs AND COVID-19. SO, WHY THIS PATTERNING OF RACE AROUND COVID? WELL, ONE CAN SAY, WELL MAYBE THERE'S SOMETHING INTRINSIC ORIGIN ETIC OR SOMETHING ABOUT OUR TREATMENT OF PEOPLE WITH COVID-19. I SHOWED YOU EARLIER ABOUT TRIUMPH TREATMENT. THAT'S NOT THE CASE. WE KNOW THAT'S NOT THE CASE. THERE'S A PAPER THAT CAME THIS GROUP AT NYU IT TURNS OUT WHERE THEY LOOK AT THE DEATH OF PATIENTS BY RACE, WHEN PEOPLE ARE ADMITTED TO HOSPITAL. ALL I WANT YOU TO LOCK AT THIS. THIS BLACK AND HISPANIC, NO SIGNIFICANT VALUE AND WHEN YOU ARE IN HOSPITAL THERE'S NO DIFFERENCE IN MORTALITY, WHICH IS GOOD. THIS IS GOOD. THAT MEANS THAT WITHIN OUR HEALTH SYSTEM WE DO NOT HAVE THIS SYSTEMATIC DIFFERENTIAL TREATMENT. IT MEANS THERE'S NOTHING INTRINSIC ABOUT BEING BLACK OR LATINO OR WHITE THAT'S KILLING YOU AND MAKING YOU MORE LIKELY TO DIE WHEN IN HOSPITAL. IT MEANS OUR RISKS FOR GREATER DEATH FROM MINORITY GROUPS REFLECTS THE GREATER RISK FOR ACQUIRING COVID AND DYING FROM COVID AND MOST OF THE TIME IN THE COMMUNITY. SO WHAT ARE THE GREATER RISK FOR ACQUIRING COVID? WELL COVID IS ACQUIRED THROUGH CONTACT. THROUGH BEING INSIDE CLOSE SPACES TOGETHER, NOT BEING ABLE TO ISOLATE, NOT BEING ABLE TO WORK FROM HOME. THESE RESOURCES ARE SOCIALLY PATTERNED. THIS IS FROM PAPER THAT OUR GROUP DID, WHICH CAME OUT IN NATURE HUMAN BEHAVIOR, LOOKING AT SMARTPHONE USERS STAYING HOME ALL DAY AND THOSE WORK OUTSIDE THE HOME. IT'S SIMPLE. THE RICHER YOU ARE THE MORE LIKELY YOU ARE TO BE ABLE TO STAY HOME AND THE RICHER YOU ARE THE MORE LIKELY, THE LESS LIKELY YOU ARE WORKING OUTSIDE THE HOME. THAT, OF COURSE, IS MAPS ON THE ABILITY TO WORK BY INREQUEST QUINTILE. THIS IS A PERFECT RESPONSE RELATIONSHIP THAT TOP INCOME YOU WORK AT HOME AND THIS RIGHT THERE IS THE CENTRAL EXPLANATION FOR WHY YOU ARE MORE LIKELY TO GET COVID IF YOU DO NOT HAVE THE RESOURCES TO PROTECT YOUR HEALTH IN GENERAL AND COVID, IT'S BEHAVING LIKE A FULL RANGE OF DISEASES. I COULD HAVE GIVEN THIS FIRST HALF OF THIS TALK 10 YEARS AGO AND IT ILLUSTRATES THAT MUCH MORE CLEARLY THAN WE'VE SEEN IT AND HOPEFULLY WE ARE NOW SEEING IT CLEARLY. SO THIS IS WORK AND THIS IS LIKELY TO BE WORKING IN ESSENTIAL INDUSTRY. IF YOU ARE BLACK YOU ARE WORKING IN ESSENTIAL INDUSTRY THAN OTHER RACIAL GROUPS. I'D LIKE THIS GRAPH. IT'S FROM THE U.K. AND MAKING THIS CASE CLEARLY THIS IS A HIGHER INCOME HERE ON THE X AXIS AND WHAT YOU HAVE IS LOOK AT THE YELLOW, HAVING DIAGNOSIS WITH ILLNESS MAKES YOU VULNERABLE TO COVID. I'M GOING TO SWITCH TO NOT JUST GETTING COVID BUT GETTING SICK WITH COVID. WHAT YOU SEE IS WHEN YOU ARE HIGHER INCOME, YOU ARE LESS LIKELY TO HAVE UNDERLYING CONDITIONS. IF YOU ARE HIGHER INCOME, YOU ARE LESS LIKELY TO HAVE UNDERLYING MENTAL CONDITIONS AND WE KNOW UNDERLYING HEALTH CONDITIONS MAKE YOU MORE LIKELY TO HAVE POOR MENTAL HEALTH IN THE CONTEXT OF COVID. SO WE'VE SEEN WHAT MAKES YOU MORE LIKELY TO GET COVID AND NOW WHAT MAKES YOU MORE LIKELY TO BE SICK FROM COVID, IT'S BEING VULNERABLE TO COVID BUZ BECAUSE WE KNOW, THAT THE DEATH RATE FOR PEOPLE WITH UNDERLYING CONDITIONS IS MUCH HIGHER THAN THOSE WITHOUT. PEOPLE WITHOUT UNDERLYING CONDITIONS ARE QUITE UNLIKELY TO DIE FROM COVID. YOU ARE MUCH MORE LIKELY TO DIE FROM COVID IF YOU HAVE UNDERLYING CONDITIONS AND I'VE SHOWED YOU HOW THAT UNDERLYING PATTERNING RESULTS IN A GREATER BURDEN OF THESE UNDERLYING CONDITIONS AMONG BLACK AND LATINO AMERICANS THAN IT IS AMONG WHITE AMERICANS. OR AMERICANS WITH THOSE WITH HIGH SOCIOECONOMIC RESOURCE AND THE POOREST 80% VERSUS THE RICHEST 20%. THAT'S DATA FROM CHINA AND THE U.S. AND THIS SHOWS BY RACE AND INCOME AND I'LL JUST FOCUS ON MY INCOME SHOWING THAT EVERY AGE GROUP THE HIGHER INCOME YOU HAVE THE FEWER RISK FACTORS YOU HAVE. THAT, OF COURSE, IS WHAT HAS TRANSLATE NOD THIS ENORMOUS GAP WHITE IS BLUE AND THE ORANGE IS BLACK AND THE GRAY IS LATINO AND WHAT YOU SEE IS THE WHITE, BLACK, WHITE LATINO GAP IS THE REASON IS VERY SIMPLE, IT'S BECAUSE WHEN YOU GET TOLD AGES WE'RE ALL MOVING TO THE MEAN AND IN TERMS OF UNDERLYING MORBIDITY AND GETTING COVID AT YOUNGER AGES, THESE TWO RISK, RISK OF GETTING COVID AND DYING FROM COVID, IS MUCH BRIGHTER AND MUCH MORE CLEAR, AND RESULTS IN MUCH WIDER DISPARITY. AND EVEN ON CONSEQUENCE OF COVID THAT ARE NOT DEATH, MENTAL HEALTH, WE SEE THIS DIVIDE. A PAPER WAS PUBLISHED LOOK AGO THE THE INCREASE IN DEPRESSION, WHICH IS ABOUT THREEFOLD INCREASE IN DEPRESSION. THE BLUE IS PRE COVID AND THE RED IS NO COVID. FOR THE SAKE OF THIS PRESENTATION, IT'S WHO IS MORE LIKE TO HAVE DEPRESSION AND WHEN WE STRAT FIE THE SAMPLE, YOU SEE GROUPS WITH LOW ASSETS, THE GROUP IN OTHER WORDS WHO DO NOT HAVE THE RESOURCES TO PROTECT AND HIGH STRESSORS, THE GROUP WORRIED ABOUT INCOME, QUARTERBACJOBLOSSES, THEY HAVE THE GROUPS AND HIGH ASSETS AND LOW STRESSES. SO THE PICTURE TO MY MIND IS VERY CLEAR. IT'S UNDERLYING PICTURE OF SOCIOECONOMIC AND RACIAL DIVIDES THAT'S SHAPED OUR HEALTH BEFORE COVID HIT AND FOUND US AS SITTING DUCKS. WE'RE SITTING DUCKS FOR THE EXPRESSION OF THE UNDERLYING DA VOIDS THAT BECAME DEEPER HEALTH HAVEs AND HAVE NOTs AT THE TIME OF COVID. AS I START TO WIND DOWN, I WANT TO TALK ABOUT OTHER THINGS. I WANT TO MOVE TO A COUPLE OF LONG VOW PICTURES ABOUT COVID. I'M TALKING ABOUT COVID BUT I WANT TO TALK ABOUT OTHER FORCES THAT ARE SHAPING OUR HEALTH IN THE TIME OF COVID THAT WE CANNOT FORGET THAT ARE ALSO GOING TO BE SOCIALLY PATTERNED THAT ULTIMATELY I THINK DEPEND ON US IN THE HEALTH COMMUNITY TO THINK ABOUT AND TO STUDY SO WE CAN MITIGATE. FIRST OF ALL, EXCESS MORTALITY FROM OTHER CAUSES. YOU'VE READ ABOUT THIS AT STROKES, ALZHEIMER'S, THIS LOOKS BY MONTH AND THE DARK BLUE-LINE IS FIVE YEARS AND THE BARS ARE WHAT IS HAPPENING IN COVID TIMES THAT WE HAVE HIGHER MORTALITY IN COVID TIMES THAN WE'VE HAD ANY TIME IN FIVE YEARS AND THERE ARE MANY REASONS FOR THIS. WE ARE GOING TO HAVE THIS PATTERN, THIS SOCIAL YE ECONOMIC MORTALITY THAT IS GOING TO EXCEED THE SOCIOECONOMIC PATTERN BURDEN OF COVID MORTALITY AND I'VE TALKED A BIT ABOUT THE EXCESS MORTALITY BECAUSE OF BLACK AND LATIN X COMPARED TO WHITE AND THIS POINT IS MADE IN ABOUT HOW THAT PATTERNING OF DISPARITY EXISTS AND HAS EXISTED FOR A LONG TIME. THIS IS MORTALITY OVERTIME AND THIS LIFE EXPECTANCY, BLACK VERSUS WHITE AND WHAT YOU SEE A ALL OUR MORTALITY IS GOING DOWN BUT BLACK IS HIGHER THAN WHITE AND LIFE EXPECTANCY IS GOING UP AND WHITE IS GREATER THAN BLACK. THIS IS DIP WAS IN 1918, THE 1918 PANDEMIC. WHAT IS GOOD ABOUT THIS PAPER, IT GOES ON TO THEN QUANTIFY WHAT THE EXCESS MORTALITY AND THE BOTTOM LINE IS THIS. THE DIFFERENTIAL MORTALITY DUE TO THESE UNDERLYING INEQUITIES DUE TO THE SOCIAL PATTERNING OF RESOURCES, RESULTING IN HEALTH HAVE AND HAVE NOTs IS SUBSTANTIALLY GREATER THAN THE MAGNITUDE OF THE DIFFERENCES WE'RE SEEING IN A TIME OF COVID. NOW THAT MAKES A LOT OF SENSE, IT MAKES A LOT OF SENSE BECAUSE WHILE COVID HAS BEEN GALVANIZED OUR WORLD IT'S NOT AS BAD AS IT COULD HAVE BEEN OR, AS BIG A CONTRIBUTION TO MORTALITY AS SOMETIMES WE THINK IT IS. MAKE THE CASE HOW COVID IS NOT AS BAD AS IT COULD HAVE BEEN. THIS IS A CASE COMPARED TO OTHER VIRUSES AND TO THINK HOW BAD IT COULD HAVE BEEN AND IT IS THE NOTION OF CONTAGION NEXT TIME. THIS IS DEATHS FROM COVID AND 24 IS 2.5 MILLION AMERICANS DIED FROM ALL CAUSE BESIDES 2.9 MILLION AMERICANS DIE EVERY YEAR SO. >> THIS IS THE SADLY THE LONGEST CONSEQUENCES OF COVID. THIS LOOKS AT SCORES, THIS IS THE SCALE SCORES LOOKING AT DIFFERENT GRADES AND WHAT YOU SEE IS WINTER 1919 IN RED AND THIS IS A CLASSIC POPULATION CURVE SHIFT AND ESSENTIALLY ALL OUR KIDS ARE DOING WORSE. THEY'RE ALL DOING WORSE BUT THEY'RE NOT DOING WORSE AT THE SAME RATE. THIS IS LOOKING AT THE DARK DOT THAT SCHOOLS WITH MORE THAN HALF STUDENTS OF COLOR AND THIS IS SCHOOLS WITH MORE THAN HALF WHITE STUDENTS AND WHAT YOU SEE IS THAT SCHOOLS WITH MORE STUDENTS OF COLOR ARE FALLING BEHIND ABOUT 10 POINTS, 10 PERCENTAGE POINTS LESS THAN OUR OTHER SCHOOLS AND THIS LOOKS AT ONLINE PARTICIPATION. YES WE ARE DOING ONLINE PARTICIPATION BUT ONLINE PARTICIPATION IS 15% LOWER LOW INCOME SCHOOLS AND BACK TO NORMAL FOR HIGH INCOME KIDS. WE KNOW MUCH OF THIS FROM DATA ACTUALLY THAT EDUCATION ATTAINMENT IS PERHAPS THE SINGLE GREATEST PREDICTER OF LONG-TERM HEALTH. THIS LOOKS AT LATINOS BLACKS, WHITES AND YEARS OF EDUCATION, FOR ALL GROUPS THE MORE EDUCATION THAT YOU HAVE, THE LOWER YOUR MORTALITY RATE. SO, IT'S ACTUALLY VERY SIMPLE THAT AS WE ULTIMATELY ARE EFFECTING AN EDUCATIONAL ACHIEVEMENT AND WE CREATE GAPS WE'LL CREATE MORBIDITY GAPS. A CALCULATION THAT THE EFFECT, THE HEALTH EFFECTS OF SCHOOL CLOSURES IN THE LONG-TERM, ARE GOING TO BE WORST NET COVID EFFECTS, THE NET COVID BENEFITS OF SCHOOL CLOSURES AT THE TIME. SO LET ME WIND DOWN. I WANT TO SAY TWO THINGS ABOUT THE ROLE OF SCIENCE AND I WOULD LIKE TO TAKE QUESTIONS. I COULD GIVE A LOT TALK BUT THE ROLE OF SCIENCE AT THIS TIME. SO I AM NOT GOING TO DID THAT AND I'VE DONE SOME WRITING ABOUT IT BUT I THINK ALL OF IN IN SCIENCE HAVE A RESPONSIBILITY THIS TIME TO SAY WHAT ARE THE -- WHAT HAVE WE CONTRIBUTED? WHAT HAVE WE DONE TO HELP IN THIS MOMENT? THIS HAS BEEN A MODEL. I INSIST AS I STARTED IN THE BEGINNING, WHAT HAS SCIENCE DONE AND HOW CAN SCIENCE DO BETTER AND DO BETTER. I THINK WHEN YOU THINK ABOUT HOW WE HAVE BEHAVED AND AND I THINK WE HAVE TO THINK ABOUT OUR ROLE IN EXTREME PRO DICTION THAT'SES HAVE HELPED POLARIZE THE PUBLIC AND A ROLL IN ARROGANCE ABOUT US, THE CERTAIN ATTITUDE THAT'S BEEN EXPRESSED IN MANY AREAS OF SCIENCE AND WHAT HAS GARY BETTMAN TO HAPPEN THAT HAS CONTRIBUTED THE POLARIZATION IN THE COUNTRY AND ULTIMATELY ABOUT OUR ROLE IN THINKING THROUGH CAREFULLY MITIGATION THINKING ABOUT EFFORTS THAT COULD MINIMIZE THESE HARMS THAT I'M TALKING ABOUT. >> LET ME CONCLUDE. I WANT TO CONCLUDE THE CONTAGION. I SHOWED YOU THE SLIGHT AND IT'S SOME RESPECT THAT COVID IS COVID AND IT WASN'T NEPA. DID I SAY THAT BECAUSE, I NEED TO BELIEVE THAT FRANKLY IT'S BEEN A LONG YEAR FOR ME AND ALL OF YOU AND I REALLY CAN'T HANDLE THE THOUGHT I'M GOING TO THROUGH IT WE NO OTHER PANDEMIC WILL HAPPEN. MY WORRY IS THAT WHAT WE ARE GOING TO TAKE FROM THE MOMENT, IS NUMBER ONE OF MY 10 POINTS. THIS IS A MOMENT OF BIOMEDICAL TRIUMPH. WE SHOULD TAKE THAT AND I THINK WITH SHOULD WALK AND STAND TALL ABOUT THAT. THAT IS NOT ENOUGH. WHAT WE SHOULD TAKE FROM THIS IS THE FACT THAT WE SHOULD STRUCTURE OUR THINKING AND GENERATES HEALTH TO AVOID THE SAME PATTERNING AND THE SAME UNDUE BURDEN OF COVID THAT HAPPENED BECAUSE OF HOW WE WERE STRUCTURED AND BECAUSE OF OUR GENERATION OF HEALTH THAT LONG PROCEEDED AND I CALLED IT OUT OF A JAMES BALDWIN BOOK AND FOR THOSE THAT NEXT TIME IS A BOOK ABOUT THE CENTRAL ROLE OF RACISM IN OUR SOCIETY AND IT'S ONE OF SEVERAL FORCES THAT SHAPE THE STRUCTURE OF OUR WORLD AND SHAPE OUR HEALTH AND SO MY GOAL HERE IS TO GET US TO THINK ABOUT THE CONTAGIOUS AND THINK ABOUT HOW WE MITIGATE THE CONTAGIOUS NEXT TIME. WE KNEW AN EPIDEMIC WAS GOING SINCE 2017. TIME MAGAZINE READY FOR THE NEXT PANDEMICMENT THEY WERE RIGHT. AND TIME MAGAZINE IS A CONSERVATIVE PUBLICATION THAT'S REPRESENTING SORT OF THE BROAD RURAL CONSENSUS OPINION. WHAT IS REMARKABLE ABOUT THIS ISSUE WAS THAT IT TALKED ABOUT THE SCIENCE THAT WE NEEDED FOR UNDERSTANDING AND BEING READY FOR A PANDEMIC. THE USE OF THE WORLD SCIENCE WAS A NARROWLY CONSTRUED USE OF THE SCIENCE THAT POINT ONE OUT OF MY 10 POINTS. ON BIOMEDICAL SCIENCE OF DETECTION OF SCREENING AND VACCINE DEVELOPMENT AND ALL OF THAT IS IMPORTANT. ALL OF THAT ULTIMATELY IS ONE THE LEVEL OF TREATMENT OF MALARIA FOR BLIND BILLY JOHNSON IGNORING THE OTHER FORCES THAT ARE LINKED TO THE CONSEQUENCES OF THIS PANDEMIC IN THE FUTURE PANDEMIC. SO I WANT TO END HERE. THIS IS MY LAST SLIDE. I WANT TO END WITH A SLIDE ABOUT SPORTS BECAUSE SPORTS BRINGS MANY OF US JOY. I ONLY CARE ABOUT SOCCER. AND I'M VERY FORTUNATE I'M FILING THIS COUNTRY WHICH HAS THE WORLD'S BEST SOCCER TEAM WITH IS THE U.S. WOMEN'S NATIONAL SOCCER TEAM AND I'M SHOWING YOU THIS PICTURE TO EXPLAIN HOW SOCCER WORKS FOR ANY OF YOU WHO ARE UNFORTUNATE ENOUGH TO FOLLOW SOCCER. BROADLY SPEAKING, SOCCER IS PLAYED BY 11 PEOPLE AND THEY HAVE TO PUT THE BALL INTO THE NET. YOU JUST TAKE THE BALL AND GET IT NO THE OTHER NET. 10 PLAYERS CAN ONLY USE THEIR FEET AS THE SPORT SHOULD BE CALLED FOOTBALL, PRO PRO ATLY. ONE WOMAN IN BLACK, SHE'S THE GOAL KEEPER AND SHE USES HER ARMS AND HER WHOLE BODY TO STOP THE BALL. IF NO ONE SCORES ON YOU YOU WILL NOT LOSE A GAME. IF YOU DON'T KNOW SOCCER, YOU CAN SAY, HUH, WELL, THINKING THAT WAY THERE'S 11 PLAYERS THAT'S A LOT OF PLAYERS, LET ME INVEST IN THE GOAL KEEPER BECAUSE IF I HAVE THE BEST GOAL KEEPER AND SHE CAN STOP EVERY BALL, I'M NOT GOING TO LOSE A GAME. THAT'S TRUE. BUT IF YOU WATCH A PROFESSIONAL SOCCER GAME YOU WILL SEE WHAT THE GOAL KEEPER DOES, SHE'S PACING HER AREA AND SHE'S PROWLING AND SHE'S YELLING AT HER UNTIL OWE PLAYERS. YOU KNOW WHAT SHE'S YELLING, SHE'S SAYING, KEEP THE BALL AWAY FROM ME. BECAUSE THE NET IS VERY BIG. ANY GOOD GOAL KEEPER KNOWS IF THE BALL COMES AT HER STRONGLY ENOUGH, SHE'S GOING TO LOSE THE BALL. NOW WHY AM I TELLING YOU THIS. BECAUSE THE GOAL KEEPER IS BY OWE MEDICAL RESEARCH FOCUSED ON CURE AND TREATMENT. IT'S TREATMENT OF MALARIA AND IT'S A VACCINE FOR AND TREATMENT FOR COVID. WE NEED THAT. WE NEED THE WORLD'S BEST GOAL KEEPER AND HAVING THE WORDS PREMIER HEALING RESEARCH INSTITUTE IN THE NIH, WE SHOULD HAVE THE WORLD'S BEST GOAL KEEPER. THE BEST GOALERRER BY HERSELF IS NOT GOING TO WIN THE GAME. TO WIN THE GAME WE NEED THE OTHER 10 PLAYERS AND THOSE OTHER 10 PLAYERS ARE OUR INVESTMENT IN EDUCATION, URBAN ENVIRONMENT, FAIR WAGES AND GENDER EQUITY, ENVIRONMENTAL CONDITIONS AND WHERE WE EAT, AND THE FOOD WE EAT THE WATER WE DRINK AND THE CONDITIONS WHERE WE WORK AND WHERE WE LIVE AND WHERE WE PLAY. AND THOSE ARE ALSO CONDITIONS THAT GENERATE HEALTH, THOSE ARE ALSO CONDITIONS THAT SHOULD BE SUBJECT OF OUR SCHOLARSHIP AND WE SHOULD INVEST TO CREATE A HEALTHIER WORLD AND MITIGATE THE CONSEQUENCES OF THE CONTAGION NEXT TIME. I WILL STOP THERE AND I WILL STOP SHARING AND I'M DELATED TO TAKE QUESTIONS. THANK YOU FOR IN INVITING ME. >> THANK YOU, SANDRO. THAT WAS MAGNIFICENT. I JUST LEARN SO MUCH FROM YOU EVERYDAY AND YOUR 10 POINTS ARE ALWAYS DIFFERENT. YOU ALWAYS END WITH SOCCER, WHICH IS GREAT. WITH FOOTBALL. I APPRECIATE THAT ANALOGY. SO WE HAVE A NUMBER OF QUESTIONS THAT CAME IN ON THE CHAT. I'LL READ THE FIRST ONE THAT CAME IN. DO OTHER COUNTRIES INTENTIONALLY INVEST IN SOCIAL DETERMINANTS OF HEALTH OR IS THERE SOME REASON THAT THE U.S. DOES NOT VALUE INVESTING IN THE SOCIAL DETERMINANTS OF HEALTH FOR SOME CULTURAL REASONS AND I ASSUME WE MEAN, OTHER HIGH INCOME COUNTRIES WITH THE RESOURCES? >> YEAH, THERE'S A REAL HIT HETEROGENEITY AND COUNTRIES INVEST MORE AND LESS AND I THINK THE REASONS ARE PRETTY COMP COMPLICATED. WE HAVE HAD A NARRATIVE FOR A LONG TIME WHERE WE'VE FOCUSED ON MALARIA, JUST TO FOCUS ON TREATMENT AND CURE AND I THINK WE HAVE NOT WRAPPED OUR BRAIN AROUND THINKING ABOUT THE FULLNESS OF THE PRODUCTION OF HEALTH AND I THINK FUNDAMENTALLY, WE NEED A SHIFT IN THE CONVERSATION AND I THINK WE NEED A SHIFT IN CONVERSATION THAT COMES FROM THAT SIGNS PLACE SCIENCEPLAYS A ROLE IN GENERATING WE ARE ALREADY FAR MORE AHEAD THAN WE HAVE BEEN. WHY WANT TO END ON PESSIMISM, I THINK WE'RE MUCH BETTER TODAY AT UNDERSTANDING THIS THAN FIVE OR 10 YEARS AGO. WE ARE IN A BETTER PLACE. THE QUESTION IS, CAN WE NOW USE THE MOMENT TO LEARN AND DO EVEN BETTER. >> SCIENTIFIC DIRECTOR. NICE TO SEE YOU. GREAT TALK. I'M GOING TO COMBINE TWO QUESTIONS BECAUSE THEY HAVE TO DO WITH INDICATORS THAT ARE USED IN THIS TYPE OF RESEARCH. THE FIRST ONE HAS TO DO WITH THE DIFFERENCE BETWEEN WEALTH AND INCOME AND I WOULD ALSO PROBABLY ADD FROM MY PERSPECTIVE IS, IN TERMS OF PREDICTING HEALTH OUTCOMES, IS THERE ONE THAT IS PREFERRED OR DO THEY TELL YOU DIFFERENT THINGS? THE SECOND ONE IS ABOUT HOW LOW AND HIGH STRESSORS WERE MEASURED IN THE STUDY THAT LOOKED AT THE RISK OF DEPRESSION AND ASSETS, INTERACTION WITH ASSETS. >> THE FIRST TO THE FIRST QUESTION IS THERE'S NO THAT THERE ARE CONDITIONS THAT ARE MUCH MORE SENSITIVE -- HEALTH CONDITIONS MUCH MORE SENSITIVE TO HEALTH AND ECONOMIC SCIO CIRCUMSTANCES. MENTAL HEALTH, COMMON ANXIETY, SUBSTANCE USE, THOSE CONDITIONS VARY QUITE QUICKLY WITH CHANGING SOCIOECONOMIC CONDITIONS. IN FACT, I HAVE WRITTEN A HAVE HE'S OF PAPERS ON CONDITIONS THAT ARE VULNERABLE TO SOCIOECONOMIC CONDITIONS. THE CONDITIONS THAT ARE LEAST VULNERABLE ARE THE LONGEST INDUCTION PERIOD SO THINGS LIKE PAN CROW ATTIC CANCER. THERE'S A SPECTRUM OF WHAT IS VULNERABLE. QUESTION TWO, REMIND ME OF QUESTION TWO. >> LOW VERSUS HIGH STRESSOR. >> YES, THERE WAS A LIST OF 14 STRESSORS WHICH COMES FROM SCALES AND YOU CAN E-MAIL AND I'LL SHARE THEM WITH YOU. >> HERE IS A QUESTION. SO, DO YOU THINK HEALTHCARE SYSTEMS FOCUSES ON MALARIA OR IN OTHER WORDS, DO WE FOCUS ON THE GOAL KEEP ERROR THE TREATMENT SIDE OF THE HEALTHCARE SIDE, BECAUSE OF THE PROFIT MOTIVE FOR INTERVENTION? IS THIS A RATIONALE FOR THE U.S., DISPROPORTIONATELY SPENDING ON HEALTHCARE AND NOT INK INVESTING ON A SIMILAR PREPORTION ON HEALTH ON THE KINDS OF THINGS THAT LEAD TO BETTER HEALTH? >> THE ANSWER IS YES. I DON'T MEAN THAT GLIBLY. THE PROFIT DOES MATTER. FUNDAMENTALLY, RIGHT, WE HAVE BUILT OUR SYSTEMS, OUR SYSTEMS OF SKIP AND INTERVENTION AND OUR SYSTEMS OF PROVIDING CARE AROUND A MODEL THAT IS CENTERS ON CURE AND TREATMENT. WE HAVE BUILT A SYSTEM TO TEND TO THE GOAL KEEPER, RIGHT. AND WHEN YOU HAVE THAT SYSTEM, ALL OF A SUDDEN YOU HAVE A LOT OF FORCES THAT GENERATE INERTIA THAT PROMOTE LOOKING AFTER THE GOAL KEEPER. YOU SAY THE GOAL KEEPER MATTERS MOST, YOU ARE GOING TO MAKE SURE YOUR TRAINERS LOOK AFTER THE GOAL KEEPER. YOU ARE GOING TO FOCUS ON THE GOAL KEEPER AND GIVE THE 10 PLAYERS HAM AND CHEESE AND THE GOAL KEEPER EATS NUTRIENT RICH FOOD. IS IT IN ONE THING, IT'S ALL THOSE THINGS. >> THE NEXT QUESTION IS, WOULD YOU GO THAT CREATING ACCESS TO BUY OWE MEDICAL RESEARCH CAREERS CAN BE AN EFFECTIVE PUBLIC-HEALTH INTERVENTION BY CREATING A PATHWAY TO THE MIDDLE-CLASS? PROVIDING USEFUL KNOWLEDGE? >> YEAH, IT'S A GREAT QUESTION, ACTUALLY. I CAN THINK OF MANY, MANY THINGS MUCH WORSE THAN CREATING A PATHWAY TO A MIDDLE-CLASS THROUGH RESEARCH CAREERS. IT'S A FANTASTIC QUESTION. IF WE, IN THE HEALTH RESEARCH ESTABLISHMENT USED THAT TERM, CAN BE PART OF CREATING SUSTAINABLE EMPLOYMENT AND LIVABLE WAGES FOR PEOPLE THE WORLD WOULD BE BETTER SERVED BY THAT. >> THERE'S A QUESTION THAT CHALLENGES THE NOTION. >> THAT REALLY UNDERSTAND HOW HEALTH IS PRODUCED. FUNDAMENTALLY, I WOULD ARGUE THAT WHEN YOU LOOK AT THE LITERATURE, THERE IS MORE EVIDENCE FOR THE PRODUCTION OF HEALTH THROUGH MANY OF THE FORCE I TALK TO. I MEAN ABOVE THE SKIN THEN THERE IS MANY MORE OF THE FORCES THAT WE FOCUS WHICH ARE ATTENTION TO. I WANT TO BE VERY CLEAR THAT MY CALL IS FOR THE SAME LEVEL OF RIGGER OF SCIENCE AND SKIP TO FORCES. THIS IS -- BY IDENTITY I'M ASSIGN TEST. I WANT THE SAME LENS APPLIED. WHEN I USE MY SOCCER ANALOGY AT THE END, I DON'T WANT DIFFERENTIATAL TREATMENT. I WANT TO STUDY ALL OF THEM. >> ONE MORE QUESTION. >> IS THE SOLUTION TO INVEST MONEY IN SOCIAL SERVICE THIS IS. >> I THINK IN PART IT IS. I THINK THE SOLUTION IN PART IS SOCIAL SENTIMENT AND IN PART IT'S CHANGING THE CONVERSATION ON HEALTH AND IN PART PAYING ATTENTION TO GROUPS THAT HAVE THEIR HAVE NOTs SO THOSE HAVE HAVE NOT GAPS ARE HEALTH HAVE AND HEALTH HAVE NOT GAPS. >> I WANT TO JUST CLOSE WITH A BIG, BIG THANK YOU. THIS WAS MAGNIFICENT, AS I'VE LEARNED SO MUCH FROM YOU EFFORT THAT YOU PRESENT AND ORGANIZE THOUGHT. AND REALLY LEAVE US WITH JUST TWO FINAL MESSAGES, ONE, HE'S THESE FACTORS ARE FUNDAMENTAL AND ALL SCIENTISTS, ALL CLINICIANS NEED TO CONSIDER THEM. AS YOU POINTED OUT, WE'RE SCIENTISTS AND WE NEED TO GIVE THEM EQUAL RELEVANCE AS WE DO ALL THE OTHER THINGS IN BIOLOGY AND IN CLINICAL MEDICINE. AND THE LAST POINT, WE LIVE IN A SOCIETY THAT IS CAPITALIST THAT BY ITS NATURE GENERATES INEQUALITY BUT IT'S THE ONLY ECONOMIC SYSTEM THAT REALLY GENERATES ENOUGH WEALTH BEFORE US TO MAKE PROGRESS AND OUR ROLE IS TO MANAGE THOSE INEQUALITIES AND TRY TO MITIGATE THEM AS WE MOVE FORWARD AND MAKE PROGRESS ACROSS THE COUNTRY. YOU DON'T SAY WE SHOULD LIVE A PANACEA AND THERE ARE DIFFERENCES FROM DIFFERENT POPULATIONS AND WE JUST CAN'T CONTINUE TO TOLERATE THIS INCREASING INEQUALITY YOU SO CLEARLY OUTLINED FOR US. THANK YOU.