 Fumi Olapade is a hematologist oncologist with expertise in cancer risk assessment. She conducts comprehensive evaluations of family history and other risk factors for patients in the cancer risk clinic. She's also an expert on individualized treatment for breast cancer, and as an international leader in breast cancer research, she continues to help scientists gain a greater understanding of the disease. Her current research interests include identifying the source of estrogen receptor negative breast cancer, which is an aggressive form of the disease, which is resistant to hormone therapy. Her talk is going to be on integrating women's health into the global health agenda. And Fumi, of course, also leads the very successful Center for Global Health here at the University of Chicago. And in discussions about that yesterday, one person, Pierce Gardner, who I think is known to all of you, made the point that that Center is now about where the McLean Center was 25 years ago. And so you can see, Fumi, you've got a lot of work ahead of you, but we think that you and Shola and your colleagues are up to it. First, congratulations, Peter, for an award well deserved. I really wanted to just share with you why I think we should integrate women's health in global health agenda. Many of you know that I study breast cancer and I study breast cancer on the south side of Chicago. And at any time you see geographic variation in any particular disease, you have to wonder why you have that geographic variation. So in breast cancer, what you see in the blue areas in low to middle resource countries where you actually still have a low incidence of breast cancer. And I get into arguments with my colleagues because they want to know, is it because the risk factors for breast cancer isn't present in those countries? And I tell them, no, that's not the case. It's because most women in those countries don't live to the ages where they can develop breast cancer, right? So you have this cute population. So what Peter was talking about in terms of maternal mortality, in terms of the number of women who died during childbirth and girls who don't even live beyond three days of their life is a reason why in those low to middle resource countries, you don't have the red numbers that you see in the developed world. So that's sort of one injustice and inequality that you see just when you see that geographic pattern. The second thing that you should think about when you see that geographic pattern is that even though you have a low incidence, people die more from breast cancer because the mortality to incidence ratio is so high. So in those places, breast cancer is a death sentence. Cervical cancer is a death sentence. So this low to middle resource countries cannot afford to treat cancer. And so the statistics in terms of who is dying and who is surviving breast cancer worldwide suggests that even though you have 1.3 million cases of breast cancer, the majority of people who are still dying from breast cancer are in the low to middle resource countries. So in October, we celebrate pink month. Everybody is in pink. We're all celebrating. We have made great accomplishments. There's great awareness. And in October, early this month, we had a World Oncology Forum because Sir Richard Horton and everyone who is concerned about global burden of disease on December 4, we're going to have this publication that will bring cancer and noncommunicable conditions as the really important global disease and diseases that we have to start tackling. And why is that? Because we expect that with the grand challenges and with all the good work that Pira is doing and everybody who is really mobilizing in support of women development all over the world, more women will survive childbirth. More children will be saved within the first five years of life. And then the question is are they then going to catch up to what's going on in the developed world now where, yes, when women became liberated, the first thing they did was to pick up Marlboro, right? Because we wanted to become like men. And you can see that if you look at the incidents and what's happened to breast cancer in terms of what we've been able to do in the United Kingdom. And I use the example of United Kingdom because they have national health insurance. I don't want to get into the problem of access, okay. I don't want to get into the problem of access because they treat everybody. And I kid them that they don't know anything that's happening to the black in the UK, but they don't keep those statistics. But if you look at this, you see the dramatic difference. And then you look at lung cancer. And the one thing that actually happened to lung cancer was because there was a policy about tobacco. They did that in the UK, the French women continued to smoke. And lung cancer death rate did not decline in France. So you know that it's not about black or white, it's just about policy of whether you smoke or you don't smoke. That's what dropped down lung cancer. And in countries where businesses, and I want to talk about China in particular, in fact, in some parts of China, the policy is that the more tobacco you sell, the more you're going to get money to fund your region. So the regional officials who don't have a high tobacco sale, in fact, are punished by the government. Now, imagine what that's going to do to lung cancer rates in that region. And we just can't really be making policies that sort of go against one another. And so in the global health context, I'm hoping that we can learn about what Peter said, intersectorial communication collaborations, right? Because the official who wants to get money from tobacco by making the officials get taxes from tobacco and measuring success by the amount of tobacco they sell is actually hindering the health of their community. So women, and if you look at what we have learned, what I'm really trying to do is that let's take lessons that we have learned in the West and hope that we can in fact stop this expected growth in cancer. So why is this important in women's health? So if you look at this graph, cervical cancer doesn't show up there at all. Now we have HPV vaccine, okay? We have debates in this country about whether we will give everybody HPV vaccine. We have debates in third world countries about whether we should treat cervical cancer or we should give vaccines. And still, if you're thinking about women's health, breast and cervical cancer, now kill more women who survived not dying at childbirth because they have no access to treatments that can save their lives. And these women are dying young and they're leaving children behind. So I know that the world's attention has been focused on AIDS HIV, but I'm telling you that let's not leave everything in global health to AIDS HIV. Let's begin to think about women's health. So then the question is, for me, instead of thinking about treating cancer, because we can't really afford to treat cancer in the developed world. It's too expensive. So I've been really focused on asking what's my risk of dying from breast cancer, because now we've really been very excited about the possibility that you can take hormonal therapy, most of the cancers that you get by screening with mammography, it's not going to be a problem. As you get older, you may get cancer, but it's not going to kill you. Well, based on what that's been done, we now know that breast cancer is not one disease, that it's really multiple phenotypes. And for those of you who don't do cancer, you're going to begin to think about all sorts of cancers as being driven by certain genetic mutations. We have invested so much money on cancer genomics that right now the race is to sequence everybody's genome. And I know that those of you who are in ethics are getting protocols in your IRBs and you're thinking about what are we going to use this genome technology to do. So in my world in breast cancer, what we've done with genome technology is to really begin to define breast cancers and to now say we can personalize it. And when you talk to people who really care about access to healthcare, they'll tell you we don't want to personalize it because it means that, you know, the rich will continue to get richer and the poor will get poorer. I have a different point of view because we know that triple negative breast cancer is a breast cancer that in fact is more lethal because we hadn't studied it. It turns out that it may be a cancer that's driven more by your genetic predisposition because we see more of that in women with BRC1 and BRC2 mutation. When you look at the California breast cancer registry, you see triple negative breast cancer in more African American and Hispanic women. And that was really what we found in Chicago was that the excess mortality for breast cancer on the south and west side of Chicago was by young African American and Hispanic women who were dying under 840 and not even showing up on anybody's radar in terms of our screening recommendation. And then we went to Nigeria and we found out that in fact, young onset aggressive ER negative breast cancer was 70% of the cancers that these women were getting. And the average age that they were getting the breast cancer was under 45. And then if you go to the literature, everyone will tell you low socioeconomic status has been associated with basal-like cancers, late-stage diagnoses and poor survival. And when I was at Cook County Hospital, that was what I saw in Chicago. That was what I saw in Nigeria. And that was when I really realized that the U.S. has two, we were living in two countries, right? Because the breast cancer at Cook County Hospital was no different from the breast cancer in Nigeria. And in those days, we used to say that these women were in denial because they really didn't come forward to get treated. Until I had a patient who came forward. Her mother had died from bilateral breast cancer. And then she came at 2024 to the University of Chicago. And the great doctor here saved her life. And then she developed a second breast cancer, was saved. And then by the time I saw her, I was like, you're going to be one of those patients with a BRCA1 mutation and you better get your ovaries out. And she said, oh, God can't be that cruel to give me three cancers. I'm not going to take my ovaries out because, you know, I don't want to get into premature menopause. And she didn't. And she developed ovarian cancer. So then I became really convinced that, well, we can do genetic prediction. We can talk to people about what they are at risk for. But in fact, if they can't change behavior or in fact, if they're in a social situation where they can't do anything about it, what's the point putting that burden on them? And so I've had many patients in my practice that we tested for BRCA1 and 2. We know their family members are at risk. And the minute I ask them, can we talk to your family members? It's like, no, no, no, they have no insurance. So what are they going to do about it? Just put that to you as a way to think about bioethics and the global setting. So the work we were doing in Nigeria was really because we wanted to figure out, I then became really curious, is this really aggressive breast cancer because these women were in denial? Or is it really because they had a really nasty type of cancer? So the work we did was that this is the face of breast cancer in most of low-resourced developing countries. And it was always this fungating type of material. And then I started sending our students to Nigeria to interview these women. And Lisa Pruy, who is one of the Boxpum scholars, went to interview these people. And they came back to me and two of them went last summer. And they said, you know what, Dr. Olopari? It's not that these women are presenting late. They show up. They show up to a pharmacy, to a medical assistant, to a low-level, low-tier person. And the person gives them antibiotics. Okay, and then they take antibiotics for a year and then finally they go to their pastor or to some witch doctor. And then they put scarification on their breast and then the breast ulcerates. And I was thinking, oh really? I thought that they presented late. But when you go to the community and you ask what's going on in a health system or in a country where the health systems are really, really poorly organized, this is what happens to women, even when they present with a problem. So my postdoc went to different hospitals across West Africa. And the story was these cancers were aggressive. The pattern was different. It was a kind of cancer that really grew very fast. If you look at this, this is a cheap man's way of looking at DNA expression profiling, which is really this big, you know, we can do the cheap for breast cancer gene expression for $400. For this experiment, we can put 30 samples on a slide. That's the innovation in doing analysis and analyze one slide for $30. Okay, we get the same results. So we've looked at thousands of breast cancers using tissue microarray, and we found different patterns, heterogeneity. But one thing that we were able to show was that by looking at the patterns, okay, this is why getting analysis, looking at data can help you think about what's going on. By looking at the patterns of breast cancer in this different population. So here's, you know, the Japanese breast cancer. Look at the pattern. It couldn't be far more different than the pattern in the young Nigerian woman with breast cancer, right? And it's because the population structure is different, right? And so before you do individualized therapy, you also have to think about population attributable risk. You have to think about so many things in organizing how you take care of breast cancer. But if we had not gone to Nigeria, we would never have known that in fact, part of the reason why we were having this excess mortality and this really high death rate was because these women were getting the most aggressive, highly proliferative type of breast cancer that made up majority of their cancers. And the one that we really have been able to treat and scream by getting mammograms is a very small fraction of their disease burden. So then I came back to the Chicago and I look at Hyde Park is of course one of the most integrated places to live. Here's the white woman, 68, with a triple negative breast cancer. She got screened and in every two years, she had a triple negative aggressive breast cancer and she was dead within a year because there was no treatment that she responded to. So it became clear to me that in fact, the problem was not that these women were presenting late, the challenge was that the cancer was the most aggressive type of cancer. So let me end by saying that we have been really trying to annotate all the different genetic mutations that could be contributing to this aggressive breast cancer. And I just want to show what I found in Bahamas. So Bahamas is a small Caribbean island when you go there to look at their breast cancer, 25% of women who walk in through the door have a BRC1 mutation, that's a founder mutation. They present at a young onset and that was going on in Bahamas for generations until we had the technology, a very cheap tool to go and do breast cancer research in the Bahamas. The same thing, Mexico, Nigeria, right? To the point now that rather than send mammograms to Africa, what I want is to get genome machines to Africa because we can drive down the cost. So this is a Boston mammography band that was shipped, in fact, two of them that were shipped to Africa by some good, well-meaning people who want to solve the problem of breast cancer in Africa. It's the wrong innovation for the wrong disease, right? And that's why they're unusable and of no use to anybody. This woman runs Hospice Uganda. She can't get morphine to take care of her patients dying of cancer, but somebody is sending mammograms because it's a thing to do. So let me bring it home. So anytime you think about technology, we worry that technology will increase disparity. And so the more genomic analysis we've done at the University of Chicago, the more we can actually annotate everybody's genetic mutation, the wider the disparity in Chicago, right? Because those, in fact, one of your fellows did a study looking at the father a patient travels to come to the University of Chicago, the better their outcomes, right? Because our neighborhood is really one of the most challenging neighborhoods in Chicago. So we're here, right? And we're surrounded by the poorest neighborhoods in Chicago. So people sort of come from the North Shore and they come to the forefront of medicine and they get the best care, right? But we live in the same city, okay? If you look at who is dying from breast cancer, right? This is, this is, this is, this is, it places with the highest mortality in Chicago is around here. If you look at where all the doctors are, right? All the doctors are on the North Shore, right? On the North side, right? So there's something about inequalities in the distribution of services, even in a place like this, not to talk about in the global setting. So I think that we have a lot of work to do. I think I'm inspired by the disruptive technologies that Peter has been talking about. Can we organize differently? So I've been really trying to organize data and to democratize how we share data. You know, as an ethicist, we were so focused on privacy that we use privacy to shut down data sharing and data analysis among scientists. And yet, if I knew what was going on in Chicago and that the reason why all these young women were dying was because they had a genetic predisposition, I would have organized our healthcare system on the South side differently. So the question is, can we learn from the lessons of the past and innovate? So it's a bold new world, right? Just like the rich can get there. You said, you want to know your mother's DNA ancestors? You can spend $159, you get it. You buy both and save $279. And of course, 23 and me is out there promoting genetic analysis. But the people who really need it are those who in fact can ill afford to get cancer because they can't even afford to be treated. Thank you. Thank you.