 Before I introduce Dr. Olapati, I just want to call your attention to next quarter. Today's session will be the last session in the Disparity Seminar for the current quarter. And next quarter, we will be starting not on March 30th, as the schedule says, because there's been a cancellation from Dr. Laxmaranian in Washington. He was called out of the country for the March 30th date. We're going to be starting with Richard Epstein on April 6th, who will give a provocative talk on the case for health disparities. We're all interested in that. The following week, Ann Beal, who is the president of the Aetna Foundation in Connecticut, will be speaking about future directions for health equity. And David Meltzer and Vanessa Gamble from Washington will be in subsequent weeks. It's a great quarter coming up to complete the year-long series. I just mentioned that the March 30th session will not take place. We're delighted that Dr. Shola Olapati is able to join us today to speak to us about indoor pollution from biomass, a global health disparities challenge. As many of you know, Dr. Olapati was vigorously recruited about a year, two years ago, from the University of Illinois to join us as a professor of medicine and as the clinical director of the Global Health Initiative at the university. Dr. Olapati is a skilled clinical pulmonologist with research interests in asthma, COPD, and sarcoid. His current work in asthma focuses on the relationship between environmental and genetic factors and their effect on the expression of asthma, particularly in developing country settings such as Nigeria. Dr. Olapati is well-published in the pulmonary field. He's a fellow of the American College of Surgeons, the American College of Chest Physicians, and he currently is the governor for the state of Illinois for the American College of Chest Physicians. He's won many awards, and it's really a delight to welcome Shola as a colleague, as a friend, and as today's speaker, Shola. Thank you, Mac. I want to thank Mac for allowing me to participate in these seminars. It's a different look from this side, but what I'm going to try to do is walk you through some of what I've had the opportunity of learning over the years in the area of disparity, but with a global twist to it. I've had the opportunity of using asthma as a model to look at disparities in care here in Chicago. I've always been fascinated by some of what is known and unknown related to asthma, and there is this concept of hygiene hypothesis that presupposes that if you see here, look at young people who grew up in developed part of the world. You don't have any exposures to any infections anymore. Everybody is immunized. All the sidewalks are paved, so there's very limited exposure to dirt. If you look on the other side, you see all these children. They have a good load of infection with Helminthic infection. They're always walking around in BF feet, and these seemingly innocuous differences in terms of how people live. It has significant implication in terms of how the immune system actually develops and works. If this is very true, it means that the immune system for the children in the developed part of the world has nothing to do. You can't fight infections because they're almost gone. We give antibiotics very easily. Most of the immune system is twisted towards allergy. On the other side, if you live in a developed part of the world, the immune system has to be primed up to fight all those parasitic infections and has little or no time to even think about allergy. There was a paper this week about... In New England, exactly. The German experience is a little different, but it's along the same line. I've always been intrigued by, is it the access to care? Is it the biology, or is it the environment, or the interaction that actually determines how asthma is expressed? This is interesting because when I see all these young people, most of them look like a lot of my children and people in Africa. When you look at where research is actually done, there are 45 countries. In Africa, people usually go to South Africa, you go to maybe Brazil in South America, and then that's it. There's really not enough information that makes it very clear that people have actually researched and recruited people to inform whether this is actually true. This was my entree into going to Nigeria. I went to Nigeria to look at this interaction in some of the rural communities. To my surprise, about 60% of those households actually use firewood. There was a lot of indoor pollution from biomass. The light flickered in my head in terms of you have all these TH1 paradigm, nobody has really gone to Africa to look at how people live in the environment, so I decided I was going to look at that. Then, shortly after I got here about 18 months ago, I went on a trip with Habiba San, who has a cohort in Bangladesh looking at the problem of arsenic poisoning in water. Wanted me to help look at the pulmonary implications in that population. As it turns out, about 80 to 90% of people in the rural Bangladesh area also use biofuels for cooking. Terribly exposed to indoor pollution from biomass. The two of us decided we were going to combine to a South-South collaboration because I know Nigeria, I know the rural area, he knows Bangladesh, to try and shine some attention on the issue of indoor pollution from biomass, which I hope by the time I'm done you realize how very little is known or even publicized about the dangers of indoor pollution. What I'm going to try to do is give you an overview of energy poverty because that's in essence what drives people to use anything that can get their hands on to cook and also for their energy needs. I'll discuss biomass fuel use and its impact on health and the global burden of disease because it's very, very huge. I'll also discuss some of our ongoing field work through the South-South collaborative between Habiba and myself looking at Bangladesh and some of the rural settings in Nigeria and then explore other sustainable options and which may have implications for the millennium developed goals 4 and 5, which address maternal mortality and death of children. When you look at globally in terms of access to electricity, most of us may, I mean we take it for granted, you flick the switch and the light comes on. This is a true picture of places in the world where this is taken from the 2008. Places where there's actually no access to electricity and I'll point your attention to areas here, it means that more than 90% of these places don't have access to electricity and here is Niger Republic just north of Nigeria, this is the Chad Republic, this is the Central African Republic and my geography, this is Bokina Faso. So in these places, they don't really have a choice, there's no electricity and even if you look at places like this in Nigeria, one thing that should be striking to you is that most of the places where there is lack of energy or what I call energy poverty, they're clustered into Africa and maybe somewhere in Bangladesh and if you look at areas that have this little halo, these are the least developed countries in the world and there are 50 of them, 45 of them are in Africa, I mean 33 of them are in Africa. So you're looking at a global lack of access to energy and I'll show you the help. So you can see where you look at South Africa, that's why when you talk about Africa and doing studies, I mean Africa, if you've been to South Africa, you realize that it's a very developed, except you're going to the neighborhoods where it's like transitioning from a developed to a developing country. This is Ghana here, this is Ghana here, so Ghana is doing very well, Nigeria still have challenges in terms of not having access to electricity and this is a nice cartoon that I actually love because it shows you what, this is what it looks like at night in some of this, this is Africa, it's always dark at night, I don't know how to bring the other one where you see at night the picture so that it's very, very striking, you can see that developed countries, you can see that and then Africa is just dark. And then you look at, you know, in transitioning from the impact of this lack of energy, this is a very striking slide that helps me pull things in perspective sometimes in terms of some of the inequities and the disparity, it just shows life expectancy over the years as a reflection of the wealth of some of these countries and I wanted to pay attention to this 1900 Cobb, this is 1930, 1960 and this is 1990 and if you look at life expectancy you can see that it's really gone up over time. If you look at a lot of the countries in Sub-Saharan Africa, places like Botswana, places like Malawi, life expectancy is like 30 or 35 years, even, you know, still stock at the 1900s, especially as the advent of electricity development has made life expectancy very, very generous in developed parts of the world. So when you look at it in terms of proportions of people who really lack electricity in developing countries, you can see where most of them are, across that, India, maybe about 28% of them, in Sub-Saharan Africa about 30%, in India you can see 28%, East Asia-Pacific, Southeast Asia-Arab states, China maybe about 1% and then within some of those developing countries you can also look at the differences between the urban and the rural settings and if you look at the rural areas almost 90% of them don't really have access to any energy or electricity and it shouldn't surprise anybody that if you don't have access to electricity you need some form of fuel for energy for cooking needs. So this is just showing the distribution of people who rely on solid fuels, you know, to maintain their cooking and energy needs and you can see that, you know, in Sub-Saharan Africa 21%, India 27%, China 21% and this has significant health implications as I'll show you in a moment. When you look at global reliance on solid fuel for energy needs, there are about almost 3 billion people in the world who don't have access to electricity and have to use biomass fuel for their energy needs and again most of them are close to that in, if you look at least developed countries in Sub-Saharan Africa they're almost interchangeable. Also a lot of people and when you look at, what happens to this one? This was just a, this slide, I don't know, it's just to show you what the energy ladder looks like when you look at the least developed countries, the developing countries and how and what people use and the least developed countries they use agricultural waste and mostly dung, okay, this is excreta from cow, you know, and that's what they use to cook. If you look at some of the low income countries they use dung, agricultural residues and then firewood and then if you look at the middle income country they use all kinds of stuff from having access to electricity, liquefied gas and the developed countries we don't really do any of that anymore. This was a picture that I actually took, you know, when I went to Bangladesh almost two years ago. What you see on the trunk of this tree is excreta from the cow. This is dung and what they do is they put it on the trunk of the tree so that it dries up and it becomes a cake so that when they want to cook they just throw it in there and it's the most unclean combustion you can ever get and as I go along I'll show you some of why it has unbelievable health implications and some of them actually get very, very creative because what you see here are, you know, sticks that people have to go into the bush to get these little twigs from the forest. Some of the kids usually have this chore and what you see is the sticks actually coated with dung so that you can have both dung and firewood together when you want to cook and the rest is live up to your imagination in terms of some of the combustion when you have such unclean fuel to cook with especially in a closed environment and you can see some of the other stuff that people used to cook. This is the house of a relatively wealthy guy in Bangladesh. You can see he's got his own stack of agricultural hay and agricultural residue. He has about four heads of cow and this is very interesting because at the back of his house he actually has a pit where the cow dung, you know, is actually deposited and they add water to it and there's a connection of tube that goes back to the back of his house where methane gas actually powers his customized stove. But to be able to actually have methane gas, enough methane gas produced, you need to have at least six heads of cow. So this is a rich guy and, you know, just think about the implications of the methane gas on the environment but this is a rich guy in Bangladesh and he still has no access to electricity. So breaking it down, you can see that in terms of the proportion of the biomass fuel that people use, most of the time almost 70 percent. I'm focusing on sub-Saharan Africa and developed countries in general. You can see that almost 70 percent use firewood, about 10 or 11 percent use kerosene and about, you know, maybe less often in least developed countries they don't use coal. Coal use is predominantly used in China and it has its own implications in terms of predisposition to developing lung cancer. So when you look at the 10 leading causes, risk factors for death in the whole world, what I want to do is just bring your attention to the fact that exposure to indoor pollution from biomass is responsible for over two million deaths every year. And it accounts for 3.3 percent of the global burden of disease. That's a big one and this is looking at the global picture. When you look at risk factors for death in low-income countries, you can see that it's no more number 10. It's actually about six and it causes about 1.3 million deaths every year. And Nigeria and Bangladesh happen to be two of 11 countries that contribute the most to this mortality. So I think our South-South collaboration is right on in terms of being in the right field to do this study. This is just a slide that pulls the risk factor, all environmental risk factors together from lead exposure, climate change, indoor pollution on safe water and sanitation and problems with hygiene. You can see again that indoor pollution from exposure to indoor smoke from biomass is responsible for most of the mortality and also for a lot of the disability I just had life years. So the implications of exposure to indoor biomass from the health perspective, it's just unbelievable. Not even to touch on its effect on the climate and degradation because you have to go and cut down the trees to get, these poor people, that's all they have access to. So there are no other alternatives for them for energy needs. In focusing on some of the most likely, most common cause of mortality, you have pneumonia, you have obstructive lung disease, especially emphysema and lung cancer, especially in settings where they use a lot more coal. And what I want you to put in perspective is that most of the women in this, most of the COPD that's related to indoor pollution from biomass, they actually are caught in women who don't smoke. And the exposure to indoor pollution from biomass translates maybe to about 60 to 70 pack-year history of smoking. So you have a very high incidence of emphysema in women who have never smoked. And a lot of children die of pneumonia. And a lot of the mortality that you see in the children is actually in children less than five years of age, and it accounts for about 30% of the 1.3 million deaths every year. So you'll see why this is the case. So in terms of the scope, you can see that 3 billion people, mostly women and children, because the men are usually not in their homes, they're usually out looking for food and stuff to take care of their families. And as I mentioned earlier, it accounts for almost 3% of the global burden of disease and contributes to degradation of the environment. So the question is, why is the exposure to indoor air pollution so dangerous to women and children? I just mentioned shortly that yes, because they're in there all the time. And because the products of the incomplete combustion of this fuel leads to elaboration of a lot of particulate matter in different sizes, if you're looking at the most respirable component of them, which is about 2.5 micron, or even the PM10. You also have exposure to a lot of volatile organic acids, polycyclic aromatic hydrocarbons, which are carcinogens, oxides of sulfone, nitrogen, and name it, and then carbon monoxide and trace metals, heavy metals. So you can imagine when you inhale that, the kind of damage that goes on in the longer. That probably drives the pneumonia and the high mortality in children, and also the emphysema and the cancer that you see in women. I think the picture says a lot. These are pictures from Nigeria. I'll show you some from Bangladesh, but it's the same story. Usually when the women are cooking, they keep their children on the back, especially when they're still little. It helps keep them warm. You can see this little guy is just there, and you can see that the intimate exposure to all these toxic pollutants from biomass use, it's a constant picture. You can see the walls, and the cooking sometimes is done indoors without any chimneys, without any windows, so you have unbelievable exposure. These are pictures that I took in Bangladesh. The face of the poor people who don't have energy is the same anywhere in the world, and they usually have their children with them or are intimately exposed to... This lady was cooking happily when I took this picture. You can see why the health implications of exposure to biomass is so bad. What we decided we were going to do, twofold, to try and figure out mechanistically why does this happen, and we decided we were going to look at the protective effect of antioxidants, because you see a lot of potential for free radical injury. Mind you, these people who are poor, nutrition is also behind, so they're not going to have any decent antioxidant defense system, so when the exposure overwhelms the system, it sets a process of inflammatory cascade and things that you can't imagine, which is responsible for a lot of the damage to the lungs and why some of these young children succumb. For the Bangladesh project, what we decided we were going to do was look at the frequency of symptoms related to exposure to indoor air pollution, to determine the concentration of some of these heavy metals, because some of these heavy metals are adherent to the particulate matter, and because they're in the respirable portions, 2.5 microgram, it actually makes it way down into the airway. We also tried to decide we were going to look at polycyclic aromatic hydrocarbon in the urine as a biomarker of exposure, because that would prove that it's actually gone beyond just inhaled it into the body. And also look at concentration of atox guanine, which is a biomarker of oxidative DNA damage, and also try to correlate those biomarkers with exposure. So that was the goal of the Bangladesh project. Here you see the, this is looking at the concentration of particulate matter in the respirable portion, 2.5 microgram per meter squared, based on the different kinds of biofuels. And you can see that wood, agricultural waste, dung, kerosene, gas, and electricity. The highest, this is about almost 900 microgram per meter squared, and the WHO standard is about 50. So you can see the kind of exposure that people get every day in the morning and the afternoon when you're cooking breakfast, lunch, and dinner. And this, just a reflection of symptoms related to the different levels and children. In some of the 192 homes that were surveyed, the level was as high as 1400 microgram. So substantial exposure to this toxic pollutants. And the filter from the equipment that was used to determine the indoor air quality was actually sent and analyzed. And you can see that these are the different trace metals that are adherent to the particulate matter. You want to bring your attention to iron, the aluminum, nickel, all kinds of stuff. So when you have all these go into the lungs with the particulate matter, you can imagine what kind of inflammatory reaction you get in the airway, especially if you don't have good nutrition and excellent antioxidant protection. And then looking at oxides of nitrogen, in that setting, the EPA limit is about 50. But you can see that a lot of the homes had levels that were beyond the EPA limits. And this is an effort to actually relate the PM levels to the urinary PAH, okay, polycytolic aromatic hydrocarbon, which when you look at some of the breakdown products, the one hydroxypyrin, these are actually acasinogenic. You can see that there's a good relationship between exposure to the biomass and biomarker of exposure. This is in the urine. So you see that people are actually getting some of this toxic effect from the exposure. And this is again looking at oxidative DNA damage, oxidative damage, looking this time at 8 oxo guanine, again relating it to biomarker of exposure. You can see that there is a good correlation with that. So with respect to the Bangladeshi work, clearly biomass use is associated with indoor air pollution. It causes respiratory symptoms just from the sampling. And we have, we've been able to show that trace metals and some of these biomarkers that are acasinogenic actually come with the exposure. With respect to the Nigerian project, what you see here is just an aerial map. I mean, we're getting, there are two rural villages that we use here and we're trying to be as sophisticated as we can. So we have GPS mapping. We actually, what you see here are individual homes, you know, where we actually went in to look at indoor air quality and some of the work that we do there. We're trying to, we just acquired our own software so we won't be using this Google stuff the next time we have to do this. And what we decide, this is just to give you an idea what some of these homes in these rural settings look like. Just like this. They don't have windows. They don't have set aside kitchens. They're different shapes. So people have intimate contact with a lot of this polluted air. What we decided we were going to look at in the Nigerian project is to again determine the degree of indoor pollution from biomass fuel use. The frequency of symptoms related to indoor air pollution to look at the impact on pulmonary function. So we had laptop-based pyrometry in the field and we, in each of the homes that we actually identified, we had a mother-child pair where we could look at biomarkers, where we also could look at respiratory symptoms and also pulmonary function. And we also introduced education into the algorithm because most people don't really, they're not aware of the dangers of the exposure and through the generosity of the Chess Foundation I had an humanitarian award that gave me money so I could buy a lot of stoves. I gave the stoves to some of the homes in these communities so it gave us an opportunity to look at the impact of education and an efficient stove on indoor air quality and some of these biomarkers. So these are ongoing work from the field and Leni will be happy here because before we went into the community what we did was we went in there to talk to the community in terms of community engagement and trying to develop a partnership to let them know what this is all about, what we wanted to do and the implications for their wives and most of the places where we went, they were so alarmed and we'll call, you know, Elijah community meeting where we came again and talked to them about some of the risk and what we were, of course, we were welcomed into the society and this, I'm spending a little, a few minutes on this because it allows you to actually get into some of these communities. It allows them to be partners in it and it makes for a more robust research work. So that's me there with some of my colleagues talking to the women and the men in this rural community. What we were going to do differently was do a survey to try to capture mortality symptoms related to headache, to lung and all the epidemiologic stuff that we could get and in the homes that we, and then we went to about 100 homes in this, this is when the early phases of this ongoing work, we went to some of these homes to do indoor air quality monitoring and we had this portable thermoelectron that, you know, corrects for humidity and all this stuff. So we had access to, so we looked at the PM 2.5, we also looked at the carbon monoxide levels in these homes and then we did spirometry. In each home we identified both a mother and a child that's older than six years old and we also looked at exhaled breath air for nitric oxide as a marker of airway inflammation. Remember, I mean, pulmonary ducts. So we had this spirometry and then we collected the blood and the urine again to look for some of these biomarkers and also because of the poverty, because these are poor and vulnerable people, we actually also looked at some of the markers of nutrition in terms of transferring. We were looking at complement to see whether there was hypo complementemia. We were looking at SOD. We were looking at lippipar oxidation product. I can't give you the results on all of those today, but we were trying to look at the antioxidant defense system to see whether nutritionally, these were people who were behind to, so that we could put all of this in context. And then after the initial phase, we had the education where we actually created brochures translated into the local language with pictures so that people could understand, you know, how to protect themselves, how not to have the kids around them. And then we gave them the efficient stoves and then came back three months later to repeat some of this indoor air quality. During that interval, we were just going there to make sure that they didn't have any problems with the stoves. In terms of the symptoms from children, we focused on chest tightness. We focused on headaches. We focused on cough. We focused on runny nose. And we also focused on about 40% of the children had cough. About 60% of them had headaches. And 20 to 30% had chest tightness. Okay. If you look at the mothers, maybe about 80% of them had headache, about 40% had cough, and another 30% had chest tightness. If you look at the pre-intervention levels of PM 2.5, the mean level in the homes, in the almost 100 homes that we've saw it, it's about 1,800 microgram per millimeter squared. That's a lot of, that's a, I mean, and WHO standard, as I mentioned, is about 50. So we're talking about 40 fold in terms of the degree of exposure that people get. When you look at carbon monoxide level, that explains why they have a lot of headaches. The carbon monoxide level, the mean was about 250 pats per million. So in this enclosed space, I don't even know why they don't develop CO poisoning the way we, maybe because it's intermittent. I wonder what kind of cognitive function, cognitive performance people have because the carbon monoxide level in those enclosed spaces was so high. But it was striking to see that, because the way I looked at it is, it had to be real, because a lot of them had headaches. And the post-intervention level and symptoms actually was very consistent in terms of, you know, decrease in terms of some of the headaches and the level came down precipitously. And in looking at the pulmonary function test, you can see that, but this is looking at some of the mothers in one of the villages, seven of them had normal, 20%. You can see that about 64% or 65%. 65% had some level of mild obstruction in about 53%, moderate obstruction in about 12% and a restrictive pattern in about 3%. When you look at the children, it's probably the same thing. Almost 60% of them had some element of obstructive lung disease. Fast back to where I started with. I was interested in asthma, looking at environment and parasites, and then you overlay indoor pollution from biomass. You can see that that is a major problem. And this is just to show you what the stove looks like. And we had these van distributing stoves, too. And, you know, the people who are very, very happy. You can see this is what they look like. And essentially, they're, you know, they're very simple. They're lined with ceramic. And it allows them to still use the same fuel, the same dirty fuel. But because the ceramic actually retains a lot of heat. So you have almost near complete combustion. Because it retains heat and it heats, I mean, the temperature gets so high. So this is what it looks like. And initially, five, six years ago, people were charging $2 through $4 for it. But I paid $21 for each one of this. So, and when you put it in the context of people who live in settings where they don't have a lot of disposable income, this model is not affordable. Although, and this is what it looks like. And you can see that, you know, where they still use the firewood, which is all they can afford. And you don't really see that much. Once you have a starter fuel in there, so even if they're cooking indoors, the exposure, the pollutants that you were getting from the pre-intervention period is not as bad. What is so important in this intervention is that just by giving people efficient stoves without really changing their lives dramatically, without making it unaffordable for them, you can see, I hope I'm able to show you the indoor air quality. And you can see the, in terms of the symptoms, the pre- and post-intervention, it's just so dramatic. And when you look at pre-intervention PM indoor levels, this is WHO limits. And what we did was, before we, they started cooking, we actually got the ambient level, okay? And then we monitored the indoor level cycling every 30 seconds. We have one of these Thamo Fisher, you know, very sophisticated instrument that will cycle every 30 seconds. So after one hour, you could plot anything you wanted. So this is what it looked like in terms of, you can see, almost 1800. That's really scary. And then this is the CEO, Carbon Monoxide, Patsma Million, the ambient level before cooking, nothing. So you could see that it's directly related to, you know, using biomass for cooking. I showed you this earlier. And this is what it looks like, you know, post-intervention, just with the education and giving them the efficient stoves. Look, it's about, I mean, the average is about 75 to 120. So if this is directly fueling the antioxidant damage, whatever process, inflammatory process that's going on in the lungs, you can see what kind of dramatic change, you know, and the potential benefit down the road. And again, similarly, when you're looking at the carbon monoxide levels, you know, similar, similar outcome when you're through education and with the efficient stoves, you can really improve the indoor environment. And then this is just coming back three months later, you know, to look at Soviet, to look at these symptoms, and you can see, you know, pre-intervention and post-intervention that, you know, some of them, and I was so happy to see that a lot of this in the children and also in the mothers, in the homes. You know, the particulate matter, especially in the respiratory segments and carbon monoxide, major pollutants from firewood, because these people use exclusively firewood, a little different from the Bangladesh data, where it was a combination of dung, firewood, and all of that. And women and children, you know, are the greatest risk, because they're the only people at home exposed and cooking. It's associated with obstructive pulmonary disease, because both children and mothers, over 60% of them had either mild or moderate obstructive defect on the chest x-ray. I think the distribution of efficient stove, I see it as an important stop-gap measure, but I think the entrepreneurial model, where they can actually manufacture this themselves using local materials, those efforts that are probably more sustainable than just going around distributing stoves. Clearly, community engagement and partnership, you know, before we started, was also very, very helpful in having them modify, you know, their behavior. And I think when you look at the fact that the indoor exposure to indoor air pollution accounts for over, almost a little over 2 million deaths every year. And you're trying to reduce the maternal mortality by 67%, and infant mortality by 75%. If you could eliminate 2 million deaths of men, I mean, women and children every year, you will be, will be really ahead in terms of meeting some of this MDG 4 and 5 goals, because it kills more than all the other potential causes of mortality. And September last year, I know, I don't know how many of you caught this announcement by Hillary, the Department of State in collaboration with the NIH have actually put down about 50 million dollars with invitation to some of the welcome trust and some of these other non-governmental organizations and foundations to distribute about 100 million stoves globally, because thank God, people are beginning to realize that, you know, 2 million preventable deaths every year, I mean, it's a wise investment, but I'm not sure that this is a, this is a sustainable model. What I was going to show you was an example of a sustainable model where people were actually using local materials to teach the people. And you can see that these happy people, you know, so these are some of the folks, you know, walking with us on the field in Nigeria, these MPH students in the field epidemiology, so it's been a great opportunity to be able to go back, you know, to Africa where people don't usually go to do research, because I think the potential to, you know, understand, you know, disease better, look at a cohort of people that are not on too many drugs, you know, done in an ethical manner. I think the opportunity to learn from some of these protected areas is just tremendous. And I just want to thank some of the collaborators and the folk, medical trust and chess foundation that have supported this work. I'll stop and take any questions that you may have. Why was there such a high frequency of cooking inside pre-intervention? What do you mean by? You mentioned that most of the mothers were cooking indoors and that this was part of the problem, but if a lot of them started cooking outside post-intervention, why weren't they doing that to begin with? No, they actually, I mean, the post-intervention stuff was done inside, you know, with the efficient stove, the same condition. We were interested in making sure that we could demonstrate that the efficient stove was actually doing what it was supposed to do. So the post-intervention monitoring was also done indoors with the use of efficient stoves and the same firewood that they would, they can afford. But she was asking, I think, why they cook inside rather than outside? Because, I mean, that's where they cook. I mean, I don't know, most of you have not seen, I mean, sometimes, I mean, these places, I mean, if you look at the Maasai Mambo, the way they construct the homes, they don't have windows. You know, the Maasai are a good tribe because, you know, they live right there in the Serengeti with the lions and, you know, if you, in fact, they have a little place inside the Maasai Mambo where they keep their goats. The little ones, they put inside. The big ones, because by the morning, you know, the hyena or the, you know, they would have taken the little goats. So they live inside with their goats. There are no windows. So, and they cook inside. And sometimes when it's cold, you know, it's another way of generating heat. So that's a way of life. Do other societies at this level of income have histories of designing homes that don't have the same problems? Is it, is it the large animals that are there that's the fundamental, I mean, it's actually just interesting. Yeah, you know, historically, people have used firewood to cook. You know, when I was growing up, you know, I didn't, I mean, it's not in the rural area, even in the city. When you want to have big parties, they bring out those big stoves. They use firewood to really cook the large when you have, but, but most people don't, I mean, I mean, even, that's even in the, in the open centers when you have access to the liquefied gas and all that. But when you have to feed a whole, that's when people bring out the big stoves and the firewood. But a lot of these poor people, that's, that's what they do. That's what they've done historically. They don't understand the impact. You know, I have a lot more pictures. I have some of, picture of some of these teenagers, you know, sometimes they have a little business where they were doing cooking outside. Femi, you remember, you know, I walked in there, I couldn't stay there for more than five minutes. My eyes were just, here was this teenager, that's, that's her job. When she comes back, she sits down there the whole day, just staring the big, you know, walking from home. So I don't know whether over time, you know, they get desensitized, but it's also interesting that people who have exposure to indoor air pollution at this level, they actually have a higher incidence of cataract. They have higher incidence of intrauterine growth retardation because it's just like smoking. So there's more, more and more health effects related to this. It's out of, I mean, I don't know whether you want to call it ignorance or they just don't have a choice. I thought David might say something about cost-effectiveness analysis and this. I mean, what strikes me is that the quality-adjusted life years per investment are, it's extraordinarily low cost compared to, I mean, compared to what we obviously spend most of our time doing in medicine in our world. And I just wondered if you have any commentary about that with respect to sort of global health care ethics? Yeah, you know this, I mean, that's actually part of the excitement that I get with doing this kind of work because you know, this kills more than HIV, malaria, and it's totally preventable. I think the idea, I mean, the fact that more and more people are aware that indoor pollution kills so many, when I was telling Mark, you remember we sat over dinner about a year ago and I was telling Mark, Mark, I don't think he believed me until he didn't believe me completely. And then when Hillary Clinton announced he was looking for me and say, Charla, I think you're right, you know. So most people really can't imagine that, you know, you have something like that killing so many people and nothing's been done over time. But it's a reflection of people who don't have a voice. You know, these are poor people who don't have access to electricity. All they have is access to whatever they can scavenge and that's all they have. So in terms of the return of investment, when you look at the disability, I just, I mean, this is a huge one. And that's why I think the sustainable model of teaching people how to use local materials to actually create the efficient stoves themselves is a more sustainable model because, you know, the efficient stoves, when they first started with the ceremony, they were $2 or $3. The ones that I distributed, it was up to, you know, $20. That's more than people making a year, you know, in those settings. So I think, yeah, it would be nice to be able to invest in training. And there's another model in Haiti. One of our students, one of Ted's students here, Art Spark, they've created an entrepreneurial system model around energy used in Haiti to the degree that people are now, they're using all kinds of sheet metal anywhere they can find it, old car doors, you know, they've figured out to create these efficient stoves out of local materials that would otherwise be thrown away. I was going to ask if you considered any model where you would have the people in the intervention pay a subsidized rate for their stoves? Because you mentioned the $20 million that the State Department is investing, but that's not going to buy stoves for 3 billion people. So I was just wondering if you had any sort of model of like having people pay something for the stove or do you know what I mean? Yeah, in fact, that's what I, I mean, again, this pilot study was to try and understand the, we're interested in the science of it, how does it do this? Because you have to understand that in a lot of these countries where they even have access to all the, all kinds of cleaner fuel, people who are marginalized can't afford it. If I had a wish, I would just say, well, why don't we just have a rural electrification program? That would wipe away a lot of this. But that's asking for a lot because a lot of these dictators, you know, they don't see the, the poverty among their people. They live big, so we're going to still see a lot of people, in fact, more people using biomass for decades to come. But an entrepreneurial model similar to the one that has been, that's been conducted in Haiti, that's actually the way it works. You know, they make people buy it and you look at your costs, energy costs and using the cleaner fuel, once you have the acquisition cost, you realize that you're, you know, you are saving money at the end of the day to acquire the efficient stoves. And then people are actually now making them and then, you know, making money out of it. So I think that's a model that I believe is sustainable. We're also from the scientific aspect interested in augmentation, nutritional augmentation, because you know, the SOD, the lipid peroxidation, the albumin, the pre-albumin, I mean nutritionally, these are just a mess. I didn't want to bog you with too much details, but when you have no antioxidant defense system and you have been exposed to such a high load of pollutants, you can understand how the antioxidant defense system can be overwhelmed. So I think something as simple as, you know, playing around with the nutrition in that area can actually also improve the antioxidant defense system. And I think Habib has also done that with people who are exposed to arsenic. You know, you give them selenium and there's more methylation and breakdown of the selenium, of the arsenic. And you have, so there's a model for, you know, augmenting the antioxidant defense system as a way of mitigating the effect of the exposure to the biomass and end up pollution. Does the fact that the stove is more efficient also mean that people use less fuel and therefore have to spend less effort obtaining fuel and also perhaps cutting down fewer forests in order to get the fuel that they need? Thank you for bringing that perspective. I failed to bring it up, but you know, usually it's the young children after school who have to go out and look for wood and agriculture or residue. So the efficiency means that people are cooking with less need for firewood. There's less degradation to the environment. And the kids actually have a little more time to do their homework. So when you look at it and then, you know, they don't die. You know, so it's a win-win, it's really a win-win situation. It's a win-win, really. I think this was a fabulous way to end the winter quarter on a very exciting, very high note of not only the extent of a problem that, as Shola says a year ago, I sure wasn't aware of when Shola told me about it for the first time, but also the potential of developing global solutions that, I mean, could save enormous numbers of lives and contribute to improving quality of life throughout the world. Shola, I can't thank you enough. Thank you. Thank you.