 My name is LaShondra Price. I am Chief of the Health, Inequities and Global Health Branch at the National Heart, Lung, and Blood Institute. And I'd like to welcome you to the seventh lecture of the Genomics and Health Disparities lecture series. This series is a part of an ongoing dialogue about how innovations in genomics research and technology can impact health disparities. In addition to NHLBI, the series is co-sponsored by four other partners, the National Human Genome Research Institute, the National Institute on Minority Health and Health Disparities, the National Institute of Diabetes, Digestive and Kidney Diseases, and the Office of Minority Health at the Food and Drug Administration. Speakers have been chosen by these five organizations to present their research on the ability of genomics to improve health for all populations. The speakers in the series approach the problem from different areas of research, including basic science, population genomics, and translational and clinical research. We are honored today to have Dr. Herman Taylor Jr. as our speaker. Dr. Taylor is an endowed professor and director of the Cardiovascular Research Institute at Morehouse School of Medicine and a nationally recognized cardiologist. His current research predominantly focuses on preventive cardiology, and his teaching is aimed at building research capacity at minority serving institutions and enhancing the health of minority communities through research and health activism at the community level. Dr. Taylor may be most well-known for his leadership of the Jackson Heart Study, the largest community-based study of cardiovascular disease among African-Americans, funded by two of our sponsoring institutes today, NHLBI and NIMHD. His extensive experience in epidemiological observation has led him to a deeper appreciation of the urgency of community-level intervention as a priority, as well as a keen interest in broadening the diversity of disciplines and scientists focused on the problem of health disparities nationally and globally. A graduate of Princeton University, Taylor earned his medical degree from Harvard Medical School, trained in internal medicine at the University of North Carolina at Chapel Hill, my alma mater, and completed a cardiology fellowship at the University of Alabama at Birmingham. Please help me welcome Dr. Herman Taylor. Good afternoon, ladies and gentlemen. It is a great pleasure to be here with you. I'd like to begin my remarks with a brief story. After leaving the Jackson Heart Study and relocating to Atlanta and Morehouse School of Medicine, one of the first people I met was a gentleman who somewhat aggressively called me and got me on the phone with my new assistant, led him through by phone. And he said, Dr. Taylor, I'm interested in your work. I've followed your career, and I'd like to hear more about some of the things that you're interested in. Could I come over? I said, well, certainly. And he made an appointment. So the day came, and in walks this gentleman, he is gray-haired and looked a little different than I expected from the vigor in his voice. He handed me a sheet of paper, and it gave his most recent physical exam. And it said, this man appears young, and then is stated age. He is about 140 pounds, about 5 foot 6. He has normal vitisines. And his physical exam is normal, although he does complain occasionally of a little bit of hip pain. His labs were entirely normal, except for a creatinine of 1.3. And everything else was unremarkable. It was a clean bill of health. I looked at the gentleman. I asked him how old he was. I'll tell you later, that's the punchline. But he cut the visit short, because he had to be on his way. He had to go and visit a friend of his who was his sergeant in World War II, who was ailing. This gentleman was 92 years old. His friend was 101. Both of them were African-American. Now, why do I tell you that story? I'll briefly today just point out to you that heterogeneity is an important concept to keep in mind when we're talking about African-Americans and their health. There has been a huge and important emphasis on disease and death as being excessive and premature among African-Americans. However, that is an incomplete story. I want to offer that we today briefly consider three dimensions of health disparities, race, risk, and resilience. American race-based health disparities, as you all know, are real, pervasive, and quite persistent. The last 30 years has given us really a very important era and a deluge of literature that has given us the outlines of this problem and made it indisputably a fact of how we view American health. Group comparisons are often the way that we dramatize the disparities. They're useful, but they may contribute to a monolithically negative view of Black health and I think obscuring some opportunities. Black resilience is overlooked and I believe that its study may offer fresh insights. This is a slide that all of the cardiologists and cardiovascular research people are overly familiar with. That is that heart disease is a problem. It is the number one killer. It has been so for a long time despite the fact that there has been a dramatic decline over the last half century and more in the deaths from cardiovascular disease. Some of that owing to possibly some of these landmark labelings, this annotation up and down above and below this line showing the trend. I won't go into each of these, but these are important advances along the way that Betsy Naval and Eugene Brownwell put together a few years back. Of course, that dramatic improvement in the public's health with regard to cardiovascular disease has another side to it and that is the fact that over that time there has been an increasingly evident and discouraging disparity that's emerged even though Black and white have seen improvements. The gap is there and widening and all of this really led to an important effort on the part of then HHS Secretary Heckler to call together a working group, a task force rather, to put together this landmark report. I think most of you are probably familiar with this and it really did usher in an era of seminal discovery and publications that, again, let the world know about the disparities in knowing certain terms and that approach has been, again, very, very fruitful. It's taught us things about excess deaths among Blacks and other groups, access and equities of a variety of sorts, risk factor differences that obtain in both groups, the potency, the great potency of social determinants of health. And a lot of this has led to the desire to get more granular data on the underpinnings of a persistent epidemic among African-Americans. And I was pleased to be part of a major effort to get more granular detail on the African-American health experience with regards to heart disease and diseases of the circulation called the Jackson Heart Study, a great idea to look in Framingham style at a population of African-Americans living in the deep South and to try to, again, get to the bottom of the underpinnings of a persistent epidemic. Great idea, but not something that was easily accomplished just briefly about the Jackson Heart Study. There was not overwhelming embrace of the study at first. As you can see, here were some of the attitudes that we confronted when we began polling people back in 1998 before the start of the study in 2000. During that two-year interim period, there were a lot of meetings, a lot of interaction with the population, a lot of surveys, focus groups, and a developing of an approach that is in large measure the community-based participatory approach, which I think was, in fact, the key to us being able to pull the Jackson Heart Study off. I mean, consider for a moment. Jackson is, what, 200 plus miles from Tuskegee where some bad things happened that were in the memory of the people that we wanted to be a part of this study. And beyond that, in 1998, there was a new movie called Ms. Evers Boys starring Lawrence Fitzburn and Alfred Woodard that dramatized this whole thing. That same year, President Clinton apologized for Tuskegee. So Tuskegee was very much front of mind for Black Southerners who were being asked the question. We're here from the government, essentially, and we want to do a study just on Black people. Are you ready for that? So it was something that we had to grapple with. And thanks to a community that was in part motivated by this steady drumbeat of bad news about Black health, it was their acceptance and building trust among them, which was led by our approach of involving them from the ground floor that led to the success of the Jackson Heart Study, which, as I think you know, is still going forward today. Here are some members of that community that we are forever grateful to. And granular indeed. So we got a lot of information, and we've created perhaps the most thoroughly phenotyped group of African-Americans that you can find. And the Jackson Heart Study remains, as a brief aside, very collaborative and anxious to work with people who are bringing good ideas for analysis of the comprehensive data set. That's just one of the high-tech things that's available. That is MRI studies. Everything from simple analyses and comparisons like obesity in Framingham versus Jackson, which led to perhaps a not surprising observation that in stage two obesity, the prevalence is three times as great among African-Americans in Jackson as whites in Framingham. In stage one, there's double the prevalence and only one third of the population being in the normal BMI in Jackson versus a Framingham standard. From those simple types of analysis to much more complex opportunities and now to analyze advanced variables such as left ventricular strain from MRI and a host of other things that I think are unique in all of epidemiology. All of this and more, there's not time to go in depth into the Jackson Heart Study and its database. But we are still, importantly, I think, focused on risk. This is one of the important recent papers to come out that talks about risk profiling, which represents, again, a positive piece of progress in that novel biomarkers and subclinical disease measures were employed to get a more refined prediction equation on the probability of an African-American developing a significant cardiovascular disease that came out of looking at a lot of the variables out of the Jackson Heart Study. But we still are looking at risk. And I think looking at risk, again, while valuable, misses an opportunity. So group comparisons, when you look at black versus white, you keep getting this story of whites up here, blacks down here. But those comparisons obscure successes within the African-American population. They obscure stories like the gentleman I opened up the story with and opened up the lecture with. And obviously, that's anecdotal. But I challenge you to ask any person of African-American descent about this and whether or not they know people like this. We all do. A lot of us see them in the front-row at church on Sunday morning. It is not an unusual phenomenon. Now, they themselves, 100-year-olds and the bigger study-year-olds, may be outliers, but they're there and they're there, I think, to teach us something. So instead of thinking of blackness as badness when it comes to health, note the facts. Yes, 50% of African-Americans above the age of 21 have hypertension. That's not good. That's bad. But 50% don't. And many people suggest that, given the stresses and strains of African-American life, that that number might be higher. You can imagine that. 85% of blacks don't have heart disease. While way too many do, substantial number don't. And I think most of you are aware of the interesting phenomenon that if blacks and whites reach an age of, say, 79 or 80, that African-Americans are at least as likely to live a long life and often outlive their white counterparts contrary to prevailing notions of black infirmity. Resilience, I think, to use a word, is an important idea that we need to look at in the African-American context, health maintenance in the face of risk that for some African-Americans is overwhelming and contributes to a deterioration in health and poor health statistics. But in others is not the factor. In fact, they overcome it and do well. Understanding the environmental individual promoters of cardiovascular health within the black population is vastly understudied. And I think important for blacks, important for health disparities, but important beyond African-Americans because we have this ongoing 300 year, if you will, experiment in social marginalization, deprivation, discrimination. These are facts of American history. We have that as a chronic stressor, but despite that, even today, there are African-Americans who are 100 years old, happy and vigorous. What is the key to that? Now, resilience obviously is not a new idea. It has its roots in medicine and social sciences in developmental psychology literature where it was noted many years ago that despite children having traumatic experiences, stressful adversities in their youth, the phenomenon of some of them not only maintaining and doing well, but some of them truly thriving has been observed over and over. That notion of resilience is usually spoken of in terms and measured in terms like the ones you see listed at these various levels. On the community level, social capital, for instance, family level and social unit, team work reduced stigma. On the individual level, things like mastery and even optimism, but the phenomenon of resilience is obviously noted in a variety of contexts with a nod to Dr. Hannah Valentine. We see in diseases like peripartum cardiomyopathy, why is it that some of the women who go through that terrible ordeal actually recover quite well as in this case, a woman whose ejection fraction dropped to 28%, recovered to 66% while others receiving similar care do not and they go on to heart transplantation, heart failure and heart transplantation. And even beneath the organ level, the notion and this is taken from the toxicology literature of cellular resilience. That is a cell exposed to say the LD50, that dose of a toxin that kills half the cells in a dish. Well, that other half lives, what happened, what distinguishes one from the other, one population of cells from the other. Here it's described in terms of starting with a baseline a naive cell having the cell undergo a stress in this model of toxin sets the cell off on basically one of two major pathways, a pathway of defense which could result in recovery and healing or even increased vigor, sort of increased toughness for this cell, robustness it says in this particular slide or a pathway of toxicity where the stressful event led to negative epigenetic imprinting let's say and put the cell on a pathway of long-term adverse outcome or a much more immediate negative outcome. So resilience on these levels I think needs to be a thought, a consideration, a construct that we embrace more fully. Again, the pattern naive stress result. Now, a natural thought is, well, you know, if we just get rid of all risks or study risks and just reduce those, won't that result in optimal health? Well, I think it's important for us to study risk and understand risk in the African-American population but it's also important to understand that risk doesn't tell us everything about what the phenomena we see that we use or that we understand to describe or characterize African-American health, particularly cardiovascular health. Here's just a couple of points. Factors that should reduce risk often don't appear to in the literature. So very often it's noted that blacks don't receive the same cardiovascular benefits from a high socioeconomic status, that great equalizer in most folks' eyes than whites. Social support has been noted by my psychology colleagues as not always as protective as it appears in whites. Some factors that should increase risk don't appear to. Some of the best outcomes in this study around the South led by Dr. George Rust formerly of Morehouse School of Medicine. Some of his best health outcomes were noted in the poorest of areas. Contextual factors that are protective in the North may be less protective in the South. There's all of this again heterogeneity that we don't fully understand and therefore can't fully exploit. When we look at the sum total of the literature we actually don't know a lot about the factors that promote resilience among blacks and that's an important omission. We feel that Atlanta offers a particularly good opportunity in terms of exploring these problems because Atlanta is an example of an American city where there is great heterogeneity among its population. I mean we've got people who obviously are down and out even to the point of homelessness. You've got Tyler Perry, you've got and everybody in between. The point being that there's a lot of black affluence in Atlanta, there's also black poverty. There's a lot of other diversity in terms of immigrant populations who are black. And there's a wide range as I'll show you in a second of cardiovascular health profiles that are represented in a place like Atlanta. Not that it's the only place, but it's an ideal place and as a lot of you know it's been called the Black Mecca of the South. Some DC natives might object to that, but that's what Ebony Magazine says so it must be true. And with an eye towards that opportunity we formed something that we called Mecca and I teamed up with some colleagues at Emory and of course my colleagues in the Cardiovascular Research Institute and across Morehouse School of Medicine to form the Morehouse Emory Cardiovascular Center for Health Equity. Health Equity is I think most of you know is in the DNA of Morehouse School of Medicine and it's what we live and breathe there. And think back to that naive stress result model. In disparities research we posit that black race equals risk. That sounds pretty dramatic when it's just said as a standalone statement. But I think all of you would agree that you've read paper after paper that has this in the conclusion, words like this. Independent of traditional risk factors African-American invaders have a two to three times increased risk in whatever is bad in that paper, right? Even after adjusting for relevant potentially confounding variables and so on. I mean it's been a steady drum beat, right? So black race equals risk in a lot of the literature that we read and consume every single day. Well we wanted to look at this idea of resilience after the chronic or while being chronically exposed to those aspects of being black that result in high risk and high cardiovascular risk in particular. And we're beginning to look at not only sort of a global impression but we're looking at three distinct levels. The contextual level that is, and we call it our population project where we're looking at neighborhood context and using the best instruments available to us. That'll include an objective and a subjective assessment of the environment. Objective limited by the data we're able to get from various databases. And subjective coming from this population of about 1500 people that we've interviewed by phone about the subjective experience of living where they live. Not in their county but down to the census tract level so we get as much of a microcosm of life as we can. And then the individual level which actually has two levels and we're calling these the clinical and the basic projects. We're looking at cycle social and behavioral aspects through interviews and using standardized instrumentation to assess these dimensions. And also we're attempting to get a look at the vascular and epigenetic fingerprints if you will of resilience by looking at people who evidence resilience by our definition and those who don't. And those who come from positive environments and those that are less positive. Okay, so the aim of the first project, the population project, again, compare, we're trying to paint a picture. We're trying to find those microenvironments that are particularly hazardous if you will from a cardiovascular standpoint. So we're gonna compare what we can. CV hospitalizations, emergency department visits and deaths among blacks across these communities across Atlanta. And the second aim is to elucidate factors that contribute to the community's cardiovascular resilience and risk at both the census tract and eventually the individual level and examine relationships between resilience and some of the standard risk factor scores. So this is what it looks like overall. There are 940 census tracts, a lot of census tracts in Atlanta and we're gonna try to distinguish the at-risk and resilient. That's the geographic spread. Atlanta eventually is gonna be all of North Georgia, but this is Atlanta right now. And in that red, we're gonna, again, look at select census tracts that meet the criteria we want. Now, this is how it looked. These census tracts with enough African-Americans to allow the calculation of the rates that we used to determine whether they are at risk or resilient. And it's interesting to see that sometimes they're right next door to each other. The ones with bad CBD health statistics are known as with great CBD health statistics. So we had these to choose from and what we did was select those, we selected a subset of these census tracts that a subset of about 214, I'm sorry, 224, that despite having similar, highly similar median black incomes because we know SES and income is a powerful predictor of positive cardiovascular health. But we wanted to take that out of the mix because I think we know the answer there in the sense that income is irrefutably important. We wanted to know what else was operative. And so you see here median incomes that are very close, but these census tracts had dramatically different mortality rates in terms of cardiovascular disease. You see here nearly twofold, dramatically increased dependence on emergency department for healthcare and the hospitalization rate for cardiovascular diagnosis was dramatically higher in the at-risk population. So we're very early in the data collecting and analysis, but this just shows us that we can construct such a comparison. And the early results from looking at the early data suggest that census tracts across metro Atlanta have variable rates of premature CBD. I think I showed you that pictorially. And this variation exists even when median black household income is taken to account and we find both types of tracts. Aim two was to look at maybe what in the context may be related to these differences. Okay, now admittedly we have to use somewhat blunt instruments to look at this, but I think it begins to help us tell a story. So with the population survey, which was 1500 people that we did by phone with all of the challenges and limitations of that, we would gather impressions subjectively of the neighborhood environments in these two types of communities and we wanted to gather through, again, phone administered instruments, health, mental health, health behavior, social information from the residents in the two types of tracts. And of course, compare outcomes in both. And to sum up the early preliminary data on this, again, intriguing, perhaps controversial thought provoking, what has turned out to be not significant in these particular tracts is the walking environment, the ability to get out and walk to where you needed to go and exercise almost passively by doing so, activities with the neighbors, that whole idea of cohesion and community somehow being helpful for cardiovascular health was not evident in our data so far. And I'm caveatting this heavily because it is early. And walkable grocery stores, interestingly, did not fall out in early analysis as a significant community characteristic in terms of cardiovascular health. In the people that did get on the phone with us, there was a significant difference in global health in these different communities where the median income was almost identical, right? But you had this vast difference in cardiovascular health parameters that we measured. We saw that their impressions of their global health were distinctly better in the resilient neighborhoods. The evidence of depression using standard epidemiological depressive symptom scoring techniques, there was a significant difference and the more positive being in the resilient neighborhoods. And levels of optimism were distinctly more evident in the resilient neighborhoods. This is just looking at the depression scores of percent using a cut point of 16 in the CESD, looking at the different percentages in, and this was a significant difference. Looking more, now, so that's where we are with the context. So some interesting findings and again, preliminary. Our next project, which is actually beginning to run simultaneously, so we're recruiting for this and enrolling in it now, is to look at more individual characteristics, including looking at biomarkers of inflammation, such as CRP, oxidative stress, regenerative capacity, vascular measures, non-invasive, simple vascular measures, to look at the condition, if you will, of the vasculature in these individuals and whether there's some subclinical disease that comes out as being more evident in people from one context versus the other. And all of these markers will be adjusted for the LifeSimple 7 score. So we're gonna, again, look at at-risk in resilient communities and march them through a protocol which will help us identify whether or not their individual characteristics that might be evident from people coming from those environments. And this project flows into the next project, three, which I'll show you in a second, which looks at epigenetic and metabolic parameters that may also be flowing with the risk that people are experiencing either in their communities or at another level, at an individual level that we don't fully assess until we get them into the clinic. And these particular biomarkers were chosen based on some preliminary work by members of our group that looked at survival after myocardial infarction. So clearly survival here in red, where the oxidative stress and inflammation score was significantly higher, was dramatically poorer for people who had, who evidence high levels of oxidative stress and inflammation. Similarly with low regenerative capacity, the post-marmicardial infarction mortality was significantly higher. And in an interesting study, we saw that neighborhood affects different neighborhoods. Actually, if you drew blood and looked at it from people who were in different types of neighborhoods, poor versus not so poor, this is a different study. But what it showed was that you actually had different levels of these inflammatory cytokines, depending on neighborhood characteristics such as environment walkability, which seems to contrast with what I just told you from our current study and neighborhood cohesion. Again, that seems also to contradict that. But these were candidate things to measure because of preliminary data from other studies. And finally, we will take these people from resilient and non-resilient environments and we'll randomize them into an intervention which will be aimed specifically at altering their risk in more traditional ways. Risk factors, so we'll be aiming at things like blood pressure, cholesterol level and so on, a physical activity with this intervention to see the before and the after, to see if there is any change in any of the biomarkers that we have decided to investigate based on preliminary data from other studies. And the basic project, which is going to look at, again, beneath the cellular level, we will be looking at microRNA patterns that may be tied to cardiovascular health or disease. We'll be taking the microRNA data, combining it with metabolic analyses done at Emory where Dr. Dean Jones has the capability to measure over 20,000 chemicals in human serum that will give us insight into all types of exposure and all types of metabolic activity. That information plus the microRNA information will ideally give us some view on a subcellular level of who the resilient people, again, by our definition are, who the non-resilient are and whether or not a change happens with intervention. So this is admittedly very exploratory, a first step in looking into the notion of resilience at the contextual level, at an individual sort of whole body level and a subcellular level. Some other studies that are going on in the Cardiovascular Research Institute related to the same idea include a very interesting rat study that looks at a rat model for stress and PTSD. And it's a very interesting idea in that you take a rat here and you expose them repeatedly to a bigger, more aggressive species, over and over. And some of the rats will develop the rat equivalent of PTSD, which is social avoidance. Now the rat scientists may correct some of what I say here, but that is the basic idea. So you have, this is the aggressor and this mouse has been traumatized by continual exposure to rats that are that size, that level of aggression over and over and over. And when you put them, although this rat is caged, you see a very unnatural response from a very social animal is turned away and is avoiding. Same exposures, but this guy has not learned this behavior, has not developed social avoidance and in a way has not developed the post-traumatic distress that this one has. Our post-doctor, Dr. Chloe Gray, is looking at what distinguishes these two mice on a molecular level and what interventions might reduce the frequency of the development of this phenotype as a model for addressing resilience with targeted therapy. We're also looking at angiogenesis as a mechanism of resilience. Already, one of the microRNAs that has been isolated and among African-Americans and whites derived from stored samples has been shown to incite if endothelial cells overexpress that particular microRNA. It's found that angiogenesis, a robust angiogenesis is induced by that microRNA. Another one of our post-docs is pursuing that line of investigation to see whether or not this could be a mechanism of a sort of resilience, particularly in the context of diseases like myocardial infarction and heart failure. And finally, another study to look at the health disparities even before, with the idea being that we can look for indicators of health disparities before they emerge by studying the young. We're looking at mobile health cohort studies that will allow us to enroll young people right now between the ages of 18 and 29 in a study that will allow the gathering of granular real-time, as some would suggest, in-the-wild data that doesn't require people to come into a clinic for examination or come into a hospital, but rather important information on things like sleep, physical activity, mental state, and other things that can be obtained with the wearing of wearable sensors to see what some of the early indicators of the emergence of disparities might be. So, what am I saying? Over the years, even before the heckler report, it's been observed by really even the most casual observer, but among those of us who think deeply about social conditions and health, people like W.B. DeBose, it's been observed that the African-American experience is quite unique and has been for the better part of three centuries. Here's his quote, one thing we must of course expect to find, and that is a much higher death rate present among Negroes than whites. They have, in the past, lived under vastly different conditions, and they still do. That was 1899. I think this remains a fairly true statement. There has been, of course, there have been many advances, but I think if we were to freeze frame today, that statement would not seem very radical in 2017. What I'm inviting, however, is for us to embrace this notion of disparities and continue to work on every possible front to resolve them, social determinants of health, making those less of an issue, access to care, all of those things have to be pounded on continually. But I do wanna introduce the notion that if we look past the great successes within the African-American population, people who are living well today, despite it all, people who have grown up through the teeth of some of the worst conditions in terms of social inequities, people who were there for all of those atrocities, all of those terrible things that happened in the 56, who are still with us, how do they do it? They are, I mean, they're right in plain sight, and I think what they offer is a new way to think about what we can do in the present time to help African-Americans and others who suffer under the burden of health disparities. I think, again, historically, we've been here, focusing on unique vulnerabilities. A singular emphasis on risk and poor outcomes neglects understanding of assets and positive aspects of black health. Recognition of heterogeneity and resilience in the face of adversity, I think, promotes a complementary and positive pathway towards the resolution of health disparities. And frankly, I think your patients grow tired of hearing nothing but bad news. They get a little weary of hearing that, you know, black equated, of hearing black equated with negative or poor outcomes, because that's not the whole story. I think as we talk to our students, and to our patients, to our colleagues, about disparities and how blacks have had problems derived from that, I think we owe it to the black population, we owe it to our colleagues and students, and we owe it, I think, to the progress of science, to simultaneously acknowledge that the general arc of blacks in North America has been one of survival, that they have overcome in the words of the Anthem of the 60s, in many ways they have overcome many, many of them. And that's something worth studying and understanding. I'll close with this. How many of you remember the song Spanish Harlem? There's a rose in Spanish Harlem. Anybody old enough to? No one will admit it. Well, Ben Hill, the same guy who did stand by me, and also, Aretha Franklin later re-recorded it. And there's a line in that song that I think is worth remembering. At the lyrical highlight of the song, Ben says, she's, well, it's about a beautiful young lady who's living in the midst of poverty, and says, she's growing up in the street, right through the concrete. I think it's important for us to remember that for many African-Americans, life has been as hard as concrete, but they've come through. What is that trying to tell us as a scientific community? These are not just anecdotes, these are facts of life that demand explanation. And my challenge to you and to me is to understand this more deeply as a positive pathway towards resolving health disparities. Thank you. So we have time for questions, if you will just proceed to the microphone on either side. Hi, I enjoyed your talk. Thank you. Did you look at the percentage of the population who were black in each of the census tracts, and did that correlate with anything? Yes, so thank you for that question. We did, and in terms of, in most instances, the higher the percentage of non-blacks in the population, the higher the median income, and the more positive the parameters for cardiovascular disease, right? Fewer hospitalizations, fewer ED visits, et cetera. Again, we are still looking at that data, and I hope I'll be invited back to give you a much more comprehensive review of it. But your question's an important one, and we're gonna continue doing analysis on that. Thank you. Yes? Hi, Dr. Taylor, Tiffany Kyle Wiley from NHLBI. It's good to see you. You as well. It was an excellent talk, very inspirational, and thinking more about the way we look more positively at the African-American community. Just two quick questions. Do you all look at perceived environment in addition to built environment measures? And also, are you looking at measures that look at experiences across a life course to really get at what those differences may be? I mean, excellent questions. This is the American Heart Association funding, which is good, it's good money, but it only takes us so far. In terms of looking at the subjective impressions, everything I showed you was self-report at this point. And it really does reflect how people view, the data I showed today, really does reflect how people view their environment. And we'll have to do more work in terms of what objective things we can find out about it, in terms of things like air pollution, and those things that are not so much subject to interpretation. And then as far as life course measures, are you? I think that's important. And I'm looking to the NIH to help us expand our work into life course. The start of this mobile health cohort, which is essentially the concept is an echo of the Jackson Heart Study and that the idea is ultimately to take a ubiquitous platform like the cell phone and use that as a means of data gathering and to start as young as we can. So we're starting at 18 with this pilot where we hope to enroll our first cohort in a big hackathon, ideathon party on November 11th. It's actually a lot more scientific than I just expressed, but we are gathering people soon for a pilot and with the help of sustainable funding, we hope to see it grow and someday scale up to give us big data that we can use and hopefully follow people over a long period of time. But in specific answer to your question, we have yet to look deep into the younger ages or even prenatally. Thank you. I did enjoy your talk as well. Jerome Flagg from NHLBI. There were a few social determinants of health that I didn't hear you discuss. Marital status, family, cohesiveness, church going, and even educational level, which may not necessarily equal the income. Are you looking at that and are you finding differences in the resilient populations versus those who are not? Okay, so again, it's still early. So the individuals, what I gave you were data, let's see, I think I showed the slide of people's self-report of their education. Did I show that? I don't think so. Perhaps I didn't. Yes, in all of these communities, it was interesting. The ones that we selected as being comparable in income but having differences in outcome. The percentage, this is categorical stuff, the percentage of college-educated individuals is actually quite high. And particularly, it was even higher among the people who actually agreed to our interview. So this is one of the challenges of this type of research. So you're getting often the best case scenario, the people who sign up are not exactly like the people who are out there. They are very rough approximation. It is a blunt instrument, but it begins to set the stage preliminarily for further studies. The point of your question is that more educated, less, I mean, more resilient. Yeah, but not just the educated. I'm thinking also the family cohesiveness, the families that are together as opposed to single parents, churchgoing things that don't necessarily equate to education probably are still quite important. And that's information that we can gather in the individual interviews and we will do so. But I agree with you very much that those types of things, and the literature agrees with you too, those things matter a lot in terms of people's feelings about their health overall, their mental conditions, their positive affect and so on. All of those things are critical. Thank you. Thank you for your question. Dr. Valentine, so good to see you. Good to see you, it's been wonderful. Thank you for that outstanding talk. Could you give us a little glimpse about what you're learning about the genetics and the genomics of health disparities from this wonderful cohort called the Jackson Heart Study. Ah, okay. I know there's lots, but there's the highlights. And you know, I wish we had one of the geneticists here to respond to that question. I think some interesting things, just to pull one thing out. And often the genetics of the Jackson Heart Study are wind up being, the Jackson Heart Study winds up having its data pooled with other cohorts that are smaller. So we were talking earlier today about sickle trait and things like kidney disease and coronary disease. So the data on kidney disease seems to be pretty strong that sickle trait does predispose to a slightly higher risk of chronic kidney disease, particularly in the context of blood pressure abnormalities and so forth. The data on coronary disease looks negative. That is that there's no increased risk from what we see of people having sickle trait as determined by genomic analysis and the incidence and prevalence of coronary disease. The Jackson Heart Study has participated in a lot of consortia that have had some major I think impact on understanding of the human genome, of revising some of the things that we have taken for granted in terms of what the human genome consists of or what other earlier work has shown us. And I think it'll continue. But to give you the best answer to your question, I need one of my geneticists to come and talk. Thank you very much. Thank you. Thank you for the talk. Kelvin Choi from the National Institute of Minority Health and Health Disparity. Yes. Interesting in your research, in particular the analysis on the neighborhood characteristics. And I know that you matched the median household income of those neighborhoods to select the resilience and the at-risk neighborhood. Have you, will you be able to look at how the socioeconomic position of the participant relative to the median household income and see their health outcome? Because, I mean, your talk is about heterogeneity. Even within those census tract, there may be heterogeneity in the socioeconomic position which can predict their health outcome. It's an important point. And the increased precision and other aspects of socioeconomic position, being able to make that case, a lot of that will depend on the subsequent interviews that we do face to face. But your point is well taken. There is heterogeneity. And until we sort out some of those challenges in the contextual data, we have to be fairly reserved in our conclusions. I think we'll be able to say things a little bit more definitively. Again, still quite preliminary. This is very exploratory, right? But we'll have some more solid answers when we look at issues of inflammation, oxidative stress, and some of the molecular parameters as we continue this study. What I really want to emphasize is that we've got to do this. The opening salvo in this new effort to understand resilience has to be taken. And I think what we're going to wind up at the end of this study is with a whole bunch of questions. I think there'll be very few answers. But I think our questioning will be more precise and we'll set the stage for what we do next. And I invite, I had my email address on one of the slides. We still have IT. I invite these questions and they will be discussed in our meetings. So I want to be sure that if you have thoughts or questions about what was presented here or about anything in this topic in general, I really would like to hear from you. So I'll just tell you, it's H. Taylor. At MSM as in Morehouse School of Medicine.edu. H.Taylor at MSM.edu. And I welcome your questions. You might put in the subject line, what a lecture series. That would help me know what it's about. Please join me in thanking Dr. Taylor.