 Good afternoon everyone, it is now officially 12.04 p.m. which is the official start time for noon conferences. My name is Peter Angelos for those of you who I don't know, it's a pleasure for me to welcome you to this first of the 42nd annual interdisciplinary lecture series of the McLean Center. This is something that my predecessor as the director of the McLean Center, Dr. Mark Siegler, started, as I said, 42 years ago and so this is now, you know, multiple iterations. I want to express thanks to the Bucksbaum Institute for Clinical Excellence that helped support the lunch today, which I hope you're enjoying, just fair disclosure, there won't be a lunch every Wednesday and so it'll be selectively during the course of the year. We will have a full lineup of speakers throughout the year and hopefully we'll be getting the entire series out to you soon, but just a special note to that next Wednesday the speaker will be Dr. Jim Weinstein who's the senior vice president for Microsoft Health who will be speaking about the ethics of AI, moral implications for society. So today it really is a true pleasure for me to welcome and introduce my friend and colleague, Dr. Shola Olapati. A couple words of introduction for those of you who don't know Dr. Olapati. He is a professor of medicine and dean for academic affairs in the biological sciences and Pritzker. Dr. Olapati completed medical school at the University of Ibadan, Nigeria, residency at Cook County Hospital in Chicago, and a fellowship training in pulmonary critical care and sleep medicine at the Mayo Clinic. Dr. Olapati rose to tenured professor at the University of Illinois where he directed clinical research in the section of pulmonary and critical care and sleep medicine for 19 years. He joined the faculty here at the University of Chicago in 2009 to provide leadership in the department of a global health program which has been successful and expanded from a department of medicine-based program to a university-based program. And he completed his clinical ethics fellowship training at the McLean Center in 2011. He's focused his research on global research ethics, the responsible conduct of research. Dr. Olapati is an environmental scientist who early on recognized the potential health risk of exposure to household air pollution, which was an under-recognized global health issue. His scientific research in Nigeria from 2012 to 2015 was the first to explore the potential health benefits of transitioning pregnant women from cooking with polluting fuels to clean fuels. And I'm sure he will share that and other important things with us today. Dr. Olapati's talk today is developing a global state of mind, a journey from the lungs to the placenta and early childhood development. So join me in virtually welcoming Dr. Olapati, who unfortunately can be with us due to illness. Sholan, thank you. Thank you so much for that generous introduction. I'm going to share my screen if I could make this work. Yeah, good afternoon, everyone. I was so looking forward to being able to do this in person. While I was heading home yesterday, I wasn't sure whether my allergies were acting up or whether I had a cold. Knowing that we live in COVID times, I just said, why don't I just check it? And it was positive, so that's why I'm home and doing this, but I actually feel okay. So what I'm going to be talking about, like Peter said, is looking at what I've done over the past 20 years and put it in context of the training that I got at McLean Center. And so that I don't forget to thank the people who have been generous in funding this work. I got this out of the way up front, Richard and Suzanne Kipat, Family Foundation, the United Nations, and then all the NIA for the multiple grants that have supported this work. And I know that Suzanne Kipat was supposed to be in attendance. She might be online. I can't thank her enough. She and her family for the generosity to my research program and also to the Global Health Program at the University of Chicago. What I'm going to try to accomplish today is to make sure that we, people who don't know yet, understand one of the most underestimated threats to human health and life expectancy and to also understand the unlimited possibilities of a global state of mind. And what I'm going to try to do through this presentation is to weave it through privilege, altruism, serendipity or log, equity, autonomy, justice, and utilitarianism, which is an idea that tries to maximize common good, which is what I've tried to do with my career consistently. You know, I've, those who went to medical school in this country know that post graduation, you have tons and tons of loans. I was privileged, just like for me, who is in the upper corner here. We were classmates in medical school before we came to the United States. We went to this wonderful institution for free. We didn't pay anything. We had no loans. So that has given us an incredible opportunity to do, to be in a good position. And since our young faculty days, we've always looked for opportunity to give back. So this might be the major driver of why global health has been such an important component of our academic areas for the past two decades. When I was a young kid, I grew up in a setting where I learned that charity begins at home. As a young faculty at the University of Illinois on the south side of Chicago, where my clinical and research work at that time focused on, on asthma. I was intrigued by the fact that on the south side of Chicago, a lot of African American patients that I saw had terrible asthma, whereas in reflecting on my education in medical school, we didn't see that much asthma. So based on that and the idea that I got a free ride from that medical school, wanted to go to Nigeria to test the hygiene hypothesis, its relationship to asthma. This was way before everybody started talking about the microbiome and the hygiene hypothesis for those who may not know presupposes that if you grow up in a setting where you are exposed to clean environment, you get vaccines, everything is clean. There's little for your immune system to do because there's no infection to fight. So that is usually simplistically an over expression of your TH2 phenotype, which is more allergic. And that pretty much if you do a skin test, you'll see that individuals who have that kind of clean existence are the ones who are going to develop asthma or any other atopy related conditions. By contrast, kids who grew up in settings, similar to what I where I grew up, where we played in the sand, if you are eating on your food drops, you picked it up and you edit. You didn't even give it any 30 seconds. You picked it up and edit. And I remember also in school when we were in lower school, they would come to school and periodically give us some of these deworming pills. Everybody took it. They just gave it to everybody that was in school because helminthic infections were very, very prevalent at that time. And it's a very potent stimulation of the immune system and the TH2, which you would expect to be an allergic phenotype. But if you do the allergy test and you'll find out that these kids would be seropositive for allergens, but then they would not develop much by way of allergic diseases. As a religious person, the way I looked at it is people have life that's bad enough with helminthic infection. Why would the good Lord punish them with asthma or allergic diseases? And if you look at it, this blockage here, there are many factors, but IL-10 seems to just block the expression of some of this allergic phenotype. So I was curious that that would be that was what was happening. So we went in there, we collected blood samples. We extracted DNA, looked at biomarkers of inflammation, CRP, did everything we could do and also went inside some of the homes to collect those samples to identify some of the environmental allergens that may be at play with the manifestation of asthma. The long and short of it was we did find out that hygiene hypothesis really does exist. If you get exposed to a dirty environment or even in this side of the world, if you get exposed to farm settings, we can see we know that that kind of early exposure sorts of prevents or reduces the risk of developing asthma. But the slide that I'm putting up here just reflects the potential opportunities to do global health, because little did I know at that time that the DNA that I extracted from my asthmatics in Nigeria would be the default DNA for the Kappa Consortium, which is a consortium trying to look for the gene for asthma in people of African ancestry. So the DNA from the Nigerian asthmatics was compared to African Americans in the US, different countries, I mean, different states from West Indies, from Brazil and from wherever every black people who are taking for slave trade. And you can see that it's been very, very impressive because a lot of these publications are in nature communications and nature genetics. But I'm just going to flag this particular this is what happens when I'm going to flag this particular this particular assembly of pan genome from deep sequencing of 910 humans of African descent. This study showed that the DNA from people of African descent that was the default had 10 percent more DNA than any DNA that's in any library that we know about. This kind of opportunity opens up possibilities to find found mutations that may be of interest to understanding other diseases, because I know in some parts of Africa, people have very, very strong bones. For example, we have a lot of problems with osteoporosis here. Similarly, people who live in the desert there, they have significant adaptation in the sodium chloride channel. So there's plenty of opportunity to actually find my incredible scholarly output from being open minded to doing work globally. And one of the observations from the Kappa Consortium, this is a work that's actually under review is that we've been able to identify using nasa epithelium. We've been able to look at identify sites of dysregulation for asthma risk that drives increase in TH2 inflammation, which is what atop is decreased capacity for wound healing and impaired drug response. And this may play a very important role in the understanding of asthma within African diaspora. And I'm sure if Fumi were here sitting here doing her own presentation, she could say the same thing for the incredible work that she's done in Nigeria and in Africa, looking at breast cancer in people of African ancestry and comparing them to African Americans on the south side of Chicago. So this opportunity to just think globally has been very, very important and influential in some of the work that I've done over the past two decades. So in doing the hygienic hypothesis work and trying to get inside the homes to collect just samples, this was the site that we found. You can see the people cooking in what one might even consider primitive ways with firewood. And you could see the walls, the walls are just black. And with a lot of pollution inside the homes. And you can imagine as a pulmonary person, I was just alarmed. And the question was, I went in there looking for atopy. The question was, is it really atopy? Asked, could this just be oxidative stress from being exposed and inhaling all of these toxic pollutants? So I came back because I had no idea how bad that kind of site was. And in looking at the global burden of disease, the shocker was when you look at ambient particulate exposure and household air pollution exposure, he accounted for number four and number five causes of the global burden of disease in 1990 ranking. By 2015, actually, after I started doing this work, you can see that ambient air pollution is still number five. With household air pollution still holding a significant number ten. I had no idea it was this bad when I was in Nigeria. But this observation has been the poking the road that's driven my academic career while still doing the asthma work. And I'm going to share some of this work today, thinking about it from the equity and justice perspective. If you look at exposure to air pollution, ambient air pollution, this accounts for at least three million preventable deaths every year. And if you add to the mortality or disability related to exposure indoors, it accounts for which accounts for another 2.9 million preventable mortality every year. That's about seven million premature deaths every year. And I had no idea it was that bad. And I don't know how many of you are tuned into the challenges of pollution related exposure. But I caught my attention. And if you look at places where this is the biggest problem, if you look at India, it accounts for about 920,000 deaths every year. The ambient exposure, if you add the indoor component, another 590,000 preventable mortality. Look at China. It's almost two million people, both from the indoor and the ambient exposure. This was something that was really difficult to walk away from. And if you look at Africa or the most affected countries in the world, if you look at Nigeria right here, about 125 million people, 75 percent of the population cook with on clean foil. And this accounts for 70,000 premature deaths every year in Ghana. It's about 10,000 every year Guatemala, 5,000. These are preventable deaths. And the common string for a lot of this bottom billion population is that they have energy poverty and don't have access to clean cooking foil. You can just turn on the light and it goes on just like we do here. And this is data from a colleague in the business school or the Milken Institute. You can see here, PM related mortality. When you look at life, yes, lost. It's about 2.3 years relative to tobacco. And all I want you to also pay attention to some of the more topical diseases. I don't want to play their importance, but if you look at HIV or safe water and sanitation, even alcohol, they pale next to the mortality and the mortality associated with particulate matter exposure. And what was most bothersome to me is that women and children who are less than five years of age, they have the brunt of the mortality related to the endopollution from cooking with unclean fuel inside their homes. If you look at the energy ladder or what I call the energy poverty in terms of what people actually cook with, if you look at high income countries, you can see we have access to electricity, gas, LPG, ethanol and methanol. I want you to look at the extreme, the value of low income. They cook with crop waste. Any dry crop waste is and don't is what people cook with low income. It's a combination of that wood and charcoal. I didn't know what cooking with don't was until I went to Bangladesh with one of our colleagues here, Habib in public health sciences. What you see here is what people cook with and what you see is don't got cow shit being wrapped around sticks of wood. Sometimes they put it on the back of trees so that when it dries up, this is what people cook with. And it's so disturbing in that they say, why is the exposure so dangerous to women and children? They say, picture is worth more than a million words. You can see the intimate proximity while cooking with these little guys in the backs of their moms. So little, so this makes it very clear why women and little children are the most susceptible to the mortality and mobility related to exposure to household air pollution because of energy poverty. And it doesn't matter whether you go to India or Bangladesh, poor people all over the world, they have the same pattern. And if we don't know about it, if we don't bring it to anybody's attention, nobody would know because we are so far removed from all of these challenges through the privilege that we all enjoy. So and when they talk about autonomy or community engagement and participatory research, haven't been alarmed by that observation. I wanted to work in one of the semi-o-ban or rural setting in Nigeria. And the first thing that I did was, you know, went to some of these communities. You can still I see had here on my head at that time, just to talk to them about some of these challenges and to let them know that we were interested in coming to explore how bad it is and whether we could walk together to protect them. And they were all alarmed because they had no idea. I mean, women were just there doing what women do for their families, cooking meals to keep their family alive and well. Little did they know that it was causing so much of the health problems that they had. And I recommend community engagement and participatory research for anyone because not only did they come up with ideas that made doing our work in this community very, very successful. They also participated in the research willingly. And each time we had to go back, they welcome us gladly because they know that we have their interest at heart because if we're not there paying attention to it, nobody was doing it. So at that time, the American College of Chess Physicians, they started this humanitarian award, of course. They wanted to fund people who had ideas of what to do with $25,000. And of course, I showed up and they gave me $25,000 to go and look into this problem that I just identified. On the right side is the rocket stove. I think at that time, before people knew how important this was, this problem was. This was about a $5 stove. And it's a stove that is lined with ceramic so that people could still hook with the firewood that they usually cook with. And because it's lined with ceramic, it can heat to such high temperatures and theoretically reduce the pollutants coming from it. What I'm showing here on the left side is we looked at particulate matter levels at baseline before people started cooking and one hour into the peak of cooking. And when you look on this side, this is $5,000, PM 2.5, $5,000. And the WHO standard is supposed to be less than 25. In fact, it's getting closer to 10 for someone to get a benefit from it. And what I want to point your attention to is that even before they start cooking, the PM level is already above the WHO standard, meaning that the circulation in those homes are so terrible that their stagnation and perpetuation of the indoor exposure, even when they're not cooking. And this was what we did at the peak of cooking. And then when I introduced this stove for them, it created near complete combustion. But you can see that there was a significant improvement in the indoor air quality. But with the mean still above 125, that's more than five times the WHO standard. It was still unacceptable, even though we had improved the indoor air quality. On this side is the carbon monoxide level. It gives you an idea of the tolerance of the human body to tolerate. I don't know that anybody would get exposed to this kind of carbon monoxide and not be dead. But you can see how high the carbon monoxide level was before and after the introduction of this rocket stove. So that made us feel very good at least that we were improving the indoor air quality in these homes. The other thing that we did, excuse me, as a pulmonologist, was we looked at the mothers and children who are older than six years old and did pulmonary functions, pyrometry in them. Nigerian women, most African women don't smoke. And if you look at it in the women, almost 40% of them had mild to moderate obstruction. And in the children, almost about 40% of them also had obstruction because you could see from the picture, they had such intimate exposure to pollutants coming from the cooking with unclean fuel. And if you look at a dose response curve, looking at HAB zone, which is really quite high, and you look at what we were able to accomplish by pulling this down to 125, you can see that we really, really were just at the top of the iceberg because people are still going to be subject to exposure that's going to have significant health consequences. In looking further in Nigeria, where I was going to focus continuation of this work, this is what the map of Nigeria is. And if you look at the prevalence of cooking with unclean fuel, mostly firewood, you can see that most of the northern and northeast Nigeria, that's what 75 to 80% of the population cook with. And they have indoor experience similar to the one that I just showed you. If you looked at the prevalence or incidence of adverse birth outcomes, you can see a near parallel between where people cook with unclean fuel and the high prevalence of adverse birth outcomes, meaning still births premature and low birth weight. So with that in mind, I was curious with respect to what is the mechanism driving this mortality that's so high. And thanks to one of my illustrious colleagues, Gokhan Mutlu, which done exactly the kind of work that I was looking for to understand what was going on. He had an animal lab setting where he was able to expose people to filtered air and particulate matter here. I don't know where he got this from Germany or something, that they sell air from Germany. Anyway, he was able to expose all of these animals to either filtered air and did some elegant studies to demonstrate that exposure to household air pollution creates a pro-thrombotic state. If you look at bleeding time, partial thromboclastin time, and also platelet count, you can see the control exposure to filtered air and to particulate matter. And you can see consistency that exposure to particulate matter was terrible. The other thing that was striking to me was that they looked at time to loss of blood flow in the coronaries. And you can see here that within a short period of time, the pro-thrombotic state was able to compromise blood flow. And unless you think that this is just a laboratory experience experiment, this is a study that was done in Europe. I don't know how they got permission to do this. But they looked at 20 men with stable coronary artery disease, some of them who had actually undergone coronary bypass. And they exposed them to diesel exist to the level of 300 microgram per meter squared of particulate matter and exposed them to filtered air and the diesel exhaust. And then I got them on this, did a stress test. What you're looking at here is during exercise, you expect the heart rate, of course, to go up and look at the ST segment depression during exposure to filtered clean air and to diesel exhaust, suggesting that the exposure to polluted air actually has a more immediate impact. In fact, the cardiovascular sequelae of exposure to household air pollution is a major cause of mortality and mobility. And for those of you who are historian, if you remember what happened to the colon version in the United Kingdom in 1952 about 4,000 people died within about 10 days when the PM 2.5 level rose to almost a thousand. A lot of them were asthmatics, but a significant proportion were cardiovascular related. With this in mind, I wanted to know what it would be like to actually do a randomized control study to transition people from cooking with this firewood or kerosene. Kerosene is a bad foil, but it was also been subsidized by the Nigerian government. So subsidizing on clean foil with adverse health outcome, at least from our hypothesis generation idea and giving them this incredibly nice stimulus still stove with ethanol, which is similar to what people who are rich cook with on their boat. So the idea was we would do this intervention and try to see whether we could look at pregnancy outcome in this group of women. This slide looks complicated, but pretty much what we did was we randomized pregnant women in the 16 to 19th week of pregnancy into either a clean ethanol stove or they continue cooking with either firewood or kerosene. And we did a personal exposure monitoring where they carried this very expensive monitor for about 72 hours. We also had a GPS monitor in there so that we could tell exposure ambient from indoor exposure. And then we did ultrasound six times during the pregnancy so that we could track intrauterine growth. And I did a lot of cytokine and on the data stress biomarkers, including blood pressure monitoring so that we could look at the impact of exposure this intervention on birth outcome. Halfway through the study, we also thought, what a minute, why can't we just look at the cold blood to be able to look at angiogenesis and hypoxia since exposure is supposed to be pro thrombotic. We were interested in looking, taking a quick, a good look at the placenta. That's exactly what we did because of time limitation. We've published all of this work, but higher levels of exposure to PM 2.5 accounted for more preterm significantly more preterm deliveries, miscarriages and stillbirths, reduced gestational age at delivery, smaller newborns, but not statistically significant. More disturbing was the fact that we were able to see histologic evidence of hypoxia in the placenta. And when we looked at biomarkers, we could also see increased level of hypoxia inducing factor, meaning that these children were actually developing in a hypoxic setting with the body trying to generate more oxygen capacity. When we looked at the placenta, we also saw dysregulated placenta angiogenesis where angiogenesis almost persisted towards delivery in an attempt to negate the placenta hypoxia. We were also able to see that TNF alpha was elevated from Dr. Mutlu's work. He found out that IL-6 was a major driver of this and its CNF alpha actually regulates the production of IL-6. So everything was just consistent with some of the observation and the work that Gokkan did in the lab. And more interestingly, the development of gestational hypertension, those that were in the kerosene or firewood group developed hypertension more than those in the control group. And without doing any other intervention with similar levels of blood pressure at enrollment, people in the intervention group actually had a significant drop in dastolic blood pressure. And if you put it in the context of hypotensive changes in pregnancy, this is really another unanticipated benefit. This is just showing here that if you look at people who are cooking with kerosene, 6.4% of them developed hypertension relative to a smaller number in ethanol users. Similarly, kerosene was a major driver of some of these hypertensive changes and preeclampsia being a major, major concern in low to middle income countries. So, because of the work that we, what we found with respect to the placenta, we were really intrigued and trying to figure out what to do. This is just what I'm showing you here. Histologically, when you want to define hypoxia in the placenta, you look for hope by ourselves, chronic vascular density, acetyl nuts. Galena in Fumis lab was very helpful in helping us to look at this histologically in the placenta. Group C here is a group of African-American women, thanks to Dr. Sarosh Reina who had placenta in African-American women that I was interested in comparing to Nigerian women. What you see here is significant increase in acetyl nuts, reflecting placenta hypoxia. This is in the unclean group. This is in the ethanol group. This is in African-American women who ordinarily shouldn't have any reason to have indoor exposure, but I'll tell you later close to the end why people on this outside and African-Americans are also annoyingly causing household air pollution, even though they have access to the cleanest of wealth. So any of the parameters that we looked at, we demonstrated the presence of hypoxia. By looking at some of these sophisticated staining, you can see that the more exposed the mothers were, these are electron microscopic work, we could see increased expression of hypoxia-inducing factor. So I haven't demonstrated the benefit of this intervention. I mean, if we talk about ethics, if people benefit from the intervention, what do you do to the control group? Luckily, we were able to actually ensure that all of the people who were in the control group haven't observed that it was beneficial. We gave this $60 stove to everyone and 81% of the participants on their own chose to adopt cooking and to start paying for ethanol. But the reasons they chose to adopt the ethanol had nothing to some of the medical reasons we were doing the research. They did so because this is a stove that made them feel as if they were in a higher socioeconomic class. It would last for about eight years instead of changing their regular stove every year. It also made them smell less of smoke after cooking, in addition to the fact that it allowed some of their children to stay with them while cooking. A shell that gave us the ethanol that we used for this study to my joy decided to do a commercial pilot of clean cook stove and ethanol in Lagos. Meaning that if we demonstrated that this thing was as good as it is to women and to protect developing children, they wanted to see how they could create a business environment in Lagos to make this available to people so that they don't cook with on clean fuel. What does the future hold for these children? I mean, I mean, I'm an adult pulmonologist, but the more I look into some of these challenges, I then found myself in the placenter and also working with young children. What we decided to do is since we had this child cohort, we have followed this same cohort of children, about 200 of them for the past nine years. And what we're currently doing, this is work that's funded by the NIEHS. We are looking at these children, looking at current exposure, whether they're in settings where they're still using pollutant cooking in their household or clean fuel and monitoring their personal exposure outside the, so that they carry this monitor customized for little kids to be able to carry them around. And so that we can have an idea of what they're exposed to. We also have data on indoor exposure and the ambient exposure. And what we decided to do is we were going to look at, we were going to look at cognitive development in early childhood to see whether the in-utero exposure to the hypoxic setting has implications for the growth and development of these children. So what we ended up doing is we're working with some of our colleagues and I need to give Michael himself from the Department of Pediatrics credit and Susan Duncan who are part of my research team. We decided we were going to use the Kaufman assessment battery for children to investigate sequential processing abilities, knowledge, learning ability, and planning ability. And to use the Vinland adaptive behavior skills to test communication, daily living skills, socialization, and motor skills in this cohort of children that we have. And the results are very sobering again too, but motivates us to keep looking for ways of making this problem go away. So in this simple little cohort, this is just looking at preliminary where we are and looking at almost 200 of these children that we've followed now for almost eight years. We have about 132 from households that are using clean stoves and 66 children from households using polluting cook stoves. And peak indoor levels were higher in households with polluting wells as we would expect. And we used a multiple linear regression to look at the differences to association between the exposure and neurocognitive ability while correcting for all of these factors. I'll show you the result which is really very elegant but very disturbing. We found if we retract to the KPC, I'm sure I hope the pediatricians who know more than I do understand the implications of this. A two-fold increase in peak personal PM exposure was associated with a significant 3.9 unit reduction in KBC2. When we looked at the mean PM exposure too, you can see this inverse relationship, meaning that the in-utero exposure and continued exposure of these children means that they're not going to be super smart down the road. And if you look at the other instrument, it's the same thing. If you look at peak indoor level, a two-fold increase was associated with a significant reduction in the VAB score. Similarly, when we look at the peak personal exposure, this one did not reach statistically significant, but the trend is quite obvious. And the message is true that if kids are exposed to this level of pollution early in life, it has implications for their cognitive development. And when we related this to the kind of stove that they were using, you can see that those that were using clean stove had slightly higher score, while those that are polluting little worse. And you have to put this in the context that ambient exposure in Nigeria is also quite high. So even though we're trying the best that we can do indoors, the ambient exposure continues to be a challenge. So our conclusion is that high-pex exposure early in life maybe associated with decrements in child neurocognitive development. And the stove type affects neurocognitive outcome. And this is the first study to look at this in a really rigorous manner. But then what next? Are we just going to fold our arms and publish and then walk away? No, we have another RO1 that's allowing us to look at an implementation science strategy working with the Lagos state government in about 32 local government communities to use an implementation science approach to look at exploration, preparation, implementation and sustainment to see how we can actually create an ecosystem where people can come in and create a business around making ethanol available or making some of these clean cook stoves available. And we are in the second year of working this program. And the idea is that hopefully we can encourage as many of these unfortunate households to be able to have access to clean cooking technology. Lest we think this is a problem out there, which is the problem that most of us have when we think about pollution. I'm sure most of us remember in the summer when the fires from Canada brought real high levels of pollution to the United States. I just focused on this particular day that was a particular day that it was much, much higher. So lest we think it's a problem out there, we need to start thinking seriously because everybody is at risk. And lest you think we're insulated, this is the result of another study that was done in six United States cities. It's called the six city Harvard study. This was published in 1993 where they followed people from Portage, Stubenville, St. Louis for 14 years to look at life expectancy. And to put it in context, the PM 2.5 level in the most polluted city, which is Stubenville, Ohio, was just about 40, much, much lower than what I just showed you when we had this problem in the summer. And what did they die of? cardiovascular issues, lung cancer, whether you are a current smoker or former smoker. So I just included this to let you know that all of us are at risk. And this is also work from the Milton Friedman Center here, looking at potential gains in life expectancy in some of the 10 most populated countries that includes the United States. And you can look at India, average life expectancy gain if only we can wrap our hands around ensuring that people are not exposed to pollutania. If you go to New Delhi, daily PM exposure level is in the 300, 400 range every day. If you look at potential gains based on all of this economic model, there's a lot we can do collaboratively to change the trajectory of our lives of people who are less privileged than we are. And the same thing in Africa, where a lot of the energy poverty continues to be an issue. Again, we have pollution threat to health and the tools to combat it remain on equally distributed worldwide. Central and West Africa is a growing pollution hotbed. South Asia continues as global epidemic for pollution and most Latin Americans are breathing air that I exceed the WHO guidelines. So all of us are potentially at risk. I'm going to tease you with this particular notion that being on the south side of Chicago is also just as bad as being in Nigeria. This was in 2018, where we actually because of the ability for us to look at indoor exposure, we can currently put indoor monitors in households in Woodlawn, Washington Park, Roseland, Orgette, Austin and in Nigeria. I think we did the same thing for Bangladesh. What I want to point your attention to is H3, which is Roseland. You know, even though they smoke, look at the level indoor exposure for PM 2.5, 1500, even higher than some of the households in Nigeria where people were cooking with. And you might wonder, why is the indoor air quality on the south side of Chicago 153, 111, 35 so bad. We live in a cold climate and poor people learn from their grandmothers that when it's cold and you have cold baths entering your household, you should turn on your gas range and as a way to supplement heat. So a lot of our African American colleagues, even though they work and have access to the thermostat, when it gets cold, what do they do? They are turning on their gas range to supplement heat. And if you look at the south side of Chicago, the Matala mortality rate and infant mortality rate is also one of the highest in the United States. So I just wanted to use this as the pattern slide to underscore that global health is also local health and anything that we've learned globally can be very applicable even on the south side of Chicago. In terms of strategies for the future, I have some of these parting questions for all of us. Will self-interest prepare us to engage meaningfully to protect ourselves from the predictable worsening of our environment and adverse consequences? Do we have a moral imperative to look out for the least privileged among us even when they are so far away from us? And is there room for an environmental justice mindset to protect everyone regardless of race, color, country of origin or income? This kind of work takes a village. I have collaborators here at the University of Chicago. I want to thank for me who convinced me to come to the University of Chicago to be part of developing the Global Health Program. It's a real outstanding colleagues from the University of Nevada. This extensive list of young people and a colleague from Michigan State University. Again, this is just want to thank all of them. This is just what the team looks like when we go to the field. Serious looking people. I'll stop here and take any questions that you guys might have. Stop sharing my screen. You know, unmute. So now I can't even unmute myself in person. So that was wonderful. Thank you very much. And I know that there may be questions here. I'm going to start just by asking you one question, Shola, which is, you know, it seemed to me that the research insights that showed that this exposure to particulate pollution indoors had this impact on health and why not. I'm just curious about it seems to me that there was an additional, maybe you could tell us a little bit about once you identify there is this health issue, how do you then affect the policies locally to make the changes that happen? Because it seems like so frequently we see there's a realization that there is a public health risk. But then it seems like the change in policy takes decades before their substantive change, whereas it seems like changes that you were showing it seemed to happen more rapidly. Yeah, that's a great question, Peter. Because this study was in Nigeria and what people in Nigeria do is just what people all over the world do. So there's ongoing effort at the WHO level to extend some of these observations and the work that we do to all of these countries. But you have to understand that low to middle income countries, where the bottom billion people live, they have dysfunctional leadership. I guess I say that with Tongan chick because even here in the United States, I don't know that we are any better than them. But for Nigeria, especially where kerosene was being subsidized, I made a strong effort to share some of this report with some of my colleagues. I mean, we played cricket together, they were commissioners to try and see whether they could influence policy to take away the subsidy on kerosene and make sure people don't cook with it anymore. There's still kerosene available. They're still cooking with it. In India, for example, they've done a much better job. They have what they call this Ujwala program where they've decided to just go to some of these poor communities and replace their firewood with LPGs. They've done a fantastic job with this, but then they negate it because they have this festival of light where they burn everything and the PM levels again go above 1,000. So as they're trying to improve it, they have some of these traditions that make things. But seriously, the Kling Cooking Alliance through the United Nations, they're creating entrepreneurship around Kling Cooking to also have carbon credits available for households that actually adopt Kling Cooking technology. You get paid about $20 every year and in settings where people are living on $1 to $2 a day, that's substantial. So there's ongoing effort to look at carbon trade to create a small business enterprise. That's why I'm actually quite excited with the new R01 that we have, which is using an implementation science approach to distribute, work with communities to let them look at willingness to pay, willingness to adopt Kling technology. But the challenges are still quite high. And on our backside, actually started a similar project on the south side of Chicago to actually look at to replicate what we did in Nigeria. But then we ran into COVID at that time because I was trying to just show on the south side of Chicago that the habit of turning on the gas rain during the summer winter months, it's a major contributor and that would be very amenable to public service announcement. Because if we could show that some of these adverse bad outcomes are season log in winter relative to summer, then we could just go and tell people, we don't need to actually still do that. Now that people are sensitized that maybe the gas that we cook with inside has nitric dioxide, even without privilege, everybody is worried about NO2 in gas. So the indoor environment is a very, very important area of investigation that even those of us who are privileged now and have access to LPG, we're worried about the impact of NO2 on cognitive development and hypertension development and all of that. So yeah, we hope that policy and some of this, in fact, the one that gets me the most, it's the trajectory of some of these young people. I mean, you grew up in a challenging household, poor setting, then you develop in a hypoxia state and cognitively you are behind. So they're not going to be economically great participants in economy, but I'm hoping that at least the pediatricians who know more than I do can do a lot more to rehab and make some of these young people have more fruitful and productive lives. Yes, Umi. The best. And yet, by the time patients come to us, it's all right in the future. So it's really a testimony for a global man, myself, to think that if you go out and you see such that you can connect the dots, but if you don't go out, they're not even going to see that they're suited these goals that people are coming from. So to answer your question here, the policy begins when you go and community engaged work, sit in a ivory tower and expect our new people to help appreciate what's happening. So I'm glad that I'm focusing on such that we're just playing around in a real play as a hospital. But today, by talking to my homologous, I realized that in preventive oncology, we can't go out to the community to the community engaged work. And I think it's a moral obligation environment that we may not do any research at the University of Chicago without engaging our community. And I'm really grateful that the Auburn Health Initiative, a lot of work that the ITN is doing, all of us really think here about all of us beyond the terrarium. So you're going to get the data, or beyond getting the data we have on socially active in our communities to change our communities. And I think as the University of Chicago, we have to change the world. So for those of you who are going to the community, I'm putting it on the top of which, but again, it's really, I don't think we can go out and see this. Thank you. Other questions? All right. So that was truly wonderful. We're going to ask if you have just a few minutes to stick around to talk with the fellows. It'll be a little bit different, but we'll see if we can get this to work. But thank you all for coming and look forward to seeing you at future noon conferences. Happy to wait.