Child Study Center Grand Rounds 03.23.2021

June 08, 2021

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The potential of using Machine Learning to collect and use Social Determinants of Health Information to Improve Health Equity

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00:00Today, let me tell you what we
00:03have in store for next week.
00:05Another one that I'm very excited about.
00:08Next week we're going to have our
00:12next compassionate care routes.
00:14And we're going to be talking about.
00:16I don't have the title in front of me,
00:19just coined it, but I think it
00:22goes something along the lines of.
00:25Actually, do you have that
00:27the title on hand row?
00:32While Roe looks for the title,
00:33I can tell you that it's going to
00:35be about the work that we're doing.
00:37On eating disorders up on the on the
00:39pediatric floors where we have been
00:42absolutely overwhelmed by the number
00:43of such presentations we usually have,
00:46you know one or two every so often.
00:49But as you will hear,
00:51we've been literally flooded and overwhelmed,
00:53and we're trying to make sense
00:55of what that is,
00:57and so we're going to have a
00:59compassionate care rounds with
01:01the clinicians from all stripes
01:02of clinicians who have worked,
01:04we're going to talk about a specific case.
01:07But more broadly about what this means,
01:10so it's going
01:11to be very special,
01:13and the title is too little.
01:15Eating too many cases,
01:16microdroplets of trust
01:17toward national rehabilitate
01:18nutritional rehabilitation.
01:20Yeah, can you say it one
01:23more time slowly?
01:25I'm Mr too little.
01:27Eating too many cases.
01:29Microdroplets of trust?
01:30Tord nutritional rehabilitation.
01:33And there you have it,
01:35and we're going to thank you, Rob.
01:37And we're going to have a real,
01:39wonderful multidisciplinary cast for that.
01:41So, so that's next week.
01:43But this week, you know I wanted
01:45to introduce our wonderful speaker,
01:47but Rob Liberal, just like ARM,
01:49wrestled me, tackled me in fact,
01:51and he said, no, you're not doing it.
01:54I'm doing it.
01:55So I said, OK Liberal,
01:56if that's how you wanna do it.
01:59But you know, kidding aside,
02:00I am so grateful to Rob.
02:03Who who really has just like I was
02:05telling that Carol has been our paragon
02:08of timeliness and and always being there,
02:11I would say that Rob has been our
02:14paragon of identifying important topics.
02:17Wonderful speakers today is
02:18the second of three wonderful
02:21speakers the the first one that we
02:23had with Reverend Amanda right.
02:25I'm still seeing it in my in my mind's eye.
02:29It was an incredible talk
02:31and today by Charles he.
02:33Permitted me to call him Charles, not doctor.
02:36Centeio will not be an exception.
02:38We're in for a real treat and I
02:41will let my good friend rob the
02:43master of making this connection.
02:45Tell us about Doctor sent a place.
02:48Rob
02:48thank you. Doctor Martin.
02:50The Yale Child Study Center is a very
02:53special place I know this because
02:55last week Doctor Martin and Doctor
02:58Fernandez helped us bear witness to
03:01that rich and fruitful tradition of
03:03making the world a better place.
03:05By honoring the legacy of our
03:08dear and beloved Doctor Cohen.
03:11Who through a series of lectures honored him.
03:14And today it is my privilege to
03:17introduce a very special person in
03:21this very special virtual place who
03:24has 1 foot in academia and the other
03:28foot on the ground in the community,
03:31making the world a better place.
03:34And his name is the doctor Charles Centrio.
03:38Today, Doctor Santio was shared with us a
03:42lecture entitled understanding and reducing.
03:45Racial inequality for COVID-19 vaccination.
03:48Doctor Sentio is an assistant
03:50professor at the Rutgers School of
03:53Communication and Information in
03:56the Department of Library Science.
03:59He is also currently the Martin Luther King.
04:04Visiting professor and scholar at
04:07Massachusetts Institute of Technology.
04:09His research focuses on improving chronic
04:13disease outcomes for underserved populations.
04:16He is particularly interested in
04:19using both existing technology
04:22such as smartphones and tablets,
04:25and emerging technologies such as machine
04:28learning to improve health outcomes.
04:31He earned his PhD.
04:33In health informatics from the University of
04:37Michigan and while in pursuit of that degree,
04:40he also earned a master's degree
04:43in social work from University of.
04:46Michigan and later acquired a
04:48clinical license and social work.
04:52He also received an MBA from U of M Ann.
04:56Prior to that,
04:57a BA in mathematics and computer science
05:00at Central Connecticut State University.
05:03Clearly Doctor Santio is a
05:05musical intellectual.
05:06He has an incredible gift to be
05:09able to synthesize and assimilate
05:11diverse bodies of knowledge in novel,
05:14tangible and meaningful ways.
05:16He is the author of numerous articles
05:19and currently has a book chapter.
05:22Under review in their Rutlidge Handbook
05:24of Health Communication on the topic of
05:27community based health interventions.
05:29Will you please help me?
05:32Welcome Doctor Charlson TL to
05:34the Yale Child Study Center.
05:39Thank you, thank you so much,
05:41I appreciate it.
05:42Thanks for the warm introduction.
05:43Both Rosemary and Razan Rob,
05:45I certainly appreciate it.
05:46Thank you also for the an opportunity,
05:49at least virtually any way to return
05:51home to Connecticut where I grew up,
05:53I was born in Hartford and I
05:55grew up in Manchester before
05:57venturing off to two other places.
05:59So thank you again.
06:00I'd like to start the talk by just
06:03grounding our understanding or
06:04developing a common understanding,
06:06as I like to say for what health informatics.
06:09Is there are various definitions out there?
06:12This is 1 by Chuck Friedman
06:14who's a professor that I had
06:17at Michigan very commonly used.
06:19So basically,
06:20by definition it's important to
06:21understand that health informatics
06:23is definitionally interdisciplinary,
06:25and what it really involves are
06:27science domains or traditionally
06:29kind of science domains as well as
06:32application domains coming together
06:33to support scientific inquiry and
06:36problem solving, and that is about it.
06:39So science domains include
06:40information science where I come from.
06:43In terms of my doctoral training,
06:46computer science,
06:46where my undergraduate training was
06:49in along with various other sciences,
06:52cognitive science, communication,
06:53science, organizational science,
06:54decision sciences,
06:55and then application domains health.
06:57Obviously for this population
06:59includes community health,
07:01Health Communication, health,
07:02behavior, clinical care delivery,
07:04bio medical informatics or bio medical study,
07:07as well as social work and public health.
07:11And I picked these domains because my works.
07:15Tends to touch each of these areas,
07:17so combining the application domain
07:19and the science you get domain
07:21informatics so health informatics,
07:23biomedical informatics.
07:24So that's just a way for you to
07:27sort of decyfer when you hear
07:29health informatics and that term,
07:31this is the generally accepted definition,
07:34but the bottom line is that people
07:36are the users of health information,
07:39so health informatics,
07:40no matter where you are in terms
07:43of the type of work that you do.
07:46Ultimately points to that people, humans.
07:48We interact with information and
07:51that information can exert influence
07:53on us as well as we exert influence
07:56on it as we produce it OK.
07:58Now,
07:58common understanding what's HealthEquity.
08:00I'll go this one through this one
08:02a little bit quicker.
08:04I'm I'm assuming that we probably
08:06have more of a baseline understanding,
08:09but basically it's about assessing
08:11the differences in health status
08:13between groups of people and those
08:15groups can be defined by race or ethnicity.
08:18That's a common sort of grouping,
08:20and the grouping that I probably deal
08:23with the most, but also importantly,
08:25immigration status, disability,
08:27gender, sexual orientation, geography.
08:28And assets and I used the term Alice
08:31now which stands for asset limited
08:33income constrained an employed
08:35SES is a common sort of bucket
08:37for that or similar bucket,
08:39but Alice is a term that I see used more
08:42and more in the term I use now differences.
08:45What does that mean?
08:47Well,
08:47differences include the extent.
08:50Of a disease.
08:51As well as impact,
08:53so I don't want to take
08:56us through FB 101 here,
08:58but basically the prevalence
09:00is the proportion of cases in a
09:03population at a time, so incidences,
09:06incidents conveys information about
09:08the risk of contracting a disease,
09:10whereas prevalence indicates
09:12how widespread it is.
09:14And in the context of COVID,
09:16that's extremely relevant.
09:17I think we've all heard some of these
09:20terms released concepts as we've looked
09:22at the Daily News on COVID updates.
09:25Now just a little bit about equity,
09:27I could cite many different examples
09:29and I'll cite some later on.
09:31But for those of us who work in equity,
09:34and I've been working in
09:36equity for about 15 years now,
09:38Milwaukee is a city that's often used in
09:40illustrating HealthEquity or health inequity.
09:42It's a fairly segregated city
09:44with a large black population,
09:4540% in the city,
09:47and then 17% in Metro Milwaukee.
09:49And we don't quite understand why there
09:51are some various theories out there,
09:54but the point is that when you see
09:56HealthEquity numbers illustrative
09:58of a larger larger phenomenon,
10:00you see Milwaukee quoted quite a bit so.
10:04Infant mortality across the United States
10:06for blacks is more than twice that of whites.
10:09That's been the case for over a decade now.
10:13And in Milwaukee,
10:14as I've mentioned,
10:14low SES households are three
10:16and a half times more likely to
10:18die in the first year of life.
10:20So these sort of dramatic indicators,
10:22again persistent.
10:23This is before COVID became
10:25part of our binocular.
10:27These are persistent inequities,
10:29and Milwaukee is a good place to
10:32sort of illustrate these this data.
10:34These facts and this.
10:36These have been the case.
10:38As I mentioned for over a decade now.
10:43OK,
10:43I want to also emphasize that HealthEquity
10:46is a persistent human rights issue.
10:50I need to assert that because there's
10:53not universal agreement on this.
10:55I read a few years ago when I was delving
10:58more into policy that we fund our priorities.
11:02I'll say that again,
11:03we fund our priorities and HealthEquity
11:06is not necessarily something that
11:08has been funded.
11:09I'm going to put a quote up here and if
11:13we were in the room I'd ask for hands,
11:15but I want to read this to you.
11:18We are concerned about the constant
11:20use of federal funds to support
11:21this most notorious expression of
11:23segregation of all forms of inequality.
11:25Injustice in health is the most
11:27shocking and the most inhuman because
11:29it often results in physical death.
11:31The quote more of the quote I see
11:33no alternative to direct action and
11:35creative nonviolence to create awareness,
11:37to create, to create,
11:38not creative nonviolence to raise
11:40the conscious of the nation.
11:41Sorry bout that.
11:42I stepped over the last part.
11:44Does anyone know who famously
11:47said that in a speech?
11:49I'm gonna move on here.
11:51That's Doctor Martin Luther King Junior 1965.
11:54Annual meeting of Medical
11:56Committee for Human Rights.
11:57So this notion of HealthEquity that
11:59it exists going to get more to that
12:02later and that it's important,
12:04has been around.
12:05This is not a new thing and
12:07I want to make sure that we understand that.
12:11So when I say persistent inequity,
12:13I'm not talking about COVID.
12:14I'm certainly not even talking
12:16about the last decade or two
12:18when this work has proliferated.
12:19We've known about these
12:21inequities for quite some time.
12:23Now let's jump into the causes.
12:25As you might imagine, summer unclear.
12:27This is an interesting question.
12:29What causes health inequities?
12:31It seems may seem innocuous.
12:33But part of what makes it complex is
12:35that it brings together many academic
12:37disciplines and many different theories,
12:40many different approaches.
12:41During my PhD study in Information Science,
12:44I was exposed as you might imagine,
12:46to several different academic
12:48disciplines that are new to me.
12:50As Rob mentioned, I was a mathematics
12:53and computer science undergrad,
12:54so my pathway to social
12:56science was was long and Anan.
12:59Winding.
12:59However,
12:59given my description of health informatics,
13:02that's probably to be expected in
13:04terms of the interdisciplinarity.
13:06Of it,
13:06so my interest in HealthEquity
13:08was enhanced by my exposure to
13:10developmental psychology literature.
13:12This is literature that I'm sure
13:14many in the crowd are familiar with,
13:16specifically through one of my professors,
13:19Daniel Keating, who I mentioned by name here.
13:22One because he does wonderful work and two,
13:25he's just an excellent professor in person.
13:27I'm using his work here to explain
13:29or try to answer the question
13:32about what causes inequity.
13:33Again, persistent inequity.
13:35As I continue to to identify the root causes,
13:39I find myself even reading more
13:42literature and sociology, psychology,
13:44even history to understand context.
13:46So it's important if we're
13:48going to ask this question,
13:50we have to embrace different disciplines,
13:53different people, different literature.
13:54That's important now, the answers.
13:57What are they?
13:59They lie in two camps, essentially,
14:02historically and contemporarily,
14:04nature versus nurture.
14:05We're probably very familiar
14:07with the concepts.
14:09Are certain groups biologically
14:11or genetically predisposed to
14:13the risk of certain conditions?
14:16And their progression?
14:17Or do social factors play
14:19more of a role nurture?
14:22For the Pearly early part,
14:23I told you,
14:24I've been reading a lot of history,
14:25so for the early part of
14:27our country's history,
14:27nature was the prevailing belief.
14:30The science was influenced by
14:32the sentiments of the scientists.
14:34This is still the case.
14:36The psychologist Charles Thomas
14:38in 1985 published a paper in part
14:41that said quote science is a human
14:44activity which is hardly neutral.
14:46Objective or impartial?
14:48So it's important that when
14:49we talk about the science,
14:51some of us imply the purity of it.
14:54It's important for us to understand
14:56that there are human beings behind
14:59the collection of that data.
15:01The analysis of that data,
15:02the interpretation of that analysis,
15:04and the dissemination of it.
15:06After all, as an example,
15:08using enslaved Africans as free
15:10labor was in large part fueled by
15:12the notion that certain groups were
15:15genetically and biologically inferior.
15:17I'll expound upon Dubois his work
15:19in this area in a couple of slides,
15:22but back to Keaton cheating.
15:24He found he and others find
15:26that nature and nurture
15:28both play a role in outcomes,
15:30so individual differences.
15:31Cognitive, behavioral,
15:33physical and mental health are patterned
15:36by socioeconomic circumstances.
15:38And that health outcomes are influenced
15:40by many inter related factors.
15:42So things like poor health status,
15:44disease risk, risk factors and
15:47limited access to health care.
15:50Social determinants of health.
15:51Stoc. Hi, I'm going to talk
15:53about those quite a bit.
15:55Those are primarily the drivers.
15:58Now let's talk a bit about this.
16:02Here how do we get from social?
16:05Factors.
16:06To outcomes, again,
16:07an innocuous question on the surface,
16:10but there's a lot going on underneath here.
16:13OK. This arrow from social
16:20circumstances to outcomes.
16:23Is about predicting outcomes based on
16:25social economic status or Sep sometimes
16:28called social economic position.
16:32So let me go and review this circle a bit.
16:35I'm going to spend just a slide on
16:37this circle, 'cause it's it really
16:39gets at the heart of the answer to the
16:41question about what causes inequity,
16:43the interplay of nature and
16:45nurture both of them play a role.
16:47But the key questions again are what what
16:50social predictors matter more than others?
16:52And how do these predictors interact?
16:56Do they relate to different outcomes
16:58and what developed mechanisms
16:59might explain this arrow?
17:01Those of us who work with pathways clinical
17:03pathways were really concerned with this.
17:05How do we tie factors to two outcomes?
17:08What's the pathway?
17:11The short answer is we don't know really.
17:14They're hard to separate.
17:15You can imagine that it's really hard
17:17to isolate someone's socioeconomic
17:19position from where they live.
17:21These social determinants are interplayed.
17:23They're almost hopelessly connected,
17:25and I don't mean hopeless as there's
17:27no hope to do something about it.
17:30I mean,
17:30hopeless in terms of trying to segment them.
17:33Segment them are very difficult.
17:35However,
17:36what we do know what has been demonstrated
17:39is that as a whole social circumstances.
17:42Have a gradient.
17:44Here this is represented by
17:47the arrow to outcomes.
17:49Lower levels of socioeconomic
17:51status and social economic position
17:54uniformly are associated with lower
17:56levels of virtually any measured
17:59developmental health outcome,
18:01and its most frequently
18:04a linear relationship.
18:06So these factors, demographics,
18:09socioeconomic, residential.
18:12Actually can predict.
18:14Physical, mental, cognitive,
18:16and social competence is.
18:19So the answer is nature and nurture,
18:22but more specifically social factors,
18:25social determinants of health actually
18:27show linear relationships to outcomes.
18:32Now let's go to COVID for a minute.
18:36What's causing the COVID
18:39inequities that we see well?
18:42For people like me who have been
18:44working in HealthEquity for over a
18:46decade and there have been people who
18:48have been doing this a lot longer than
18:50I have before I learned how to spell
18:52PhD point to these social factors.
18:55So wouldn't it follow that social factors
18:59are also exerting influence on COVID,
19:03specifically risk of infection?
19:05Risk of hospitalization and mortality risk.
19:08Those are the three kind of markers
19:11that have been used since the
19:13beginning of the pandemic in terms
19:15of the work that I've looked at.
19:18Again, social factors for over
19:20100 years social factors,
19:21not genetic factors as was first
19:24speculated have been described as primary
19:26causal factors of health disparities,
19:28and we also find them in COVID.
19:31Risk of COVID infection,
19:34hospitalization and death.
19:35Just some more in terms of HealthEquity data.
19:41African American and Native American
19:43individuals have shorter life
19:45spans and more illness than whites.
19:48Hispanic immigrants initially tend
19:50to have relatively healthy profiles,
19:52but with increasing lengths of
19:55stay in the United States,
19:57their health tends to decline.
19:59That's also true of immigrants
20:02from African and Caribbean nations.
20:06Now, in terms of COVID.
20:09And think COVID social factors COVID
20:11social factors by the end of the talk,
20:13I hope that we're making that association.
20:16Let's look at the Bronx, New York City.
20:18Rob knows about the Bronx, don't you rob?
20:21Familiar, the Bronx had the has the lowest
20:23levels of income and education and highest
20:26proportion of black and Hispanic persons
20:28of any of the boroughs of New York.
20:30It also had the highest rate of
20:32COVID hospitalizations and deaths.
20:35This is data as of September.
20:38In contrast, Manhattan primarily
20:40predominantly white most affluent
20:41borough of New York City by far,
20:44had the lowest rates of hospitalizations
20:46and deaths related to COVID-19.
20:49Although it had the highest population
20:51density of any New York City borough.
20:55Again, this is data as of September.
20:58New York City reflects other
21:00major US centers. For example.
21:03Disproportionate death rates of black
21:05persons in Chicago are concentrated in four
21:08majority black neighborhoods, so we see.
21:11Almost as data was being collected
21:14around COVID racial disparities.
21:18So let's go back a bit.
21:19I told you I've been reading
21:21a little bit about history.
21:22I'm going to take you through
21:24a little bit of this.
21:25It's important to understand that
21:27racial health inequity did not start.
21:28Unfortunately,
21:29nowhere that end with COVID.
21:31But when did racial inequity emerging health?
21:33Well, the answer is pretty clear.
21:36Racial differences in health are
21:38present at the very inception of health
21:40records being kept in the United States.
21:43Up until an through the Civil War in 1861,
21:47physicians debated.
21:48Physicians these are trained individuals.
21:51Whether the already well known racial
21:54disparities were due to biology.
21:56Because blacks were inferior or
21:58social factors because many blacks
22:00were enslaved and lived in society.
22:02Steeped in white supremacy,
22:04steeped in white supremacy.
22:05At the time,
22:06the debate was rooted in politics
22:08as anti slavery physicians,
22:10which included the first generation
22:12of black doctors,
22:13argued that social factors were the drivers.
22:16These factors at the time defined
22:18the need for cheap labor and those
22:21conditions were what determined
22:22both the progression of disease.
22:25And health status of enslaved blacks
22:26in the South and impoverished blacks
22:28in the north. This work was captured.
22:31This biological versus social
22:33debate was captured by Dubois and
22:37his Seminole work the Philadelphia.
22:39Now Dubois was a trained sociologist.
22:42I think of him as the first
22:46HealthEquity scholar in our country.
22:49And he's also deeply,
22:50deeply into epidemiology.
22:51If I could talk to him,
22:53I'd love to talk to him about his epic work.
22:56'cause that's really what this is about as a.
22:59I read this book before I learned how to
23:02spell PhD and then I reread it after.
23:05And it's a book about epidemiology.
23:07Essentially.
23:07Now why am I bringing it up here?
23:10He can't rasted the biological point
23:12of view and his observation that.
23:15Uh, that social factors?
23:17Were in the vastly different conditions
23:21were at play, and I'm putting up.
23:24US knows that this is the
23:26I submit that Dubois is
23:29important to public health.
23:31United States ice snow is to to
23:34public health around the world.
23:36This is the famous water spicket
23:39that London physicians know.
23:40I identified was the cause of cholera.
23:43This kind of launched modern epidemiology.
23:47And I think that this work the
23:49Philadelphia is approach is as
23:51important in terms of racial equity,
23:53both in the United States and beyond.
23:58So Dubois argued that social
24:01advancements and vastly different
24:03living conditions were the causes
24:06of the known 1899 known racial
24:09differences in health outcomes.
24:11Now one more on Dubois.
24:13Before I leave what he pointed out,
24:15I pulled this quote from the Philadelphia
24:17and I think it's really important.
24:20I alluded to this earlier when I talked
24:22about we fund our priorities again,
24:24we fund our priorities.
24:26The most difficult social problem
24:28in the matter of health is the
24:30peculiar attitude of the nation
24:32towards the well being of the race.
24:35There have been few other cases in
24:36the history of civilized peoples
24:38where human suffering has been viewed
24:40with such peculiar indifference.
24:441899 Let's go back to social determinants.
24:49I want to ground us in a common
24:51understanding as I did for health
24:52informatics and for HealthEquity.
24:56And we see here what Dubois observed.
25:00Social advancement vastly
25:02different living conditions.
25:04Stop one moment Sir.
25:06OK, there are five central
25:09social determinants of health.
25:11Economic stability, education,
25:13social and community context,
25:15health and health care,
25:17neighborhood and built environment.
25:19And this. Diagram.
25:22From the Institute of Medicine.
25:24Helps articulate.
25:27Illustrate their interplay there all.
25:31They all can play a role.
25:33And some can play the role
25:35of role more than others for
25:37group for certain groups.
25:38But the point is in trying
25:40to isolate causal factors.
25:41This is perhaps what makes pathways
25:44so difficult to definitively describe
25:46is that they are all at play and
25:48they can be a play at different
25:50times for different individuals.
25:52So these are social determinants.
25:57And these determinants have been
25:59articulated for various groups.
26:01I've mentioned black.
26:03I've mentioned Latin ex but also Haitian.
26:07Afro Cuban Trinidad Ian
26:09Appalachian Poor Asian Americans,
26:11older adults, immigrants,
26:12individuals with disabilities,
26:14Native Americans.
26:15It goes on prisoners as well.
26:20Social determinants of health
26:22of health are not like gravity.
26:25They're not some natural law
26:27that just sort of happens.
26:29They are the drivers and the result of
26:32institutions that create and sustain them.
26:34They are populated these institutions
26:37by individuals who either actively make
26:39decisions to maintain an equity or perhaps.
26:42More commonly, they passively
26:44maintain an equity by simply looking
26:46the other way by not caring quite
26:48enough for the least of these.
26:49Back to Dubois is quote.
26:52When I first started started
26:54studying health inequity,
26:55I thought the healthcare system was broken.
26:58Maybe not.
26:59Perhaps like the criminal justice system,
27:02it's working as intended.
27:03Deanna Hoskins has seen the senior policy
27:06advisor for the Department of Justice,
27:08Bureau of Justice Assistance is noted.
27:12The criminal justice system is not broken.
27:14It is operating just as
27:16it's designed to operate.
27:18The cost,
27:18perhaps some of you are familiar
27:20with some of this data.
27:21The cost of imprisonment in jail in
27:23the past 20 years has grown as a faster
27:26rate than any other state budget item.
27:28It costs about $80.00 a
27:30day to house an inmate.
27:31And the United States spends in excess of
27:33$68 billion a year on corrections federal,
27:36state and local.
27:36I point this out because we should never
27:39assume that we're all united in our
27:41desire to eliminate racial inequity.
27:43I never assumed that.
27:46This is uphill. It's a noble fight.
27:48But there's a slope.
27:52To that line?
27:54OK, social determinants of
27:55health impact everyone,
27:56but not everyone equally important
27:58point here. It can impact all groups.
28:02But children in particular
28:04are especially vulnerable.
28:06Why well?
28:09Askeaton, another seven have taught
28:11me in terms of developmental.
28:13Children are especially vulnerable
28:14because the physical,
28:15social and emotional capabilities
28:17that develop early in life,
28:18which many of you are well steep,
28:21provide a foundation for life,
28:22course health and well being.
28:26As I mentioned,
28:27developmental scientists have settled
28:28on the nature versus nurture debate,
28:31both in concert matter.
28:32But how they interact with the course
28:35of development is still being described.
28:37What we do know,
28:39as I mentioned with Keating's work.
28:41But important nature,
28:43nurture interactions occur during
28:44early childhood development that set
28:47a course throughout someone's life.
28:52I'd like to also point out that
28:55systematic racism and colorism colorism
28:57prejudice or discrimination against
28:59individuals with dark skin tone.
29:02Among people of the same ethnic group.
29:05Are types of determinants which
29:06do not impact groups equally.
29:08So while social determinants impact all
29:10of us, they don't impact us all equally.
29:12Much like Kovit,
29:13I remember early in the pandemic
29:15where COVID is affecting us all.
29:17We're all being affected by kovid.
29:19That's largely true,
29:20but it's not affecting us all equally,
29:22and that was brought home to me
29:24more than at any other time.
29:26When I was freaked out like the rest of
29:29us have even walking out the door and
29:32going to the grocery store was an adventure.
29:36And anxiety.
29:38Yet when I talk on the phone with one
29:40of a friend I've had since 7th grade.
29:42Ann, I said you're out,
29:43what are you doing out? And it hit me.
29:46He's a mailman. He delivers the mail.
29:50He didn't have a choice.
29:52He was essential. And the people
29:55that we walked by in grocery stores,
29:57stocking shelves, essential workers.
29:58So we have to keep in mind that
30:01this pandemic and these determinants
30:03don't affect us all equal.
30:04And that's important for us
30:06to keep in mind me include.
30:07OK, structural inequities.
30:09I've mentioned that what are they?
30:12Well, they're important 'cause
30:15they undergird these drivers.
30:17They are the personal interpersonal
30:20institution and systematic drivers excuse me,
30:23such as racism, sexism,
30:25classism, ableism, xenophobia,
30:26homophobia,
30:27that make those identities salient
30:29to the fair distribution of
30:32health opportunities and outcomes.
30:36I want to point out here that there's a
30:40distinction in the American narrative.
30:42As you might imagine in the
30:45summer after Memorial Day.
30:47I was asked to talk to different groups
30:50in ways that I hadn't before about
30:53racial justice, and I'm not a race
30:56researcher by training or by identity.
30:58However, I do research and equity.
31:01I'm a person of color,
31:03therefore I bring myself to my work.
31:06So. What I so I did some homework
31:09so more reading of history,
31:11which has been extremely illuminated,
31:13instructed from.
31:15And I uncovered that there was a
31:17prevailing and Eric American narrative
31:19that draws a sharp line between
31:21the United States past and present.
31:25So within 60s and 70s marking a crucial
31:28before and after moment in that narrative,
31:32the narrative is search asserts
31:34that until the 1950s, U.S.
31:36history was shaped by the
31:38impacts of past slavery.
31:40American Indian removal,
31:41lack of rights for women,
31:43Jim Crow segregation periods of
31:46nativists restrictions on immigration,
31:47and waves of mass deportation of
31:50Hispanic immigrants, eugenics,
31:51the internment of Japanese Americans,
31:54Chinese exclusion policies.
31:56The criminalization of homosexual acts
31:59and more so think 50s pre 50s this past.
32:03And then after the 1950s.
32:06We had this rush to the present
32:09civil rights women's liberation,
32:11gay rights, disability rights movements,
32:13and their aftermaths.
32:14May have contributed or be contributing
32:17to this narrative that social,
32:20political, and cultural institutions
32:21have made progress towards equity,
32:23diversity and inclusion.
32:25DI it's a thing.
32:28Highlights include the Civil Rights
32:30Act of 64 Voting Rights Act of 65,
32:32Fair Housing Act.
32:34Title 9 American with Disabilities Act.
32:38Even the Affordable Care Act.
32:41And most recently, the Supreme Court
32:43case that legalized marriage equality.
32:46United States.
32:47Yes, that was progress.
32:49That is progress.
32:50However,
32:51when we look at remaining persistent
32:54structural inequity.
32:55I'd like us to reconsider
32:58that before after narrative,
33:00even after what I call this past summer
33:03of radical racial reconciliation.
33:06How much of that energy will be
33:08sustained and how will we know
33:10what indicators might we use
33:12'cause from a health standpoint,
33:14I'm still looking for evidence of that.
33:17Sharp distinction.
33:24Persistent racial inequity suggests
33:25that the distinction is not so good.
33:30OK, causes of racial inequity.
33:32I alluded to this a little earlier.
33:34For kovit or similar to the
33:37causes of persistent inequity
33:38for common chronic conditions.
33:40So I cited some data earlier
33:43about racial inequity,
33:44and we see that the structural social
33:47factors exert have exerted are
33:49exerting their influence on COVID-19.
33:51Again, risk of infection
33:53hospitalization and death,
33:54and that shouldn't shock us right?
33:57Wouldn't it wouldn't be surprising if we
34:00found that somehow these structural factors,
34:03which are by definition structural.
34:05Wouldn't be exerting an influence
34:07on covert outcomes for me early
34:09in the pandemic and I'll talk a
34:11little bit more about where my work
34:13is today and where it's headed.
34:15I saw a crisis room. Because these
34:20structural factors are structural.
34:22So what we found in some early data.
34:24This is a Banga is a wonderful
34:27mentor of mine.
34:28He's at the university.
34:30He's at NYU.
34:31School of Medicine does some
34:33wonderful work in population health.
34:34Published in JAMA in September.
34:37Addressing some of it questions
34:39about genetic predisposition
34:40predisposition to COVID infection,
34:42they ask that was out there
34:44reasonable questions to ask.
34:46But are people of color
34:48genetically predisposed?
34:49The questions were asked and answered
34:51by Gbenga and others that yes,
34:54social factors like greater proportion
34:56of essential jobs like my friend,
34:58my lifelong friend who delivers the mail
35:01continues to deliver the mail everyday.
35:04Never missed a day of work.
35:07Number of people in the household.
35:09Multi generations in the household,
35:11the things that we know
35:13predispose you to COVID risk.
35:15Also exert their influence
35:17disproportionately on people of color.
35:24So just as medical care alone.
35:27Has not rat eradicated
35:29racial inequities in health?
35:31Medical care alone will not
35:34result in racial, ethnic,
35:36ethnic inequities for COVID inequity.
35:40So I, as I've been reading about vaccine
35:42rollouts and I'll talk a little bit
35:44about some of that data in a moment.
35:47It occurred to me early
35:48on that this is great.
35:49Our bench scientists are going to work.
35:52And God level yes, we need that.
35:54Should create a vaccine.
35:57And they get. However.
36:01We also need the social scientists
36:03to bring that.
36:05Bench science genius to real.
36:10OK, it's important to understand.
36:11I'd like to discuss some
36:13work that I'm I'm into now.
36:15So early in the pandemic I
36:17speculated that social determinants,
36:18which I have been reading about
36:21studying and writing about for
36:22several years at that point.
36:24Combined. With people of color
36:27having high medical mistrust.
36:30Which was an area that I hadn't
36:32done much work in specifically.
36:34Also, the proliferation of
36:37misinformation and disinformation.
36:40But it was vital to understand perceptions.
36:43Particularly a future vaccine.
36:45This is back in the fall or actually this
36:48summer was going to affect behavior because.
36:50Part of what I'm really interested in
36:53is how do perceptions impact behavior?
36:57To what degree do they?
36:59Because they do.
37:01So.
37:03Given this high level of mistrust,
37:06given all, by the way,
37:08is an information scientist,
37:09I must point out that misinformation
37:12and disinformation or not the same.
37:14They aren't synonyms, misinformation,
37:15wrong disinformation,
37:16deliberately wrong.
37:17That's the new monik.
37:18Just information deliberate.
37:20They are not the same.
37:22Some people just don't know or some sources
37:24are not sure where as dis information is
37:27a deliberate attempt to decieve DDD got it,
37:29got the new mnemonic.
37:30That's the one I use.
37:32Use whatever one you wish.
37:34So in the early summer.
37:36Largely due to the perceptions
37:38and beliefs I was hearing upon
37:41my network of people of color.
37:44About where this came from.
37:46Who was responsible?
37:47What's going to happen when a
37:50treatment or a vaccine comes?
37:52Exacerbated by miss and disinformation.
37:54Remember back to the glorious
37:56time last summer and last fall
37:58and we were hearing all kinds of
38:01things about all kinds of topics.
38:03Some did some misinformation.
38:05I thought that we might have
38:09a crisis looming because.
38:11Vaccines don't make us safe, vaccinations do.
38:15So we need the bench scientists.
38:18To help us.
38:20Do their work to develop the vaccines,
38:23but that's part of the journey.
38:26What we're seeing now?
38:28Are where social determinants may
38:31exert their influence on vaccination.
38:34Because vaccines don't make
38:35us safe vaccinations.
38:38So a key tenant that I wanted to.
38:42Incorporate into this work which turned
38:44into the COVID and race project.
38:46The sites up is that intragroup
38:47differences were important to investigate.
38:49Largely in I mentioned earlier,
38:51bring myself to my work.
38:53I was when I, when I was trained,
38:55I was trying to mix methods.
38:57I do mixed methods work,
38:59but in my qualitative training I
39:01remember a particular lesson where it
39:03says the qualitative researcher goes
39:05in with an empty mind and an open mind,
39:08but not an empty head.
39:10An open mind, but not an empty head,
39:12and that resonated with me 'cause
39:14I bring myself to my work.
39:15How can you not?
39:16As a social worker,
39:17I know that you bring yourself to your work.
39:20You don't leave your experiences at the door.
39:23Or before you get into your analysis
39:25or before you start writing,
39:26it comes with you.
39:28Embrace it so I knew that black
39:30people of color were different.
39:33Rob and I may be people of color,
39:35but that might be we have similarities,
39:38but we also have distinctions
39:39and differences.
39:40So intergroup relations were
39:42important for me to understand.
39:44And there are.
39:45Validated acculturation skills that
39:47have been around for a couple of decades
39:50to measure intergroup difference.
39:52Because if we're going to create
39:54an intervention,
39:55or if we're going to target
39:57a group that's at risk,
39:59how do we possibly do that with just
40:02having all the Asian Americans in one
40:05group Latin X in another group, and?
40:09Blacks in another.
40:11So here's an opportunity to apply
40:14acculturation scales for me in my work.
40:17Anyway,
40:17to to test the hypothesis that
40:19intergroup differences would
40:20help target health information
40:22interventions and address potential
40:24racial inequities in vaccination.
40:25Again, at the time this was last May,
40:29I was interested in a future vaccine.
40:34Using mistrust and perceptions,
40:35we could measure that that's what we do.
40:37We ask questions and we try to measure
40:40and that's what we do in research.
40:42So what I did. Right in July, August,
40:47when I started at MIT, I connected with
40:51a behavioral economist at MIT, Dave ran.
40:55Added some of his expertise given
40:57he does online surveys all the
41:00time that measure perceptions.
41:03Again, this notion of interdisciplinary enter
41:06discipline work is extremely important if
41:09for in most cases I think I've heard of 1,
41:13there's no traditional academic
41:15Center for HealthEquity.
41:17HealthEquity, just like the virus doesn't
41:20care about your political leanings.
41:22Equity work doesn't care about
41:24what your doctorate isn't.
41:26Or where your academic home is.
41:29It's definitionally multidisciplinar,
41:31so we combine and we have
41:34run various experiments on.
41:36We've established it, yes intragroup.
41:40Racial perceptions do affect
41:41COVID perceptions.
41:42There's a strong.
41:43This is preview now where where our
41:46work hasn't been published yet.
41:48We're submitting a research brief end
41:50of this week early next that shows
41:53that there's a strong correlation
41:55where less acculturated participants
41:57have more negative vaccine attitudes.
42:00And this relationship is fully mediated
42:01by suspicion in the health care system,
42:03and that's something that all
42:05of us should care about.
42:06Those of us that touch patients
42:08or do work that eventually does.
42:11On the flip side,
42:13less acculturated participants are more
42:15likely also to have had themselves
42:18family or friends hospitalised due to Kovit.
42:21So it reveals differential exposure.
42:24To harm from cobett
42:33OK, so moving forward we are going to
42:37run more experiments to try to refine and
42:42finetune where perceptions connect to.
42:46Behavior, intended behavior and outcomes,
42:48and this is work that holds potential.
42:52I hope long after COVID.
42:56Or long after COVID is contained,
42:57let me say that.
42:59Because I think that there's quite an
43:01opportunity for us to get a little
43:03bit more refined and understanding
43:05where perceptions influence
43:07behavior which influence outcomes.
43:09So what we're doing now,
43:11we've applied for some funding
43:13internally at MIT.
43:14We've structured a project that
43:16has two central objectives first.
43:19We want to with a larger population measure,
43:22hasn't vaccine hesitancy and its
43:24underlying perceptions and beliefs in
43:26order to develop messaging approaches to
43:28help address the causes of his hesitancy,
43:31it's no longer sufficient to just
43:33say that people of color have
43:36higher mistrust therefore.
43:38I think that can be used as an excuse.
43:42To shut down the efforts.
43:44To reach people and meet them where
43:46they are and also understand the
43:48influence of structural factors like
43:50social determinants which may be
43:52presenting barriers to FactSet vaccination.
43:54This is important because
43:56there's emerging research.
43:57That suggests.
43:59That intention to receive a COVID
44:02vaccine may be actually higher among
44:04black Americans and other racial groups,
44:07specifically white men.
44:09May perhaps some of you have
44:11seen some of this data.
44:12This is a publish or it there was
44:15a poll that NPR help sponsor about
44:17a week and a half ago that found
44:20that 73% of adult black Americans
44:22intended to get the vaccine when
44:24it became available again when
44:26it became available to them.
44:28Higher than white men who leaned
44:32conservative or a Republican.
44:35So it's important to understand these
44:36inequities and that would be an equity
44:38and equity that we would want to address,
44:39or at least some of us would want to address.
44:43So preliminary data suggests that.
44:47Social determinants,
44:48not just medical mistrust.
44:51May explain racial disparities
44:53in vaccination rates,
44:55so we will solicit feedback on efforts
44:57made to get insight or to get to get
45:01vaccination to get further insights.
45:04So we're hopeful that these insights will
45:07will will help us address vaccination
45:09disparities and just real quickly
45:12here vaccination disparities by race
45:14are or reported all over the country.
45:17LA had a particularly interesting and
45:20comprehensive view where, as of February.
45:2214th you see the dramatic differences
45:25in race according to vaccination.
45:28Actual vaccination.
45:31Somewhat ironically, people of color
45:32are vaccinated at lower rates.
45:33They are at highest risk.
45:36OK, so in summary,
45:38what I would like to do is posit that
45:42provider credibility may have a link to.
45:46Outcomes of behavior and outcomes.
45:48I'm interested instead of or in addition to,
45:52measuring medical mistrust.
45:53I'd like to also measure
45:55credibility of provider,
45:56team health care system
45:58to help define a pathway,
46:00perhaps more definitively,
46:02from credibility to health
46:03behavior to outcomes,
46:05and that could provide us with a
46:08unique novel opportunity to address
46:10racial equity and cost of care.
46:12I add cost of care here because
46:15depending on the audience.
46:18As I alluded to earlier,
46:20addressing racial inequity.
46:21Does not necessarily hold
46:23the day when the argument,
46:25but when you combine the
46:28human side of inequity,
46:29reducing unnecessary suffering,
46:31and the financial side,
46:33reducing things like avoidable
46:35hospital utilization through Ed
46:37visits an unplanned admissions
46:39that tends to capture most of
46:41the audiences that I talked to,
46:43either wonderful.
46:44So collecting data among vulnerable
46:47communities understand credibility to
46:49measure its effect on behavior and outcomes.
46:51We can then assign a credibility
46:54index to healthcare institutions and
46:56provider teams and start to really
46:58test or continue to test how the
47:01patient provider relationship may
47:03influence health behaviors and outcomes.
47:05We could start with vaccination,
47:07but we could translate this to far
47:11beyond other health behaviors.
47:13So medical mistrust I would
47:16posit is important,
47:17but pathways are difficult to define.
47:21And it actually points the finger outwards
47:23towards individuals and communities,
47:25suggesting that something
47:26needs to be done to fix them.
47:28We need to create an invention
47:30to get their medical mistrust to
47:32reduce their medical mistrust.
47:34So they'll follow behaviors as recommended.
47:36I submit that a credibility is more
47:38of a inward look at the self to
47:41try to figure out what we can do
47:43to be more kredible clinicians in
47:45terms of their touching patients
47:47as well as health researchers
47:49like myself to actually.
47:51Understand what that what
47:53behavior that might influence like
47:55participation in health research.
47:59OK, as I conclude here.
48:02There are paths.
48:04There are not pathways specific pathways
48:07from perceptions like medical mistrust,
48:10discrimination, everyday racism,
48:12perceived racism in healthcare.
48:14Yes, there's a validated.
48:17Measure for perceived
48:19racism in healthcare PRM.
48:21That always strikes me as
48:22we have a measure for that.
48:24Which suggests that it might be a thing,
48:27so we see that perceptions as
48:30perceptions get more negative.
48:32Health behavior like seeking care,
48:34testing and screening.
48:35I check hemoglobin, A1C,
48:36check a cholesterol screens
48:38go down and then outcomes,
48:40like patients that go down.
48:42And as and also behavior like drug use,
48:46misuse, cigarette smoking,
48:47HIV risk behavior goes up,
48:49as does blood pressure,
48:50risk inflammation, risk,
48:52alcohol dependence.
48:52So we see that there are some
48:55associations if not pathways.
48:57So credibility.
48:58I would surmise is a novel way,
49:00a valuable way to assess the
49:03patient provider relationship.
49:04Because it focuses on the source
49:07of the mistrust.
49:08Us and it provides insight to
49:10refining some of these elusive
49:12pathways and insights on how
49:15perceptions influence behavior.
49:17With that, I'll pause.
49:18I'm going to keep this up that adipic,
49:21the integration of these
49:23various structural issues,
49:24and I welcome your questions,
49:26comments and rebuttals.
49:29The only rebuttal that I have
49:31for you Doctor Centeio is that
49:33we want you again and again,
49:35and again, and again and again.
49:38This has been so extraordinary, and I
49:40know there's going to be many questions.
49:42I saw things popping up in the in the chat,
49:45but I am so grateful and you
49:47have touch on so many things.
49:49I have questions but I I'll keep them.
49:52Let's start with Belinda,
49:53who had a couple of really hard
49:55hitting wonderful questions.
49:56Belinda
49:56go for it. Yes, this was wonderful
49:58and I'm sorry it wasn't my camera.
50:00My grandchildren are here this week. But we'd
50:04like to see him.
50:07There's a play. But I have a question
50:11about so as you were talking, Anne Anne.
50:13I've been doing some research
50:15and so forth for me.
50:17I believe gentrification is a new form
50:19of redlining, if that makes sense.
50:21Because once a community is cleaned out,
50:24you can't afford to go back into.
50:26For example, is my sons God brother bought.
50:29You know you St area in the
50:3160s and DC it got burned down.
50:34And so David bought a brownstone for
50:37say 250 for DC goes for $2,000,000
50:39or right about now is the tax rate.
50:42So there's no way so the community
50:45has totally changed and the other
50:47part of that when we talk about the
50:49social factors are they also still?
50:52Attached to racism.
50:53No, because it's a social construct
50:55that where we struggle struggle with
50:56some things for people of color.
51:00Certainly yes, perceptions are
51:02part of of social determinants and
51:04perceptions do influence behavior.
51:05Perceptions of maltreatment of discrimination
51:07that I'm not being treated equally,
51:10which is a foundational sentiment.
51:11So that's one thing you don't have to wait.
51:15You know this more than I do.
51:17I actually was reading about
51:19babies and water babies know.
51:21And what do we have to teach them?
51:24And there's an innate sense of
51:26justice that were born with,
51:28so I think that.
51:29Even if you don't know all about
51:31Tuskegee or you don't know all about
51:34Doctor Marion Sims and what he did
51:37with Anna Kahran other slave girls,
51:39you have a sense for any quality
51:41and part of why those kinds of
51:44historical anecdotes are still
51:45present is because the bias and
51:47injustice is still present.
51:52I'm trying to keep my answers short here.
51:55You are doing great.
51:57We really I I could listen to you
51:59for hours and I know that there's
52:01other people who have questions so.
52:04Walter, I saw you active on the chat.
52:07Amanda Detmer, Jose Pious,
52:09Lilia Benoit, in no particular order.
52:11But let's go for it.
52:18OK, well they're being shy
52:19while they're being shy.
52:21I have a couple of questions.
52:23First of all, I loved, loved,
52:24loved your shout out to qualitative
52:26methods and to the importance of people,
52:29and I think that you said something you said
52:32a couple I took a lot of notes by the way,
52:35but you said this is a bumper sticker.
52:38Vaccines don't make us safe.
52:40Vaccinations do and that we have,
52:42you know, warp, speed it ourselves
52:44to this blessing of a vaccine.
52:46But if we don't get it right through,
52:49knowing what hesitation
52:50and what people think,
52:51and we're going to find out
52:53through qualitative methods,
52:54so, so thank you for that.
52:56And and two,
52:57maybe a inner baseball questions,
52:58but you mentioned the group based
53:00medical mistrust scale in the PRM,
53:02the perceived racism and medical care
53:04are those actual scales where their
53:06concepts because their scales on them.
53:08Yeah, they're
53:09validated scales. Somehow.
53:10I have a collection in my in my notes of
53:13these scales that measure perceptions,
53:14and these are validated scales much
53:16like the acculturation skills.
53:18I can email them to you, you wonder.
53:22Yeah, and and and when I when I heard the
53:24term warpspeed about vaccine development,
53:27I thought that's that's great cool
53:29warp speed that I thought oh I bet
53:31social scientists weren't in the room
53:33when you when they met like that
53:35might not be good for all folks.
53:38The fact that it's rushed right out there.
53:41We need social too.
53:42Absolutely. And you know we have a a social
53:45question from Justin Justin. Go for it.
53:49Thank you for that amazing
53:50talk you mentioned.
53:51Something about immigrants saying that
53:53as they stay in America over time,
53:55it seems like their health outcomes
53:57start to resemble individuals.
53:58I've been in America for who look
54:01like them for a long period time.
54:03Can you speak more on that?
54:06Yeah, I can talk about how when
54:09Caribbean immigrants specifically,
54:10this is when I just have the top of my head.
54:14I'm doing some work with the OR
54:17proposing to work with the the National
54:20Cancer Institute about prostate
54:22cancer treatment and you find that.
54:24And this is this is found fairly consistency
54:27in the literature that the rates of
54:30prostate cancer for Caribbean immigrant men.
54:331st generation are lower
54:36than subsequent generations.
54:39So second generation immigrant health
54:41status is much worse than first,
54:43and it's like the Mexican or the
54:45Latin American paradox, right?
54:46So you get here and then I'll
54:48get to why in a moment.
54:50The short answer is we don't really know,
54:53but there are a couple of important.
54:57Sort of theories or or guesses,
54:59let's say so.
55:00Part of it is that to get here you
55:03have to have a certain health status.
55:06So there's this notion that the
55:08people that are predisposed to
55:10illness never make it to the shores,
55:12never make it here,
55:14so we're not getting a
55:15representative immigrant population.
55:17We're getting the people that make it here,
55:20and that's not representative,
55:21so that's part of an explicit
55:23explanatory factor.
55:24But what one of my wonderful
55:26treasured mentors, James Jackson,
55:28who passed recently?
55:29When I was talking to him about some
55:32of these equity issues and he was
55:35finding that when when people got here,
55:38their health status actually second
55:40generation was was was lesser than what.
55:43Why do you?
55:44What could that be?
55:46We don't know yet,
55:47but what he did cause me to
55:50think about what we discussed is
55:52that the impact of what's called
55:55weathering in the literature.
55:57The repeated sort of burdens.
55:59Trauma overtime actually wears
56:01on your your biological systems,
56:03your immune system,
56:04your ability to sort of deal with
56:08the the micro traumas of getting
56:10through the day or viewing the OR
56:13actually the trial of the officer
56:16who kneeled on George Floyd's neck
56:18and murdered him like just that.
56:21Just think about what I was talking
56:24to a colleague last summer who was
56:27appropriately aghast at that imagery
56:30that was flashed again and again and again.
56:33On our screens and and it happened
56:35to be a woman,
56:36a white woman who told me like
56:37that so terrible that's so true.
56:39And I said,
56:39how do you think it makes me feel as
56:41the person who's been in the back of
56:43a police car and spent the night in
56:45jail because of over aggressive policing?
56:47So if you're traumatized or outraged by that,
56:50what might that do to people
56:52that look like me?
56:54Charter home articulation and
56:56education and having a license and
56:58registration isn't a protective factor.
57:00I'm sorry under no no Charles.
57:02Let let me
57:03let me do this.
57:04What we're going to do in in Rosemary.
57:08We're gonna keep recording for a little bit.
57:11We're going to close now formally
57:13after Robla Brill's idea to you.
57:15But if you are so kind of
57:17Charles to stick around,
57:19I know that some of us would
57:22love to stay for the after.
57:24Party but I wanna I want to
57:26be mindful of peoples time.
57:28This has been absolutely extraordinary
57:30and I want to thank Rob Labrie.