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Burchard delivers Faculty Research Lecture in Clinical Science
By Tom Johnson / Mon Nov 15, 2021
Esteban G. Burchard, MD, MPH, delivered the 20th Annual Faculty Research Lecture in Clinical Science on November 2. The UCSF Academic Senate selected Burchard for the honor in recognition of his substantial contributions to our understanding of population differences in asthma and asthma treatment, as well as the interactions between genes and environment that drive health disparities.
Burchard’s internationally-recognized research focuses on genes, race, and the environment, and their combined contributions to the development of asthma, particularly in minority children. His lab employs a cross-disciplinary approach that generates both primary research findings and data for use by other researchers.
Burchard’s lecture, titled “My Wonderful Journey from the Hood to Academic Medicine,” was presented via Zoom. Before discussing his latest research, Burchard detailed the obstacles and challenges he and other minorities faced when pursuing careers in medicine. Burchard is of Mexican-American and mixed-race descent, a factor he said contributes to the direction of his research. Burchard described his difficult childhood growing up in the Mission District of San Francisco, the discipline he gained through wrestling in high school and college, and the critical part mentors and role models played in his personal development.
good afternoon and welcome to the ucsf academic senate's 20th annual faculty research lectureship in clinical science i'm vanessa jacoby professor in the department of obstetrics gynecology and reproductive sciences and vice chair of the academic senate committee on research it is my honor to introduce the academic senate faculty research lecture this award recognizes the exceptional career achievement and major contributions of faculty in clinical science research nominations are made by ucsf faculty who consider the research career of their colleagues and submit nominations for this prestigious award to the academic senate committee on research every year the community then selects a recipient to highlight and celebrate their achievements today we are very proud to honor dr esteban gonzalez burchard who will be introduced by his nominator professor tejal desai and his longtime friend and collaborator dr dean shepard please note that this event is being recorded and it will be available on the senate website there will be an opportunity for questions and answers at the end of the lecture so please submit your questions and comments using the q a function at the bottom of the zoom window and now to introduce dr desai who is the deborah cohen endowed professor in the department of bioengineering and therapeutic sciences in the schools of pharmacy and medicine professor desai's research spans multiple disciplines including materials engineering cell biology and tissue engineering dr dean shepard is a professor of medicine chief of the division of pulmonary critical care allergy and sleep his research focuses on the molecular mechanisms underlying pulmonary fibrosis asthma and acute lung injury dr desai thank you so much dr mccoby uh it really is uh such a pleasure for me to be here today on this really special uh evening or afternoon um and especially gives me great pleasure to introduce dr esteban gonzalez bouchard as the recipient of the academic senate's faculty research lecture in clinical sciences dr bouchard's scientific achievements have had immeasurable impact on ucsf and the lives of so many people across the globe i'm just going to spend a few moments talking about some of his contributions which are really so numerous to highlight right now but he is internationally recognized for his contributions to our understanding of the genetic basis of population differences in pulmonary diseases in drug response and the critical interactions between genes and the environment that really drive health disparities in this country he's been a tireless advocate for increased research to address health disparities and is one of the leading voices nationally and internationally for the inclusion of diverse populations in human genetics his research is highly collaborative and he is an outstanding mentor really bringing together a diverse group of trainees who reflect his ethos of doing science with impact and his lab really reflects the type of diversity that is the goal for ucsf and one that can really have a broader impact in the biomedical research enterprise a couple of examples just to give you a glimpse on his impact intrigued by the varying responses of puerto rican and mexican asthmatics to albuterol dr burchard established tools to analyze populations to really tease out the impact of ancestry in various populations he was the one who pinpointed through meticulous research and a body of work encompassing over 285 peer-reviewed publications the specific genes responsible for specific responses and showed that these ancestries affected people's responses to current therapeutics and most importantly he really showed that failure to acknowledge these differences emanating from racial disparities can result in his diagnosis and impressed imprecise treatment importantly dr burchard has made it his mission to eliminate sampling bias which has life-changing consequences in a nature article he co-authored in 2011 he challenged the nih for its lack of compliance with its own 1985 mandate for the inclusion of diverse subjects in its studies he was able to really open the eyes of nih and many institutions around the country to show how important it was to include these diverse perspectives and in 2021 he published a piece on race and ethnicity and its reckoning in the new england journal of medicine i could go on and on but one thing is clear dr burchard has fought for racial equity and precision medicine for decades and he has shaped healthcare as we know it today that is why i'm so pleased and thrilled that the depth of his scientific achievements and the impact on all communities is being recognized here today to share a little bit more about uh dr richard's journey and what brought him here to ucsf i will turn it over to dr dean shepard thanks so much um it's really also an enormous uh pleasure for me to contribute to the introduction of uh dr bouchard so uh step on to san francisco native who uh grew up in the mission district and was raised by as one of four siblings by his single mother um so he's had a mixed uh relationship to fishing throughout his uh life so this is a picture from mission rock in 1975 when i think stevonn was eight years old and his dad who was only at home until about this time uh used to go to mission rock resort to drink and would leave stebon sitting on the rocks fishing by himself so he had a pretty mixed view of fishing uh early on but he certainly embraced fishing over the subsequent course of his life and has found fishing actually to be a source of major uh achievement and uh and gratification and also fun so um his mom helped her that when uh at the age of 12 she arranged for him to work as a junior deckhand on san francisco fishing boats she really did that because she was worried about stefan being on his own while she was working in the mission district in the summer time and that that paid off but uh he was still having a tough time of it until he had the good fortune to be expelled from saint ignatius high school as a freshman uh and landed at mcateer high school in san francisco where there was a dynamic young wrestling coach who took step on under his wing and uh wrestling uh has actually provided for steven as it did for me uh an object val a lesson in the value of hard work and perhaps most importantly an opportunity to build self-confidence he subsequently parlayed wrestling and uh quite a bit of intellect grit and determination into a college degree from san francisco state an md in his first scientific training at stanford medical school and then a residency at brigham and women's hospital in boston and from his first experience with research stephan knew that he wanted to focus whatever research he did on work that would have an impact on the traumatic health disparities that characterize u.s health care and he found the opportunity to do that as a resident when he connected with jeff drazen on a study they published in the new england journal before he came here as a fellow showing an impactful sequence variant in the inner interleukin-4 receptor gene that was greatly enriched in african-american patients with asthma but in a preview of the rest of the pattern of the rest of stevon's extraordinary research career he quickly changed the direction of the project and began digging into the genetic underpinnings of the dramatic differences in asthma prevalence and mortality between two different groups that were traditionally lumped together as latinos puerto ricans and mexican-americans as somebody who really understood uh what that term meant stefan was really able to provide enormous insight that jeff and others involved in the project really didn't have so we were incredibly fortunate when stebon decided to return to san francisco for his pulmonary fellowship and really quite amazingly he brought with him a substantial amount of nih funding which i've never seen another uh entering clinical fellow do and it was based on a grant he had written together with jeff as when he was a resident to study the genetic underpinnings of his differences in asthma mortality and severity between mexicans and puerto ricans i i was especially fortunate that uh stefan chose me as his alleged mentor but as many of you know stefan's a fortune force of nature and he knew exactly what he wanted to do so my major roles really were as a cheerleader and occasional facilitator and so stefan knew that he needed to build a large network that nobody had built before with sites all around the country and eventually around the world in order to be able to enroll enough patients to really study and detail the the genetic underpinnings of this major difference in asthma mortality and severity and within a few years in his spare time as a clinical fellow he built the largest uh cohort of patients that could be used to study genetics of asthma in latino americans and not being satisfied because devon stefan never is he rapidly turned around and also built the largest cohort in the world focused on genetics of asthma in african americans and as taisha's already alluded to these cohorts and the meticulously compiled clinical databases and biosamples he oversees have facilitated a continuously growing series of remarkable biologic insights by stem on and also by us collaborators around the world so stefan continues to build new collaborations write impactful papers and receive an extraordinary number of large nih grants and this has led many of us to wonder whether stubborn ever sleeps but we finally now have definitive evidence that he does so finally as teja alluded to perhaps stebon's most enduring legacy will be his fierce and unwavering advocacy calling attention to the needs of populations that have been historically ignored by the biomedical establishment and his commitment to diversity and equity is the engine that drives his remarkable research productivity and also as tasha all pointed out he's from the beginning of his academic career he's authored a series of very high profile papers beginning with a 2003 paper in the new england journal of medicine calling attention to inequities in medicine and important inequities in research funding so i expect we're going to hear more uh in this talk today about the strong connection between stebon's research and his advocacy and i'm really looking forward to his talk great thank you tejal and thank you dean let me set up my slides um okay can you see that okay yes you're good great well first of all uh thank you for the wonderful introduction uh dr tsai and dr shepard and i want to thank the the academic senate for selecting me my name is esteban gonzalez brachard and i'm going to talk about my wonderful journey from the hood to academic medicine today is uh dia de los muertos it's also called the day of the dead it's a mexican holiday in which we uh invite our ancestors back for a reunion it's actually a celebration and on the left i have a couple that's celebrating in mexico and on the right i have my personal altar at home and what i'm going to use this for is to acknowledge some of the people who have been very influential in my life and who have subsequently passed in the last couple of years so the big debate in medicine is whether or not we should you race and ethnicity in clinical and biomedical research well the world has been divided into two camps one believes that it's a social construct while the other believes it's a biologic construct but individuals like me and many others at ucsf and around the nation believe that it's a complex interaction and not this black or white dichotomy and i was actually shocked by an email that josh adler who's the clinical officer of ucsf chief clinical officer ucsf he gave me permission to publicly share this email but in this email that he published on october 14th last year they announced that they are excluding race and ethnicity from estimates of kidney function because it could percep perpetuate the incorrect belief that race has a biologic basis well unbeknownst to josh i've been thinking about this all my life and this is the picture of my grandfather who's second from the right esteban gonzalez he's we are mexican he was a farm worker in the central valley and when i took this photo i didn't realize that i it was superimposed on the top of my current issue of the new england journal so i'm very proud to say that i'm descending some farm workers my mother was a farm worker and now i'm a full professor at ucsf this is my uh extended family these are my great grandparents and my grandmother and my grandfather's on the top right but my as you can see with my great grandfather we are racially mixed he's part african he's part native american he is part european and that's what makes up a typical mexican this is my mother and you can see that she's very dark and i'm very light and i recall the days when i used to crawl on her bed and she used to read the dr seuss books to me and one of the books that she read was to me was are you my mother that question has always challenged me throughout my childhood and my current existence but i was very fortunate to get a 23andme on my mother before she passed away and these are the results on the left are are the results of my mother's ancestral composition on the right are of my ancestral composition and you can see that my mother is 53 native american she's about 39 european and about 5 african i'm 28 native american and 65 european and the rest is african-american ancestry and these early discoveries are uh recreational sciences have really served the foundation for my future work but before i dive into my science i want to talk about a little bit more about my background growing up with a single mom my mom had to have a distributed network of women who took care of me and so one of the women that took care of me was alicia joe shown here and she's in my house now watching zoom in the other room she's chinese and she had two young boys michael on the left marco on the right and in my formative years all the way up to 13 i spent probably more time in san francisco chinatown than i did in the mission district i even went to chinese school cantonese school for two years um unfortunately marco died in 2016 five days before his 49th birthday of an adverse drug reaction so as i mentioned i was born and raised in the mission district and for those of you that don't know the mission district is a latino barrio in san francisco is is well known for its great food great weather vibrant culture but also violent gangs and and drugs and as a fatherless kid i was susceptible to all those and as dean mentioned i got kicked out of my first high school i was bussed from an all latino neighborhood in on the what on the east side of san francisco to the west side of san francisco to an all-white magnet school and they let me know that i did not belong i had fights every day and ultimately got kicked out the picture that you see here is a picture of me in balmy alley on the left are is a mural of mothers who have all lost their children to gun violence in high school my best friend was shot and killed and i knew that i was headed down a path the left i changed i was very fortunate to get kicked out at si because i landed in inner city high school that had a very rigorous wrestling program the program taught me discipline it taught a lot of young men who didn't have father's discipline it's like joining the military we lost weight we were in we had grit we were in great shape we went to the california state meet we had some state placers but more importantly i went on to go on to college and wrestle and there i met some wonderful mentors and this is my my coach dr morris johnson you can see he's african-american he was an ncaa champion two-time uh olympic team member in 84 and 88 and he was also pursuing a phd he was a father figure to me he was a tremendous role model but the team that i was on we were national ncaa champions and we attracted a lot of individuals from around california and it's the first time in my life that i met positive role models that were national champions that were olympic champions that were doing something positive and it's quite a contrast to what i experienced growing up as a child in the mission district well my mom was a school teacher and she was also an activist and so growing up these two charac these two individuals were embedded in my life dr martin luther king and cesar chavez and in fact they served as a moral compass if not the north star for everything i did i was fortunate to go to a great college where we had very strong biology program and i was fascinated by biology and math but i wanted to have clinical applications and in particular i wanted to meet in this sweet spot of the venn diagram and i wanted to go to medical school to do medical research but i knew that the odds were against me and this is a slide that was recently published in in the new england journal this year 2021 and it describes who gets into medical school over the last 43 years the top graph shows whites and asians and women are on the left men are on the right you can see that women have steadily increased uh men white men have decreased over the last 43 years asians and south asians have steadily increased now if you look at the bottom two graphs those are the graphs for minorities but it's don't be deceived because the y-axis is truncated uh instead of comparing a zero to a hundred we are now comparing zero to four and you can see in the lower right corner the number of black men in 1978 was 3.8 uh down 2.9 and if you account for u.s born african americans that number would almost be zero latinos are the same and i could talk for hours on this slide but the main point that i want to emphasize to you is that my entire academic career from medical school residency fellowship to faculty to even now has been a lonely existence i'm often the only minority in the room i'm the only one here that's doing minority research i'm often second guessed i'm often put down i they're macro aggressions they're microaggressions and i want to flip the tables if women if this were the case for women we would be up in arms this was the case for women 50 years ago when medical school classes had one or two women today medical school school classes have one or two minorities and it's a lonely existence so i was very fortunate to get it to stanford in fact i got into a medical scholars program which is like an md phd light program but stanford is a world away from the mission district and i want to show you that we had a rude awakening on my first medical school exam rob dodd who's featured on my right and i were pulled over by the stanford police while driving to our first medical school exam we were pulled out of our car we were frisked we were interrogated what are you doing here why are here where are you going and anyone that's been to medical school can tell you that medical schools or exam exams are very stressful enough and to be late was terrible and this feeds right into the social determinants of health and it reminds me of an event that happened 26 years earlier with the civil rights workers james chaney michael schwerner andrew goodwin who were arrested by the police handed over to the kkk and killed and although we were not killed it severely impacted the beginning of my medical career at stanford rob dodd is now an md phd and a neurosurgeon and if you have the misfortune of having a brain tumor and are at stanford rob's going to operate on you i was an icu physician at san francisco general and when the president of the united states came to town the fbi interviewed me preemptively to make sure that if the president came to my icu i would not kill him but i'm telling you that to show you the treatment of minority students in medicine at least on stanford's campus well i'm going to put that behind me and the fact that we didn't have very many minority students my class was only 86 and there was a handful of minority students i needed to be creative i had the very good fortune in my last two years of medical school to live in a jewish house and these are two of my jewish roommates there are two of my best friends from medical school daniel crafts in the middle lee sanders is on the right i'm the godfather of daniel's son and you can tell that they're jewish and i'm not and the reason i i show this slide is actually for the trainees because it's easy if you're coachable to find mentors who don't need necessarily look like you act like you are your same gender or sex or come from where you're from the fact is if you can be coachable you'll thrive and i learned that trick very early on from wrestling and from my experiences in in medical school i was very fortunate to land at the brigham and women's hospital in boston and i was very fortunate to have a wonderful program director marshall wolf who selected me to be one of 42 individuals in his uh residency program and marshall encouraged me to find a way to merge personal passion with academic rigor marshall wolf had an open door policy and he mentored me on a weekly basis and he tried to figure out what drives me and i told him i was really interested in ethnic disparities but i spent three years at stanford in a genetics lab studying pulmonary disease but i didn't know how to converge these two i did not know how to make them overlap they almost seemed antithetical and marshall was quick to point beach in the direction of jeff drazen jeff drazen at the time was the division chief of pulmonary critical care at the brigham and women's hospital in 1997. jeff was studying asthma genetics and pharmacogenetics he was a nice guy he encouraged me to study asthma genetics gave me a book and i read the book and i actually turned him down and i said no you know i'm not interested i really want to do health disparities jeff put his hand on me and said son i think you're making a mistake give it a shot so i worked with jeff for a year he doesn't recall but he sent me to the harvard school of public health for training in epidemiology and biostatistics and then i joined his lab later on but because i already had genetics training at stanford i was able to hit the lab running and we had a first author publication before i finish my residency at the brigham one of the great things that jeff did for me though is he sent me to the american thoracic society which is our professional society i was one of the only medical residents there out of a population of about 20 000 individuals but i challenged myself to look at all the abstracts and one abstract that was published by the center for disease control was this abstract it showed hispanic asthma mortality in the united states by geography and what you can see on the left is asthma mortality and prevalence are highest in the northeast lowest in the midwest the south and the west and to me this was key because i knew exactly what this was this is my aha moment but i want to tell you this is where diversity comes in because a million people looked at these data but when i looked at these data i knew what it was and it takes a mexican kid from california who studies genetics who lived in boston to figure this out i told jeff that is not about geographic region it's about mexicans versus puerto ricans and two years later the cdc up updated their paper and demonstrated that yes indeed that it was puerto ricans versus mexicans but by 1998 before i finished my residency we were off to the races jeff drazen at silverman and i came up with this idea to study the genetics of asthma and latino americans or the gala study the plan was to recruit 700 mexican and puerto rican family trios from new york city to san francisco and san francisco jeff was able to tap into the ni uh ni nhlbi funded asthma clinical research and we were funded before the time i graduated from my residency so to sum up this the score at that time i had as a resident i had a first author publication we had funding to start de novo recruitment but the way the match worked at that time the match you matched two years in advance and the wheels were in motion for me to come to ucsf and in particularly to san francisco general and there i met some wonderful mentors dean shepard took me in even though he didn't study uh genetics of asthma but he was one a wonderful mentor and a wonderful coach and has mentored me since 1998. thomas king was my department chair he's a pulmonologist he also took care of my mother who was diagnosed with interstitial lung disease and talmud helped me make connections all around the united states and mexico and puerto rico neil risch is probably the most world famous population geneticist took me under his wing in 2000 kathy giacomini became my department chair in 2004 and she studies pharmacogenetics so we had a wonderful team of four well during my fellowship it was time for me to implement the gala study and i have to say it was very difficult number one we were trying to get intact families and that was difficult because the divorce rate is very high so we could recruit intact families from new york and then number two mexicans don't go to ucsf parnassus hospital so i had to retool and i spent every weekend in my clinical fellowship going to small clinics all around the bay area that served latino patients and recruited mexican-american families mom dad and a child with asthma recruitment was going slow so we expanded with the help of thomas king who introduced me to moises selman in mexico city introduced me to antonio and zueto in texas who introduced me to william rodriguez and then subsequently jose rodriguez and i'm very proud to say that by the time i finished my fellowship my pulmonary critical care fellowship we completed recruitment of 701 complete family units puerto ricans and mexicans and with that huge data set i joined the faculty in 2001. when i joined the faculty in 2001 i started what's called the ucsf asthma collaboratory collaboratory means that we only work with nice people but the focus of my lab was that we focus on the majority minority populations that have been understudied in clinical and biomedical research we blew up the gala one study we've expanded all over the united states we included sites in new york we included sites in chicago we included sites in houston we included sites continuing with sites in in mexico city and puerto rico in the san francisco bay area and in 2013 i invited my first graduate student max seibold to join even though he's uh not a clinical recruiter well what we did and we i'm very proud of this over the years we recruited more than 13 000 minority participants the majority of those individuals are children probably about ten thousand all the people listed here are key principles that were involved i mentioned jose dr lenore who was a president of the national medical association helped me break into the african-american community neil rich was a brilliant statistical or population geneticist and epidemiologist ira teger was my epidemiologic guru mentor luisa burrell and shawn xen helped me write the r01 that funded the recruitment of all these individuals and all the individuals on the lower panel are the key principle people that help me recruit combined we created the largest and richest gene environment study of asthma and minority children in the united states we collected very detailed information on genetics clinical information questionnaire-based information on perceived discrimination socioeconomic status and then geocoded measures of air pollution every single child and one thing that we did right is we standardized spirometry at all the sites we had every child and this is little juanito breathing into a spirometer and what for those of you that don't know a spirometer measures how tight your airways are and we can measure drug response so on the top we have exhalation and we use that as a quantitative trait to measure how severe someone's lung function is well we were very fortunate because in 2016 the nhlbi provided us with funding to do whole genome sequencing on 16 000 participants rna-seq on 3500 participants now we can integrate all this very rich genetic data with very rich clinical social and environmental data and we have all that data in my lab at rock hall at mission bay well it took a while to build this cohort and so while we were building we were doing other things in 2000 the human genome project the initial sequencing was done at that time bill clinton tony blair and francis collins got up on stage at the white house held hands and said we're all 99 equal therefore it should eliminate the idea of race and ethnicity many social epidemiologists and others jumped on this and said this is a good opportunity to get rid of race and medicine for good well i had worked with jeff tracing i knew allele frequencies differed by populations by race so what what i did is elizabeth neil rich and i got pretty upset and we organized a coalition of scientists not all of whom agreed with us but we agreed to disagree and write about what we agreed on and we made a strong coherent argument arguing for the inclusion of race ethnicity in clinical and biomedical research well i met a wonderful collaborator one of my best in in my entire career carlos bustamante about 11 uh 12 years ago and carlos and i in francesco de la vega we asked the question who's benefiting from the human genome project out of all the modern studies done in the world who benefits and what we found is that 96 of all modern genetic studies benefit european populations less than four percent of non-european populations benefit now europeans make up less than 16 percent of the world so 85 84 of the world is missing out on modern advances in genetics this is problematic and it in fact pisses me off well alicia martin eight years later repeated our analysis and asked the question who's benefiting from genome-wide association studies europeans are shown in red you can see that there's been a persistent trend upward that they're the biggest beneficiaries and what she also pointed out on the bottom is that african americans and latinos make up less than two percent and 0.5 respectively of all modern genetic studies even though we make up 38 of the us population we are contributing a significant amount of tax dollars to the national institutes of health and we are not getting our due diligence all the money is focused on whites and i think that's because the field largely largely is is dominated by whites study sections are dominated by whites white physicians white scientists feel comfortable dealing with whites and so it's easy for them to include whites if we had more minorities it would be easy for minorities to recruit minorities well to that end i want to add that the human genome project systematically excluded native american populations so there are no biorepositories in the united states on native americans at all and that's a travesty because that's a missed opportunity i'm very grateful that a colleague of mine cheryl winkler from the nci has assembled one of the largest biorepositories of native americans from oaxaca mexico she recently retired and asked me to be the steward of her samples my lab accepted all the genome-wide or genetic data all the plasma but we didn't have the ability to accept the lymphatic blastoise cell lines the cbcs and the precision medicine initiative program led by keith yamamoto accepted them now i hope that keith and his colleagues will raise funds uh from private foundations to do whole genome sequencing and rna-seq so that we can freely share all these data with ucsf investigators now finally this year it's the 2020 has been rough we saw with george floyd brianna taylor and the mod aubry that we continue to have racism in america in fact racism is woven into our fabric jim crow is not dead he just went underground we as a society and as a world had a racial awake awakening also because of george floyd many people tried to use this opportunity to argue let's get away from race and ethnicity just like josh adler advocated and what luisa burrell and elijah and i did is we assembled a team of a scientist and physicians minority and non-minority leading minorities deans of universities ceos and companies that are all minorities and we put out a position statement arguing that the the importance of race ethnicity and genetic ancestry still is is important but what's different about the first this article compared to our first knowing the journal paper is that we used empiric data from the 13 000 individuals that i recruited to bolster our point of view now enough with the background i want to go back to this slide we recruited you know 13 000 individuals my colleague and i elijah and i've worked with the live for more than 21 years we've always talked about using genetic ancestry and trying to leverage it to scientific advantage now jeff drazen my former mentor always advised me think about clinical relevance who cares if it's not clinically relevant well i'm a pulmonary specialist and we do pulmonary tests and i showed you this slide earlier this juanito performing spirometry well when an individual performs spirometry we have to compare that individual to a population average and in the united states there are only three population averages and that's demonstrated here these are data by n haines on the left we have male on the right we have females on the y axis we have lung function the higher you are the better on the x axis we have age and you can see that when you compare african americans to african americans in green they have lower lung function values than mexicans than caucasians and so anyone of you who has lung disease and if you come into a clinic you're going to get assigned to one of these groups now what happens if you're chinese what happened if you're south asian you are going to get assigned to the caucasian group now there's another equation called global lung initiative or gli that also has race-specific equations but they have a pureed version where they took all the equations from the different races and collapsed them and averaged them and so basically we're getting a white watch version of lung function well this got thrown in my face when i was a clinical fellow working in a pulmonary function lab i had a firefighter that looked just like this guy we know his history he is nigerian and he's white the question is what would you call him is he black or white i know it sounds like a joke but it's actually very important the police would call him black and he'd have a high likelihood of being killed or incarcerated but on a as a physician and as a pulmonary specialist i had to make the distinction and i asked him since since i'm from the hood and i code switch i said hey man what are you are you a brother are you white and he goes i'm half and so when the technician was doing this test the technician was going to pull downs you're either white you're black you're mexican but i knew from my own previous work search that african americans are racially mixed and this is a slide of about 300 african americans each barb represents an individual who have genetic ancestry green yellow or orange is african proportions of african ancestry green are proportions of european ancestry and you can see it runs the gamut then within going from left to right you have decreasing amounts of african ancestry so obama might be the last to the right he's half half but denzel might be over there to the left so with my colleagues we ask the question should we use self-identified race versus genetic ancestry and here's what we did we were able to access seven independent cohorts of african americans that are primarily healthy and had lung function and we had two asthma cohorts that had asthma lung function and had genome-wide estimates of genetic ancestry and what we found is that there is an interaction the y-axis is lung function higher you are the better the x-axis is increased in amounts of african ancestry and what you can see is it's an interaction and when we wanted to compare an individual patient to a population average there are only two in this case there's a white reference equation which would have been comparing your individual number to save 4.5 liters whereas if you're african-american we would compare your individual values dependent upon your ancestry to an african-american standard at 3.9 liters now mind you that's a one liter difference and on average we have about four liters in our chest and women might have about three and a half three liters in their chest but what we demonstrated is that dependent upon your genetic ancestry if you're under the average african ancestry which is 78 we would underestimate your disease if you are over we would overestimate your disease and what we did is we demonstrated that by including genetic ancestry into the equation we can improve the accuracy the diagnosis of lung disease by as much as 15 percent that is huge and has tremendous clinical implications now this is one of my favorite favorite publications my favorite collaborations so i'm 55. i met carlos bustamante when i was 44. carlos bustamante is a professor at stanford he's now at miami but for the first time in my career first time i was 44 i met someone a peer who was interested in the same things that i was interested genetics latinos bilingual and what what we did is we assembled an all-star team of latino physicians and scientists and i'm going to call chris gnu who is one of my pspgi graduate students an honorary latino but we had andres moreno estrada who is a mexican physician md phd josh gallanter who is also latino who currently works at genetech was a postdoc in my lab but he's from venezuela fully bicultural bilingual and what we were able to do is we were able to collaborate with the genomics institute in mexico and anthropologists in mexico and and access indigenous populations some people might call them tribes but we just call them populations and on the left we did an ancestry-specific principle components analysis and demonstrated that populations the indigenous populations are just as genetically distinct from each other as asians are from europeans and then we extrapolated that to contemporary and mestizo populations in mexico and you can see that depending upon the ethnic grub subgroup on the left the contemporary latino population lined up to different geographic regions and finally what we demonstrated was why is this important so we had lung function on two mexican cohorts of children we had our gala one study we had the mexico city asthma study provided by stephanie london and what you see in the bottom right corner is that the type of native american ancestry varies your lung function varies on the type of native american ancestry based upon where you're from so if you're from sonora you had high lung function but if you're from the yucatan which is in the southeast which is where i got married you had low lung function and so instead of going from global ancestry like african european native american we went to subcontinental ancestry showing types of native american ancestry influenced lung disease by as much as 10 and what this means is that a decline of attempt there's the northwest to southeast gradient depending upon the type of native american ancestry you have your lung function will drop by 10 and that corresponds to a 10 decline in lung function which corresponds to getting older by 10 years and having your lungs decline over 10 years so what about social and environmental factors we always get this question i had a great bose talk in my lab maria pinoglianis was who's a geneticist now faculty in spain uh anita talker was a fellow who's a pulmonary physician now faculty and we had 5 500 latino children we asked the question what's more important is it genetic ancestry is it environmental factors like second-hand pollution air pollution or socioeconomic factors income education discrimination and what they did is they demonstrated that ancestry was the biggest driver of lung function at least in latino children and maria went on to demonstrate that on the x-ax on the y-axis we have lung function higher you are the better on the y-axis i'm sorry the y-axis lung function on the x-axis we have increasing amounts of african ancestry and she replicated our new england journal results now these are all association studies and i know that people here will want to see functional work well we had the whole genome sequencing data and eunice lee who was a postdoc in my group took this to the mac she demonstrated that she could find that a chromosome 1q32 if you you've inherited african ancestry at that particular locus you had a 0.2 liter decline in lung function and she used this to identify novel genes particularly uh tm m9 or 10 9 and she looked at rare variants and what she found is that gene expression of 10 9 corresponded to gene expression of pro-inflammatory cytokines il-6 and il-1 beta now when you look at the alleles at that particular locus if you inherited two african alleles you had lower temni gene expression than if you inherited one allele or two alleles the same is true for the other variant that's in ld with that uh eunice went on to demonstrate that amongst native americans if you inherited a native american segment of chromosome 5 q35 you had increased lung function by 0.15 liters and these are clinically significant values so what does this mean we're talking about disease misclassification if we throw out racist is like throwing out the baby with the bath water we get disease misclassification that has clinical implications disability ratings lung transplant referrals pre-operative risk workers comp impairment now i want to remind my pulmonary colleagues who have been reluctant to integrate modern technology into pulmonary medicine i'll remind you that penicillin was created in 1928. the human genome project was completed 21 years ago don't you think it's time to improve and integrate modern advances in science and medicine into pulmonary function testing i think it's time i think it's bad if we go back to 2000 to say let's whitewash everybody and use one-size-fits-all i think that's equally discriminatory now there have been a lot of discussions on this topic there have been editorials written the ats has had special sessions on this and i could tell you having been participants a participant of those committees 90 is driven by commentary or viewpoints or opinions less than 10 are empirical evidence-based studies and i'm very proud to be able to say to the best of my knowledge we are the first in the world to correlate genetic ancestry with clinical measures like lung function and of that 10 percent my lab and my team has contributed the most we have several copycats who have also supported our work but the fact remains that we are making big decisions just like josh adler did on very little empiric evidence-based data so the takeaway that i want you to take from this point of the lecture is that race genetic ancestry and medicine are intertwined the epidemiological importance of race and ethnicity will never go away throwing out race and ethnicity without careful clinical consideration is not the answer and may lead to more inequality inequalities and increased health disparities what we need is empiric evidence and not opinions so i want to switch topics and i want to talk about some fun stuff that we're doing this is brand new hot off press we know that 80 of disease-associated variants lie in non-coding regions now we have some of the world's largest data whole genome sequencing data rna-seq data and this is the project that was led by angel mock linda katuri supervised by elijah and also helped by don leihu what angel linda and the team did is they took our whole genome sequencing data from african americans puerto ricans mexicans other latinos combined it with rna-seq data from the same populations and what they demonstrated was that gene expression patterns differ by race and ethnicity this paper is it was is under review it's favorably reviewed at a high profile journal and you'll have more to come but we they demonstrated that the gene expression heritability tracks with genetic ancestry this slide is a little bit complex but i tried to make it as simple as possible on the left i have a dimmer switch african ancestry on the right i have the proportion of phenotypic variation from uh of the heritability of gene expression and whether or not it's due to genetics or environment and what angel and her team demonstrated that with increasing amounts of african ancestry the proportion of unit phenotypic variation in the population due to genetics increase and that's likely because africans have more genetic variation than any other population in the world what she also demonstrated was that 30 percent of the genes this is the whole genome now have at least one ancestry-specific eqtl now a new analysis that angel and allah did is they try to take a crack at the heritability of asthma we know that the heritability of asthma from twin studies is ranges from 35 to 70 percent but those twin studies are done in whites and so it's practically irrelevant to a cosmopolitan population like the united states or the other 84 of the world so the way for us to we as a scientific community to get at the heritability is to do genome-wide association studies which look at common variants common variants have only been able to explain 13 of the heritability of asthma but using whole genome sequencing data a lot and angel were able to to increase that to 53 by including rare variants rare variants make up about 70 percent of the heritability of asthma and this is in minority populations this is a first this will be a groundbreaker study now i want to return to my roots i didn't crack this nut i didn't explain why puerto ricans are have higher prevalence than mexicans i will tell you an aside since i have a minute that we published sam oh published the paper demonstrating that 95 over the last 20 years 95 of the nih research focused on lung disease has focused in on whites even though minorities represent 38 of the population minority children today born today more than 50 percent are non-european so i wanted to start a longitudinal study and i asked my peers uh to help me one of the ways we we did it we is we looked at the early origins of asthma cmo published a beautiful paper demonstrating that viral infections were the strongest risk factor for the development of asthma particularly rsv and human rhinovirus now i got a grant to study do more recruitment in puerto rico in 2013. i invited max seibel max was my first graduate student he was a faculty at national jewish he was interested in nasal epithelial cells so i allowed him for the first time to come to puerto rico and he brought a nurse that showed us how to do the nasal epithelial cells and the clinical team in puerto rico was able to do that perfectly and i'm showing this to show you how how it looks uncomfortable but it's not that bad in fact on the lower right corner is my colleague noah zeitlin who got a nasal brushing so i want to put this in context the only way physicians pulmonary physicians get lung tissue is to do an invasive bronchoscopy now that's pretty invasive you cannot do it in children because it's unethical we had a whole system on gathering nasal brushings and in fact i paid for the collection of a thousand nasal brushes for max to start jump start his lab and what max did is he demonstrated that the gene expression patterns in the the nasal genes overlapped 90 with bronchial gene expression patterns so it obviated the need for us to do uh bronchoscopies or the tremendously invasive bronchoscopy the nasal brushes are so easy we can get thousands and thousands of brushings in a couple of months and what max was able to demonstrate is that there are different flavors of asthma based on gene expression patterns of the nasal epithelial cells he demonstrated that there's th too high th too low and and that was critical for going forward now jose this is jose rodriguez we have been working together since 1998 he's been a father figure a mentor to me a colleague we've worked together for many many years in many different settings jose happens to like fishing i like fishing we brought in our closest collaborators maria pinoyanis who is one of my postdocs is now a faculty in spain she's a geneticist we brought in luisa burrell in 2004 she's a social epidemiologist at the city university of new york and because we're starting we study minority populations we needed to have social epidemiologists we needed to have geneticists that were proficient in understanding racially mixed populations then i reinvited max back into the team now he's a professor at national jewish and here's a scouting trip that we did max is on the left and the red t-shirt sam is our lead epidemiologist who was the designer of our longitudinal study and we took time out and went fishing and that's my big fish on my 50th birthday but on a serious note we had a planning meeting in puerto rico this is the back of the envelope meeting and we are planning a longitudinal study which ended up being a birth cohort study and we came up with this primary pre-medal research primero is puerto rico's first birth cohort study it means puerto rican infant metagenomic epidemiologic study of respiratory outcomes i paraphrased a line from abraham lincoln's gettysburg address science of the people by the people for the people shall not perish from this earth we are fortunate that the nhlbi funded us our goals were to recruit 3 000 mother infant pairs follow them for the first five years identify the early origins of asthma and study the life force of health and disease now anyone who's in science and medicine knows the framingham birth cohort or framingham cohort pre-medal is a birth cohort we could do so much with it and i hope that this cohort outlives me we we are collecting data on mothers we can look at the epigenetics of maternal stress we are collecting data on infants core blood nasal brushes we can look at genetics gene expression of the host the viruses longitudinal epigenetics disease biomarkers we are connect collecting longitudinal data on the children looking at the long-term impacts of genetic environmental risk factors on health gene expression and epigenetics not just for asthma but for obesity in a variety of other diseases that come over the life course now this is an example of a postpartum mom two days postpartum bringing her baby to the clinic this is dr rodriguez santana doing a nasal brushing and i we started recruitment in march of 2020 during the covet shutdown and i'm very proud to say that during that time we've recruited over a thousand mother injured para dyads despite the shelter in place this is a testament to jose and his team so i'm going to end the science there i covered a lot of ground i'm a complex person i think my worst experiences were growing up as a single parent to a school teacher all the things that people talk about adverse childhood experiences i experienced we had food insecurity we were poor i missed christmas one day my mother gave me an iou and started crying she told me i'd rather see you dead than on welfare i had the disadvantage of being a latino kid from the hood i had grit because i was born poor i learned how to fight i learned how to wrestle because i needed to in a in a gang infested barrio i was very fortunate to get it to stanford and not only stanford i was very fortunate to get into the medical scholars program where i did three years of basic research on lung lung disease genetic research and lung disease it was on transplants the transplants are for wealthy people primarily white people and they didn't address my interest in health disparities so i dropped it quickly when i got to harvard harvard was great harvard marshall wolf bred social activism people like paul farmer who started palter partners in health jim kim who led the world bank the current surgeon general vivek murphy i was very fortunate to get into ucsf where there's a strong role of activism and as a pulmonary physician working at san francisco general i was there during the aids epidemic and i saw the activism not only on the physicians from the scientists and the community i was very fortunate to get a scholarship from the robert wood johnson foundation to go back to uc berkeley and up my and improve my training epidemiology and biostatistics and create the idea for the galaxy ii study now it's time for me to take a few minutes just to thank the people that supported me and one of my biggest supporters has been my wife we met in college when i was a sophomore she started dating me when i my stock was low i couldn't even give away my stock and here's a picture of us we got married on chichen itza which is the mayan empire the mayan civilization were the some of the greatest mathematicians in the world they created the zero we produced two beautiful daughters and i wanted them to be smart independent self-confident my daughter milena on the left is a project manager at microsoft she's a computer scientist my daughter maya on the right is a computer scientist still in college she is named after the mayan empire and i am proud to be able to say that i delivered them both i delivered milena at the brigham and women's hospital i delivered maya at ucsf now going back to my my family life at the lab even though i'm getting the opportunity to present today i have hidden pillars of stability and as a fatherless child always wondering where i was going to get food from not having christmas gifts i like stability celeste ing who's there on the left has been the steel girder of our lab the backbone of our lab she's going on 17 years in my lab sandra is going on 16 years she's our clinical recruiter dongle and scott are going on 14 years in my lab jennifer laraway is one of my right hand persons in helping me write all my grants and papers i want to thank my team i especially want to thank neil rich for taking me under the his wing a lot ziv for being my partner for the last 21 years luisa burrell being my partner on social epidemiology and everything since 2004 noah zeitlin who is one of my first hires i want to thank the sandler foundation for providing the fuel that helped me go forward and my very diverse team in my lab i want to thank my funders and i want to say something last we all start off as students then we become trainees and postdocs and then we become assistant professors and it's like wrestling one day you're in the mat one day you're on the side of the mat and you're coaching and i'm very proud that i've left a strong and proud legacy of trainees most of whom have gone into academics academic medicine or have scientific careers some of them will be world leaders i think christine you will be the next world leader in population genetics same with noah's island and many others will have a significant impact josh gallanters is has a tremendous job at genentech and leadership role at genentech leslie cemetery just went on to the nih and she's now my my program officer angel mock is going off to do great things ryan hernandez was my first my first first hire at ucsf and max seibold was doing very very well so i'm going to end there and i just want to say thank you for the opportunity and i'd be happy to take any questions wow um dr burchard thank you so much i so wish that you could hear the very loud applause from the almost 200 people on this call which if we were in person i think at this point would probably be a standing ovation um you're experiencing the deafening silence of zoom right now and uh i just hope to convey our thanks for your extremely inspirational talk hearing about your life your life course your scientific insights and advancements has had a huge impact on the audience i know um i want to we have a couple questions in the q a but first i want to just introduce elad ziv who you mentioned many times and i think he's going to kick off the q a dr ziv is a professor in the department of medicine and i think i maybe saw him on one of the fishing boats but i'm not positive so i i should introduce them okay please do please sorry that was my mistake elad and i started off together in i think 2000 maybe 2001. eliza general internist he's trained in statistical geneticist genetics and we made a pact we knew that the likelihood of academic success was very low and i asked i told a lot we could swim alone and have a high risk of failure or we could swim together and have a high risk of success and that was in 2000 and we worked together closely uh from 2000 to to now we drove every two twice a week to stanford to take a course with neil risch when he was a faculty there on population and statistical genetics we share a lab we we recruited together we gone to mexico and taught classes i helped connect him to to collaborators in mexico to jump start his breast cancer and latinas cohort and it's been a wonderful collaboration and it's uh very synergistic and i'm very proud to to know him and to be his friend and call on my colleague thank you um i just want to say also i i want to thank you for being my teacher for uh this these two decades and going strong um and and also highlight the way i think that you have done your science both with the combination of determination and passion um i think that's really been uh the things i've learned the most from you um i have the program of the first question um so i'm gonna ask you kind of a broad question which is um genetic ancestry and medicine where do you think it's going do you think um we need to be measuring genetic ancestry you think we should be measuring how do we do we incorporate it um it's become something that many people now know about just from their kind of recreational genetics uh but um this is something that you think we we need to kind of put into medicine how well i i actually think that for i'm only gonna talk about lung disease because i'm a lung specialist for the majority of patients it doesn't really matter probably 70 percent of patients but in those few patients that go say to parnassus where we need a specialty diagnosis and what we demonstrated in the new england journal paper that there's a fifteen percent error rate and that fifteen percent air rate um could put you on one side of the cut off for whether you qualify for transplant or not qualify for disability or not and so in those special cases i would use genetic ancestry to we talk about precision medicine but the way my field pulmonary field is going is that we're going back 30 years to a white only reference equation and like i said penicillin was developed in 1928 it works it's time to get with the speed the human genome project was completed 21 years ago it's time for us to get up to date and start incorporating modern advances to medicine you know that the cancer field has been revolutionized by genetics in fact god forbid that any one of us gets cancer but if we do if you're at ucsf your tumor is going to be biopsied and sequenced and we'll be able to determine what drugs work for you and which drugs won't and we'll be able to sub phenotype your cancer into various types that will respond to treatments um elide i'm gonna if should we go to some of the questions now we've got sure sure um all right go ahead and i've got more questions but i i let let's kind of let we've got moderate great um i'm going to ask you some of the questions that are coming in on the q a and i see some people some celebrity sightings in the q a too so actually maybe i'll start there because i see uh jeff drazen has put a question in i don't know if you knew that he was listening so um his question is how reliable is assessment of genetic ancestry which he puts in quotes is the technology used to make an assignment now stable or can a person have their genetic ancestry evaluated and placed in their medical record for use as an immutable trait uh well thank you jeff for showing up you said it was uh you weren't going to show up because it was too long so i'm very pleased that you're here um it is an immutable trait um we don't have complete reference equations for the entire world um and so that's that's a shortcoming but we do have very good reference equations for the majority of populations uh in the world and that's why i'm glad that ucsf accepted the oaxacan samples there are no biorepositories of native american samples except for what exists in mexico and now ucsf has one we the genetics field is and national geographic are continuing to collect samples all around the world and so the the genetic estimates will get further and further improved and if you signed up for 2083 and me pretty every now and then you get an update where your estimates get a little tighter and and that's because they're adding more reference equations to their data set but yes it's an immutable trait just measure it once and you're done great we have a lot of questions coming in and please keep sending them i also was just told i want to say that this is the faculty research lecture series apparently with the highest recorded attendance in a long time so again i think it just speaks to the importance of your work and the engagement that the ucsf has community has with it we have a question from neil poe saying does the correlation of ancestry with lung function parameters represent biology or environmental like social and behavioral causal influences since self-identified race is associated with ancestry classification of course social effects can have effects on biology eg epigenetics sure so we we did publish that very nice paper uh looking at the social and environmental factors that we collected now being an epidemiologist i know that we cannot collect everything so we demonstrated even after adjusting for social environmental factors genetic ancestry was the strongest predictor one of the projects that i didn't have time to talk about was a very cool paper published by josh gallanter and noah zeitlin everybody knows that epigenetics is influenced by social environmental as well as genetic determinants we had data on hundreds of hundreds of latino children different types of latino children we had genetic ancestry we had methylation we had social and environmental determinants and what josh and noah demonstrated that 75 percent of the methylation patterns are driven by genetics whereas 25 percent are driven by social and environmental factors that co-vary with race and ethnicity which is one of our best papers because it tells us that we have a long way to go to really disentangle what's more important genetics or the social determinants of health now the social determinants of health i can ask you this question what's the likelihood of a kid dying in ferguson missouri okay the your first principal component would be uh male or female okay and then age and then race that has nothing to do with biology that is purely a social determinant of health and we are seeing that over and over and over again we have a lot of work to do but unfortunately the study detections are primarily 85 white male and they don't appreciate this and we get ridiculous reviews when we study minority onlys and they we get reviews where's the white reference group how is this generalizable to whites and that is discriminatory because when we have white studies when i was on study section for six years when a white study came in we never said where's the black reference equation again as i said racism is baked into our system jim crow never went away it just went underground and we saw it rear its ugly head in 2020 that's a perfect segue to a question from bob walker that's asking you to take on some political environment issues so his question is i'd be interested in esteban's take on how the political environment in which all matters of race become potential hop buttons influences his work particularly his argument that we don't necessarily throw out race as a meaningful variable on certain measures it's a delicate topic but like i said i i've grown up with race all my life um my mom was dark skinned she spoke spanish went to a segregated school all the way up to high school um my whole family uh is dark spanish is our first language um i see it i see it every day and um it's difficult but i i'm very comfortable talking about it well i want to give you a recognition and there's some things coming in on the chat and i just want to read one from um raul rodriguez jr that says thank you hermano for allowing me to be part of this today you've made all the kids from the mission overly proud i say this with tears of joy i love you brother i just wanted to read that to you because i don't know if you'll see it after um and then i wanted to put this question which comes from [Music] someone from the university of iowa who actually wrote go hawks because wrestling's wrestling season is starting soon um but this is some mentorship issue so says you've done a wonderful job training the next generation of physician scientists but can you share some of your thoughts about how we can get underrepresented or historically excluded faculty in the room for funding and editorial decisions so we have no problem recruiting for the nfl and the major league baseballs so there are new ways to recruit and i think that we have to have a holistic view and i think that ucsf um had the largest number of uh minority students underrepresented minority students in the medical school in this entire history this year so there's a way to do it and we just have to think out of the box diversity adds scientific value it has different ways of thought my experience at harvard looking at those data and i told you it takes a mexican kid from the mission district training genetics who moved to boston to know that that wasn't geography it was puerto ricans versus mexicans um you know people talk about the pipeline but i don't i don't agree and people tell me to be patient and you know dr king talks about being patient but 43 years is a lot to be patient for i'll be dead in 43 years probably so i i think we have a have to rush on this um i think we have time for one more question this is from your colleague carlos mustamante and so but this is about the future so i said thank you for your great talk um the question is as you think about the next decade what role could a latin american biobank like the uk biobank play and how could or could pharma help move this field forward how can we advocate this for non-nih funding since they've continued to miss the vote on this issue and he says to me nhlbi has been uniquely inspired institute but the rest is quote too little too late so thinking about the next decade latin america represents 18 of the world population it is incredibly diverse incredibly diverse and they have been tremendously untapped even in the united states we have the study of latinos seoul they recruited 16 000 latinos i was the one that helped design it with francis collins but it's locked up very few people can get access to it so it's almost useless the million veterans program same thing tremendous resource but it's locked up almost useless kaiser beautiful data set locked up we need to have increased diversity latin america is a tremendous opportunity untapped it's in our backyard we have plenty of scientists that are bilingual bicultural i've had josh in my lab who can do that go to latin america maria pinoyanes puerto rico is another example is tremendously diverse and the admixer adds benefit because within one population you get three and you you can look at european african and native american ancestry great um i think we're going to have to end unfortunately but i did want to highlight that daniel craft is putting in a comment and he did bring up what looks like a nickname of stubby am i saying that right so in the jewish house they were called stubby yes and so he is saying hello and um asking about including your work into medical education and how it can impact clinical care and medical education so maybe we'll have that as the last question well you know the bridges curriculum is trying to standardize what we teach and i don't believe in censorship i have a pretty good career on showing that there is biologic benefit to looking at diverse populations and i'd hate to be censored so i think that we can have a variety of point of views in the medical education not only the school of medicine but i taught uh pharmacogenetics for about 14 years in the full pharmacy and we talked about this all the time in fact we tested the children we are the children the students we we perform pharmacogenetic testing in all 99 of the kids sam oh and alan wu and i did and with that we could show that there's racial differences in gene frequency for pharmacogenetic variants and that plays a role in who responds to plavix who's going to respond tamoxifen who's going to respond to xyz drug and that all corresponds to race great well i'm sad that we have to end um i just on behalf of the academic senate committee on research want to thank you so much for incredible talk scientifically inspirational but also just inspirational to so many about your life journey and successes and um a reminder to everyone on the call that this talk will be available on the academic senate website so please watch it again and have your colleagues and trainees watch it as well and thank you so much dr burchard and congratulations thank you very much
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