Dr. Esteban Burchard – A Life in Medicine: People Shaping Healthcare Today
12
February

By Adem Lewis / in , , , , , , , /


(upbeat casual music) – This is another in our
series of Fireside Chats. So I’m Bob Wachter, Chair of
the Department of Medicine. My voice does not normally
sound like Clint Eastwood so apologize for that
but getting over a cold. Thrilled to be here with Esteban Burchard who is a professor in the
Department of Engineering and Therapeutic Sciences. Which is actually in
the School of Pharmacy but he has a secondary appointment in the Department of Medicine. So we proudly claim him as one of our own. And Esteban is really a
world renowned researcher in genomics and precision medicine. Areas around disparities, asthma. We’ll get into all of that. But also has really an
extraordinary life story. So part of the reason I
wanted this opportunity to talk to you Esteban was
to hear really about both. So, thank you for joining us. – Thank you for having me. – So let me start off
with something cryptic. But I think this will become
obvious why I’m asking. Tell us about the meaning
of Fall City Nebraska. – Fall City Nebraska. Someone found me on Ancestry.com and asked if I was related to someone by the name of Burchard. And I’ve known that I
have some sort of history. And after a little more
digging I found out that I come from a long
line of physicians. Three generations of physicians
dating from the 1850s. Started in upstate New York Buffalo. Moved to Nebraska in the 1870s and started a hospital in 1880 and it was financially kicked off in 1920. And they had the 100 year
centennial this past October. – So your family comes basically through a long line of people involved in medicine through Falls City Nebraska. And you found out about it ’cause somebody looked you up on
Ancestry.com and contacted you. – That’s exactly right. – Pretty amazing. And I saw that going way back. Your family tree begins
with, this may have been great, great, great, great
grandfather or something. But someone from Germany
and somebody from England. – [Esteban] Yes. – And yet I know a big
part of your identity as a Mexican American and
you’ve done a lot of your time studying disparities and
diversity and issues like that. So when did that connection get made from sort of European part of your family and the Latino part of your family? – So I was raised Mexican by a single mom. And I know the answer, I did
it on 23andMe and Ancestry. I’m 26% Native American, 8% African and the rest is European. So I knew that most Mexicans have a significant amount of European as well as indigenous populations. Know that going forward for many years. Probably as far back as 2003 but the Fall City was a surprise. – And so tell us about your upbringing. I understand you grew up in San Francisco in the Mission District. Tell us about being raised here. – So continuing with Fall City. My father was orphaned at the age of six. Given up for adoption
and worked on a farm. – [Bob] In Nebraska? – In Nebraska and that
was during The Depression. And was drafted in World War II. And served as a pharmacist
in World War II. And came out to California
and met my mother. My mother was passed away. Mexican farm worker, didn’t speak English. Learned English and at the
time there was a big push for assimilation. So she married my father. They were separated by
the time I was seven. – What was your father’s ancestry? – European. That’s all I really knew. – Okay. – Until this past April. Raised in the Mission
District of San Francisco. My mom was a school
teacher so hard to raise five kids on a school teacher
salary in the Mission. And the Mission District at the
time was incredibly diverse. Racially segregated very poor population. And great culture, great
environment, great weather, lots of gangs. And so my mother was
very cognizant of that and had a network of
women who helped raise me to keep me away from gangs. – What does that mean? Network of women who raised you. What did everybody actually do? Did they take shifts and how she set out to be sure that you didn’t
fall in with the gangs? What was her strategy? – Well, early on she had. Other women would take
me to a baseball game or take me to events
and things that normally a father would do. One family took me in
particular, a Chinese family. They had two sons, one
older and younger than me. And for about four years I was with them. Even went to Chinese
school here in Chinatown to learn Cantonese. And that was an interesting
experience, very interesting. And then I still needed a father figure and so I was being bused
from the Mission District. All Latino and African American to an all White high school in Sunset. And was subsequently
kicked out for fighting. Landed at inner city high school– – How old were you then? – I was a freshman. – Freshman in high school? – Mm hm, you know my
mom’s a school teacher so it was a big embarrassment
to her, I apologized. But I found in inner
school I found wrestling. And there was a young college
coach right out of college that brought a really
national level program to an inner city high school. And we went on to the state meet and I went on to continue
and wrestled in college. And so that became my discipline
and I did really well. Took a state placer, took
second in California. In college my coach was African American on the 84 and 88 Olympic team. I get in a PhD, so had great role models and my study partner was
African American, NCAA finalist. So I could not have asked
for better role models. That discipline merged
my passion for science and really allowed me to
focus and run with it. – And so here you are
growing up as a poor kid in the Mission in a racially
segregated environment with a single mother, one of five kids. And you’re, I imagine when you
got kicked out for fighting this was your moms nightmare. – [Esteban] Yeah. – That this was part of, you’re lost. You’re now part of the gang. What did she say to you? Do you remember the incident? – Um well, I mean. Saint Ignatius which was at the time was all White male school. They had a tradition of beating me up or starting a fight everyday. But I fought back incredibly. It was terrible. I’d take a bus from the Mission District. Go to Sunset, have fights. Come home and there’s
gangs and it was just a terrible situation. I remember being kicked out and my mom almost washing her hands of me. And just saying I’m disappointed. And as a teacher and at the time she was an assistant principle. It was a big embarrassment for her. – I’ll bet. Did you find wresting? I mean were you looking for an anecdote? Were you looking for something? Or was she looking for something for you to settle you down and give you something to sort of focus your energies on? Or how did that actually happen? – The Mission District
was crazy at the time. There were lots of gangs. There was White flight
so the tax base was low. My best friend in high school
was murdered when he was 14. And I saw myself heading down this path and not by my own choice. But by being a product
of a bad environment. I started wrestling to
learn how to defend myself. And it turned out to be a wonderful thing. I lost about 80 pounds
and was league champion. And went to state meets
and we had a great team. And wrestling is a blue collar sport so all you needed was a pair of shoes. And I finally got to meet
Olympians, national champions that looked like me,
that had my same story. And regardless of your socio
economic status or your race. The wrestling mat is flat. So it’s an even playing field. – Yeah and then where did the. So that may explain discipline and the fact that you’re
channeling your energy in what might have gone into fighting into something more productive. How about the academic side of you. Where did that come from? – Well I was always academically gifted. I was at a magnet high school. My mom was a school teacher. I was always interested
in biology and science. And I started off as a
biology major in college. – Where’d you go to college? – San Francisco State University. And I only applied to two colleges. UC Santa Cruz and San Francisco State. – You wanted to stay, did
you feel like you needed to stay locally? – That wasn’t really an option. That wasn’t, I didn’t
have any good role models to look up to. – Did you have any role
models in science, biology, medicine? Now that you’ve discovered
half your family was doctors but you didn’t
know that at the time right. – Not at all. – So you had no role models
who were professionals? – No, the only role models I had were my. As I said, my father figure
who was on the 84 Olympic team getting a PhD and my study partners. And that’s hard to believe now and I feel sorry for kids
that don’t have role models. But the other role models I was meeting were national champions
and really disciplined. Olympic gold medalists. And that’s something you
couldn’t put a price on. – Did you ever think
of doing pro wrestling? – No, no. Pro is at the time was people
jumping off the tables. – Yes, right exactly. – No, no, no, no, no. – That’s wasn’t going to be your thing. – No no. – All right so you go to college and you just have a passion
for and you’re good at biology. – [Esteban] Yeah. – Did you find that you were. Were you at a disadvantage
given your prior experiences in the schooling? Or you felt like you’d gotten
a pretty good education through it all and you hit college? You were able to hit the
ground running in college. – It was tough my freshman year. I was working to help
pay my way through school and wrestling. Once I, I found a UCF
medical student who found me and he started mentoring me. – How did he find you? – Through one of the pre-med conferences that was hosted here at UCSF. His name is Francis Felix. And he advised me all along. He said you know, no one looks at how long you go to school for. We do look at your grades and MCATs. So, San Francisco State was relatively inexpensive at the time. And I could get
scholarships from wrestling and I was able to slow it down. And having a slower pace
allowed me to really excel. Not only athletically but academically. And I met my wife of 34
years in the library. So there’s three of us. My wife and my study
partner who’s NCAA finalist. Who is brainwashing me to
think that I could do anything. And you know part of being a pre-med is a lot of psychological
baggage goes along with that. Insecurities, can I do it? Can I not? And here I am. I have an Olympian and a national champion say you can do it, you can do it. So I never hung out with pre-meds. And I’d just walk into my
exam and sit at the front and walk out. And wouldn’t let any pre-meds talk to me. And that strategy started working. And at the time beautiful
experiment happened in San Jose California
called the Frozen Addict. Where there is LSD that
was laced, contaminated. And overnight patients were
getting Parkinson’s Disease, Parkinson’s like syndrome. And at the time I was
taking organic chemistry. And it was all O-chem. And it was like ah ha. – So you felt like Walter White right. – This is amazing. – From Breaking Bad. – This is amazing. – Yeah, that it was all chemistry. – And then that’s, I knew
that’s where I wanted to go. – So it sounds like you were initially pretty intimidated by the pre-med thing. And other kids– – I was not because I never
allowed myself to be– – Because. – Around the pre-meds. – Your friend gave you
confidence that you could do it and sort of sequestered yourself off. – [Esteban] Mm hmm. – And it sounds like
the wrestling was partly kind of your main confidence builder. You can make it in something really hard. – I didn’t need external validation. You know when you wrestle the only pair. You put on a pair of
shoes and you’re out there in front of a thousand people. And you are either the
winner or the loser. – Yeah, do you have a signature move? Were you, something you were known for? – Yeah, I did. I was known for– – I don’t want you to
demonstrate it on my by the way. But– – I was known for, my coach
was on the Greco Roman team. So I was known for throws. In the US Olympic trials
in Vegas I threw a four time NCAA champion on his back and it was absolutely amazing. – Sounds like fun. Okay, so you do the pre-med thing and you also get a PhD at the time or– – No. – PhD, how did that work? – So Stanford had a
medical sciences program. Not a MSTP but a program where you could place out of courses. The first two years the
preclinical curriculum and working in research labs. So instead of going four years,
I went to school for five. I worked three years in the lab. And that was a great experience. I was learning by osmosis
translational research. It was a lab with three PI’s. The head PI was Carol Clayburger who was a hard core
basic immunogeneticist. Jim Theodore was a pulmonologist
transplant physician. Von Starns was a transplant surgeon. And what we were looking at
is we were getting biopsies. The lung, heart, lungs. And try to correlate gene
expression in the organ, the allograft to gene expression
patterns in the blood. To see if we can predict what
was going on in the blood without having to do a biopsy. So I didn’t appreciate
it but I was learning translational research. Whenever a patient would
come in, they’d call me. I get a clinical history, I get the blood. Take it to the lab. Do the gene expression analysis. When they got the
biopsies of the allograft. I do gene expression for correlations. – And what drew you to that
part of the research world? Both in terms of the pulmonary piece and then the genomics
and the translational. What was exciting about that? – This is pre-email. So I remember I applied to 20 labs. Put my CD– – None of them know out
there that there was a time pre-email but there actually was. (laughing) Believe it or not. I don’t know what we all
did with our time right. – I know. – Hard to imagine. – I put my CD into 20 doors
and I only got one response. And it was by Jim Theodore. He was a former wrestler at Pittsburgh. And he said you know,
I see your application. And I saw that you wrestled and did well. You’re a good scientist and
I’m gonna be in your corner and give you a shot. And that’s how I got my lucky break. – So it wasn’t that you really set out to look at genomics or do
pulmonary or any of those– – Well I applied to the genetics labs. – So the genetics labs. This was one of them,
one out of 20 chose you. And did it feel that they think they were taking a risk on you in part
because of your background? What do you think was the
obstacle to the other 19? – First off, coming from San
Francisco State University. I remember being at the anatomy
table, total of six of us. – [Bob] Yeah. – And my classmate who ended
up later being my roommate said how’d you get in? And he was from Harvard. So I got a lot of that. – [Bob] Yeah, how’d you feel about that? – Oh, I felt pretty small. – [Bob] Yeah. – But now I know that you can
buy your way into Stanford. (laughing) So now I know that he
might have had a backdoor. (laughing) – All right, we’re gonna
leave that in the tape. All right. (laughing) Yeah, did you feel like
you had to prove yourself? – [Esteban] Oh definitely. – More than any other folks? – Yeah you know, Stanford
had a class of 86 and there were six minorities students. And the first day of, the first
quarter of the school year the class president posted
an article claiming that Stanford was flagrantly
admitting in minority students that were under qualified. And we all looked at each other
and thought oh, that’s us. And so, you know. When a guy like me goes down
to 158 pounds, that’s tough. So I knew that I could do it. I knew that I could work hard. I would not– – Meaning you had to get
to, that was what you had to get down to for wrestling? – Yeah, that’s what I wrestle in. – You knew you could sort of manage a tough challenge like that. That’s when you took that
kind of comment at Stanford. That I’m gonna be better than everybody? – Yeah, I mean I lived in the library. And I hung out with people
that were like minded. – That’s where you met your wife right? – No I met her in college. – But in the library. – Yes. – So it sounds like
this has worked for you. – It has worked, it has worked. – Living in the library. – Yeah, I made the library my home. And like I said, I wasn’t the smartest guy but I was the hardest working. – And so and so you went
there to do an MD and a PhD? – No, it was called the
Medical Scholars Program. – One first then the other? – No, you didn’t get a PhD but I spent three years in the lab. – I see, okay. And when you finished what was the career that you thought you wanted to have? – I was confused. I was passionate about health
equity and health disparities. I lived it, I’ve seen it. Coming from the Mission District. Being a patient at San Francisco General. That was a big driver
or what I wanted to do. But I’d always wanted
to be a basic scientist. You know, getting trained by Paul Berg who won the Nobel Prize for genetics. And having role models like Paul Farmer who was into social equity. I could not figure out how to merge this. And I graduated from
Stanford as a medical student with two publications. And was fortunate enough to get into the Brigham Woman’s Hospital. And there I found great mentorship. I found wonderful mentorship. And Marshall Wolfe, the
former Program Director introduced me to Jeff Drazen
who was until recently the Editor New England
Journal of Medicine. And Jeff asked me to think about asthma and he gave me a book. And said I read it over the weekend and I said thank you Dr.
Drazen but no thank you. And he put his hand on me and he said son, I think you’re making a big mistake. – What was the question about? – He wanted me to study asthma. – Oh, to the asthma. – Genetics, and he said I have a project where you could look at the genetics of asthma severity
between Blacks and Whites. And I said sure. I took a year off, worked with Jeff. And because of all my
previous genetics training at Stanford, I hit the ground running. And we identified a gene
associated with asthma, severity that was 40% more
prevalent in African Americans. And for the first time in my career I could really see how I
can merge personal passion with academic rigor. I thought god, everyone’s talking about these health disparities
as being access to care. But here we have biologic proof that might contribute to part of the puzzle. And we had just had a baby
and I had just finished being on call to two three for two years and working at lab was easy. And I could not stop working. It was like falling in love. You know when you’re falling in love you can’t think, you can’t
sleep, you can’t eat. And I could not stop working. And by the time completed my residency I had a first author publication
and we had an IH grant. Because the Center for Disease Control published this abstract
of asthma prevalence and mortality in Hispanics
across the United States. And they said that if you’re Hispanic and live in the Northeast. Prevalence and mortality three fold higher than if you’re Hispanic
and lived in the Midwest, the South and the West. Being Mexican myself, having
grown up in California. Having lived in the east coast. Having this energy looking
forward African data that we had. I said to Jeff, this is add mixture. It’s an African gene coming through the Puerto Rican population. We need to study Puerto
Ricans versus Mexicans. Jeff thought that was a great idea. He put me in front of the
Director of the NHLBI. And three minute elevator speech worked. I said this is what we got to do. And that was in April of my
senior year, we wrote a grant. And by the time I graduated as a resident. We had 1.2 million dollar
supplemental funding to start off my study called
The Genetics of Asthma in Latino Americans. – Sounded like that
finding a clinical area paired with at least a high probability you thought at there were
clinical disparities. And maybe some interesting and important sort of chemical or genetic
explanation was important. Why asthma in particular? – Asthma is, to be honest
I wasn’t really interested in the physiology of asthma. But what is fascinating about asthma. Number one, it’s the most common chronic disease in children. Number two, it’s one disease
that has tremendous racial and ethnic disparities. In the United States depending
upon which data you look at. Prevalence in Puerto Ricans
is 36%, Mexicans is 4%, Whites are 12%. And it can be very conservative prevalence for Puerto Ricans, for children. Recurrent asthma is 18%,
Mexicans still four. So I was fascinated with the fact that here you have two Hispanic
groups on the extremes of the tail that prevalence
and mortality distribution and no one’s studying them. And Jeff showed this data and
this is where diversity helps. People were looking at the
same data I was looking at it and within one minute I said it’s Puerto Rican or Mexican. – And what is it about
Puerto Ricans and Mexicans in terms of their lineage that
that clicked in your brain? – So the average Mexican
in the United States is 50% indigenous and
the rest is European, maybe 4% African. The average Puerto Rican is
25% African, 16% indigenous and the rest is European. There’s a lot of variation. And the type of indigenous
ancestry differs between the two populations. – So you would have seen, some people would have seen those disparities and say there’s something
different in the environment in the two places. And you immediately said
there’s something different about the genetic makeup
of a predisposition to the disease. And you can sort of sort
out the environmental by looking I guess at Mexicans– – Yeah. – Living side by side
in the same environment. – Except they don’t live side by side. – They don’t live side by side so you have to sort of sort that out. Okay so you finished your residency and you had this amazing experience. A great role model and somehow
you make your way here. So, why? – Yeah. So the match was different back then. The amount, you apply
two years in advance. – And this is match for
pulmonary fellowship? – Yes. – Okay. – I love my experience at the Brigham. I loved my mentorship
with Marshall and Jeff. I had a gnawing hole in my gut that I needed to come to UCSF to
diversify my clinical training. I did two savi’s here. I wanted to come to UCSF
at San Francisco General. One in the emergency room and one on 5A which was the AIDS ward and ward 86. That was in 1994 and I was so
blown away with what I saw. And I knew that I was getting
great clinical training. Great exposure at the
Brigham but I also knew that in my three years there I
saw probably three HIV cases. Maybe one tuberculosis
case and I’ve always put my education as my top priority. And so I said to myself
I couldn’t sleep at night knowing that if I didn’t come to UCSF I wouldn’t be a great clinician. And despite my successes. The publications, the 1.2
million RN grant came to UCSF. I turned down an offer to
stay, seven year contract to stay with Jeff Drazen. And bonus package and I
came here to be a fellow. – And it wasn’t just to
be closer to your family. – [Esteban] No. – It was really the breathe
of the clinical training and particularly the county
was the thing that drew you? – Lee Goldman recruited me. Lee Goldman was a former
chair of medicine here. Lee convinced Jay Nadel who is the acting Director of the Pulmonary
division to take a risk on me. – And by that time were you still a risk? – No, I wasn’t. – I wouldn’t think so. Sounds like you’d done
incredible work right. – I did super well. – Yeah. – And I even wore a bow
tie, played the part. – Oh, you did the whole thing. – Yeah. (laughing) – I’ve seen pictures
of you with a bow tie. I assumed you ditched it
once you got here right? – You know, I tried to
wear one of my ties here and I was very adamant about wearing ties in San Francisco General. And within my pulmonary division, the peer pressure was too great. And they made fun of me and
they called me Teflon Don. (laughing) Finally I realized that
I got to lighten up. – Although the chief at
the pulmonary, John Murray, wore bow ties quite often. – But he’s significantly older. – [Bob] Yeah, yeah. – And I still get mad when I see residents don’t wear ties in San Francisco General. – You’re making me feel bad
but you don’t have one either so I think we’re okay. – Yeah, I think we’re okay. – All right, so you come here and how’d your career play out compared to what you thought it was gonna be? – Tumultuous actually, tumultuous if you want me to be honest. Here I am like a kid, naive
kid with 1.2 million dollars. And– – This is a while ago by the way. That’s three million an hour,
four million an hour probably if you do the math. – Yeah. – Total them up. – That was 1998 and I found people that wanted to take that money from me. And I found great people
that wanted to help me. And really when I got in trouble and people wanted to take
the money away from me. My mentor at the time, Dean
Shepard, came to my rescue. And been forever grateful for that. People have been tremendously supportive. There’s a time that our
study wasn’t doing well because we were trying to
recruit intact families. Two biological parents and the child and the divorce rate is really high. And so I talked to Dr. King, Thomas King who is Chair of Medicine
at San Francisco General. And saying as having problems and people trying to steal my money. And not being able to recruit and he said why don’t you talk to these folks. And it was wonderful, he introduced me to a guest speaker, Antonia Suerto
out of Texas who’s Hispanic. And another person by
the name of Morses Salmon in Mexico City. And I was a fellow working
in the intensive care unit. And I went down there to
Mexico City and Puerto Rico, gave my rounds. And said I’m young but I’m eager. Can you help a brother out? And they did and to recruit in Mexico is one twentieth the cost. To recruit in Puerto Rico
is one tenth the cost. So I was able to take
the remaining money I had and complete our study. – So the biggest problem was actually being able to recruit– – [Esteban] Yes. – Subjects and patients
for your previous studies and that became easier to do
in Puerto Rico and Mexico. – And we had residual money and recruit out of San Francisco General. And also in smaller clinics
like La Clinica Villa outside in Oakland and all
up and down the Bay Area. – So talk a little bit
about what you’ve learned from your research? What are the key findings that you set out to really helping explain
variations in care and disparities? I mean you were very
clinically grounded as well. You were really trying to move the needle in terms of equity. So what are some of the
key things you found over the years that you think have helped? – One of my most awesome
experiences in medicine happened here on the 13th floor in the pulmonary function lab. I had a Caltrans worker who
had an occupational injury. Obviously, you know, whether you or me. We would want to get disability benefits. And the insurance companies
don’t want to pay. So they send them to UCSF for the independent third party assessment. We did his lung function
test and in the United States up until now there are only
three standard references. White, Black and Mexican American. And this person looked like Obama. And so you know, I’d follow
the technician around and there’s a pull down. Is he White, Black or Mexican? And the technician goes well he’s Black. And I’m like well you don’t know that. And I asked him and I said what are you? And he goes well I’m half. And so that was incredible
because it depending if we compared him to Whites. We would have got the diagnosis wrong. If we compared him to
Blacks, we would have got the diagnosis wrong as well. Either way I could make a
decision that would have either led him to get benefits or not. And we have these clinical standards in every form of medicine. Whether it’s for your
GFR, your lung function. And at the time I’d already
been doing ancestry testing before 23andMe came along. And so my colleagues and I said well what if we measured
his genetic ancestry? And we included that in the equation. And we demonstrated that
for African Americans who are racially mixed
populations we could improve the diagnosis of lung
disease by as much as 15%. We probably said in the
New England Journal 2010. We did the same thing in Mexicans. We demonstrated that
there’s a 10% error rate. So we can make the diagnosis
more precise by 10%. We published that in
the Journal of Science. And that happened here and
I’ll never forget that. Because that was a
tremendous clinical influence that now we had a lot of Me Too people trying to do the same thing. And that’s what a lot of
companies are working on now. I do also want to say in my early days. I want to say thank you to
Sandler Family Foundation because they were based in Oakland. And they’re one of the
biggest contributors to UCSF. And they saw me and I
was just a young person. And there’s lots of people around them trying to get at them. And the Sandler said we would like to talk to that guy over there. And they, Herb Sandler
and Marian Sandler said you know, what you’re
doing is so important. We would like you to make
San Francisco General your soapbox for you
to preach to the world. And I’ve been forever grateful
for their support for that. – Yeah, they have been. Is it Herb that just
passed away last year, really extraordinary person. How do you negotiate the politics
and ethics of disparities? That you’re really, in some
ways people sometimes talk about we should be completely color blind. And we have to treat everyone the same. And in some ways your research says people are actually quite different. And it’s actually in their DNA and we need to understand that. And in order to treat them correctly there may be certain
drugs that work better in this person than that person or the normals are not the normals. So it must be that that’s tricky, it must be a tricky space. – It is for a lot of
people but not for me. – Uh huh, how come? – Number one, I’m Hispanic. I can tell you my ancestry. I’ve lived it, I’ve seen it. And I’ve seen it in my clinical practices. That individual, the Caltrans worker. When he checked in at the
registration downstairs. Some clerk made a decision about his race. And he or she may not have
had training in anthropology. But that information got
put into his medical record and came up to the 13th floor. And I was making a life
death situation about him. There are about 100 drugs
that have racial labels and I brought a package
insert just in case. Everyone who met gets a medication– – In case we run out of
things to talk about. You gonna read a package insert– – No but this is a package insert for one of the number
one asthma medications. And it’s the first thing we
get when we get a medication. It’s the first thing we throw away. But if you read this one and
this is why you don’t read it. (laughing) But if you read– – This is Times New Roman
II I think by the way if you can’t see it. – It says if you’re African American and you take this medication
you’re made for risk of dying. And there are about 100
medications right now. – What is the med? – This is Ceramedx. So now they have Advair which
is a combination medication. But there’re about 100 medications, Mirtazapine is one of them. Bidil or not Bidil,
Clopidogrel is another one. They have racial warnings
and I taught genetics, pharmaceutical genetics here
at UCFS for the last 14 years. It’s just well known that
genes vary by population, allel frequencies. And in the case of Plavix,
number one medication for cardio vascular disease and strokes doesn’t work in about 50% of Asians. And it’s just a fact, it’s just– – So, you think we have
to move to a world where you’re genetic information is
sort of known to the system and every diagnostic therapeutic
decision normal range is somehow embedded in the computer? It sort of knows that and
provides decisions report? I’m speaking for you but
tell me how this plays out over the next 10 year as we get more and more sophisticated here. – I would like that
but I’m also pragmatic. I had a very wise chairman
tell me, like a year ago. That we need to have a financial impact. We need to prove that it’s– – Could I say that? – Yeah. – Okay. (laughing) – We had to prove that
it’s cost effective. – Okay. – So that might be a pipe
dream to include genetics in every test that we do. But we’re beginning to see
it in every cancer diagnosis, there’s a genetic test done. And I’ve seen some miracles. A young woman that came
to my class in her 30s with stage four metastatic lung cancer. Got genetically tested
and walked out clean, completely resolved. – To cancer sort of the
early case where we’re seeing what precision medicine
will ultimately look like for the rest of us. I think that’s probably right. And the cost effectiveness
is on certain things. I think we were talking about sort of changing the normal
range for certain tests. But I think for the
issues of once we decide that drug A works better than drug B in this particular patient population. I think that’s more
matter of getting through all the pipeline. And then I’m struggling with
how we educate clinicians or provide clinicians
with the information. I can remember you treat
high blood pressure this way patients. But if they’re over
60, you do it that way. You start throwing in if they
have this genetic signature, they need to use drug C. There’s no human clinician that
can possibly remember that. So it really raises the stakes in terms of clinical decision support. – You know you mentioned
about how do you navigate the race ethnicity hot button topic. And I do what to put a
plug in for UCSF here ’cause I don’t think I could have done any of this work at Harvard or UCSF. – Or Stanford. – I’m sorry, sorry. Stanford. – I’ll correct you when you’re… (laughing) – And when we did, we published in the New England Journal of
Science and they turn. We went 0 and 11 for RO1 funding and we took on the NIH. And demonstrated that their biases in their review process. And I knew that our publication was gonna potentially jeopardize
my colleagues here at UCSF that were NIH dependent. And I got threatened by the NIH. One institute director called me asking me to withdraw the paper. The head of the scientific review, Center for Scientific Review called me asking me to withdraw. And I got cold feet and
I’m very grateful for this. I went to Sam Hallgood. Sam said, Sam’s a chancellor. I got your back, we got your back. I talked to Dr. King,
he goes I got your back. I talked to my department
share, she said I got our back. I went to Joe Guglielmo,
the Dean of School Pharmacy. Gave me a hug, he said
just do what you do. We got your back. – [Bob] That’s great. – And I am very grateful for that and I’ll never forget that. – And you were taking on NH because you had demonstrated
that the review process was bias around who the investigator was or around the topic or both? – Both, so we demonstrated. There’s a law that was
put into effect in 1994 requiring inclusion of
woman and minorities in all clinical federally funded research. And we demonstrated over the last 20 years that less than 4 1/2% of all research related to lung disease
included minority populations. We demonstrated that
over the last 30 years if you were an African
American investigator you have a 10% purely lower
likelihood of being funded. If you’re Asian, you had
a 6% lower likelihood to be funded, over 30 years. So we published that in PLOS Medicine. Science scooped it, scooped
PLOS and Nature scooped it. And they wrote editorials
and (mumbling) Barbara Lee picked up on this. And called me into her
office to update her and she subpoenaed Princess
Collins into Congress to talk about our paper. So I’m very proud that UCFS supported me and I’m very proud. Part of that today that I moved
the moral compass of science towards social justice. – That’s spectacular. I mean just so people recognize, you know. UCFS gets 600, $650 million
a year in funding from NIH. So, taking them on, an issue
like this is nontrivial in the fact that all of the
leadership rallied around you. It’s actually quite impressive. Tell us about the Primero
Study speaking of the NIH. – So we’ve been busy. I raised about $15
million in the last year. One of them was for Primero,
primero means first in Spanish. The acronym stands for Puerto
Rican Infant Metagenomic and Epidemiologic Study
of Respiratory Outcomes. It’s a birth cohort of 3,000 mothers and their newborn children in Puerto Rico. And we’re launch (mumbling)
for all the children to look at the early origins
and the development of asthma. I think the NIH has good people there. So I don’t want to make them, vilify them and I think the recognize
the value of a birth cohort like the Framingham. But in children and in
minorities in particular. We might start a collaboration
with White Memorial in East LA to do a
parallel study, Mexicans. Really trying to address
this epidemiological paradox and why asthma is so
prevalent to Puerto Ricans. And despite all the risk factors, relatively has low prevalence
in Mexican populations. – Okay, I want to throw
it open in a second but I’ve had the privilege
of visiting your lab. And I know you’re very proud of the way you organize your lab
and the kind of people who work in your lab. Tell us about your lab and
your philosophy about the lab. – Well, I grew up with all women. So I predominately have a female run lab. I believe in loyalty
so my longest employee has been with me for 15 years. The second two 14 years, 13 years, 12, 10. So there’s very few labs
where there’s longevity. We take all kinds. And I believe that I have a responsibility to help those that I can. So I look for first
generation and low income kids that would not get help otherwise. And very proud of that. We just had a student, first generation, get a full ride to Michigan. That’s worth about $500,000 right there. Recently I had three
African American females. One was a pulmonologist, one’s here. PharmD PhD, one is PhD. Probably the only African American female statistical genetics person
in the United States. I have a lot of Latino
applied mathematician. We have high school
students, under graduates and when there’s a quorum. When there’s a safe space people come. And I just gave a keynote speech at Soc NUS in Hawaii. And I mentor kids all
over the United States. And I feel it’s my responsibility ’cause someone did it for me. I don’t get paid a dime for this. But it’s something I really
derive pleasure and joy from. – It’s obvious, that was
really very impressive seeing the lab and the
diversity of the lab. And how passionate they are about the work and about working with you. Last question, your picture is on the side of about every other
vehicle in San Francisco. Was it Mission raised, Mission driven. I think something like that. How does that feel when
you see a bus go by and it’s got your picture on it? – I’m proud to be part of UCSF. I’m proud that I’m from the Mission. I feel that I’m part of
something bigger than me. And I think really a lot of my work is shaped by the UCSF history
with the HIV, AIDS movement. The social activism around that. Stuff that Paul Volvading did. And I worked on 5A, you know. AIDS patients died primarily
of lung disease or they did. It’s something to be very proud of. And when I was at Harvard Thouchy came, the head of one of the NIH institutes. And I remember act up the
political action group of the AIDS movement. Really combined with UCFS scientists worked together to really
change the NIH and the FDA. To fast track drugs,
to set aside money that wouldn’t take money
away from breast cancer or other diseases. And it’s a privilege to have a job where you can merge personal
passion with academic rigor. And really bend the moral
compass science towards justice. And I only think that can be done at UCSF. – [Bob] That’s great. – And I’m proud of that. – Great, well we are proud of you. Let’s throw it open for. We have seven or eight minutes. See if anybody has any questions. – [Woman] So I think what you said about, really about marriage
between basic science and social justice is
such an important space. And I’d also seem to
me like another message about you were saying is that mentorship, representation, recruitment. That that lens and having
that sort of thread in your work is really what allowed you to push forward this idea. So on the heels of recruitment
and as we move forward. How do you think about that piece? How do we improve and continue to mentor under represented trainees to try and really increase
prevalence and presence in the basic science world? – It’s difficult. The numbers have not
changed from when I applied to medical school in 1990. It’s still about 4 1/2% for Hispanics and less than 5% for African Americans. I can’t change national policies but I’m part of the rebel with Johnson’s Harold Amis Program. I volunteer my time
there and there we have a specific charge to
identify top physicians who are doing basic
science or applied science and really support them. So there are some things that I can do but I can’t take on the whole world. I got to feed a lab and UCSF is, we’re a Tier I institution. And we have to publish top science. So the other stuff is my side job. – We’re gonna have some intern applicants start coming through soon. What are the messages that
you think are worthwhile? Giving people to make clear
it’s a supportive environment. And the goal to improve diversity is real. It’s a, particularly those of us who come from less diverse
backgrounds sort of. How do you get that message
across in a way that it works? – I mean you’re a first to
go, you’re a first gen kid. – First to go to college yeah. – Yeah, and you know. I identify a lot of those kids. Whether they’re White, Black or blue, pink or purple or pink. I think it has to come
from the leadership. So we have a new program director here in the Categorical Program. I was very impressed to learn
that her major in college was African American studies. You know, I think it’s
that sort of coaching. You’re the department chair
but she’s the one that’s in the trenches. And I think support from someone like her is gonna be critical support
from other department division chiefs is gonna be critical. – All right, any other
questions or thoughts? All right– – You didn’t ask about the Jewish House. – Go ahead, go for it. (laughing) We’ll take this as the last one. (laughing) – You know when I was in medical school even though I went to Chinese
school I spoke Spanish, I had African American coaches. There’s a Jewish House at Stanford and one of the students lost their Visa’s right before Labor Day. And they needed a warm body
and so they interviewed me. And I didn’t realize I
was being interviewed. – Being interviewed to do what? – To live in the house. – To live in the house, okay. – And at the end of
the interview they said would you like to live here? And I had already had a
lease and the school year was about to start. I broke the lease and (laughing). I moved in for two years
as a Shabbat school aid. So the guy goes around on Friday nights, turns on and off the lights. But just like Rebecca Burman’s
experience of being Jewish and then African American studies. Here I am Hispanic in
an all Jewish household. And I’m now the godfather
of one of my roommates and we’re good friends, Daniel Kraft. – [Bob] Sure. – Who’s the Chair of
Medicine and Singularity and Lee Sanders who is the Chief of or the head of pediatrics,
general P’s of Stanford. That was a really good experience. If I look back at my
whole life experiences. Growing up with a dark
skinned mom who’s Mexican. Going to Chinese school, having
African American coaches, living in the Jewish House. It provided a unique lens
on which I view medicine and science. And now we’re paying all
these hundreds of thousands of dollars for cultural emerging programs. Or Spanish only or Cantonese only and I got all this for free. – It’s cheaper to have people move in with each other right. – Yeah it was awesome, it was awesome. – That is– – That was a cool experience. – That is very cool. Well we should quit there. – Thank you very much. – Thank you, it was really marvelous. – Thank you. (applauding) Thank you Bob, that was great. (applauding) (upbeat casual music)


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