So we're really privileged to have Dr. Max Luna with us today. Max came to us in 2008. But prior to that, his career started actually in Guatemala in 1983. He started medical school at the University of San Carlos, graduated there in 1990, spent a year as a research fellow with a Pan American Health Organization, PAHO, in Guatemala. 

After he finished his fellowship, he spent six months as a research epidemiology fellow with PAHO in Spain. In 1992, he came to the US and was a resident in internal medicine at University Cincinnati. 

After he completed his residency, he went on to Brigham and Women's where he does cardiology fellowship. He returned to Guatemala in 1999 and spent six years there as a cardiologist and director of non-invasive cardiology. 

He returned back to the US in 2005 where he was director of the division of non-invasive cardiology at Ochsner in New Orleans. And with that background, he came to UVA in 2008. He worked clinically as a non-invasive cardiology, moving over to the academic side in 2017. 

As a member of the UVA faculty, he's really been instrumental in our Center for Global Health and strengthening our relationships and our partnerships in Guatemala. He has been on the CTSA first task force on community engagement. 

Now he's a member of CTSA and really was instrumental in putting together that proposal and its success with NIH funding, in part, because of all the work he's done in creating the Latino Health Initiative, which we'll hear about today. 

He is a faculty affiliate in the Batten School of Leadership and Public Policy. And as I said, a founder and the director of the [INAUDIBLE] Latino Health Initiative, which involves students, residents, fellows, but also, it really is one of our model community engagement activities. 

He is on the Dean's Diversity Committee, the Latino Community Engagement, is a centerpiece of the President's Initiative on Community Engagements. Max is also widely published, and his work really reflects his commitment to population health and preventive cardiology. 

Where he has worked-- published in poor glycemic control and risk of acute MI in multi-ethnic groups, population risk factors for cardiovascular disease in Latino Americans in the Caribbean, and enteric infections and their impact on childhood growth and development, as well as adult disease in Central America and Panama. 

So we can see his commitment to population health not only in countries around the world, but also his commitment to care of the Hispanic community in our own Charlottesville area. So with Max, I'm going to turn that over. And I would say that he's a 2018 Martin Luther King awardee from the University of Virginia health system for his work that we're going to hear about today. Thanks. 

[APPLAUSE] 

Thank you, Ann Preston, and thank you all that joined us today to talk about an important topic. The prior topic was an interesting one, very elegant. I am when I start with a quote. You have a rumor out there in the restaurant industry or bars that people meet and say, do you know how to get a private room at UVA? Just get one of those bugs in your nose and you get a private room there. So we need to work on that. 

I don't know if you heard it before, but we heard it from patients talking about it. So I'm going to talk-- I didn't realize-- I didn't put together in my mind, that we were shorting the chat for 45 minutes. So I'm going to need to move faster. Hopefully, my new slides have been changed. 

So we're going to talk about some demographic changes and some interesting recent data that has been generated by UVA. We'll talk about social determinants of health in Latinos and how this translates into their health. 

We'll talk about challenges in caring for Latinos. And then, in the last 10 minutes, we'll try to summarize what we're trying to do in the community with help of many, which I'm representing. I don't want to take the credit of many of our collaborators without acknowledging them. 

So it is of no news to you all that there is going to be significant demographic changes in the country. We now locally-- we quote 5% to 7% Latino population in Albemarle County, Thomas Jefferson district, that is quite different than the national statistics. 

And that statistic is just about to grow over the next 40 years. You all know that year 2044, white Americans will be a minority. And that we as professionals, health centers, and universities need to prepare for that demographic change. 

In Virginia, we will see a similar pattern, in [INAUDIBLE] pattern, where we will go up from-- where's the mouse here-- from 11% currently, to 12%, and up to 23% by the year 2040. And this is data that was published a few years ago by our own Weldon Cooper Center for Public Service, that do a national registries. 

And we anticipate being 9% in next year, from 7% to 9%. In 10 years, we'll go up to 15%. And in 20 years, we will overpass the Virginia rate. And that generates on questions of, is this correct? Why is this happening? How do we prepare for that? 

One of the files comes to mind is that you UVA as a health system has been very welcoming of our community. And perhaps, they want to move closer to a health center that are friendly to them or want to be even more friendlier. 

So when we talk about health disparities, we need to keep in mind all the dimensions that people are exposed, and trigger, and determine their health care outcomes, and access to care that includes their physical environment, their relationship and access to public safety, their neighborhoods, transportation, access to education and educational achievement, stable employment, health systems and health services, housing, and income and wealth. 

And in that context, we need to think about the challenges that Latinos have that are shared with other underserved people. In regards of health disparities challenges, these are features that are shared with poor whites, poor blacks, poor Asians-- that includes poverty educational achievement in health literacy challenges, inadequate housing, and access to health care. 

Focusing on minorities, they share with others discrimination experiences at employment, at school, and at the doctor's office. That also leads to challenges in cultural competency and humility both in the health system and in the school system, very significant lately. 

When we move to specific immigration issues beyond minority health where Latinos and other minorities have challenges in language gaps, challenges in legal status, access to safety nets-- in transculturation, that is a challenge at the family and the community level that generate and trigger health disparities in outcomes and access to health. 

We do really need to recognize that Latinos, although we share a very common feature that I just mentioned-- and we'll talk more about those features-- there is a significant heterogeneity in the Latinos. And we cannot stereotype them as all sharing similar features. 

South Americans and Cuban community are older than the Central Americans in the Mexican community, a feature that is important in the growth of the population. And I may want to go back to describe the growth of Latinos, both in Virginia and the community, is not tracking immigration pattern, but is tracking birth rate. 

And it is because Latinos are 10 years younger than non-Latinos. And that has a large group of women in childbearing age. And those kids are born here, are citizens, up to now, and will require access to care. So that the majority of the growth of Latinos are based on citizens and legal residents in Virginia and the entire country. 

Latinos are also heterogeneous in regards of achievement of scholarity. South Americans usually have much more scholarity than Central Americans. Access to health care, health insurance is also heterogeneous. Of course, Puerto Rico will have higher access to Medicare and Medicaid versus Central Americans-- have less access to health insurance, particularly state insurance. 

Living in poverty is also a feature that is less common in the South American community, but much more prevalent in the Central American community. And I think I've set the stage to start thinking of looking at Latinos differently. 

But when we average data, we know that Hispanics have improved in the level of poverty rates over the past decade, have improved including than African-American community. Less improvement seen in the poor white, which this reflects our current federal government selection likely. 

So Hispanics still are twice as likely to be poor when compared to whites. And children, or the youth, are three times as likely than Hispanic whites to be poor. More significant in intergenerational on impact-- intergenerational impact is median household net worth. 

That five years ago, Latinos had 1/5 of their net worth compared to non-Latino, non-Hispanic whites, which this translates to the challenges of family opportunities generations down the line. Educational attainment is also a critical. 

And we talk about poverty and education as a similar social determinants of health. But in Latinos, is significantly more important where we see that all Hispanics have four times as much chances of at 20 years or 25 years of age not having achieved a high school diploma. In foreign-born Hispanics-- are six times as likely to non-Hispanic whites to have a high school diploma. 

In access to health care, Latinos have more than twice as likely to have no insurance. And locally, we know that Hispanics have a bit lower rate of access to a health insurance from national rates of 22% to 27%, based on five-year-old data. And foreign-born Hispanics are likely-- around 50% of them don't have access to care. And this is not stratified based on documentation status and access or safety net. 

A cultural and an educational feature of our Latino patients in clinic is that Hispanics are twice as likely to leave a clinical encounter with their questions unanswered. So how do we translate these social determinants of health in Latinos in specific domains of the social interaction? 

Do they live in safety areas for exercise? Do they trust and are supported by law enforcement to be around their neighborhoods and travel back and forth to work and to the hospital? Do they have transportation for employment, health care, education, recreation? Do they have access to drive? Do they drive with a legal document? 

And we see limited participation in community health events at night when they are afraid that they're going to be picked up by law enforcement if they are drive without a license, even though they're committed to the community for the past 10 years. We're talking about community health workers. How is their limited health literacy impact their health care? 

And these are features that I think we should always think about as medical students, health staff, and faculty. When we clinicians-- just seeing a patient in clinic and thinking about our success on behavioral lifestyle modification. 

Employment-- Latinos are exposed to high-risk employment, higher than other groups. They suffer discrimination in employment. And they have the lowest rate of health insurance linked to their employment. 

They are exposed to household insecurity, sanitation, and crowding that leads to physical and behavioral health challenges. And our health system services-- are they exposed to culturally competent, empathetic care that leads or not to trust in the clinicians and systems in response to their needs. 

We'll talk in more detail about our program. But what we have seen-- just passionate expression of messages to our group-- is Latinos feel alienated from the benefits of the University of Virginia and their health system. 

Community leaders have mentioned to us when we began sharing time and efforts with the community-- is this really a legitimate interest in our community now, Dr. Luna, for students? 

In regard of research, I value very much the diverse recruitment of patients in trials, both clinical research and community. And we've had responses that if we, my family, or friends don't have access to health care, how and why should we contribute to science and to others? 

Our board of community members and organizations consider that research efforts are valuable, particularly in they're welcome, particularly if they're paralleled to other type of services to the people involved in the research. 

So how does this social disparities translate into health outcomes? We can not leave a room like this without stating the most there is a leading cause of death. And what is a relatively significant is that there is a relative higher rate of cancer and mortality compared to heart disease that is different in other major, ethnic groups. Diabetes is number four. 

And the rate of accidents-- we talked about risky employment. If you don't have access to a license, then you don't need to train how to drive. So there are social features that make accidents a more prevalent problem of dying in Latinos versus non-Latinos. 

Hypertension is what we do, not necessarily because I think it's as critical in their care, but it tracks health disparities. It tracks access to great care for chronic disease. So we know that African-Americans have a significant higher rate of hypertension. This is adult populations. 

In non-Hispanic whites and Hispanics have a relatively similar rate of hypertension in adult population. This is NHANES data. And you may have been familiar with this very NIH-funded cohort that started in 2013 of 16,000 and so more Latinos. Unfortunately, it's a urban Latinos that have given us a wealth of data from cardiovascular disease to mental health. 

But the only interesting feature in hypertension in Latinos is that once Latinos are older than 50 years of age, Latinas have a slightly higher rate of hypertension. The distribution of hypertension varies depending on country of origin, where Caribbean countries have a higher rate of hypertension. This is likely due to a higher rate of black Hispanics in the Caribbean, but also their diet. 

Salt-based diet is a strong explanation for that. And we'll see South Americans have a lower rate of hypertension compared to the white, the non-Hispanic white, and the rest of the Hispanic cohort. We also think that hypertension contract can be a mark of health disparity. 

We discussed that between Hispanics and non-Hispanic, the rate of hypertension is relatively similar. Hypertension awareness becomes a bit more different, but not dramatically different. But hypertension control is significantly different than Hispanics-- are the ethnic group with the poorest hypertension control. 

And I think and we think that the lack of access to blood pressure control both in the community setting, health care, access to medication, tracks likely with other chronic disease risk factors in morbidity. 

Just to talk briefly about other features that you all may know already-- and may even know more than me-- is asthma is twice as more frequent in Latinos, both a genetic predisposition, but predominantly a lifestyle in housing, environmental exposure versus non-Latinos. 

Cervical cancer is 45% more likely to be diagnosed in Latinas, likely a combination of lack of access to cervical cancer screening and a higher rate of HPV and Latinas. HPV colonization in Latinas-- 40% more likely to die from cervical cancer, a condition and a cancer that is really not a lethal condition where well-attended societal-wise. 

Latinas are diagnosed with more advanced cervical cancer than non-Latinos due to lack of access of screening programs. Diabetes-- you all know that it's a 65% higher likelihood of having diabetes as Latina compared to non-Latino whites. 

And if you see the Caribbean population in this cohort, a Caribbean population has up to 90% higher rates of diabetes when compared to non-Hispanic whites. They are more likely to have end-stage renal disease and more likely to die from diabetes. 

I'm not a social or a mental health scientist. But as a clinician, it is critical to understand where the symptoms come from. Why are they not showing to clinic? Why are they not following our advice? And mental health is critical to keep in mind as well. 

They come from backgrounds of hardship, war, poverty, and persecution that leads to subgroup with very high rates of PTSD from Central America. The transculturation process in their family leads to stress, depression, and anxiety. 

Exposures to discrimination leads to depression and chronic anxiety disorder, but also leads to a lack of trust in health providers and system, leading to less a interest in seeing mental health providers. And Latinos have the similar rate of depression and chronic anxiety disorder, but is a minority group that seeks the least mental health care. 

Cultural language and challenges generate an empathetic gap with other community members, including their doctors. In Latino youth, is a sad story. There has been a 50% increase in depression over the last 20 years in the youth. And this is much more significant in Latino youth girls. 

You probably have heard about the Hispanic paradox-- that after describing this dire scenario of social determinant of health, dire scenarios of risk factors in morbidity that we can't translate into more obesity, more diabetes, more hypertension that is not controlled, Latinos have less heart disease, less heart disease deaths, less cancer, less cancer deaths, and longer life expectancy. 

It is not only reflected in outcomes in adults, but also a marker of social progress in countries is child mortality. We can see that within the three leading ethnic groups, African-American child mortality rate is significantly higher than Latinas. 

And Latinos even have a significant, but not dramatic, difference in non-Hispanic white infantile mortality. Anybody wants to explore why this is? It's five theories. And maybe we'll have time to discuss them. But there's been theory of the healthy immigrant effect. 

And immigrants come with purpose. And they are self-selected as strong, physical in minded Latino, the common struggle. And they build this resilience from home. And during the travel and their hardship, that resilience builds up a biological strength. 

But also the salmon effect of Latinos at their end of their life or when they get ill, they travel back to their countries. And that statistic is not counted. That has been debunked partially. 

But the most prevalent theory of the Hispanic paradox is this effect of familisimo, a community social and emotional network that Latinos have that tend to build a emotional and physical resilience to hardship that may explain some of this paradox. 

This effect peters down, but this does not disappear 10 to 20 years later after living in the US. But is still present, at a less effect, 10 years later after the immigration experience. 

So if we in cardiovascular prevention-- both in the community and clinical setting-- we know that we don't have much to do with a non-modifiable risk factors. And I don't know if this displays well. But I put it in green because these risk factors are opportunities to change that we see in cardiovascular prevention. 

And what we need to reflect in any setting that we encounter people at risk of cardiovascular diseases is, do they know the risk factors? Do they trust our advice? Can they follow our advice? Do they live in an environment conducive to exercise? 

Do they have time to exercise? Can they purchase healthy food? Do they have time to prepare healthy food? Do they have access to care, primary and specialty care? Do they have access to medications? 

And they are exposed to particular psychosocial stress settings according to their ethnic group, socioeconomic status, and immigration status that limits their ability to make these changes to improve their outcome. 

I was opening my email this morning and Lancet has this just published. And I'm just going to list the four major, emerging challenges that I had talk about over the past six months. And I'm glad to see that this update-- it really explains what are the public health challenges that immigrants see in the US. 

After the change in the administration, there's been a decrease in use of primary and emergency care due to fear of deportation, that includes US citizens children. Of course, the child is going to go to a state institution. UVA is a state institution. Is this the time I'm going to be picked up by ICE in the parking lot. 

[INAUDIBLE] expansion of [INAUDIBLE] public charge, the administration is trying to change the definition to add other social services that are not financial services that underserved community receive from the government, and add the services that include Medicaid, Medicare part B, SNAP, and an housing subsidy included as a public charge so that this people have limited opportunities to change their status from a legal documented, to permanent residence, into US citizen. 

There's been delays in states like California that was expanding the state Medicaid program to non-documented Latinos. And they pulled the bill and delayed for more than a year and a half with a change of administration because there was a concern that this registry of undocumented people getting state services for Medicaid will be a list that will be subpoenaed and listed and shared with ICE for deportation. And discussion about end of birthright citizen is on the table still. You may revisit it soon. 

So what we have worked over the past six years and more, defined three years is, organize a group of faculty and students from the School of Medicine and Nursing that we collaborate with university and community organizations to look into the health needs and services in the Latino community. We didn't want to start with bringing everybody we worked in the past and the community that bring insight, critique, keep us grounded on what we want to do. That includes the health district, nonprofit organizations that are closely linked with a community, organizations that are already working with underserved communities, school district, faith groups, and Habitat for Humanity. And we recently created a faculty advisory group where we hope to get a deeper insight, academic or non-academic insight. On how to enhance our program. 

We hope to contribute to the health and well-being of the Latino community in Charlottesville. Hope to narrow the gap between UVA and minority communities locally. We hope to enhance cultural competency among UVA students and faculty. We believe that institutional, faculty, and student dedication to this group may enhance diversity and inclusion in our institution. 

Here are two of the senior medical students presenting their work at Latino Medical Students Association, as well as and last year presented in the National Hispanic Medical Association as a way to show that UVA has begun a footprint of community engagement with the Latino community, and hoping to bring people interested in this field in this community. We have five programs that we're going to try to go quickly. One that relates to cardiovascular prevention, one that relates to community health workers, La Clinical Latina, we have a community health education program in Southwood. 

In a smaller program, which is the radio program, we'll talk more about it. We have bi-weekly sessions in one of the churches, the major Latino church, where there is likely already around 500 parishioners plus their family members. We're there twice a week. We check their blood pressure ourselves as a gate to discuss chronic disease prevention. 

There we advise them in facilitated access to affordable health care for this underserved community. That includes a track to UMA Spanish speaking providers that we see Latinos that they have access to UVA. And we develop a track for that. 

We have a track for La Clinica Latina at the Charlottesville free clinic. And we have a track also for the federally qualified health center to see some patients. We are hoping to grow that relationship. 

Around these sessions, that are two-hour sessions, we continue to train and empower community health workers in cardiovascular prevention. And here we have one of the community health workers giving a talk on cardiovascular prevention after mass. We've seen up to now 439 people in 1,200 visits. And this is a pretty even gender distribution, a bit older than the average community, the Latino community, because we encourage only adults to spend time with us. 

The hypertension rate at entry is a bit higher than the national rates. It is likely because it is an older population. And more than 50% of them will return to get their blood pressure reassessed if they are found hypertensive. 

We're following community based [INAUDIBLE], coincidentally, the study of Latinos protocol for hypertension and referral protocol so that we not increasing false positive rates of hypertension. We have an expected protocol on who gets referred. Either to a two-day follow up with moderate hypertension in the free clinic, or emergency room, or a two-week follow up where we deal with the blood pressure is manageable in the community still. 

Out of two years of experience, more than 60% of them remain normal or improve over time. That is with or without pharmacological therapy. Pharmacological therapy is addressed in the clinic or homes and not by us. We have a subgroup of people that [INAUDIBLE] worse over time. 

We have been using chronic disease risk assessment tools for the past five years in health fairs. And now we just started in January to use in this population a serologic, a risk assessment tool that's been validated in the NIH database and was published in The Lancet eight, 10 years ago. It replaces a cholesterol with BMI. The validation was quite accurate in identifying the subgroup of high, intermediate, and low risk patients. 

So we are following precision medicine but in a non-genetic approach. In hypertension guidelines they suggest is that the our goals of lifestyle changes and pharmacological therapy should be based on the patient's risk. So now people are getting risk stratified. And this is in our first 47 people. I call them people because they're not patients. 

We try to encourage a concept of health in our sessions and not of disease. We have a fair amount of high risk patients, higher than our population studies that I did in Guatemala, significantly higher. Fair amount of intermediate risk patients. 

If we follow the new hypertension guidelines, these two subgroups should be meeting this standard. We have a very high rate of hypertension in these two subgroups. We try not to medicalize or talk about pharmacological therapy prematurely. 

We talk a lot about lifestyle changes, as much as we can. But you can see that as we change the thresholds, the prevalence of hypertension is much higher. And it is important to identify these people that are high risk, where these people really need to get the appropriate under control soon. 

The Compañeros Training and Empowerment Program is our community health worker program that connects in partnership Latino community health workers and educators with medical students and other members of our team. We've been working for the past three or four years with a changing number of community health workers. But we have a steady group of 10 workers, where we develop advance knowledge and skills for community health education screenings and health care navigation. 

One of the challenges. We did a survey four or five years ago. Central Virginia has had a 25-year experience with community health workers. And many of them were not active. I would say 90% of them. 

And one of the reasons was that they did not have a setting or a team where they can go and deliver this emerging skills. So we have identified and developed community settings for them. They have been key to building strong links between our program and the community. 

This is an example about a lovely experience. Eight of our community health workers took an 18-hour pro training program in mental health and wellness. And eight months later, five of them facilitated an 18-hour workshop with 20 families on nutrition, mental health, and others. That's an example of how we get community health workers empowered to work with their people. 

La Clinica Latina has been open for 2 and 1/2 years in a lovely partnership with a free clinic and many a colleagues from UVA and non-UVA primary care physicians, where we offer free medical care at the free clinic model. At the moment, we're just twice a month there. We have 12 physicians and more than 40 students that are a language fluent and culturally competent. The patients are seen from the entrance to the exit in four or five different stations in their language. 

We partnered a year and a half ago with psychiatry. And we now have an integrated model of care, where people are identified have high risk in HBQ9 for depression or chronic anxiety. It features in the clinical encounter, where there's a warm handoff to psychiatry. They have agreed to do some early counseling and identify people who need psychiatric care. And then are referred to the social worker at the free clinic that is a fluent Spanish speaking counselor. 

We have a monthly community health educational session at Southwood. This is a community of 1,500 people, 700 of them are Latinos. Here we have a promotora giving talks on different topics, partnered with a speaker. Pediatrics has been a close partner with us in several of our programs, but mostly in Southwood and connecting with youth in healthy childhood, oral health. We brought EMS services for management of teaching health transportation, how to ride safely a bike, free helmets for the kids, and other topics of relevance. 

We have once a week a radio program where we invite anybody who wants to challenge their Spanish to talk about community health. Again, heart disease is the topic of the day. We've brought palliative care topics. [INAUDIBLE] has talked about the Latino culture and kidney transplantation, which we've had many other people talk over the past year. This was the chairman of dermatology talking about Latino skin and Latino culture. 

Latino health initiative is a service-oriented program. But we have been lucky. We're seeking to enhance our role in undergraduate and ideally graduate medical education, where we think we can enhance the language and cultural competency, Latino health care for undergrad medical school, and the undergraduate student body. We've had some participation of undergrad students, where now they are [INAUDIBLE] where people that go to their long-term session in Guatemala where they have a deep language and cultural immersion. They come back and deliver their emerging skills in global health, global-local, global health at home skills in our Latino community. 

Now we have a group of a fluent first-year medical students spending their first year with us in the community. We are an option for General Scholars Program that are medical students that are interested in primary care and community health to come and do their community health work, as well their projects. Last but not least, a very robust group of independent students that find time and passion to spend time with us in the community. We're hoping to increase the involvement with GME programs. 

We have currently a couple, two or three, IRB protocols open. One is particularly focusing on a prospective review of our success in lifestyle understanding and modification for chronic disease prevention. And then we have a protocol in cervical cancer education by promotoras. We had a few publications. 

And again, a busy agenda, as you can see. They limited capacity for a true deep academic experience. But we welcome others to join us for that. I want to thank you, but more importantly our collaborators. 

Each program is led by a group of three medical students in a different class so that they can transition, depending on their commitments. We started three years ago with some students that are now in different programs. Many of them are doing global health or minority health, and are current student leaders. More than 50 collaborating students, community health workers and educators are key to our success. 

Our advisory board members and organizations are a key, as well, our physicians at La Clinica Latina, including psychiatry residents and faculty that oversee their work, and our recent group of faculty advisors with whom we hope to get them more involved with us. Thank you. 

[APPLAUSE] 

I know we didn't have much time for questions. But hopefully, we can address questions, comments, or the final form is out there to sign up to work with us. Well, thank you very much. 

[INAUDIBLE] 

Yes, sir. 

One of the things is when we talk to people using [INAUDIBLE] advice, cardiology is very different. It's hard to get the nuances when you talk about just [INAUDIBLE] anything like that. Do we know how accurate the translation is and whether we're getting nuances in [INAUDIBLE] history. 

I don't think there's any data on our clinical understanding of it. But there is data in cardiovascular prevention that there is a tiered response and behavioral modification based on no interpreter, interpreter, or fluent clinician. Their outcomes in regards of changes in lifestyle, in risk factors improve significantly when there is a fluent engagement that has cultural and language competency. 

We value very much our medical interpreters. I'm not sure if there's any data on that. I'm not sure if some of the interpreters can tell us if-- yes, Angie. 

How should I say, there's actually data on [AUDIO OUT] versus [INAUDIBLE]. Basically, we need [INAUDIBLE] [AUDIO OUT]. There's actually an impact, [INAUDIBLE] of understanding. [AUDIO OUT] for Latinos, at least [AUDIO OUT] There is impertinence on [AUDIO OUT] in the center whether information on [INAUDIBLE]. [AUDIO OUT] 

Wonderful, wonderful. Next person. 

I don't have data per se, but I have a lot of years of listening to residents. And we do the evidence of [INAUDIBLE]. And we talk about cultural issues. And across the board, they say that they are able to establish a more empathic relationship. [AUDIO OUT] interpreter there that would [AUDIO OUT]. 

They emotionally experience a very different encounter. [AUDIO OUT] are more superior [AUDIO OUT]. That's from the resident perspective. 

I think it must be true. And it is that empathetic connection that the bridging of the cultural gap between the interpreter, some of them being Latino but some of them very, very experienced to bridge not only the language but the cultural gap with the clinician. It is very important instead of a iPad or a phone. Yeah. Yes, sir. 

Do you know why the Latinos are doing [INAUDIBLE] as African-Americans? [INAUDIBLE]. 

Yes. In health outcomes, they do better and even better than white non-Hispanics. And we were talking about the Hispanic paradox. 

And I think the stronger argument is the sense of network and resilience that families, and neighborhoods, and extended families bring to the ill relative, or the patient who needs to change their lifestyle that makes some of the difference. But there is also the immigrant effect. The people that leave the country and die in their countries, and have their heart attacks in their countries instead of here, there is likely some effect of that. I don't think that chapter has been written, a true explanation of Hispanic paradox and how people do better. 

[INAUDIBLE] Latinos they are born in New York [INAUDIBLE]. 

Yes. We mentioned the Hispanic paradox peters out over time. 10 years, and significantly, 20 years later, if they're born here, the Hispanic paradox protection is not as strong as people that have been in the US for less time. That is the process of family transcultural changes that begin to detangle and deconnect our families separately. 

And that is not judging-- and I always have to be careful that this is not a negative judgment about non-Latino families. But it's just the fact that we-- and sometimes that family's [INAUDIBLE] is not-- we were just talking about depression in Southwood two days ago. Close knit families sometimes is intrusive to your family dynamics. 

We talk with Jorge Diaz, a psychiatrist who came to talk about this, that Latinos may feel much more comfortable in their families discussing or not discussing their mental health struggles. So they feel that's enough, I got my mom, I got my grandma, so that's enough. And maybe I'm not going to go and talk to this serious psychiatrist or counselor at UVA. 

But yes, there is that understanding or the suspicion that this family networking, the environment, the social network that Latinos build, that is protective. Yes, Mitch. 

Next. Thank you. I think your passion, and dedication, and the results are really a model for all of us. Congratulations. 

Thank you, Mitch. Thank you. It's been very rewarding. 

[APPLAUSE]