EPITalk: Behind the Paper
This stimulating podcast series from the Annals of Epidemiology takes you behind the scenes of groundbreaking articles recently published in the journal. Join Editor-in-Chief, Patrick Sullivan, and journal authors for thought-provoking conversations on the latest findings and developments in epidemiologic and methodologic research.
EPITalk: Behind the Paper
Cardiovascular Resilience among Black Americans – Do Positive Neighborhood Characteristics Play a Role?
Drs. Islam, Kim, Lewis, and Taylor, authors of the Annals of Epidemiology 2023 Best Junior Investigator Paper Award winner: “Neighborhood characteristics and ideal cardiovascular health among Black adults: results from the Morehouse-Emory Cardiovascular (MECA) Center for Health Equity” explore the compelling association between desirable neighborhood characteristics and cardiovascular resilience among Black Americans. Their paper can be found in the January 2022 issue (Vol. 65) of Annals of Epidemiology.
Read the full article here:
https://www.sciencedirect.com/science/article/pii/S1047279720304270
Episode Credits:
- Executive Producer: Sabrina Debas
- Technical Producer: Paula Burrows
- Annals of Epidemiology is published by Elsevier.
Hello, you're listening to EPITalk: Behind the Paper, a monthly podcast from the Annals of Epidemiology. I'm Patrick Sullivan, Editor-in-Chief of the journal, and in this series we take you behind the scenes of some of the latest epidemiologic research featured in our journal. Today we're talking with Annals of Epidemiology's 2023 Junior Paper of the Year Award winner, Dr Saba Islam, co-first author, Dr Jeong Hwan Kim and their co-authors, Drs. Tene Lewis and Herman Taylor, about their article "Neighborhood Characteristics and Ideal cardiovascular health among Black adults: results from the Morehouse- Emory Cardiovascular (MECA) Center for Health Equity". You can find the full journal article online in the January 2022 issue of the journal at www. annalsofepidemiology. org. I'll do a brief introduction of our guests.
Patrick Sullivan:Dr. Saba Islam is a clinical fellow in the Advanced Heart Failure and Transplant Cardiology Program at Brigham and Women's Hospital, Harvard Medical School. Her research interests are in understanding the social determinants of health in cardiovascular health and disease. In particular, she's interested in geriatric cardiology and implementing novel strategies to improve care and delivery for this vulnerable population. Dr. Jeong Hwan Kim is an advanced heart failure and transplant cardiologist at Brigham and Women's Hospital and the Boston VA. He has clinical interest in taking care of patients with advanced heart failure requiring advanced heart failure therapies such as cardiac transplant or ventricular assist devices. His research interests lie in the understanding of the cultural determinants of cardiovascular disease outcomes in the US, such as geographic disparities and social determinants of health.
Patrick Sullivan:Dr. Tene Lewis is a, professor of epidemiology in the Rollins School of Public Health at Emory University. Her primary area of research is in psychosocial epidemiology, with an emphasis on racial disparities in cardiovascular disease. She has a particular interest in understanding how psychological and social factors contribute to the disproportionately high rates of cardiovascular disease morbidity and mortality in African-American women compared to women from other racial ethnic groups. And Dr. Herman A. Taylor is an endowed professor and director of Morehouse School of Medicine's Cardiovascular Research Institute.
Patrick Sullivan:Dr. Taylor is known for his work in cardiovascular disease disparities and in establishing the groundbreaking Jackson Heart Study in African Americans. This is a study that's made contributions of international significance. Currently he's leading research at the intersection of clinical medicine, artificial intelligence, multi-omics and social determinants of health. Doctors, thank you for joining us today. So we're going to dive into talking about your paper a little bit and I'd like to just start, maybe, with Dr. Islam and ask you to talk a little bit about the purpose of the study. What was the research question that you set out to answer?
Saba Islam:Yeah, thank you for the introduction. So the purpose of our study was to understand which positive neighborhood features was associated with improved cardiovascular health in a cohort of Black Americans living in the Atlanta, Georgia area. We were trying to elucidate which factors may promote cardiovascular health in the community, or cardiovascular resilience, and our hope was that, you know, the findings that we see in this study can inform public health interventions in the future.
Patrick Sullivan:Great. So this is for Dr. Islam or Dr. Kim, either one. What are the epi methods that you used to try to identify these factors that might be associated with the cardiac disease outcomes?
Saba Islam:So we used a cross-sectional study design to explore the positive neighborhood factors that is associated with cardiovascular health in the Black adult cohort living in Atlanta, Georgia. So our hope was that, you know, showing this association and a cross-sectional study would again, you know, in the future allow us to perform longitudinal studies to further elucidate these associations and hopefully again inform public health interventions.
Patrick Sullivan:Just to go a little bit deeper into that how are the data that you used, collected, and were they at the individual level or the neighborhood level or sort of? How is that data structured?
Saba Islam:I can let Dr. Kim take that, because he was intimately involved in that process.
Jeong Hwan Kim:Sure. Thank you for the opportunity to explain a little bit more about our paper, which is very exciting. This was actually part of the larger project called MECA that's conducted between Emory University and Morehouse School of Medicine under the funding by AHA. So we had a very ambitious plan to look at multi-layers of the social determinants of health for the Black Americans living in Atlanta, Georgia. So we started with a separate paper that was published a little bit before this paper, looking at the census tract level determinants of cardiovascular health for Black Americans, looking at the neighborhood characteristics based on the census tract level.
Jeong Hwan Kim:The current paper that we're talking about is at the individual level. We recruited, not targeted to a certain census tract to represent the whole region. We purely recruited people based on the clinical criteria, based on the age of 30 to 70, and without known cardiovascular disease, and we wanted to see and there's perception of neighborhoods at the individual level and how that correlates with their left, basically cardiovascular health scores, called left self-assessment score by AHA. So it is an individual-level paper but, however, it's in the context of our attempt to understand in multi-layer, multi-level analyses of what is it that's actually driving the better cardiovascular health among Black Americans in Atlanta, Georgia.
Patrick Sullivan:Great. Thank you. And so what were some of those main findings or key conclusions you had from this level at that sort of first individual data levels phase?
Saba Islam:Yeah, I can speak a little bit to that. So the main takeaway from this was that social cohesion, which includes activity with neighbors, was associated with higher odds of ideal cardiovascular health, which was defined as the American Heart Association's Life's Simple 7. For certain outcomes, it was noted that there was a two times higher odds of improved cardiovascular health with one standard deviation increase in this neighborhood perception score.
Patrick Sullivan:And what were some of those factors that had that positive relationship?
Saba Islam:It was the social cohesion and the activity with neighbors. So the neighborhood social environment we noted was extremely important for cardiovascular health in our cohort.
Patrick Sullivan:So why, then, is it important to focus on? I mean, these are sort of positive aspects, and a lot of the work that we all normally do focuses in a, maybe because we're thinking of causality, but we get more into things that have a negative impact on the risk. Can you talk a little bit about the decision to focus on like these positive factors in this analysis?
Jeong Hwan Kim:So that's very important. As I alluded earlier, the theme of the MECA project is resilience within Black Americans for cardiovascular health. Basically, we have labeled being an African American or Black American being a risk factor for cardiovascular disease traditionally speaking in clinical medicine. Yet we're ignoring the humongous amount of basically intraracial heterogeneity within the population because some people, some group of people at least 50% of the African Americans that we know of do not suffer from significant cardiovascular disease, based on statistics. So something is already working for them to be resilient toward any adverse events of cardiovascular disease in their life. So I think that we were focusing on the positive aspects and promoters of cardiovascular health in efforts to find out and identify potential interventions that are more novel, that are already working in place in these people's lives and in neighborhoods. So that was a different angle looking at the same program, same problem. However, we are hoping that they'll enlighten us in terms of what is actually more feasible and more practical and more effective in terms of intervention.
Patrick Sullivan:Yeah, I really appreciate that because I think this is a theme in sort of where we are in the world, which is that Black race has been associated with so many health conditions and but of course it's almost never Black race.
Patrick Sullivan:It's really how society has provided, you know, for the people who live in our communities. And so really getting specific about you know what those factors are and the extent to which they have been shaped by decisions that have been made in communities is so critical. And then I think the focus on resilience also is kind of upside down from where we often are in describing quote unquote risk factors. But these resilient factors are in some ways, much. There's a much more direct path to say if these factors are associated with better outcomes, then we're not trying to take away things, we're trying to enhance things that improve health. So you know, in that sort of context, what do you think the implications are for policy around cardiovascular health, for practice, particularly for Black Americans or for people who may live in these communities where the research was done? So what do you think we do with this to improve health?
Saba Islam:So I can speak a little bit to that.
Saba Islam:So you know, the communities that we live in are extremely important.
Saba Islam:I recently moved, and I moved into a community where, you know, people have lived here for generations and you know just like the level, you know like the support of safety that you feel is just so important, and this is just me talking about myself personally.
Saba Islam:So I think that is especially so important for communities. You know, vulnerable communities that have been disparately affected by a lot of historic policies that are extremely cringeworthy and still policies that are made that are extremely, extremely cringeworthy. I think that you know the research that we did shows, you know, like positive aspects of communities and our hope is that this will inform public health officials first of all, hopefully not to put those cringeworthy policies in, but to also invest in communities to improve the social structure of these communities. You know, for example, a lot of, you know Black neighborhoods have been desperately affected by gentrification, for example, and that takes away the community bonds that are there. So you know, our hope is that what we're showing in a scientific way will help, you know, policymakers advocates create more favorable policies.
Patrick Sullivan:Great.
Saba Islam:That will hopefully help the health of the communities.
Patrick Sullivan:Right, and there is other research around, just sort of the impacts of gentrification on multiple areas of health, and it's obviously, you know, complex and complex to figure out what to do with that from a policy perspective. I'm going to bounce around just a bit here and ask to talk just a little bit about, you know, how this research will make a difference in terms of the kind of structural inequities, and I'm going to see if Dr. Lewis and Dr. Taylor want to jump in a little bit, and then I'm going to come back. I've never had four you know scholars at once, so we'll try and navigate.
Tené Lewis :Sure, I'll speak to that a little. So you know it's interesting. We did this research pre-pandemic, right? So this is before shutdown, isolation, et cetera, and what you heard people talking about was how much breaking those bonds, right, so how much being isolated impacted their mental health, their physical health, and for some people that was the worst part of the pandemic. It was the fear of COVID actually was not as problematic as the social isolation, to the point where the Surgeon General declared that we were in the middle of a loneliness epidemic.
Tené Lewis :Right, and so you see the opposite, what happens when you don't have social cohesion and activities with neighbors? Right, and so this is sort of, I think, almost you know our paper, I mean, and we weren't the only people to find this, I do want to say that, right. But there is a bit of prescience there, right, in terms of, you know, putting forth this notion that it matters who you are surrounded by, it matters in your neighborhood, and again, we should just to sort of big picture. The questionnaires ask about things like safety and crime and all of that, and those aren't the factors that seem to make the difference. What made the difference was really thinking about? Do you have the disconnectedness with your neighbors?
Tené Lewis :And so, when we think about structural racism, when one of our papers came out, it was in the middle of 2020, 2021.
Tené Lewis :And someone was saying, well, we don't need, we don't really need to care about resilience. We need to care about structural oppression and discrimination and so on, and I absolutely think that those things are important, right, and so we need this top down as well as this bottom up approach to really thinking through how to improve the health of Black Americans in these communities. So I do think we want to be thinking about these things in concert, right, they operate synergistically. And so, when we talk about structural factors, those things, I think, to use Saba's term, you know there have been a lot of cringeworthy policies, right, and unfortunate policies, but at the same time, communities themselves talk about the fact that they don't only want to talk about the negative things, right, that there are strengths in these communities, there are assets, and how do we leverage those assets? As we wait for policies to change, as we advocate for policies to change, what are things that people are already doing that we can leverage to continue to improve the health of individuals and the health of communities.
Patrick Sullivan:Thank you, Dr. Taylor. I saw a lot of nodding and some more thoughts coming.
Herman Taylor :Well, first of all, I have to say that it is incredibly, really gratifying to hear our former postdocs, who helped us tremendously and in many cases drove us in this work, articulate some of the original and originating ideas that Dr. Lewis, Dr. Arshed Quyyumi, who is also at Emory, and others at Morehouse and Emory wanted to get people thinking about. We wanted to challenge the narrative that Black health is bad health and in fact, if you look at the true experience of African Americans over the last 400 years, it's a story actually of triumph in many ways. However, when we do group comparisons on health, we see evidence of gross inequities, certainly gross disparities, that are devastating and lethal. So that's important, as Dr. Lewis and others have already said. It's important for us to look at that and we're drawn to that problem. Certainly, for 30 years I've been drawn to that problem. But, looking a little bit deeper, we avoid, I think, the danger of others have called it a single story again, that black health is bad health.
Herman Taylor :What we're exploring is how is it that people that have experienced, I'll go a little bit further than cringe-worthy that have experienced at times near genocidal conditions, how is it that out of that you can have a modern population that has this vast heterogeneity in outcomes. Certainly, the disparities is almost a duh moment. Given the whole, the totality of the differences that the two populations have undergone, you'd expect disparities, but in fact there are many successes of individuals and communities where people are living long, healthy lives that are really quite impressive as you begin to think about it and catalog it and so forth. So we wanted to understand what contributed and this was a beginning exploration into finding explanations at the census tract level, at the individual level and in broader context. And this work would not have been possible without great thinkers like Dr. Lewis and our dynamos, the energetic postdocs who really helped drive this work.
Patrick Sullivan:Thank you.
Patrick Sullivan:I want to just further on the last piece of what you talked about a little bit, because this is the first time we've had four you know authors and I think, as we think about what goes on behind papers I mean you started to talk about this a bit in terms of how the research was conceived and the historical picture and how these things are framed that's a piece for me of what's behind this paper. But the other story is we have four colleagues across institutions and at different stages of career who work together to make this happen, and I think that's inspiring and I think that's worth understanding. So when you think about you know, the roles in this project, I wonder just if each of you might want to say just a few words about how you see some of the main things you did and how you benefited from working with your colleagues, and that obviously goes in all directions. So this, this isn't a planned question, but like what's the main thing you saw yourself doing? And then what's something that you really learned or grew in or thought about differently because you were working with this group of colleagues? And since it's a surprise question, I'll let anybody who wants to jump on that first you can raise your hand and jump in.
Patrick Sullivan:Yeah, Dr. Kim.
Jeong Hwan Kim:Yeah, that's actually very interesting. And the question I asked myself, kind of spending years with Dr. Lewis and Dr. Taylor as a postdoc fellow- what am I doing here? Because I am trained as a heart failure cardiologist at this point. I'm a clinical person, mainly day-to-day. I see individuals. We are immersed with the day-to-day chronic activities and treatment plans and management plans, diagnostics, and we forget what's going on outside the hospitals a lot on a day-to-day basis.
Jeong Hwan Kim:When I came to Atlanta for my residency training and I trained at Grady for my residency and then 99% of the patients that I saw in my clinic were African Americans suffering from multiple traditional cardiovascular comorbidities that we often talk about, yet I was not really thinking a lot about what's going on outside the hospital. But the opportunity for me to work on this paper and this project frankly and then meet with the people who are outside of clinical medicine and meet with the epidemiologists and meet with the statisticians about study design, analyses and talking with psychologists, I think these are the things that would not have been possible for me from kind of traditional linear training track of being a cardiologist. Yet I took a sidestep and then I was able to immerse myself to think about what is actually going on outside the hospital and they made me really appreciate these- one, the gross disparity of the cardiovascular disease in the communities in the communities. And second, you know, to appreciate the actual society and communities that these patients live in and then you know, understand them as more of, in a way for the better, lack of word. It's maybe a package right?
Jeong Hwan Kim:It's not just individual's problem that he's having, someone's having hypertension, diabetes that's uncontrolled. There's something that's playing a role in their lives, in their family situations and communities that are making them hard to you, hard to adhere to the medical therapies that I would like to get on board in a clinic. I think that really made me a better clinician, to think about not just as one patient in a clinic room, but more as a patient that I'm treating but I'm also treating the population that I'm seeing and facing every day. That really made me grow as a clinician as well, and obviously there's a growth. As you know as uh, you know as I do more analyses and do the studies and research studies, I appreciate the intricacies of how I study these things in an academic way, this convincing way to the audience, but in the end, at the end of the day I felt that I grew as a person, but also as a clinician, to to be able to kind of appreciate not only the individual patients, but beyond the walls of the hospital.
Patrick Sullivan:Thank you so much.
Saba Islam:I guess I'll go ahead after that so a lot of my, you know interest in working in health disparities actually kind of stems from my own background.
Saba Islam:So you know I'm first generation Bangladeshi immigrant. You know my parents are from a lower income background so we struggled quite a bit, you know, and so that's always been very important to me. And Bangladesh is also, you know, like there's a large community in New York and there's a lot of health disparities in that. So my interest in working with communities comes from there and I also did my training, my residency training, at Boston Medical Center, the old Boston City Hospital, which is similar to Grady, so it is the safety net hospital and over there I feel very fortunate about my training.
Saba Islam:You know being able to see people from various walks of life and there's so much, you know like there are medications that we can prescribe, but you know there's so much social determinants of health that matters into good outcomes for the not just, you know, health outcomes that you're measuring, but also quality of life for the patients. So you know, you know in residency you work with patients, you do things on a day-to-day basis, but what I realized is that you know to really change things globally you have to do it in a methodological way. So prior to joining the Emory program. I actually did not have any research background, but I knew that I wanted to work with you, know vulnerable communities and to help their quality of life and also to help health outcomes.
Saba Islam:So I ended up, you know, joining this and I was just so fortunate, you know, and I followed Dr. Kim's steps.
Saba Islam:He's laid such a wonderful foundation. So, in terms of this paper, he, you know, actually started it even before I joined, done a lot of the analysis, had presented preliminary findings at different conferences, so I already had an amazing background to build on. And, you know, I came to Emory and I worked with wonderful mentors Dr. Lewis, Dr. Taylor you guys mentioned Dr. Quyyumi, and there were other mentors as well who had different expertise, and I was able to learn from all you guys you know Dr. Lewis in epidemiology, Dr. Quyyumi, who's a cardiologist who focuses on subclinical cardiovascular disease, Dr. Taylor, of course, you know, and then Dr. Searles, who's a basic scientist, to bring all of those things together, I just learned so much about methodology, about combining different fields together, and that's what is what you know like made MECA so amazing that we were able to combine so many different fields together and have so many interesting and important findings that are just, you know, a start to hopefully improving health, findings that are just, you know, a start to hopefully improving health.
Tené Lewis :Sure, so I am just beaming because I'm so proud they did an amazing job. But I should also say I think one of the things we haven't talked about is the fact that not only did they move into epidemiology as individuals trained in cardiology right, neither of them have a master's degree in epidemiology or anything of that sort they moved into thinking about what is really difficult. You know, sort of conceptually, this idea of resilience. When we started publishing these papers, reviewers were like what are you talking about and what is the stressor and how can you say that? You know, Black race is a stressor, and so on and so forth. And they actually really grappled with this.
Tené Lewis :This would be difficult for someone with a PhD in epidemiology and I know this because I train students to think about psychosocial constructs and they're different because they're not objectively measurable.
Tené Lewis :It's not like you're measuring blood pressure, it's not like you're measuring cholesterol. You're measuring something that is subjective, it's self-reported and the literature is mixed on exactly what is this and how do you measure it and how do you think about it. And they were able to not only grasp the methods and you know the writing and everything else that we do but really dig deeply into this psychology literature that really talked about what do we mean when we talk about resilience? And I remember sitting with each of them individually. You know Jeong Hwan started first and then Saba came after him and he's like well, I went back and I found this original article where they were talking about orphaned children in Europe. That's honestly where some of this literature began, and so I think what that is particularly noteworthy, because their peers weren't doing that. So they're meeting with, you know, epidemiologists and psychologists and the other cardiology fellows are doing basic science and looking over at them, like you know.
Tené Lewis :So sorry for you all that you have to grapple with all of this complexity, but they were really- so, I you know, I think we're we're not giving them or I want to give them even more kudos for this, because it was two steps beyond what would typically be done in a cardiology fellowship, even focused on research. It was not bench science, it was not pure clinical research, it was really this amalgamation of a few different disciplines, all of which, the majority of which were different from the discipline that they originally trained in. So I think that was, for me, particularly eye-opening and encouraging, and I'm just, you know, incredibly grateful and proud to have had the opportunity to work with them. They're smart and brilliant people.
Herman Taylor :Absolutely. Let me 100% endorse that. And the very first lecture I gave as cardiology faculty was related to disparities in some of the contributors as we understood them now more than 25 years ago, and after getting some good questions, I got a question that was actually meant a little derisively to the topic and the person asked me, Dr. Taylor, now understand, I am brand new, Dr. Taylor, are you a cardiologist or a sociologist? Now, that was meant to be at least mildly insulting.
Herman Taylor :If I were given that question again today, I would say absolutely I'm not a sociologist, because that is an extremely difficult field that takes deep expertise to really be a master of.
Herman Taylor :But what I would also say is, as a Black cardiologist, I cannot afford to be just a cardiologist. I cannot afford that because my personal mission in being a cardiologist is to try to help establish equity, access and a level of sensitivity and humility in this profession to truly provide for people who traditionally have not gotten the care that they should've or traditionally didn't understand how to utilize the care that was available to them to the optimal degree. Now we've trained and influenced, hopefully, a couple of future leaders in cardiology and and I believe they've been trained to not just be a physiologically- based, hemodynamically- based cardiologist, but rather people who will inject a degree of humanity and humility and understanding in their practice that perhaps their forebearers didn't typically have. So, like Dr. Lewis, I am extremely, extremely proud of them and really that I think, among the outcomes of our MECA adventure here between Morehouse and Emory, producing young leaders like this is probably one of the things I'm most proud of.
Patrick Sullivan:I am going to leave things there, because I think that what each of the four of you just said is profound and insightful and meaningful and better than any way that I could summarize this. I do want to say that when we started this series of podcasts, so we want to talk to researchers about their work and how they made the decisions and what they found but Behind the Paper is meant to get at this full world of how we identify ourselves as researchers, how our relationships actually shape the work that we do, and it's so meaningful to me to see our listeners can't see, but I can see on my Brady Bunch on Zoom- You know these two earlier career researchers and these two mentors who work together across institutions to do something that added such insight and with the whole framework about resiliency and how we think about race as a marker for disease and how we quantify that. So I am just going to say that it's been my privilege to hear you talk about your work, to see you interact with each other and to understand that it really represents such a meaningful developmental piece, I think, for our earlier career colleagues, and I'll put myself on the bottom row with the later career colleagues and say that these are often the things that make our jobs so worthwhile.
Patrick Sullivan:So I'm just grateful to all of you for the work that you've done, for your openness and talking about this and for bringing your work to Annals, and I'm so glad that we could give it recognition, and so I'll encourage our listeners to find the paper, to read it in full, on the Annals of Epidemiology website, and I will thank our guests today. Thank you to Drs. Islam, Kim, Lewis and Taylor for joining us. It's such a pleasure to have this discussion with you, and I hope that our listeners will stay tuned in. Join us again on the next episode of EPITalk and, in the meantime, visit us at annals ofepidemiology. org to access this paper and see the other papers in the journal. Thanks to each of you for your work and for sharing what you have today.
Saba Islam:Thank you, thank today, thank you, thank you, thank you.
Patrick Sullivan:I'm your host, Patrick Sullivan. Thanks for tuning in to this episode and see you next time on EPITalk, brought to you by Annals of Epidemiology, the official journal of the American College of Epidemiology. For a transcript of this podcast or to read the article featured on this episode and more from the journal, you can visit us online at www. annalsofepidemiology. org.
