It started with this patient-clinician communication model, and although language was a big factor, it grew from there. It gradually expanded to all racial and ethnic populations – and realizing that sometimes the outcomes are actually better than the general ones.

WebMD: Your institute funded a study showing ethnic and racial disparities cost the U.S. up to $451 billion annually. Break that down. 

Pérez-Stable: Most costs to societies come from premature death – people who die too early and we lose out on their productivity in their job and in their community with their family. The average U.S. woman lives to her early 80s, and males 2-3 years younger, so you get a sense of where we should be.

When people are sick and no longer able to work or their work is limited, that’s a cost. Presumably, with proper intervention, they could’ve worked another 5 or 10 years. Someone with high blood pressure doesn’t get it under control and has a stroke at 60 – they’re still in the prime of work life. Maybe thinking about retirement, but still working, and they’re not going to be the same retiree after a major stroke. 

There are also genes that increase risks for certain cancers. The breast cancer gene is probably the most famous. But there’s actually a gene that’s protective against breast cancer, discovered only in women with Indigenous background from Latin America. 

WebMD: Your work shows environmental and living conditions affect how genes express themselves. Can you explain how it works?

Pérez-Stable: This is the field of social epigenomics. It’s evolving. The epigenome concept involves changes that occur on the gene from external factors. Where this has been studied the most includes cardiovascular health, asthma, maternal health, and a little bit in cancer.

For example, if you’re under 5 and you’re really stressed – because there’s a dysfunctional family, maybe there’s lack of food, maybe violence in certain contexts – these adverse events change your epigenome in a way that maybe 30 years later you’ll get a disease. That’s a hypothesis. 

WebMD: Explain how the Community Engagement Alliance (CEAL) that you helped spearhead addressed disparate COVID-19 outcomes in underserved communities.

Pérez-Stable: In summer 2020, there was a study to test the Moderna vaccine. After the first month or so, 90% of study volunteers were White. Dr. Francis Collins (former NIH director) said we can’t allow this. 

We all discussed strategies. Out of those early conversations, CEAL was born. We wanted to create an infrastructure to activate the community. Initially, it was, “Participate in this clinical trial,” because we didn’t know what the outcome was going to be. Once the vaccine was out in December (2020), we had to convince everybody to get vaccinated. 

We saw how poorly Black communities were doing, the Latinos, American Indians, and Native Hawaiian/Pacific Islanders. The deaths were two to three times the average, but we saw by fall 2022, death rates had decreased across the board and the gaps narrowed or eliminated. It was a success. 

We are in the middle of a transition, but CEAL will continue as an infrastructure for community engagement and partnership of community organizations with academic researchers to make a difference in those communities’ health. We now have 21 teams across the country. 

WebMD: You talked about some outcomes being better. One of your areas of study shows African Americans who engage in unhealthy behaviors are more resistant to depression than White people and most Latinos. What factors might be at work?

Pérez-Stable: The fact that African Americans have less diagnosed depression and actually less suicide – that has been known for a long time. Latinos are in between. They’re not really as high as White people, but they aren’t as low as Black people. 

Among Puerto Ricans, using the (Hispanic Community Health Study/Study of Latinos) we did see a trend: that chronic stress didn’t lead to more depressive symptoms, but did lead to more unhealthy behaviors. But Mexican-Americans did not fit this model at all. (Two-thirds of Latinos in the U.S. have Mexican backgrounds.) Stress made them more depressed, and they didn’t engage in more unhealthy behaviors to cope. 

It wasn’t gender specific because the sample sizes were not large enough, and we couldn’t say anything about Cubans or Central Americans.

WebMD: Another focus for you is how Latino heritage and adaptation to American culture impact smoking behavior. Can you expand?

Pérez-Stable: I’m Cuban myself. In Cuba, cigarette smoking was much more prevalent. In the U.S., Latinos smoke at lower rates. Again, the U.S. data is driven by Mexicans. The pattern for Cuban Americans and Puerto Ricans is more intense smoking and higher rates. I think that’s fairly consistent. 

Well, Mexicans and Central Americans – and curiously, Dominicans – smoke at much lower rates. 

Generally, it’ll be influenced by social mobility as well. In general, women, as they become more acculturated, they’re more likely to smoke and men are less likely to smoke. The traditional gender role of women in Latin American culture may be functioning as a protective factor against cigarettes and alcohol. That’s one hypothesis. 

For men in the U.S., there’s the social environment where it’s not always as cool to smoke as it had been in Latin America. We see the same with Chinese males immigrating to the U.S. There were high smoking rates when they were in China. They came to the U.S., their smoking rates dropped dramatically.