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Noel Bairey Merz 談女性面臨的最大健康威脅

Noel Bairey Merz: The single biggest health threat women face

 

Photo of three lions hunting on the Serengeti.

講者:Noel Bairey Merz

2011年12月演講,2012年3月在TEDxWomen 2011上線

 

翻譯:洪曉慧

編輯:朱學恆

簡繁轉換:洪曉慧

後製:洪曉慧

字幕影片後制:謝旻均

 

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MAC及手持裝置版本請按此下載

閱讀中文字幕純文字版本

 

關於這場演講

一個令人驚訝的事實是:死於心臟病的女性比男性還多,但長期以來心血管疾病研究均集中在男性身上。心臟病研究先鋒C. Noel Bairey Merz醫生與聽眾分享我們對女性心臟健康的所知及不知處-包括女性心臟病發作時呈現出與男性顯著不同的症狀,及為何其常被忽略的原因。

 

關於Noel Bairey Merz

C. Noel Bairey Merz是Cedars - Sinai心臟研究所婦女心臟中心主任,並擔任此機構的醫學教授。

 

為什麼要聽她演講

醫學博士C. Noel Bairey Merz擔任婦女健康機構的婦女協會主席,也是Cedars-Sinai心臟研究所的婦女心臟中心與心臟病預防及復原中心主任,並擔任此機構的醫學教授。

 

Bairey Merz博士的研究興趣包括婦女與心臟病,精神壓力與心臟病,運動與壓力管理在疾病復原中扮演的角色,及營養在心臟病中扮演的角色。她目前是美國國家衛生研究院(NIH)資助的WISE(婦女缺血性症狀評估)計畫主持人。

 

她的研究由史翠珊基金會贊助。

 

觀看芭芭拉.史翠珊在TEDxWomen對Bairey Merz博士的熱情介紹

 

Noel Bairey Merz的英語網上資料

Home: Women's Heart Center at Cedars-Sinai

 

[TED科技‧娛樂‧設計]

已有中譯字幕的TED影片目錄(繁體)(簡體)。請注意繁簡目錄是不一樣的。

 

Noel Bairey Merz 談女性面臨的最大健康威脅

二分之一女性在有生之年當中會受到心血管疾病的影響,因此這是女性的頭號殺手。這是一個鮮為人知的秘密,我不知道原因為何,除了它與個人息息相關-所以我們要談論妳與妳心臟的關係,及所有女性與她們心臟的關係。我們也要討論它與政治的關係。因為如妳們所知,個人與政治息息相關,人們在這方面的努力並不夠。我們藉由乳癌運動關心女性戰勝乳癌的議題,這就是我們現在需要為心臟做的事。

 

自從1984年開始,美國女性死於心臟病的人數逐漸高於男性,因此,我們一向認為心臟病主要是男性問題-這完全不正確,但這就是1950和60年代大眾普遍的觀點。所有教科書也都這麼寫,這正是我受醫師訓練時所學到的。如果我們對這種疾病保持性別偏見,這是不正確的,但如果我們繼續以性別偏見來看待這種疾病,事實上它屬於女性疾病,所以現在它屬於一種女性疾病。

 

妳從這條代表男性的曲線可看出一點,死亡人數正逐漸下降,妳可以看見,自1984年以來,女性死亡人數和男性的差距正逐漸擴大,越來越多女性-死於心臟病的女性比男性多了二倍、三倍、四倍。這段時間太短,我們無法藉此得知所有造成改變的不同危險因子。因此,這確實暗示我們,以國家層面來說,為男性量身打造的診斷和治療策略,在過去50年當中對男性來說相當有效,對嗎?對女性來說卻非如此,所以這是1980年代一個非常大的警訊。

 

以所有年齡層來說,因心臟病死亡的女性比乳癌還多,而乳癌防制行動-同樣的,這並非一項競賽,我們試著使它的成效跟乳癌防制一樣好,我們必須使它的成效跟乳癌防制一樣好,以解決這個危機。現在,有時候,當人們看見這張圖表,我會聽見屏息聲,或許我們會這麼想,某個人-通常是一位年輕女性,可能受到乳癌影響;我們往往不認為年輕女性會罹患心臟病,現在我告訴妳們其中原因。心臟病往往很快就會令人死亡,因此,當男性和女性首次心臟病發作時,有一半機率是因為突發性心臟病死亡。沒機會說再見、沒機會帶她進行化療、沒機會幫她挑選一頂假髮。

 

乳癌死亡率已下降到百分之四,這是40年來女性不斷宣導的成果。貝蒂.福特和南西.雷根挺身而出,說,「我是一位乳癌倖存者。」而且還能好好地談論這個疾病。然後醫生們大力支援,我們做了相關研究,我們現在擁有有效的療法,女性比以前活得更長。心臟病也必須比照辦理,是時候了。目前尚未有所行動,但是時候了。

 

我們應該感謝這兩位女性。正如芭芭拉在她精彩的電影作品「楊朵」中所飾演的,她飾演一位希望接受教育的年輕女性,她想學習猶太法典。那麼,她如何才能接受教育?她必須冒充成一名男性,她必須讓自己看起來像一名男性,她必須讓其她人認為她看起來像一名男性,她可以擁有與男性相同的權利。Bernadine Healy,Healy博士是一位心臟病專家,大約在1980年代,我們看見女性因心臟病而死亡的人數不斷上升,她為新英格蘭醫學雜誌寫了一篇社論,說這就是楊朵症候群。女性死於心臟病的人數比男性多了二倍、三倍、四倍,死亡率不減反增,她質疑,她假設,這是一種楊朵症候群嗎?

 

這就是其中的來龍去脈。因為女性不像男性,她們的情形不同於男性型心臟病,就是我們過去50年深入研究,獲得相當棒的診斷和治療方法的心臟病類型。因此她們沒被診斷出罹患心臟病,病情就這麼被忽略了。她們沒有獲得治療、沒有進行檢測、沒有獲得現代藥物的幫助。

 

Healy博士後來成為美國國家衛生研究院第一位女性院長,這是世上最大的生物醫學研究機構,它提供我很多研究資金,資助各地的研究機構。她成為院長是一件相當重要的事,她在眾多爭議下展開女性健康促進計畫,在場每位女性都因女性健康促進計畫而受益。它告訴我們關於荷爾蒙替代療法,讓我們瞭解骨質疏鬆症,告訴我們關於女性乳癌、結腸癌等知識,因此這是對知識的大筆資助。同樣的,儘管許多人告訴她別這麼做,這太費錢了,其中隱含的意義是女性不值得這一切。她這麼說,「不,抱歉,女性值得這一切。」

 

女性健康促進計畫有一小塊延伸到美國國立心肺與血液研究所,這是美國國立衛生研究院掌管心臟病研究的部分。我們必須進行WISE研究,WISE代表女性缺血性症狀評估,我於過去15年主持這項研究,這是一項明確提出「女性發生了什麼事?」這個問題的研究;為什麼有越來越多女性死於缺血性心臟病?因此,15年前,在WISE研究中,我們開始進行並瞭解到,「哇!有幾個或許應該持續進行的重要觀察。」我們在華盛頓特區的同事,最近發表因心臟病發作死亡的女性與男性間的比較。同樣的,這是每天發生在數百萬人身上的事。在女性的脂肪斑塊當中-這是她們的冠狀動脈,所以這是供應血液至心肌的主要血管,女性的會逐漸潰爛,男性的則會爆裂。妳會發現,這個生理現象與男女之間的差異存在有趣的相似性。

 

(笑聲)

 

因此,我先描述一下男性首次心臟病發作的模式。好萊塢電影中,心臟病發作的情形是這樣-呃啊啊啊,可怕的胸痛、心電圖劇烈變動,因此醫生可以看出這種嚴重異常的心電圖。動脈中出現一個大血塊,於是醫生們進入心導管實驗室,砰砰砰地將血塊清除,這是男性心臟病發作的情形。有些女性心臟病發作也是這種情形,但很多女性心臟病發作的情形是這樣-它逐漸潰爛,血塊不會完全堵住血管,症狀極不明顯,心電圖結果大不相同,這是女性型心臟病。所以妳認為這些女性會發生什麼事?她們通常不會被診斷出來,草草地被打發回家;我不知道這是什麼,或許是漲氣吧!

 

因此,針對這一點,我們說,「你們知道,我們現在有能力觀察人體內部,利用這些被稱為IVUS:血管內超音波的特殊導管。」我們說,「我們假設女性血管中的脂肪斑塊,沉積情形很可能不同於男性血管中的脂肪斑塊。」因為根據男性與女性發胖型態的一般常識,當我們看見人們發胖時,男性發胖的部位是哪裡?在這裡,只是一個特定部位-在那裡。女性發胖的部位是哪裡?全身。脂肪囤積在這裡、還有這裡,所以我們說,「看!看來女性很擅長收拾這些垃圾,平均地將它放置在各處,男性則是將它傾倒在同一個區域。」所以我們說,「我們來看看這些。」

 

所以黃色部分代表脂肪斑塊,A組是男性型態,妳們可以看到,它是凹凸不平的,他的冠狀動脈會有啤酒肚。B組是女性型態,相當平滑,她整齊地將脂肪平鋪在血管裡。(笑聲)如果妳進行血管造影術,會看見紅色部分,妳可以看出男性型態的疾病。所以50年來不斷進行血管造影術研究的結果,我們很容易就能識別出男性型疾病,卻很難看出女性型疾病,所以這是其中一項發現。現在,這會產生什麼影響?好,同樣地,女性接受血管造影檢查,沒人能識別出她們身體出了問題。

 

所以我們現在致力於研究一種非侵入式-同樣的,這些都是侵入式研究,理想情況下,妳會希望這些檢查都是非侵入式的。所以,同樣的,50年來已發展出良好的非侵入式壓力測試,我們藉由壓力測試能有效辨識出男性型疾病,所以這是心臟磁共振造影。我們正在Cedars-Sinai心臟研究所女性心臟中心進行這項研究,我們選擇這種方法進行研究,妳無法在社區醫院裡進行這項檢查,但我們希望能轉移這項技術。我們為期五年的研究大約已經進行兩年半。

 

這是唯一可看見心臟內層的方式。如果妳仔細看,可以看見這裡有一塊泛黑的區域,顯示有微血管阻塞的情形,這個症狀代表女性型心臟病,現在它被稱為冠狀動脈微血管功能障礙或阻塞。我們喜歡使用MRI的第二個原因是,它不會產生輻射,所以不像電腦斷層掃描、X光、鉈放射性追蹤劑等用於檢查女性乳房、心臟的方法。每當我們訂購一些,即使僅含有少量輻射的物品時,我們會說,「我們真的需要使用這種測試法嗎?」因此我們非常喜愛使用磁共振。妳目前還無法預約這種檢查,但這是我們積極探索的領域。實際針對女性進行研究,將使這個領域的女性及男性研究更進步。

 

若無法識別出女性型心臟病會發生什麼後果?這是來自我今年(2011)夏天發表在歐洲心臟雜誌社論中的一張圖表,它只是一張顯示出為什麼越來越多女性死於心臟病的圖表,儘管早有這些我們已知並使用的良好療法。當女性罹患男性型疾病時,看起來會像電影裡的芭芭拉,她們能獲得治療;當罹患女性型疾病時,妳的症狀看起來會像一位女性-就像這個跟丈夫在一起的芭芭拉;她們無法獲得治療。這些是可拯救生命的療法,那些紅色小框代表死亡人數,所以這就是結果。原因在於女性型疾病,以及為什麼我們認為楊朵症候群可解釋其中巨大的差異。

 

最後,關於心臟病的女性研究也有好消息。其中尖端研究領域之一是,我們對幹細胞療法相當期待。如果妳問女性與男性生理上有什麼重大區別?為什麼會有男女之別?因為女性將新生命帶入這個世界,這跟幹細胞有關,所以我們推測使用女性幹細胞或許更能辨識出受損之處,進行某些細胞修復,甚至產生新器官,這是我們在幹細胞療法中嘗試的項目之一。這是男性和女性的幹細胞,如果妳的器官受損,如果妳心臟病發作,我們希望能修復受損部位,妳會希望使用頂端這些健壯、數量豐富的幹細胞,還是這些看起來像打算出去吃午餐的傢伙?

 

(笑聲)

 

我們一些研究小組已證明,女性幹細胞-這是動物實驗,我們將會逐漸進行人體實驗-當我們將女性幹細胞放入男性體內,效果甚至比將男性幹細胞放入男性體內更好。我們所討論的其中一項關於女性生理的事-因為同樣的,如同這許多關於女性與心臟病的討論,平均來說,女性確實比男性長壽,因此,揭開女性生理上的秘密,並瞭解其中原因,對男性和女性都有幫助。因此,總之這並非一場零和賽局。

 

好,這是我們演講開始之處,記得嗎?兩條線在1984年交叉,之後,死於心血管疾病的女性逐漸增加。這項工作在過去15年當中有什麼成效?我們使這條曲線向下彎曲,我們使這條曲線向下彎曲,因此,如同對抗乳癌的方式-進行研究,讓大眾有所認知。這確實有效,只要持續進行即可。現在,我們對此感到滿意嗎?女性的死亡人數仍是男性的二到三倍。

 

我想提出的是,以女性整體上較長壽的優勢來說,如果能獲得治療,理論上來說,女性的表現應該更好。因此這是我們的現況,但我們還有一段艱苦漫長的路要走。我們已經致力於這項工作15年,我必須告訴大家,我們致力於研究男性型心臟病已有50年光陰,因此我們已經落後了35年。我們希望趕上這個進度不需花上35年,事實上或許不需要,但我們現在不能罷手,太多生命已危在旦夕。

 

那麼,我們需要做什麼?現在,希望妳與妳的心臟建立更良好的個人關係。女性聽見乳癌的呼求,挺身而出,進行宣導運動。現在,女性在乳房X光檢查方面做得非常好,女性為此進行募款,女性參與這項運動,採取實際行動,她們進行宣導並加入防制行列,這就是我們現在需要為心臟病做的事。

 

它也與政治有關。從聯邦資助的觀點來看,女性健康宣導有時受到大眾支持,有時並不那麼受到注意,因此其中存在著盛衰期。因此,我懇請大家加入紅洋裝募款運動。乳癌,如我們所知,會導致女性死亡,但心臟病導致更多女性死亡。因此,如果我們能像乳癌運動進行的那麼成功,並賦予女性這份新責任,就能挽救許多生命。

 

感謝大家參與。

 

(掌聲)

 

以下為系統擷取之英文原文

About this Talk

Surprising, but true: More women now die of heart disease than men, yet cardiovascular research has long focused on men. Pioneering doctor C. Noel Bairey Merz shares what we know and don't know about women's heart health -- including the remarkably different symptoms women present during a heart attack (and why they're often missed).

About this Talk

C. Noel Bairey Merz is director of the Women's Heart Center at the Cedars-Sinai Heart Institute, where she is a professor of medicine. Full bio »

Transcript

One out of two of you women will be impacted by cardiovascular disease in your lifetime. So this is the leading killer of women. It's a closely held secret for reasons I don't know. In addition to making this personal -- so we're going to talk about your relationship with your heart and all women's relationship with their heart -- we're going to wax into the politics. Because the personal, as you know, is political. And not enough is being done about this. And as we have watched women conquer breast cancer through the breast cancer campaign, this is what we need to do now with heart.

Since 1984, more women die in the U.S. than men. So where we used to think of heart disease as being a man's problem primarily -- which that was never true, but that was kind of how everybody thought in the 1950s and '60s, and it was in all the textbooks. It's certainly what I learned when I was training. If we were to remain sexist, and that was not right, but if we were going to go forward and be sexist, it's actually a woman's disease. So it's a woman's disease now.

And one of the things that you see is that male line, the mortality is going down, down, down, down, down. And you see the female line since 1984, the gap is widening. More and more women, two, three, four times more women, dying of heart disease than men. And that's too short of a time period for all the different risk factors that we know to change. So what this really suggested to us at the national level was that diagnostic and therapeutic strategies, which had been developed in men, by men, for men for the last 50 years -- and they work pretty well in men, don't they? -- weren't working so well for women. So that was a big wake-up call in the 1980's.

Heart disease kills more women at all ages than breast cancer. And the breast cancer campaign -- again, this is not a competition. We're trying to be as good as the breast cancer campaign. We need to be as good as the breast cancer campaign to address this crisis. Now sometimes when people see this, I hear this gasp. We can all think of someone, often a young woman, who has been impacted by breast cancer. We often can't think of a young woman who has heart disease. I'm going to tell you why. Heart disease kills people, often very quickly. So the first time heart disease strikes in women and men, half of the time it's sudden cardiac death -- no opportunity to say good-bye, no opportunity to take her to the chemotherapy, no opportunity to help her pick out a wig.

Breast cancer, mortality is down to four percent. And that is the 40 years that women have advocated. Betty Ford, Nancy Reagan stood up and said, "I'm a breast cancer survivor," and it was okay to talk about it. And then physicians have gone to bat. We've done the research. We have effective therapies now. Women are living longer than ever. That has to happen in heart disease, and it's time. It's not happening, and it's time.

We owe an incredible debt of gratitude to these two women. As Barbara depicted in one of her amazing movies, "Yentl," she portrayed a young woman who wanted an education. And she wanted to study the Talmud. And so how did she get educated then? She had to impersonate a man. She had to look like a man. She had to make other people believe that she looked like a man and she could have the same rights that the men had. Bernadine Healy, Dr. Healy, was a cardiologist. And right around that time, in the 1980's, that we saw women and heart disease deaths going up, up, up, up, up, she wrote an editorial in the New England Journal of Medicine and said, the Yentl syndrome. Women are dying of heart disease, two, three, four times more than men. Mortality is not going down, it's going up. And she questioned, she hypothesized, is this a Yentl syndrome?

And here's what the story is. Is it because women don't look like men, they don't look like that male-pattern heart disease that we've spent the last 50 years understanding and getting really good diagnostics and really good therapeutics, and therefore, they're not recognized for their heart disease. And they're just passed. They don't get treated, they don't get detected, they don't get the benefit of all the modern medicines.

Doctor Healy then subsequently became the first female director of our National Institutes of Health. And this is the biggest biomedical enterprise research in the world. And it funds a lot of my research. It funds research all over the place. It was a very big deal for her to become director. And she started, in the face of a lot of controversy, the Women's Health Initiative. And every woman in the room here has benefited from that Women's Health Initiative. It told us about hormone replacement therapy. It's informed us about osteoporosis. It informed us about breast cancer, colon cancer in women. So a tremendous fund of knowledge despite, again, that so many people told her not to do it, it was too expensive. And the under-reading was women aren't worth it. She was like, "Nope. Sorry. Women are worth it."

Well there was a little piece of that Women's Health Initiative that went to National Heart, Lung, and Blood Institute, which is the cardiology part of the NIH. And we got to do the WISE study -- and the WISE stands for Women's Ischemia Syndrome Evaluation -- and I have chaired this study for the last 15 years. It was a study to specifically ask, what's going on with women? Why are more and more women dying of ischemic heart disease? So in the WISE, 15 years ago, we started out and said, "Well wow, there's a couple of key observations and we should probably follow up on that." And our colleagues in Washington, D.C. had recently published that when women have heart attacks and die, compared to men who have heart attacks and die -- and again, this is millions of people, happening every day -- women, in their fatty plaque -- and this is their coronary artery, so the main blood supply going into the heart muscle -- women erode, men explode. You're going to find some interesting analogies in this physiology.

(Laughter)

So I'll describe the male-pattern heart attack first. Hollywood heart attack. Ughhhh. Horrible chest pain. EKG goes pbbrrhh, so the doctors can see this hugely abnormal EKG. There's a big clot in the middle of the artery. And they go up to the cath lab and boom, boom, boom get rid of the clot. That's a man heart attack. Some women have those heart attacks, but a whole bunch of women have this kind of heart attack, where it erodes, doesn't completely fill with clot, symptoms are subtle, EKG findings are different -- female-pattern. So what do you think happens to these gals? They're often not recognized, sent home. I'm not sure what it was. Might have been gas.

So we picked up on that and we said, "You know, we now have the ability to look inside human beings with these special catheters called IVUS: intravascular ultrasound." And we said, "We're going to hypothesize that the fatty plaque in women is actually probably different, and deposited differently, than men." And because of the common knowledge of how women and men get fat. When we watch people become obese, where do men get fat? Right here, it's just a focal -- right there. Where do women get fat? All over. Cellulite here, cellulite here. So we said, "Look, women look like they're pretty good about putting kind of the garbage away, smoothly putting it away. Men just have to dump it in a single area." So we said, "Let's look at these."

And so the yellow is the fatty plaque, and panel A is a man. And you can see, it's lumpy bumpy. He's got a beer belly in his coronary arteries. Panel B is the woman, very smooth. She's just laid it down nice and tidy. (Laughter) And if you did that angiogram, which is the red, you can see the man's disease. So 50 years of honing and crafting these angiograms, we easily recognize male-pattern disease. Kind of hard to see that female-pattern disease. So that was a discovery. Now what are the implications of that? Well once again, women get the angiogram and nobody can tell that they have a problem.

So we are working now on a non-invasive -- again, these are all invasive studies. Ideally you would love to do all this non-invasively. And again, 50 years of good non-invasive stress testing, we're pretty good at recognizing male-pattern disease with stress tests. So this is cardiac magnetic resonance imaging. We're doing this at the Cedars-Sinai Heart Institute in the Women's Heart Center. We selected this for the research. This is not in your community hospital, but we would hope to translate this. And we're about two and a half years into a five-year study.

This was the only modality that can see the inner lining of the heart. And if you look carefully, you can see that there's a black blush right there. And that is microvascular obstruction. The syndrome, the female-pattern now is called microvascular coronary dysfunction, or obstruction. The second reason we really liked MRI is that there's no radiation. So unlike the CAT scans, X-rays, thalliums, for women whose breast is in the way of looking at the heart, every time we order something that has even a small amount of radiation, we say, "Do we really need that test?" So we're very excited about M.R. You can't go and order it yet, but this is an area of active inquiry where actually studying women is going to advance the field for women and men.

What are the downstream consequences then, when female-pattern heart disease is not recognized? This is a figure from an editorial that I published in the European Heart Journal this last summer. And it was just a pictogram to sort of show why more women are dying of heart disease, despite these good treatments that we know and we have work. And when the woman has male-pattern disease -- so she looks like Barbara in the movie -- they get treated. And when you have female-pattern and you look like a woman, as Barbara does here with her husband, they don't get the treatment. These are our life-saving treatments. And those little red boxes are deaths. So those are the consequences. And that is female-pattern and why we think the Yentl syndrome actually is explaining a lot of these gaps.

There's been wonderful news also about studying women, finally, in heart disease. And one of the the cutting-edge areas that we're just incredibly excited about is stem cell therapy. If you ask, what is the big difference between women and men physiologically? Why are there women and men? Because women bring new life into the world. That's all stem cells. So we hypothesized that female stem cells might be better at identifying the injury, doing some cellular repair or even producing new organs, which is one of the things that we're trying to do with stem cell therapy. These are female and male stem cells. And if you had an injured organ, if you had a heart attack and we wanted to repair that injured area, do you want those robust, plentiful stem cells on the top? Or do you want these guys, that look like they're out to lunch?

(Laughter)

And some of our investigative teams have demonstrated that female stem cells -- and this is in animals and increasingly we're showing this in humans -- that female stem cells, when put even into a male body, do better than male stem cells going into a male body. One of the things that we say about all of this female physiology -- because again, as much as we're talking about women and heart disease, women do, on average, have better longevity than men -- is that unfolding the secrets of female physiology and understanding that is going to help men and women. So this is not a zero-sum game in anyway.

Okay, so here's where we started. And remember, paths crossed in 1984, and more and more women were dying of cardiovascular disease. What has happened in the last 15 years with this work? We are bending the curve. We're bending the curve. So just like the breast cancer story, doing research, getting awareness going, it works, you just have to get it going. Now are we happy with this? We still have two to three more women dying for every man.

And I would propose, with the better longevity that women have overall, that women probably should theoretically do better, if we could just get treated. So this is where we are, but we have a long row to hoe. We've worked on this for 15 years. And I've told you, we've been working on male-pattern heart disease for 50 years. So we're 35 years behind. And we'd like to think it's not going to take 35 years. And in fact, it probably won't. But we cannot stop now. Too many lives are at stake.

So what do we need to do? You now, hopefully, have a more personal relationship with your heart. Women have heard the call for breast cancer and they have come out for awareness campaigns. The women are very good about getting mammograms now. And women do fundraising. Women participate. They have put their money where their mouth is and they have done advocacy and they have joined campaigns. This is what we need to do with heart disease now.

And it's political. Women's health, from a federal funding standpoint, sometimes it's popular, sometimes it's not so popular. So we have these feast and famine cycles. So I implore you to join the Red Dress Campaign in this fundraising. Breast cancer, as we said, kills women, but heart disease kills a whole bunch more. So if we can be as good as breast cancer and give women this new charge, we have a lot of lives to save.

So thank you for your attention.

(Applause)
 


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