0:00

In these challenging times, organized solidarity is our

0:02

strongest tool. It's how we understand the threats

0:04

we face, refine our strategies, and craft a

0:06

unified vision for a future driven by love

0:08

for our planet and the belief that everyone

0:10

has a pivotal role to play. That's

0:13

why Marguerite Casey Foundation is launching a new

0:15

program, Summer School, Building a People

0:17

and Planet-Centered Future. From June through

0:19

October, join them for in-person and virtual sessions

0:22

designed to help you a. get clear about

0:24

how we can defeat fascism, b. plant seeds

0:26

for a bold, progressive future, and c. support

0:28

organizing to win a better world. Featuring

0:31

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0:33

Summer School will dive into topics

0:35

like multiracial solidarity, the government we

0:37

want, and holding powerful forces accountable.

0:40

Join MCF Summer School

0:42

today. Visit caseygrants.org/summerschool. That's

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caseygrants.org/summerschool. Together, let's build

0:46

a future centered on

0:48

people and the planet.

1:00

The Supreme Court reverses a lower court ban

1:02

on the abortion pill Mifepristo. Moderna

1:04

announces a new combined COVID and flu vaccine.

1:07

The FDA issues a warning on paralytic shellfish poisoning.

1:11

And federal agencies come together to form

1:13

a new enforcement unit to tackle illegal

1:15

flavored e-cigarettes. This is America Dissected.

1:17

I'm your host, Dr. Abdul El-Sayed. Wednesday

1:26

is Juneteenth, a federal holiday commemorating the

1:28

moment that enslaved people in Galveston, Texas,

1:31

one of the last bastions of slavery

1:33

in the U.S., heard about the Emancipation

1:35

Proclamation. Commemorating days like

1:37

this is absolutely fundamental for a few reasons.

1:41

First, it's a day that commemorates a moment

1:43

of genuine joy for people from whom joy

1:45

had so assiduously been stolen. But

1:48

second, if done right, it protects

1:50

us from a certain tendency to forget the worst

1:53

things about our history. Commemorating

1:55

the end of slavery forces us to

1:57

remember that there was once slavery. press

2:00

us to tamp out all the last vestiges

2:02

of the essential racism that enabled it. And

2:05

as much as we'd like to ignore it, that

2:07

racism persists today, written

2:09

into the bodies of black folks across this

2:11

country. It shows up at the very first

2:13

moments of the transition of life. According

2:16

to data from the CDC and others, black

2:18

mothers with college degrees still die at higher

2:20

rates in childbirth than white moms without them.

2:23

Overall, black moms are three to four

2:25

times as likely to die giving birth

2:27

to a baby as the national average.

2:30

Their babies, they're two to three times as

2:32

likely to die before their first birthdays as

2:34

the national average. If they

2:36

survive in a childhood, they're up to two times

2:38

as likely to be exposed to lead and three

2:40

times as likely to be hospitalized for asthma. In

2:43

adolescence, black teens are more than twice as likely

2:45

to be shot to death. And that's all before

2:47

their 18th birthday. Heart attacks,

2:49

strokes, most types of cancers, all higher

2:51

among black folks. Why? Racism.

2:56

Racism that robs folks of opportunities like

2:58

good schools, college degrees, good jobs, owned

3:00

homes in stable neighborhoods, clean air and

3:02

water. All of it is a

3:05

function of racism. We've covered the

3:07

consequences of racism quite a bit here because

3:09

we could literally do the whole podcast on

3:11

this singular topic and it still wouldn't be

3:13

enough. But I was particularly interested

3:15

in learning from our guest today because she

3:17

brings such a multifaceted perspective to these issues

3:20

and taking a bit more time with this

3:22

type of question can unlock new insights and

3:24

hopefully new ways of addressing it. Dr.

3:27

Lael Liverpool is the author of the new book

3:29

Systemic, which explores the ways that racism

3:31

gets under our skin. Her background is

3:33

unique. She did a PhD in virology and

3:36

immunology at Oxford. She then decided to pivot

3:38

into a career in journalism. That

3:40

cross-disciplinary approach unlocks a unique perspective on these

3:42

challenges. Couple that with the fact that she's

3:45

a mixed Lebanese and Ghanaian heritage and she's

3:47

lived all over Europe throughout her life. It

3:50

all means that she has a unique international

3:52

perspective to what is a global problem. So

3:54

I knew I had to speak with her. My

3:57

conversation with Dr. Lael Liverpool after this break.

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right, let's get started. Can you introduce yourself with

5:33

a take? Absolutely. Hi,

5:35

I'm Laelle Liverpool. I'm a science

5:38

journalist and I'm the author of Systemic, How

5:40

Racism is Making Us Sick. So

5:42

I want to get into the book, but

5:45

first you have a really interesting pathway to

5:47

your work in this space. You

5:49

are a PhD bench

5:52

scientist. Can you tell us a little bit about

5:55

that work and how you got into it? Yeah,

5:57

sure. So even growing up, I was always

5:59

interested. in the world around

6:01

us, but also kind of the

6:04

world inside our bodies, human biology.

6:07

So I studied biomedical science

6:09

as my bachelor's degree in

6:11

London. And then after that,

6:13

I decided to get further

6:15

into infectious disease and immunology.

6:18

So that's what I specialized in for

6:20

my PhD. So my

6:22

PhD research was in Oxford and

6:24

I focused on investigating how viruses

6:26

are recognized when they first invade

6:28

the body. So looking at that

6:31

intimate interaction between viruses and

6:33

our immune systems. Yeah,

6:35

that's quite relevant to a lot of

6:37

what we talk about on this podcast. And I think something

6:39

a lot of folks unfortunately have too much experience with over

6:42

the past three plus years, but

6:44

grateful for that. Definitely. A lot

6:46

of times when I trained in

6:48

an MD PhD program and my

6:50

PhD was in the

6:53

public health sciences and most of my colleagues were

6:55

bench scientists, and it's rare for the bench scientists

6:57

to come out of the laboratory. And

6:59

that's one of the things I really appreciate about

7:02

your background. So as you did your work and

7:04

as you thought about the implications of that work

7:06

for society, what led you down

7:08

this path to thinking more broadly about

7:11

social dynamics when it comes to our health? Yeah,

7:13

so I think it's something that actually started

7:15

quite early on. I mean, in the book,

7:17

I share an experience that I had as

7:19

a teenager growing up in the Netherlands

7:22

where I struggled for

7:24

a while to get a diagnosis with a skin

7:26

condition that I was experiencing. So

7:28

we went back and forth to doctors and

7:30

eventually I moved to the UK to go

7:33

to university and it was there that I

7:35

met a doctor who just happened to have

7:37

darker skin similar to mine. I have sort

7:39

of brown skin for the benefit of listeners.

7:42

And he's the one who said, oh, it looks

7:44

like you just have a classic case of

7:46

eczema or atopic dermatitis, which is obviously a

7:49

really common skin condition. And

7:51

I was really surprised because I'd assumed I

7:53

must have some really rare, difficult to diagnose

7:55

condition. But he thought that the reason that

7:57

doctors had kind of missed that is is

8:00

because of difficulty recognizing

8:02

that condition on darker skin like

8:04

mine. And that

8:06

kind of got me thinking already about

8:09

how there are these inequalities that can

8:11

affect our health. And

8:13

then in the course of researching the book,

8:16

I got to know a lot of people

8:18

who shared their stories and their experiences in

8:20

health. And there was

8:22

an experience, for example, of a young

8:24

British Nigerian woman living in London who

8:26

also has brown skin. But

8:29

she actually almost died because of the

8:31

failure by health care workers to

8:33

recognize a very serious condition called

8:35

Stevens-Johnson syndrome on her skin. And

8:39

then looking into that, I came

8:41

across a case report of an African-American woman.

8:43

So this is in the US now, who

8:45

experienced something very, very similar. And again,

8:47

there was that difficulty of health care workers

8:49

to recognize that. So

8:52

being a scientist, I wanted to kind of

8:54

look into the research in this and understand,

8:57

why is this happening? Is

8:59

this a more widespread problem? So

9:02

I can share a little bit. I found that there

9:05

was research showing that 75% of the

9:08

images in medical textbooks,

9:10

for example, in the US, showcase

9:12

images showing conditions on lighter skin.

9:14

Just 5% show how those

9:16

conditions look on darker skin tones, for example.

9:19

But also, it affects the confidence of

9:21

health workers to recognize conditions. So there's

9:23

work showing a survey

9:26

of medical professionals internationally

9:28

found that only 5% said

9:31

they felt really confident to diagnose health conditions across

9:33

diverse skin tones. So that was surprisingly low

9:35

to me. And I think that's what kind

9:37

of led me to think, OK, this is

9:40

a more systemic problem. It's

9:42

not just about one or two doctors, but

9:44

it seems like there are wider problems maybe

9:46

in medical education that are affecting our

9:48

health. One of the

9:50

things that I think is really interesting about

9:52

your background, and I say this as someone

9:55

who is Egyptian-American, born and raised in

9:57

the US, spent a lot of my time abroad.

10:00

abroad in Egypt and then did some of my graduate

10:02

education in the UK, is that

10:04

you've traveled in the world in

10:06

your body in

10:08

a number of different spaces. I

10:11

always think that that gives you a sort of sense

10:13

of the ... You're constantly

10:15

running in N equals one trial of

10:18

what the experience of racism feels like

10:20

and looks like in different places. And

10:24

then you're also an observer of how

10:26

that interacts with other people. It's

10:28

fascinating for me when I go back to

10:30

Egypt, I'm biologically

10:33

100% Egyptian and people

10:36

can sniff the fact that I didn't grow up

10:38

in Egypt very quickly on me. And

10:40

there's all these questions about like, so where are you actually from?

10:42

From. And here my whole life it was like,

10:45

oh wait, so where are you actually from? And

10:47

then you get this whole different tone of, okay, but

10:50

it was fascinating. Here it was like, yeah, but you

10:52

don't look Egyptian. I ask why. It was like, well,

10:54

your hair is ... There's this word naim which is

10:56

like soft, meaning it's not very curly. My father has

10:58

very curly hair and looks

11:01

more traditionally Egyptian for that

11:03

reason. And then you

11:05

start to realize that this is sort of

11:07

a very implicit sort of form of colorism

11:10

about where you can actually

11:12

be from as a function of your hair

11:14

texture or the color of your skin. And

11:17

I want to ask you, because every book doesn't just

11:19

start as a ... Exploration, nonfiction

11:21

books, they don't just start as an exploration of a

11:24

particular topic. They're usually motivated by

11:26

something a bit deeper. And you shared

11:28

this experience of not being

11:30

able to get this diagnosis in the Netherlands and then

11:32

having this diagnosis in the UK. From

11:34

your experiences in your travels, what are the goals

11:38

and ideals you really wanted to plumb when

11:41

you decided to write this book? Yeah, I think

11:44

definitely thinking about the

11:46

way that race changes in time and place.

11:49

I think that really shows us the

11:51

kind of absurdity of race in

11:53

any kind of scientific or biological

11:55

sense. In

11:57

the book, I highlight research from even the last

12:00

... century from the 70s showing that

12:02

there's much more genetic variation

12:05

within geographic groups or

12:07

even so-called racial groups globally

12:09

compared to between those groups. So

12:12

95% of the variation that

12:14

we see is within groups

12:16

compared to between, just 5% is between groups.

12:19

And that shows us that race doesn't

12:21

exist in a biological sense, but unfortunately,

12:23

race is a very real thing that

12:25

we experience as we travel around the

12:28

world. It changes how we are perceived,

12:30

how we're even believed or treated in

12:32

medicine might change because of how we're

12:34

racialized. So I think it's

12:37

a very real thing in a social sense.

12:39

I think that's why people say race is

12:41

a social construct. But in the

12:43

book, I also argue that even though it

12:45

is a social construct, it can affect our

12:47

biology. It can harm our health. So I

12:49

think it's important to make that distinction that

12:51

race is a social construct, but racism can

12:53

affect our biology and harm our health. And

12:56

that's something I've come across. I think

12:58

in the book, I give the example that when I travel to

13:00

Ghana, which is where my parents are from, I'm sometimes

13:03

called Obrone, which is a term that refers

13:06

to foreign people or white people. But

13:08

then in the Netherlands, I'm very much black. I've

13:11

traveled to Brazil. I have a friend from

13:13

Brazil. And I've also experienced the way that

13:15

race is used there is different or

13:18

in South Africa. So I find that quite

13:20

interesting. And I think it just underlines this

13:22

point that race is

13:24

a social construct. Because if something is

13:27

scientific, you know scientists, we like clear

13:29

definitions which should be consistent in time

13:31

and place. And race is nothing like

13:33

that. It's messy. It's chaotic. It's social.

13:36

And I think that just illustrates how it

13:39

doesn't have a basis in science or in medicine.

13:42

Yeah, I want to zoom in on that point, because I

13:45

think one of the big reasons that

13:47

racism gets missed in a lot of

13:49

clinical interactions, and then certainly the science

13:51

that educates those interactions, is

13:54

because scientists fancy

13:56

ourselves as wholly

13:58

objective. And what happens

14:01

when you assume that you are wholly

14:03

objective and are unwilling to plumb the

14:05

potential of your own subjectivity is

14:08

that you bake in that subjectivity into

14:10

otherwise objective claims. And what's

14:12

interesting about this is that this has come in

14:14

two forms. And I

14:16

think your book and a lot of literature right

14:18

now is starting to educate and trying to get

14:21

us to evolve. In the beginning, right, like early

14:23

on in the scientific endeavor, when you think about,

14:26

you know, original science, you

14:29

just had this like very plain-faced

14:32

racism that was about trying to

14:34

in effect justify a lot

14:36

of the social construct that drove racism

14:38

by trying to create some science around

14:40

it. And then in

14:43

a moment when we started to appreciate

14:45

the fact that racism is a terrible,

14:47

awful, unethical, immoral, um, just

14:50

scab on our existence, people

14:52

then just ignored race. They were like, Oh, okay, we're just not going

14:54

to talk about this and we're going to pretend like it doesn't exist.

14:58

Right. And then what happens is that there's

15:01

this iteration, I would argue in

15:04

the like seventies, eighties and nineties, where

15:06

rather than explicitly

15:08

try to, um, bastardize

15:11

science to demonstrate

15:14

why racism is justified or

15:16

ignore race altogether, we

15:18

tacitly started to include it in our models

15:21

as just a feature that you would want

15:23

to adjust for or, uh, engage

15:25

with. And the mistake

15:28

there was essentializing race rather than

15:30

racism. Right. And we're

15:32

getting to this new, this new

15:34

position. I

15:36

think one of the challenges, um,

15:39

that, that I, I, I

15:41

try to think through, and I know you try to grapple

15:43

with in the book is how

15:45

should we be thinking about it

15:47

and operationalizing it in, in work?

15:50

Right. And the last three iterations kind of sucked.

15:52

They were terrible, did a lot of damage, but

15:54

like, what is the right way forward in the

15:56

way that a scientist should engage with this and

15:58

interrogate it? when

16:00

it's not the exact or focus

16:03

of the research? Yeah, I think

16:05

that's such a great question. And

16:07

I think you summarized that extremely

16:09

well, all of those iterations, there

16:11

was a kind of colorblind phase,

16:13

people say, I don't see color, and

16:15

then you're not seeing the experiences that

16:18

people are having. So I

16:20

think you're so right. And I think

16:22

it's a great question to think, how should

16:24

doctors consider race? I

16:26

think I would love to see doctors think

16:28

more about racism and not race.

16:31

So what I mean by that

16:34

is thinking about the way that

16:36

systemic racism, for example, the structures,

16:38

systems, institutions, underpinning our societies, how

16:40

that affects people's health, but

16:42

also interpersonal racism. In the book, I

16:44

look at racism-related stress and even racial

16:46

trauma, how that affects our health just

16:48

on a day-to-day basis, or

16:51

indeed interactions in healthcare, in medicine,

16:53

and then biases that have been

16:56

incorporated into algorithms. There has been,

16:58

unfortunately, in the past, this effort

17:01

to kind of incorporate race

17:03

into algorithms, but without really reckoning with

17:05

the cause of racial disparities in health.

17:08

And so, in effect, you're kind of

17:10

automating inequality or making it seem like

17:12

it's inevitable. And that was something that

17:14

was so important to me to kind

17:16

of get across in the book. It

17:19

was also empowering for me as a black

17:21

woman that there's nothing wrong with me. You

17:23

keep hearing these statistics that black women are

17:25

more likely to die in childbirth in

17:28

the US, but also here in the UK, where I am right now

17:30

as we're recording this. And, or

17:33

you hear about a black people experience more

17:35

cardiovascular disease, die more from cancer. There are

17:37

so many of these statistics, and it can

17:39

sound like it's a permanent thing that we

17:41

can't change. But when you say that racism

17:43

leads to these problems, when you say that

17:45

it's living in a racist society, that's harmful,

17:47

suddenly you've changed the framing slightly, but it

17:49

makes such a big difference, because racism is

17:51

something that we can do something about, right?

17:54

So I would love for doctors to think more

17:56

about racism rather than race, and

17:58

think about how racism affects their patients.

18:01

the environment they live in, the air

18:03

we breathe, what they're exposed to, and

18:05

also how that operates in that doctor-patient

18:07

interaction. Yeah, I really appreciate that point.

18:09

There are two things I want to pick up. The

18:12

first one is, you know, I actually wrote my

18:15

doctoral dissertation about ethnic inequalities

18:17

in obesity in the UK. Oh, wow. What's

18:19

interesting about the UK is that you have

18:21

two very large minoritized

18:25

communities that tend to be

18:27

black African, either from the African

18:29

diaspora or from the Caribbean, or

18:33

South Asian, right, from Pakistan,

18:35

India, Bangladesh. And

18:38

if you think about like original automation, we

18:41

often, when we think about automation in research

18:43

or algorithmification, you tend to think about it

18:45

in terms of AI

18:48

tools, right? And you have to have a computer

18:50

behind it. But like BMI is the way that

18:52

we've tended to measure adiposity,

18:55

and it's not a very good measure for

18:57

adiposity. And it's particularly bad for both of

18:59

these groups, right? Because if you look at

19:01

the South Asian community, you

19:04

find that BMI tends to

19:07

vastly underestimate adiposity, in

19:10

large part just because of bone density or muscle

19:13

density. And then in the African population, it's

19:15

exactly the opposite, right? And so you end

19:18

up having this automation where you're systematically mismeasuring

19:20

this idea of adiposity and all the downstream

19:22

consequences. And, you know, we've had several episodes

19:24

about whether or not adiposity is actually a

19:27

measure of the things that we really want

19:29

to measure downstream, whether you're talking about diabetes

19:31

or cardiovascular disease. But even leave

19:33

it there. If you think you're measuring

19:35

a certain thing and you've got two

19:37

minoritized populations that you are systematically mismeasuring

19:39

relative to, you know,

19:41

to the sort of quote, white normal in

19:44

the UK, you start to appreciate that like we've

19:46

been doing this for a real long time, and it tends to

19:48

embed a certain level of inequity in

19:50

terms of who gets treatment or who gets cared

19:52

for, right? Because in theory, you walk into a

19:54

doctor and they say, oh, your BMI is perfectly

19:56

fine. Or you walk into the

19:58

doctor and you've got a body. and like, oh

20:00

yeah, well your BMI is super high. We should do

20:03

something about that. And neither of those things really work

20:05

out well for that patient for

20:07

a number of reasons. And I

20:09

guess the question I want

20:12

to think through with you is the tough part is

20:15

too often the challenge

20:17

with racism is that it

20:20

is an exposure that is ubiquitous,

20:23

but the people who are

20:25

affected by it by definition are the ones

20:28

who are of the race that is racist against.

20:31

So it's like saying, a couple

20:34

of folks, it's raining outside. Some folks have umbrellas and

20:36

you're like, well, we're going to measure who's wet. And

20:38

you're like, well, actually you probably want to either do

20:40

something about the rain. And this

20:42

analogy is not quite right because you can't really stop

20:44

the rain, but in this case you do want to

20:46

stop it. Or you want to give everybody an umbrella.

20:49

There are a couple of different approaches here, but

20:51

we've always just focused on, well, well the wet

20:54

ones, like let's think about and

20:56

measure that. And I think the tough part in

20:59

terms of thinking about that is when you're

21:01

trying to measure to your point earlier is

21:03

that science beckons us to

21:05

have very clean, crisp, comparable

21:08

measurements. And when

21:10

you know that you have a ubiquitous

21:12

exposure that literally everyone is swimming in,

21:14

right? If you live in a society

21:16

where there's racism, it's there for everybody.

21:18

You're just not feeling it if you're not

21:23

a member of the minoritized race. And

21:27

so it tends to violate a lot of the

21:29

way we think about science. A lot of what I was

21:31

trying to do in my dissertation was to get us to

21:33

think beyond like simple clean metrics and think a little bit

21:35

more about complexity and the way we measure

21:37

complexity. But one

21:39

point that I think a lot of, that's

21:41

pointing us potentially in the wrong direction is that

21:43

I think we're headed back into a colorblind phase

21:45

because people are going to be like, oh, well

21:47

racism, can't really measure it. So let's

21:49

just ignore it. And then

21:52

there's going to be like a bifurcation and then there's

21:54

a whole other literature that's like all about race. But

21:56

the challenge for me is what happens when you want to bridge these?

21:58

You want to talk about, you know. know, some clinical

22:01

algorithm, but you want to engage

22:03

the experience of racism because it's

22:05

meaningful, but you run

22:07

into this inference problem

22:10

around how to measure something that

22:12

only some people actually

22:14

feel the exposure of, even though it's ubiquitous. Yeah,

22:16

I think it is really challenging to

22:18

measure racism. And I think a lot

22:20

of people have even felt kind of

22:22

gaslit sometimes, or that their experiences aren't

22:24

captured because of that difficulty. I

22:27

think just because it's hard, we can't shy away

22:29

from it. I think it's important that we try.

22:32

And there has been also research really

22:34

trying to look at effects, for example,

22:36

of racial trauma or racism-related stress in

22:39

the brain, where there have been attempts

22:41

to kind of, of course,

22:43

there are qualitative experiences and you have qualitative data

22:45

that is really helpful. But of

22:47

course, we also want to have quantitative things that we

22:49

can really look into. And I

22:52

think, yeah, capturing more of people's experiences

22:54

will be really valuable. There's work looking,

22:56

for example, so there's

22:59

been work looking at the literature in

23:01

general on racism and trauma, for example,

23:03

that's found a positive association between those

23:05

two. There was a study

23:08

that I found really interesting I highlight in the book in Australia

23:10

in 2017, found

23:12

a link between childhood trauma related to

23:14

racism and then late life dementia.

23:17

That was among Aboriginal and Torres Strait

23:19

Islander peoples who experienced higher rates of

23:21

dementia. So

23:24

that study found that participant scores in

23:26

a childhood trauma questionnaire were linked to

23:28

a few indicators, but including separation from

23:31

family by a mission, the government or welfare.

23:33

So this refers to a series of racist policies

23:35

that were put in place by the Australian government

23:38

in the last century, separating

23:40

many Aboriginal and Torres Strait Islander children

23:42

from their families. But

23:45

also, you know, racial disparities in dementia exist

23:47

in a lot of countries, including the US. And

23:50

there's also been interesting work there, you

23:52

know, the prevalence of Alzheimer's related dementia

23:54

is greater among black people

23:56

compared with white people, for instance. And there was a

23:59

study in 2019. that found early

24:01

signs that this could be related to

24:03

racism. So I thought

24:05

that was really interesting because as you say,

24:07

it's a very difficult thing to capture, to

24:10

measure, but it's really important, I think that

24:12

we go beyond just saying, okay, there are

24:14

these health gaps and looking at why they

24:16

exist, what can we find? So in that

24:18

study, the researchers surveyed a group of African-Americans

24:20

about their experiences of racism, and then they

24:22

scanned their brains later using MRI, and they

24:25

were able to show that among older African-Americans,

24:27

self-reported lifetime discrimination

24:30

and burdens of racism across a lifetime

24:32

was associated with an increase in what

24:34

they call white matriligian volume

24:37

in the brain. So that's an early sign of cognitive

24:39

decline that's been linked with dementia.

24:41

So obviously measuring the effects of racism

24:43

in the brain, it sounds difficult,

24:46

it's not easy, but I think this

24:49

type of research and also just listening more

24:51

to people's lived experiences in medicine

24:53

and healthcare, it does show that it's worth

24:55

investigating. And dementia is

24:57

a condition that affects, I believe

24:59

it's more than 55 million people

25:01

globally, it's expected to affect

25:04

almost 80 million people by 2030. So

25:07

it's a condition that I think this

25:09

affects everyone. You mentioned that, of

25:12

course, it affects minoritized people, but in

25:14

the book, I really make the case

25:16

that it's an issue that we should

25:18

all care about because racism, it permeates

25:20

medicine and science, it makes healthcare systems,

25:23

of course, deeply unfair, and that's a

25:25

huge injustice, but it also makes healthcare

25:27

inefficient, right? You're wasting time, money, resources

25:29

of medical professionals, and we would like

25:31

our healthcare systems to work efficiently and

25:33

in a logical way. So I think

25:35

it's an issue that affects us all.

25:37

And in COVID, that was very clear,

25:40

right? I mean, I think

25:42

racism, in the book, I make

25:44

the case that it kind of acts as these

25:46

fault lines in our society, these cracks in society

25:48

through which health problems can

25:50

creep like infections, right? Like infectious disease

25:52

epidemics. And again, that can affect all

25:55

of us at some point. Of course,

25:57

some of us might be disproportionately impacted,

25:59

but eventually... even if you think

26:01

you're more privileged and this isn't your problem,

26:03

I would argue that this is everyone's problem.

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AD. The

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point that you do a great job making, and

29:50

one of our previous guests made a very

29:52

similar argument. Heather

29:55

McGee, it's that in

29:57

a society where there is racism, where we're

29:59

we have to engage in collective action. When

30:02

one group of people wants to deny others

30:04

a service, they by definition are denying themselves

30:07

the service because the service either exists or

30:09

it doesn't. And the other part

30:11

of it is even if you were to be able to say

30:13

in a racist society, actually we get the service and they don't.

30:16

So long as you all living in a collective

30:18

space, right? Especially when you talk about an infectious

30:20

disease, well, every single person who gets the disease

30:22

is a risk for other people getting it. And

30:25

so this idea that when we are

30:29

a sense to a level of racism in

30:31

our society that it destroys the

30:33

firmament within which we can even think about

30:35

collective goods, whether you're talking about a healthcare

30:38

system or a public health system, or even

30:40

a transit system, right? To be able to

30:42

get places so you can walk

30:44

on your way to work rather than having to

30:46

hit the gas pedal and drive for 30 minutes and

30:48

waste your life in the back of a car. Like

30:51

these are all things that all of us

30:53

benefit from. And when one group decides that

30:55

another group is not worthy of having those

30:57

things, there are real consequences

30:59

to it. I

31:02

wanna also just sort of zoom

31:04

in a bit on this

31:07

question of scale, right? You

31:10

talk a lot about the ways that we've embedded

31:12

this in healthcare. Part

31:14

of the challenge I think is that when

31:18

someone is a, and let's use the word victim, right?

31:20

You talked a lot about the

31:22

cognitive implications, right? So much of racism

31:24

happens, it's mediated through one social experience

31:27

in the world of being treated that

31:29

either through a series of traumas or

31:31

being treated as perpetually less than, right?

31:34

That that's gonna induce a certain amount of stress

31:36

and stress we know has all kinds of hazardous

31:38

consequences in the body. But

31:40

so much of that happens before anyone gets

31:42

into the healthcare setting. And I've thought a

31:44

lot about, like if we were able to

31:47

perfectly eliminate all racism inside

31:49

of healthcare, right, and we're

31:52

a long way from doing that. But

31:54

even if we were to eliminate all of racism inside of

31:56

healthcare, I think the most

31:59

caustic consequences racism happen before anybody ever

32:01

even gets into a hospital. Right? It's like so

32:03

much of it is the job you can get

32:05

the access to a walkable community, the quality of

32:07

food that you can get access to, whether or

32:09

not you are treated as an esteemed member of

32:12

society, simply because of the color of your skin

32:14

or how you look when people see you, the

32:16

ability to afford proper housing.

32:20

All of these things are a function of a systemic

32:22

racism that is well

32:24

beyond anything that happens in our, you know,

32:26

especially talking to us, a broke ass health

32:28

system, right? And, absolutely. I agree.

32:30

Yeah. And I want to ask you, like, how

32:32

should we be thinking about the proper space for

32:34

intervention? I mean, I think it's easy for us

32:36

to focus on the healthcare system because it feels

32:38

like it's like something you can wrap your arms

32:40

around, but I don't know that it actually accounts

32:42

for a large proportion of a lot of these

32:44

disparities that we experience. And I think

32:47

that's what makes a lot of doctors somewhat

32:49

frustrated with it. Like, you know, we're really

32:51

trying here, but like still, right? How

32:54

do you think about that? And, and, and are there ways

32:56

for us to sort of, to

32:58

think beyond the healthcare system around leveraging this

33:00

data to try and induce or maneuver real

33:03

change? I mean, it's what I, what I

33:05

try and think about most days, but you

33:07

know, I'd love your, your insights on that.

33:09

No, thanks for bringing that up because that's

33:12

a point that I've been making a lot.

33:14

And I was actually speaking with a GP

33:16

here in the UK, so a family doctor

33:18

about these kinds of inequalities. And he was

33:20

saying that he feels that so many of

33:23

the problems he sees, the

33:25

causes are just upstream of healthcare. It's the

33:27

societies we live in, what we're exposed to,

33:29

as you say, the jobs we do, our

33:32

environments. I mean, maybe to take an example,

33:34

I think air pollution provides a really good

33:36

example because it's, you know, it's literally the

33:38

air you breathe. It's this, it's really an

33:41

invisible killer in many ways. And there's

33:43

a lot of evidence showing that people of

33:45

color, for example, here in England where I

33:48

am are more likely to live in a

33:50

very polluted area in the US. Black and

33:52

Hispanic people are more exposed to air pollution.

33:54

Even though they contribute less to its production.

33:56

So there's also that injustice there. But

33:59

that's linked to health. outcomes, you know, black

34:01

and Hispanic people also experience higher rates

34:03

of asthma. And this

34:05

is a huge issue that really disproportionately

34:07

affects communities of color. And again, that's

34:09

not something that a doctor has really

34:11

any influence of where you live or

34:13

what kind of air you're breathing. So

34:16

I do think that a lot of the solutions

34:18

to these problems are also kind of

34:21

upstream of health care. And you know, I won't

34:24

get political, but here in Oh, you're welcome

34:26

to get political. Thank you.

34:28

So we're heading towards an election. That's

34:30

what I'll say. The US is also

34:32

having an election that I think no

34:34

one could miss at the moment. And

34:37

I'll just say that thinking, you know, when

34:40

we're going towards an election, that's a place

34:42

where we can think about, okay, what kinds

34:44

of policies would be helpful to lead to

34:46

change in society, because these solutions will not

34:48

come just from health care, there's a lot

34:50

we can do within health care. And I

34:52

think that's great. But I think we also

34:54

need to, you know, support campaigns for clean

34:56

air, environment, and also just,

34:59

you know, how we treat

35:01

one another, I think this seems like a small

35:04

thing. But I think in the course of writing

35:06

the book, it's something I've recognized as actually quite

35:08

important, you talked about stress. And

35:11

we talked about racial trauma, which is, you

35:13

know, really traumatic experiences. But there's also

35:15

just more day to day things, there are

35:17

things which I've even dismissed that I experienced

35:20

that, you know, I go into a shop,

35:22

and I'm being followed by security, because there

35:24

might be stereotypes that black people steal

35:26

more, or like, in the airport or traveling

35:29

and experiencing that you're being

35:31

randomly checked. I think it's

35:33

something that a lot of people may have experienced

35:35

these kind of biases. And those

35:37

things do cause stress, it seems like maybe

35:39

trivial and small. But I think day

35:42

in and day out, again and again, having

35:44

that kind of low level stress, there's also

35:46

research showing that that's harmful to health, that

35:49

it can lead to high blood pressure, which

35:51

again, is more prevalent, for example, in black

35:53

communities in the US and the UK. So

35:56

I think, yeah, that we can also think about just how

35:58

are we Are we

36:00

treating our friends, colleagues, neighbors? Could we

36:02

actually be impacting each other's health just by

36:04

interacting with each other? That's something

36:06

that's been really powerful

36:09

for me to think about how we live

36:11

our lives. But of course, there are gonna

36:13

be many layers and healthcare is important because

36:15

when we do need that urgent care, we

36:17

want to make sure that it's equitable. So

36:19

I think there are a lot of layers

36:21

to this, but absolutely I agree with you

36:23

that looking upstream of healthcare at our society

36:25

and policies that will make our society more

36:27

equal will of course be beneficial to our

36:29

health. I really appreciate the point

36:31

that you made about air quality. You

36:33

know, it's this question of

36:35

where people live, where we've located industrial

36:38

polluters and who gets

36:40

to live in a clear naira shed versus who doesn't. It

36:44

is literally, literally the

36:46

foundation of your ability to live, right? I

36:49

do this, when I teach, I often ask

36:52

people, I'm like,

36:54

okay, so what is the most important resource you have?

36:57

Well, water, right? If you didn't have water,

36:59

you didn't live for three days. That's it.

37:02

And other people will be like, well, food, right? You need that.

37:04

I'm like, well, you got three weeks without food. And

37:08

rarely do people say air, right? And you got about three

37:10

minutes without air. And we

37:12

don't think about it that way. You just don't even think about

37:15

it. It's just, yeah, it's just, you know,

37:17

we're just breathing right now and you're not

37:19

thinking about it. But when you can't breathe,

37:21

suddenly, you know, that's a huge

37:23

thing. And people are dying, you know,

37:25

in the UK, yesterday, I

37:27

was speaking with the mother of

37:30

Ella Kissy Deborah, who is a young black

37:32

girl who died in 2013 here in London,

37:35

because of exposure to air pollution

37:37

in the neighborhood where she lived. She developed

37:39

a very severe form of asthma. And

37:42

it's just so, so sad. You just

37:44

can't comprehend losing a child like that and

37:47

what she's been through. But she's managed to

37:49

really turn that into such an inspiring campaign,

37:51

trying to improve air quality here in London,

37:53

but also around the world. And I was

37:55

talking to her and she said that she's

37:57

been looking at the US and that environmental

37:59

racism. in the U.S. She said it's something

38:01

else, that there's just so much inequality in

38:04

not just air, but yeah, also water, pollutants,

38:06

what people are exposed to. And of course

38:08

that affects our health, but sometimes we just

38:10

don't see that. As you say, we think

38:12

about, okay, I'm in the doctor's office, or

38:14

I've collapsed, I need urgent care, and we

38:16

think about health care. But what got us

38:18

to that point? So no, I agree.

38:21

I think it's a really important point. No,

38:23

I appreciate that. So in the county that

38:25

I serve as health director, we just put

38:28

up 100 air quality monitors, and we are

38:30

the most, we're home to the

38:32

most polluted zip code in the entire state

38:34

of Michigan. And to your point, right,

38:37

who lives there? It tends to be black and brown people.

38:39

And it's because of where

38:41

we've concentrated both poverty and

38:45

industrial activity. And you know, you see

38:47

the consequences. When there's a bad air

38:49

day in Michigan, it's the worst in

38:51

that community. One

38:53

point that you made about health care that I

38:55

think is really important is a lot

38:57

of it is what happens in health care. And

38:59

then there's this juxtaposition between what's happening in society

39:02

and what happens in the clinic, and it's who

39:04

gets access to health care. And of course, what's

39:06

interesting, I think about your experiences, you're

39:09

writing about systemic racism and health in

39:12

a number of different contexts. And one

39:14

of the important differences between the UK

39:16

and the US is the NHS, is

39:18

that there's been studies

39:21

to demonstrate that the quality of the

39:23

NHS differs substantially based on what community

39:25

you're serving. But there is health care,

39:27

and it is something

39:30

that you have guaranteed

39:32

access to as a UK

39:34

resident. Whereas in the US, we have

39:36

a number of safety net systems, Medicaid

39:39

being the predominant one, that reimburses at

39:41

nearly half the rate. And because our

39:43

health care is entirely privatized, that

39:46

makes you a second class health care citizen. And

39:48

I wanted to ask, in your research in this

39:50

book, there are of course,

39:52

health disparities, because of what's happening in

39:55

society and what's happening in the clinic. But that's a

39:57

really big difference between these two. And I wanted to

39:59

ask the degree to which you're

40:01

able to suss out the impact

40:03

of who gets access to

40:06

the healthcare system across these two

40:08

societies in terms of the

40:10

disparity that we're seeing in health

40:13

status as a function of racism. Yeah,

40:15

I'm really glad that you mentioned that

40:17

because that is a huge thing. And

40:19

again, thinking about elections and what we

40:21

might change in the future, I think

40:23

that there's so much

40:25

evidence showing that universal healthcare

40:27

access is just so beneficial.

40:31

And particularly for those of us in

40:33

society who are most marginalized, discriminated against,

40:36

it's just so important. And as we kind

40:38

of touched on before, isn't that beneficial for

40:40

all of us to all have access? We

40:43

would all hope that if we're in an

40:45

acute situation, if we develop cancer or some

40:47

problem that we need that care, that we

40:49

would want that to be freely available and

40:51

accessible. So I know that

40:54

this is a very political issue in the

40:56

US, but in Europe, it's considered in many

40:58

countries as just, you know, health is a

41:00

basic human right. And I think providing

41:03

that kind of improving healthcare access for

41:05

everyone will certainly improve many of the

41:07

issues that I touch on in the

41:09

book. Having said that, I think that

41:11

even in the UK, which is a

41:13

great kind of case study for this,

41:15

we do have universal healthcare access and

41:17

still we do see racial inequalities in

41:19

health. And I think that perfectly illustrates

41:22

how it's not just about healthcare, it's

41:24

about the lives we lead outside of

41:26

that setting. And it's, you know, it's

41:28

what do I eat for breakfast in

41:30

the morning? What kind of air I'm

41:32

breathing? What's my job? And so all

41:34

of those things play a role as

41:36

well. But I do think that, of

41:38

course, improving access to healthcare is beneficial

41:40

in terms of addressing racial health disparities.

41:43

Yeah. The other question that's important in the

41:45

healthcare setting is who your doctor is, right?

41:47

To your point, the vignette you shared about

41:49

your own experience, right? If you have

41:52

a doctor who has skin that looks like yours, the

41:56

ability to sort of recognize and

42:00

treat, right, is going to be fundamentally

42:02

different versus somebody who's only ever really

42:05

spent time thinking or reading in a

42:07

book that doesn't even share anything about

42:09

skin that looks like yours, right? And

42:11

one of the big challenges we have,

42:13

right, is because of this, there's these

42:15

systematic differences in who gets

42:18

access to, you know, to go to

42:20

a high quality school or extra tutoring

42:22

or you guys call it tuition there,

42:24

to be able to excel at your,

42:26

you know, in our case, you know,

42:28

AP classes or A levels in yours.

42:30

Like those questions, they make a big difference.

42:32

And you know, I remember I was in

42:35

the UK and in the summer to make

42:37

some extra money, I would actually tutor A

42:39

level biology and chemistry. And

42:41

there was the most promising student in my

42:44

class. He

42:46

I'd asked him, I was like, so what do you

42:48

know, what do you want to study? He's like, I

42:51

had intended to study medicine. And

42:53

this was the year that they instituted university

42:56

fees. Yep, that was my year. It

42:59

was your year. I was the

43:01

first year where they tripled the fees. Yeah.

43:05

And the kid basically said, I can't go to university.

43:08

Yeah. My family doesn't have the money for it. I

43:10

don't have the money for it. We're not going to

43:12

take loans. It's not something my parents are comfortable with.

43:15

So, I mean, it was just such a, to me, it was

43:17

like such a shocker. And,

43:20

you know, so we don't often think

43:22

about that, but can you speak to

43:25

the importance of having a clinician

43:27

that shares your experience

43:29

and comes from that same

43:32

experience of understanding the wiles

43:34

and the methods of racism

43:38

to the kind of care that you might

43:40

get? Yeah, definitely. I think that like

43:42

in any profession, I think diversity is

43:45

important. It's beneficial. So it's great to

43:47

have, you know, clinicians who represent the

43:49

communities that they're and

43:52

there is actually research showing that there

43:55

are benefits of, you know, physician race

43:57

concordance with the patient. There was research.

44:00

I think in California, looking at

44:02

black men who saw black physicians and

44:04

they had better outcomes when it came

44:06

to cardiovascular health. In the book, I

44:09

also talk about maternal health inequalities

44:11

and infant health gaps. Black infants in

44:13

the US are sadly more likely to

44:15

die before the age

44:18

of one. And those inequalities were also

44:20

reduced in a study when black

44:23

infants were treated by black physicians. So there

44:25

does seem to be an effect. But

44:27

I actually think that it's more

44:29

important that your physician is, as

44:31

I mentioned, aware about racism and

44:34

treats patients in an equitable way. I think

44:36

that's more important than their race because

44:40

I think a lot of the problems in

44:42

medicine are systemic, which means that even if

44:44

you are a clinician who is from a

44:48

marginalized group, you might still be ending

44:50

up perpetuating that legacy of harm because

44:52

there are guidelines telling you that black

44:54

people's kidneys work differently. You need to

44:56

adjust their test results or lungs function

44:58

differently and you need to adjust them.

45:00

And if you're following the rules, as

45:02

it were, then even no matter who

45:04

you are, you might still be perpetuating

45:06

that. So I don't necessarily think that

45:09

it's not that, okay, every black

45:11

patient must see a black physician.

45:13

Having said that, of course, I've

45:15

experienced the benefit because I think

45:17

black physicians in particular are underrepresented

45:19

among clinicians. It

45:22

seems like almost a special thing or a

45:24

benefit when you see a clinician who looks

45:26

like you. I think if there was more

45:28

equality, then that wouldn't have to be such

45:30

a special thing. And if all physicians were

45:32

better trained to treat diverse populations, then of

45:34

course we wouldn't have to be worrying about

45:36

this. But given the context that we're in,

45:38

I do think that diversity is so important.

45:40

And I think just that training and understanding

45:42

and having confidence to,

45:44

for example, diagnose across diverse skin

45:46

tones, that's something that in the

45:48

survey I mentioned earlier, that's not

45:50

even there. So I

45:52

think that there's a lot of work we

45:54

can do to increase diversity representation, but

45:57

also train physicians of all backgrounds to be

45:59

able to care for all patients. I

46:02

don't think the owners should not only be

46:04

on marginalized groups to take care of each

46:07

other. I think that everyone has a

46:09

responsibility. If you're a doctor, it is your

46:11

job to learn how to care for all patients.

46:14

Yeah. I really appreciate that. On that note, I

46:17

want to thank you for joining us and for

46:19

writing this book. Our guest today is

46:21

Dr. Leah Liverpool. She is

46:24

an author and journalist based

46:26

out of Berlin, Germany.

46:28

And join us today to talk about

46:30

her new book, Systemic. Thank you so much for joining. Thank

46:33

you so much for having me. As

46:38

usual, here's what I'm watching right now. This

46:41

happened last week. The implications are

46:44

enormous. The Supreme Court unanimously

46:46

rejecting an effort to roll back access

46:48

to the abortion pill, Mifepristo.

46:51

In a much awaited ruling, the Supreme Court

46:53

reversed two lower court decisions restricting access to

46:55

the abortion medication Mifepristo. The court didn't take

46:58

on the substance of the case per se,

47:00

but rather they rejected the plaintiff's standing

47:02

outright. The case, brought by a collective

47:05

of doctors claiming damages for having had to care

47:07

for people who may claim were injured by the

47:09

medication, despite the fact that there are decades of

47:11

data showing its safety, was manufactured

47:13

as an alley-oop of sorts. The collective situated

47:15

the case in a Texas district where they

47:17

knew the district court judge would rule in

47:20

their favor. His ruling ultimately reversed

47:22

the FDA's approval of the drug more than

47:24

two decades ago, not just putting

47:26

its access at risk, but preempting the

47:28

FDA's entire remit as an agency that

47:31

uses scientific evidence to make decisions about

47:33

medication safety and efficacy. When

47:35

the case was appealed, the appeals court tried to find

47:37

what we'll call an unhappy medium, allowing

47:39

the drug to continue to be used, but

47:42

severely restricting access by, for example, banning it

47:44

from being sent by mail. The

47:46

Supreme Court had put a stay on that ruling

47:48

pending their ultimate decision last Thursday. Let's

47:50

be clear about something. The case was

47:52

specious from the jump, and I'm glad that

47:54

even this ideological accord ultimately saw through it.

47:57

Think about it, if a doctor regardless

48:00

of the circumstances, they are doing their

48:02

job. To claim damages would create a

48:05

really problematic precedent. But while

48:07

this particular threat against abortion medications may be

48:09

over, I wouldn't assume that efforts

48:11

to curtail access to them are behind us. ID

48:14

logs have made it absolutely clear that restricting

48:16

abortion medications is in their crosshairs. And while

48:18

this case was thrown out, they'll bring others.

48:20

And we'll be watching. As

48:23

a proponent of vaccines, I have to be honest with

48:25

you all, I absolutely hate having to get them. I

48:28

cannot stand it. The idea of somebody poking me with

48:30

a piece of metal. And now that I

48:32

have to get vaccinated for both flu and COVID every

48:34

year, you can imagine how that makes me feel. Which

48:37

is why I was pretty excited about this. Just

48:40

one shot now could soon provide protection

48:42

for both COVID-19 and the flu. We

48:44

had biotech company Moderna just moments ago

48:46

with data from its phase three trial

48:49

of a combination. Moderna announced last week

48:51

that their combined COVID and flu vaccine,

48:53

which would deliver immunizations for both seasonal

48:55

viruses in one dose, was more effective

48:57

than either individually in older adults in

48:59

a phase three clinical trial. But

49:01

this combination vaccine isn't likely to be

49:03

available until, well, fall of 2025. Meaning

49:06

that folks getting vaccinated will have to take two shots

49:09

again next season. Which, if trends continue,

49:11

it's not great. See, last

49:13

year only about 23% of eligible Americans

49:15

were vaccinated against COVID-19, compared

49:17

to about 48% for the flu. The

49:20

hope is that offering these two together may help close

49:22

that gap. Importantly, the vaccine,

49:24

currently known as mRNA 1083, also

49:27

uses mRNA technology to vaccinate against the

49:29

flu. A new approach for a vaccine

49:31

that has relied on more traditional vaccination

49:33

platforms. We'll keep you posted. Meanwhile,

49:36

a warning tonight if you enjoy

49:38

eating shellfish. The Washington State Department

49:40

of Health said they found high levels

49:43

of paralytic shellfish poison in shellfish along

49:45

the coast. The FDA issued a

49:47

warning about shellfish hailing from Netarts and

49:49

Tillamook Bays in Oregon over the risk

49:51

of paralytic shellfish poisoning. Recommending that stores

49:54

and restaurants stocking oysters, clams, scallops, and

49:56

gooey duck from the area dispose of

49:58

their stocks. Paralytic shellfish poison. occurs when

50:00

affected shellfish consume and accumulate strains of

50:02

algae that produce the toxin that causes

50:04

the poisoning. While some species of shellfish

50:07

can break the toxin down, others accumulate

50:09

it, which then causes poisoning in people

50:11

who consume them. The symptoms

50:13

can range from numbness and tingling to

50:15

full-on respiratory paralysis, which can be deadly.

50:18

There's no specific treatment for paralytic shellfish

50:20

poisoning, but if people survive the initial

50:22

poisoning, the prognosis is usually good. The

50:25

algae doesn't have a specific taste or smell, so

50:27

there's no way to know if your shellfish is

50:29

affected, and the toxin isn't removed by freezing or

50:31

cooking. However, it can be identified

50:33

in testing, which is what prompted the FDA's

50:35

warning. Finally, as we've discussed

50:37

here previously, illegal vapes continue to penetrate

50:39

the US market, hooking a whole generation

50:41

of young people to nicotine addiction, not

50:43

to mention the fact that unregulated vapes

50:45

coming in illicitly can often be contaminated.

50:48

Remember back in 2019 and the before times

50:50

when there was a spate of deaths attributable

50:52

to cannabis cartridges? Yeah. To

50:55

crack down on this, a suite of federal

50:57

agencies, including the Bureau of Alcohol, Tobacco, and

50:59

Firearms and Explosives, the US Marshals, the FTC,

51:02

and the US Postal Service, yeah, the male

51:04

folks, have come together to form a cross-agency

51:06

law enforcement team. Up until now,

51:08

most of the focus has been on enforcing at

51:11

the distribution level through letters and penalties for

51:13

gas stations and convenience stores. This

51:15

represents a much more concerted effort to tackle the

51:17

problem at a much higher level and to target

51:19

the inflows of these products before they ever hit

51:21

the street. While teen nicotine

51:23

use is down from five years ago,

51:25

vaping still remains common. Nearly 10%

51:28

of high school students in a recent survey reported vaping

51:30

in the last month. Interestingly, legacy

51:32

tobacco companies who've now pivoted into the

51:35

e-cigarette space have been urging government action

51:37

against what they see as an encroachment

51:39

into their market. Locally manufactured

51:41

vapes are far more limited regarding flavor

51:43

than the illicit vapes coming from abroad.

51:46

Those come in flavors like Juicy Peach and

51:48

Strawberry Ice Cream. Too bad the

51:50

same companies crying foul sell similarly flavored products

51:52

in dozens of other countries. But I digress.

51:55

While I think enforcing the law on illicit

51:57

nicotine is an important step, we should also

51:59

be thinking more. about how to take on

52:01

demand for these products. Remember, Juul, the original

52:04

vaping king, made its name targeting kids on

52:06

social media. And while teen vaping may be

52:08

down, other nicotine formulations like the chew pouch

52:10

Zinn is on the rise. To

52:13

that end, we need to engage the tech

52:15

industry to assure that kids aren't being exposed

52:17

to undercover marketing for nicotine products, whether vapes

52:19

or tabs or whatever comes next. Before

52:22

we go, just a housekeeping note, I'm going to

52:24

be away on vacation next week, but we'll be

52:26

back right here the week after. See

52:28

you all then. That's it for today.

52:30

Thank you so much to Dr. Leah Liverpool

52:32

for joining us. If you have guest recommendations

52:34

for the show, share them with us at

52:36

info at incisionmedia.co. On

52:38

your way out, please don't forget to rate and review the

52:40

show. It really does go a long way and your feedback

52:42

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52:44

is also on YouTube. Follow us on YouTube

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52:51

Finally, to check out more of my content

52:54

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52:56

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53:05

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53:56

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53:58

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54:00

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54:03

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54:05

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54:07

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54:09

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