June 29, 2021 • 49 mins
Sexism is baked into every aspect of our health and safety -- from how cars are tested to the way women, and especially women of color, are treated by doctors and hospitals. And the results can be deadly.
In this week’s season finale, Chelsea sits down with writer and advocate Caroline Criado Perez and Congresswoman Lauren Underwood to discuss the mind-boggling ways sexism shapes the world around us, puts women at risk, and what we need to do to fix it.
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Episode Transcript
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Speaker 1 (00:00):
Hi, I'm Chelsea Clinton, and this is in fact a
podcast about why public health matters even when we're not
in a pandemic. We know that misogyny and sexism affect
the way women are treated every day, but the problem
is even bigger and more systemic than it might seem
(00:23):
as well. Here today, sexism is baked into everything from
how cars are tested for safety to the way women
and especially women of color, are treated by doctors and hospitals,
and the results can be deadly. We don't often talk
about sexism as a public health crisis, but that's exactly
what it is. Later, I'll be talking with Congresswoman Lauren
Underwood from Illinois, who has made maternal health one of
(00:45):
her top priorities. But first, I'm delighted to be speaking
with Caroline Creato Peretz. Caroline is a writer and advocate
whose best selling book Invisible Women, exposing data bias in
a world designed for men. It's the many mind boggling
with is that sexism shapes the world around us and
puts women at risk. As you're about to hear, I
(01:08):
was recovering from strep throat and we spoke, so my
voice was a little horse during our conversation, thank you
for being here and having this conversation with me, even
with my raspy voice. Well, thank you for having me.
So I know your expertises on data and gender, and
I just thought maybe we could start with you explaining
(01:29):
what that means and what you do. What I really
work on is what's called the gender data gap they
like the gender pay gap, but in data. And basically
what that means is that the vast majority of information
that we've collected globally and continue to collect, everything from
(01:49):
transport data to economic data to medical data, has been
collected almost exclusively on men, both male bodies and typical
male lifestyle patterns. And that means that the vast majority
of pretty much everything you've come across in the world
has been designed to work better for men. So I
work on the gender data gap and also both its
(02:10):
causes and consequences. And I'm particularly interested in its causes actually,
because the cause I've identified is one that I identified
in myself, first of all, which is our tendency to
when we think of a human being, to think of
a man, and how subconscious that is that we don't
notice that we're doing it. And so it ends up
with ridiculous situations like using a car crash test dummy
(02:34):
based around the average male body and thinking that is
a good fit for the average human body for everyone, right.
And so I find this bias fascinating because it's not malicious,
it's not deliberate, it's just something we don't even notice
that we're doing. And yet it has these huge ramifications.
And Galan, how did you first notice that in yourself?
You said you first got interested in this when you
(02:54):
realize that you had this default to human equals male,
and so of human equals well, all of us. I
discovered it in myself when I was in my mid twenties.
I went to university as a mature student, and prior
to this point, actually I've been pretty anti feminist. I
instinctively felt that it wasn't for me, and that it
(03:15):
was just kind of embarrassing that it was painting women
as victims, and I didn't like it. And I had
to read this book called Feminism and Linguistic Theory. I
was studying English language and literature, and the author of
the book, Debbie Cameron, referred to this issue with generic
masculine in grammar. So in English that would be he
to mean he or she man to meet humankind using
(03:37):
the male form as the gender neutral form. And I think,
like a lot of people, I had heard about this
before and just dismissed it as just incredibly stupid and facile.
Who cares what prow noun you use. Everyone knows it's
gender neutral. But then she pointed to studies that show
that actually, when people read or hear these words, they
picture a man. And that just completely blew my mind
(03:58):
for two reasons. One that I realized I was doing that,
but also I just thought, how have I never noticed
this before? You know, it's just staggering to me that
despite having heard these conversations about generic masculine excluding women,
it had never been something that I've noticed in myself
that I was picturing men. And then gradually I started
(04:19):
realizing how it went much further than that. And actually
it was when I was picturing anyone, lawyer, doctor, professor, writer,
I was just always picturing men. And it has to
be said, actually I was picturing white men. That was
my standard default for what a human looks like is
a white man. And I just found that incredible. And
so I think because that's the way I came into feminism,
(04:40):
I was really primed to notice it when it cropped
up in other areas. So the next thing that I
studied was behavior economics and feminist economics, and economics is
just riddled with the default mail. The way that we
count GDP is set up to wholly exclude the unpaid
work that mainly women do that props up the formal economy,
(05:01):
for example, but we just don't count in. As a
result of not counting it, we undervalue it, and then
we design economies and allocate resources in a totally skewed
way to the detriment of everyone. Actually, so I was
just noticing all of these examples building up and starting
to see that this was just entirely systemic and entirely
hidden because all of these things are presented as gender neutral.
(05:23):
And then eventually I came across the fact that it
appears in the medical profession as well. So it first
came across my attention when I was researching my first book, actually,
and I came across this paper talking about female heart
attack symptoms, and I just thought, wait, what isn't an
heart attack pain in your left chest and down your
(05:44):
left arm, And yeah, it is for men, and it
can be for women, but actually a lot of women
don't experience that. A lot of women present very differently exactly.
Women tend to present more with what feels like indigestion, breathlessness, fatigue, nausea,
and women aren't reckoned. I think that they're having a
heart attack because we have this very strong public health
message that it's painting the chest down your left arm.
(06:07):
But even more shocking to me was that doctors are
misdiagnosing women as well, because we're not necessarily training all doctors,
you know, it's not part of the curriculum to teach
a whole host of different symptoms for various diseases that
do exist, and it's not just heart disease. And so
discovering that you had this default male even in medicine,
even in medicine, it was just so so shocking, It
(06:30):
was so shocking, and at that point I just thought,
I have to write about this. This is just too big,
This is too huge, and so can you just share
some other examples that you probably found equally shocking of
the ways in which medicine, public health, and science have
effectively excluded women. You know, I could go on all
day giving you examples. They're really shocking. I think for me,
(06:55):
one of the things that was most frustrating was the
excuse use that I heard time and time again for
why women and female animals and female cells, because it's
not just in humans were excluded from research, and Karlin,
I think that's an important point, right, like that for
anyone listening to us who also may not know that
(07:17):
the majority of animal studies that are the precursor to
human trials you have historically been done on male mice
and other male animals. So the gender bias starts from
the beginning of a research design and experimentation. But Chelsea,
even in cells, we test on male cells. And that's
(07:41):
just staggering because one of the main excuses is, well,
there's too many excuses. One is women don't want to
participate in research, and the other is do people actually
say in it, Yeah, yeah, that women. You know, it's
just too difficult to recruit women. Interestingly, not when it
comes to cosmestic research. Their women dominate. That is the
one area I found that actually apparently you can find
(08:03):
women to take part in trials. But yeah, the big excuses,
it's really difficult to recruit women, and also that female
bodies are too complicated, and basically what they mean by
that is they're too hormonal. Congratulations us, Yeah, I got
this menstrual cycle and nobody knows what's going on there.
Better not look into that box because who knows what
you might find. And so that is why they have
(08:25):
historically excluded females and continue to exclude females. But as
you start going from humans, you're like, right, you've got
the sort of women. Women are actually more busy, they
have less leisure time because they're doing a lot of
unpaid care work. So there are ways around that of
designing the times that you do it, of making the
centers more accessible so it's easier for women to get to.
(08:45):
But that is a legitimate issue. But then you start
looking at mice, and we'll like, mice don't have any
care giving responsibilities, so that excuse goes out the window.
But they've still got, you know, these pesky hormonal bodies.
And then you look at cells, Right, cells do not
have a menstrual cycle, and they definitely don't have care
giving responsibilities, and yet still we are using male cells.
(09:07):
And let me give you an example of why this matters.
There was a really fascinating study done, I believe in
twenty sixteen that I reported on an invisible women, where
they exposed male and female cells to estrogen and then
exposed them to a virus. It was the flu virus
in this case, and what they found was that the
(09:27):
male cells didn't respond to the estrogen and they weren't
able to fight off the virus, but the female cells
were able to use the estrogen to fight off this virus. Now,
if you think about the fact that the vast majority
of cell stage research is done in male cells, it
just blows your mind to think of how many medications,
treatments that could have worked for women have we missed
(09:49):
out on because we excluded them at the cell trial stage.
And one of the things we know about COVID is
that women have been more likely to survive it than men.
But crucially, we don't really you understand the mechanisms behind it,
which has seriously and definitely hampered our ability to fight it.
When I wrote the book, I started from the position
of this is very bad for women, but now we
(10:11):
see from this pandemic, actually it's not just bad for women.
You know, it hampers our understanding of humans overall and
the human body and treatments that could work. And of course,
on the other side, when you think about vaccines and
the fact that women are represent the vast majority of
those who suffered side effects, including the more serious anaphylactic reactions.
(10:31):
But we did it take into account the menstrual cycle
when it came to vaccine research. We didn't investigate sex
specific dosages, even though we have known for a really
long time actually that women may require lower dosages, both
not just because of the size, but also because of
the far more active female immune system. What do you
see if you see any point of progress here or
(10:55):
not yet, there has been progress. I mean that cell
study that are of heard too. That is progress that
was led by this amazing woman called sab Recline, who
has done a lot of this kind of research, and
actually a lot of this research is being led by women.
It's a really interesting study that found that actually the
gender makeup of the researchers does actually make a difference
(11:18):
to whether or not they do sex analysis and whether
or not they sex to saggregate their data. And surprise,
if you have a female lead researcher you're much more
likely to find that the research has done this sex
analysis that is so important. On the other hand, I
have never seen so much media coverage of this as
an issue, from looking at the impact of lockdowns on
(11:41):
domestic violence, to reporting the fact that the vaccine hasn't
been researched in pregnancy, to reporting about side effects differential
side effects between men and women. That's been a huge,
huge difference. If you look back at a Bowler and Zeeker, actually,
both of which had very very obvious sex differential impacts.
(12:01):
Women were more likely to die during the Ebola epidemic,
not because they were more susceptible, but because their care
giving roles, and of course in Zeka it particularly affected
pregnancy and fetal development. But only one per cent of
published studies on Zeker and Ebola looked at sex or gender.
And yet here for COVID that's not been what I've
(12:22):
witnessed at all. I've never seen such huge coverage of
these issues, and I think that is huge. I really
think that's huge. We'll be right back to stay with us.
(12:44):
You spoke earlier about how during COVID you've seen more
coverage than ever before of how women have been affected
by the disease, but affected by treatments for the disease.
Are there other way is that you've seen the pandemic
affect women, and even more, have you seen the gender
(13:06):
data gap positively or negatively affected by the pandemic. I
wouldn't say I was surprised by the differential economic impact,
but from the perspective of gender data gap, I think
it has been positive to see a this being reported
in a way that I've never seen before. I've never
(13:27):
seen so much awareness of how crucial the care industry is.
And I say industry, but i'm including of course unpaid
care work, but how things come to a grinding halt
when there's no one there to take care of the kids,
and how crucial it is to have childcare provided if
you want women to engage in paid labor, and of
(13:49):
course countries do need women to engage in paid labor,
and so seeing those conversations happen has been kind of amazing.
But then, on the other hand, felt hopeful at the
beginning of well the earlier stages of the pandemic, that
perhaps this was going to signal a shift. But then
you know, if you look at several types of economic
(14:11):
recovery plans. It just feels like we're falling back on
old ways of doing things without having learned the lessons
of the pandemic, which is actually care and health are
really important and maybe we should pay them better. So,
for example, in the UK, we had our recovery plan
in the summer of and then of course we had
another wave and another lockdown. But the slogan for that
(14:33):
recovery was build back better, And basically it was all
focused on construction, literally, built back back, literally, build back better.
And what do we know about construction, Well, we know
the construction is heavily male dominated. And what do we
know about the economic fallout of COVID, Well we know
that it's been heavily dominated by women. Right, women are
(14:53):
the ones who are much more likely to have lost
their jobs to have had to go part time, both
because of the types of jobs women are more likely
to be working in. And again this has been doubly
or trip lely so for women of color, and yet
there has been little to no recognition of that in
terms of the recovery. And by the way, this is
(15:14):
not a new problem. There has been research looking at
the US various European countries finding that if you invest
in the care industry as opposed to the construction industry,
you will create as many jobs for men, but far
more jobs for women, and you'll get as good a return,
if not better, on GDP. So there's the economic argument
for investing in the care industry. Was already there throwing
(15:37):
COVID and suddenly how important the care industry has become,
and it makes zero economic sense to immediately fall back
on jobs for the boys and construction. And yet that's
what we end up doing. And how much of that
do you think has to do with inertia? And how
much of that do you think has to do with
who's better specifically largely men, white men, And how much
(16:00):
of that do you think has to do with construction
is more visible, and often care is more invisible, even
though it's clearly a part of, if not all, of
most of our lives. It definitely will also have something
to do with whose in power. There is very good
research on this going back decades showing that the more
(16:20):
women you have in a country's parliament, the more money
gets spent, for example, on education, or the more time
gets spent discussing issues that affect women, right, It's very
clear that women have a different set of priorities to men,
and therefore it makes sense to have a balance of
people in power so that the balance of citizens is
(16:41):
adequately represented. So that will be part of it. But
I think also, and this is probably the hardest one
to address, is inertia, the status quo bias. We don't
like change. We do like doing the same thing over
and over again, even we know it doesn't work. It's infuriating. Oka,
And we've talked a lot about medicine science from a
research perspective. I wonder, though, if you could share other
(17:05):
areas where you've seen the gender data gap. Well, I'll
start with the crash test dummies, because I feel like
that one's almost the most blatant example, because it's like
a literal man. Right. So, historically, the only car crash
test dummy that was used, and it's still the most
commonly used car crash test dummy in tests, was based
(17:26):
on the body of an average American male, and that
body is obviously too large and too heavy to represent
the average female of any country. But it's more than that.
Women aren't just small men essentially, and so they have
created a very very scaled down male dummy, which they
call a female dummy, but it doesn't represent differences, for example,
(17:50):
in spinal flexibility. It doesn't represent differences in muscle mass distribution,
so for example, men tend to carry more muscle on
their shoulders and their necks than women. Doesn't represent pelvic differences,
all of which are very important when you're coming to
preventing injuries in a crash. Seatbelts, for example, as well
haven't been designed to accommodate breast tissue. We haven't designed
(18:11):
a seatbelt that is safe for pregnancy. And the result
of all of this is that women, if they get
into a car crash, are more likely to be seriously
injured than a man in the same car crash and
sevent more likely to die. Essentially, that comes down to
not having tested it on a body that represents the
(18:32):
female body. But you will find some people saying, oh, well,
maybe the female body just is I don't know, naturally
weaker or something than that's why they die. But there's
a really interesting example if you look at whiplash prevention systems,
and there are two main types which were introduced in
the past couple of decades, and one of them reduced
(18:53):
whiplash frequency for men, who, by the way, were less
likely to suffer from whiplash than women. Anyway, reduced it
for men, but actually increased it for women, whereas the
other most common whiplash prevention system, which was used in
Volvo and Toyota, I believe, decreased it for both men
and women. So there are clearly design issues going on
(19:14):
here that if you account for the female body, you
can create a safer car for both men and women,
but if you don't count for the female body, you
can end up creating a safer car for men that
ends up being more dangerous for women. Karlin, that's just
shocking to me. I know most people don't know that
this is a problem. Well I didn't know this was
(19:35):
a problem. And I think I'm like a pretty well
educated person and consumer. So are there other kind of
equally egregious examples, And I want to depress you, but yes,
most things. So one example I came across recently that
made me pretty infuriated. I'm a runner, and I'm a runner.
(19:57):
You buy women's running shoes, right, I do buy women's
running shoes. You don't. You don't buy women's running shoes.
You buy scale down men's running shoes, and that is
why women are more likely to suffer from injuries, because
the vast majority of shoes are designed around the mold
of a male foot. But actually women's feet aren't just
small men's feet. So women have narrower heels in proportion
(20:18):
to their toe box. And so if you have a
shoe that is designed around a male lust, what women
find is if it fits their heels, it's too narrow
on their toes, and vice versa, it fits their toes,
it's too wide on their heels. There are, however, some
companies that are actually designing around a female, but the
vast majority say that they are women's shoes, and they're
(20:39):
actually just scaled down men's shoes. And the more you
look around, the more you sort of it's going to
start to drive you crazy. I'm sorry, You'll start looking
at things and going does this not work for me
because I'm a woman. Okay, So crash test stummies running shoes.
What about are built environment and where we spin time
(21:00):
or our homes, our office buildings or parks. Two of
my favorite examples. One of them is quite quick to
tell if you've ever worked in an office, you may
well have noticed that in the summer the men are
all wandering around in their shirts and the women are
snuggling under blankets because they're freezing. And there's a very
good reason for that. The formula used to determine office
(21:21):
temperature was based around you'll never guess the average American
mail Yes, the metabolic resting rate of an average fort
to year old man. And it turns out that women's
metabolic resting rate is lower, and so the average office
is about five degrees too called for women, and the
(21:42):
other one actually is also it's also about being cold,
specifically when it's snowing. And this is just such a
fascinating example, I think because I'm going to talk to
you about snow clearing, and the idea that snow clearing
could be sexist just sounds so ridiculous. But as soon
as you start thinking about it, you sort of realized, yeah, okay,
that actually does make sense, So let me make the
case for you. It came about in Sweden in a
(22:04):
town called carlst Skoger, and they were doing a gender
audit of all their policies, which you know is so
Swedish we all just need to move to Sweden. Anyway.
They're doing a gender of all their policies, and someone
actually made a joke about the snow clearing, and we're like, oh,
we should check the snow clearing because they'll never be
able to find anything wrong with that, But actually they did.
They were clearing the roads in an order that privileged
(22:25):
male typical travel over typical female travel. So this is
something that holds around the world. Men and women tend
to travel differently, So men are much more likely to drive,
women are more likely to use public transport. That's partly
like women are more likely to be poorer than men,
but also if a household has a car, men tend
to dominate access to it. And men also have a
(22:48):
much simpler travel pattern of basically commuting in and out
of work A to B. Women, because they are usually
combining unpaid work with paid work, have a much more
complicated type of travel, which is lots of short, interconnected trips,
and that's called trip chaining, and that's things like you're
dropping the kids off at school before you go into work,
maybe you're picking up some groceries on the way home,
(23:10):
dropping in on an elderly relative they're dotting around the place.
This sounds very familiar, I'm sure it does. And so
women as a result basically are more likely to be walking,
and they're more likely to be using local roads, whereas
men are more likely to be using main roads. And
the way that the town council in Calstkoga had always
(23:31):
cleared their roads was clearing the main thoroughfairs first and
then the sidewalks and the local roads. So they decided, well,
let's switch it around. It's easier to drive a car
through three inches of snow than it is to push
a buggy or to walk. Not only did they find
that it didn't cost them any more money, it actually
saved the money off their healthcare bill. And the reason
(23:52):
for that is that, yes, it is harder to push
a buggy or walk through three inches of snow. The
majority of single person accidents during the winter months were pedestrians,
and the majority of those pedestrians were women, and the
entire cost of those injuries was three times the winter
(24:14):
road maintenance. So just there's little shift in the schedule.
By paying attention to how men and women travel around
the city, save them this huge bunch of money on
the question of gender audits. Since you mentioned Sweden was
conducting a gender audit, are other countries taking a similarly
(24:36):
clear eyed view to really determine where there are biases
against women effectively? Really interestingly, and this is on my
list to look into. Hawaii came up with a feminist
economics recovery plan from COVID which seems to have quite
broad based support, thankfully from women and men. Right, it
(24:56):
should because it just makes sense, Like it's called feminist
deacon mix, but it's actually economics that accounts for how
people actually live their lives. Like that's the less catchy titled, right,
which is good for everyone. What would you say, maybe
to your younger self, for two people today who might
be cynical and think, like, why does this matter? If
we invest enough money in enough places, all boats will rise?
(25:21):
What do you say to people who have that perspective
to help them understand, No, actually, we really need to
be investing in places where women and particularly black and
brown women have been historically excluded, because that's good for
you too. I turned the question on its head and say,
why wouldn't you want to collect all the data before
(25:41):
deciding where to invest your resources? It just doesn't make
sense that we're not collecting all the information, that we're
only collecting half of the information and making decisions based
on that. But it's just common sense, isn't it. You
want to have all the information at your disposal and
then you make your decision. And at the moment, we
are consistently making decisions based on only half of the
(26:03):
information that we need, and therefore we're making bad decisions,
we're making expensive decisions, we're wasting money. So essentially, I
would just challenge someone to defend the position that it
is better to make decisions without all the information at
your disposal. Well, I have something new to work on. Caroline.
Thank you so much for all your time. I'm hugely grateful.
(26:24):
Thank you very much for having me. Caroline's book is
Invisible Women, Exposing data bias in a world designed for men.
I was so inspired by Lauren Underwood's campaign for Congress back.
She's a registered nurse who has worked in public health policy,
(26:45):
and she beat in a cumbent to become the first
woman and first person of color to serve her district
in Illinois. She's also the youngest black woman ever to
serve in the United States. House of Representatives. After taking office,
she co founded the Black but Nal Health Caucus, which
is working to raise awareness about and solve the crisis
of black women's maternal mortality in America. I was thrilled
(27:08):
and honored to speak with Congresswoman Underwood, So thank you
Congresswoman Underwood, who assured me that I not only can,
but should call her Lauren for being here with me
today to talk about the real crisis that is sexism
as a public health issue. Before we dive into that,
(27:30):
I'd love if you could just share the story of
your career in advancing health care, which started well before
you came to Washington. Yes, well, thank you for having me.
I in third grade was diagnosed with the heart condition,
and that is really what sent me on a course
of interest in healthcare and improving the health and well
being of my community. I ended up picking nursing as
(27:50):
my career path, and during my second semester of freshman year,
I the course that changed my life Policy and politics
and nursing and health care. And I discovered this whole
field of health policy and was really fascinated by the
idea that we could change some laws and some policies
and improve the health and well being of people. We
could end disparities just by making some different policy choices,
(28:12):
and so I said, on this path that took me
to the Department of Health and Human Services, whereas a
career employee, I worked to implement the Affordable Care Act
for four and a half years. We love the a
c A. Over here. I joined the Obama administration, where
I worked on public health emergencies and disasters. We did
a Bola, we did Zekea, we did the water crisis
in Flint. And then I had this wild idea to
(28:34):
run for Congress after my Congress and then made a
promise during the time of Obamacare repealed the spring of
Seen that he would only support a version of repeal
to let people with pre existing conditions keep their healthcare coverage.
So here, I am a nurse who worked on the
a c A with a pre existing condition. I believed him.
And then literally two weeks later, he broke his word
(28:54):
voted for the American Health Care Act. I got really
upset and decided, you know what it's on, I'm running
and I want And so now I'm here in Congress
and I get to do this amazing work to improve
health and during the time of a pandemic. Obviously, I
think that my background and skill set have been a
value add to our nation. We know the pandemic isn't
(29:14):
the only public health crisis that we're confronting in our country,
and we have long had a maternal mortality crisis in
our country. One of the things my mom and I
talked about today is that it is far more likely
for women my age to die while giving birth than
it was when my mom gave birth to me. And
that reversal of progress and the burden of pain and
(29:36):
loss and grief has fallen most heavily on black and
brown mothers and families in our country. And I know
that the maternal mortality crisis, and especially the black women
maternal mortality crisis, has been a major focus of your
work in Congress. Is that something that you expected to
be a focus of your time in office? How did
(29:58):
you come to connect to this issue so passionately? Are
we doing now what we need to do to ensure
that everyone is able to deliver a child safely? Or
are we not there yet? So when I was I
was in graduate school in two thousand nine at Johns
Hopkins and I had a great friend. Her name was
Dr Salon Irving. She was a sociologist and gerontologist that
(30:19):
wanted to get an MPH and we connected and stayed
in touch after graduation, and while I was finishing up
my service in the Obama administration, she was preparing to
deliver her first child in January, and she gave birth
to a beautiful baby girl named Sleigh, and then three
weeks later we lost her. So we were talking about
a highly educated federal employee. She was a lieutenant commander
(30:42):
in the United States Public Health Service Commission Corps, had
a doctorate, had insurance, had healthcare, she got all her
prenatal care. She did everything right, and yet we lost her.
And that experience was so shocking, horrifying, devastating for me
because as a nurse, we learned that, you know, black
(31:02):
women were more likely to die of a pregnancy related complication.
In my clinical education, it was presented, oh, there's just
something about black women which is not quite right, but
and also not really science. E No, And then I
lost my friend. And then I made this major decision
right to run for Congress, And so I knew that
if I won my election that this would be an
(31:23):
issue that I wanted to tackle because the more and
more than I learned about this problem, that this disparity
has persisted my entire lifetime. I'm thirty four years old,
and we have not seen any kind of change or
progress in this disparity where Black birthing people are three
to four times more likely to die of pregnancy related complications,
(31:47):
and for every death, we have seventies seven zero near misses.
And so when I think about all the things that
we've tackled as a country, all the innovation and resources
that we have leaned in and problems that we've solved,
the idea that we would have this maternal health crisis
that has just been allowed to flourish, it's something that
(32:10):
I found unacceptable. And so when I was elected, I
was elected and became the youngest Black woman to ever
serve in Congress, and I knew that we had an
incredible opportunity to save lives, and we decided to jump in.
So I co founded and co chair the Black Maternal
Health Caucus with Congresswoman Alma Adams from North Carolina, and
(32:32):
together we drafted and introduced the Black Maternal Health Mommy
Bus Act, a comprehensive set of twelve bills to um
end our nation's maternal mortality crisis. We introduced it in
with then Senator Kamala Harris, and we've reintroduced it this
year with Senator Corey Booker, and we've already seen one
of our Mommy Bus bills past the House, and so
(32:53):
we're really excited about the progress that we can make
to save lives and this disparity. Do you inc if
this crisis affected men, just to be really blunt, there
would have been the same apathy effectively in our public
health discourse, in our lack of interventions that we've seen
(33:15):
in the maternal mortality crisis. I absolutely think that we
would have had more interventions, more solutions, and that the
disparity certainly would have been narrowed if this was something
impacting men only or the population at large, men and
women together. We live in a society and you know,
(33:37):
receive our health care in a system that by and
large views pregnancy as in many ways pathologic, that there's
something wrong and it requires these aggressive interventions. But we're
not necessarily seeing the kind of innovation and investment in
pregnancy and delivery and postpartum care as we do in
(34:00):
other areas of medicine, and so then when we see
something go wrong, we're not getting the investment to really
be precise in the data collection. We're not seeing the
level of investment and trying to figure out the evidence
based solutions that work across geography, because there are solutions
that are better in rural areas than in urban areas. Right.
(34:20):
There are solutions that work better for maybe tribal indigenous
communities than they do in suburban white communities. There are
interventions that work regardless of what language you speak, but
we don't have that kind of research being done to
understand this issue, or it's only more recently that that
kind of research is being done and implement at scale.
I think a lot of people are surprised when we
(34:42):
put forward the Mommy Bus and it was so big, right,
there are so many solutions and they weren't deplicative, right,
So we didn't even in the Mommy Bus. For example,
we didn't even touch Medicaid, which we know is a
major opportunity to save mom's lives because they are the
number one payer for for and deliveries in this country.
But there are so many areas requiring intervention that have
(35:06):
to happen in order to save lives, because this problem
is multi factor world. It's not just any one thing.
And I would have thought over the years we might
have been able to tackle a few of those. We
shouldn't have to put forward a twelve bill solution plus
everything else related to medicaid in order to really make
(35:27):
a dent in this problem. And yet here we are.
And I just want to say one other thing, Chelsea.
You mentioned that this is a crisis that's gotten worse
over time, and you're absolutely right. The United States leads
the industrialized world and maternal mortality, and that is not
an acceptable place to be. In my state of Illinois.
Last year, black women were six times more likely to
die the The new data just came out and now
(35:49):
black women are three times more likely to die because
white women started dying more, and so the disparity narrowed.
Not because not because health status improved, it's because it
got worse for everyone. We are moving in the wrong
direction and it's happening right in front of our faces.
(36:10):
We're taking a quick break. Stay with us, Lauren. I
want to go back to the importance of data collection.
I imagine for people listening to us, they might be
surprised to realize how little data we're collecting on expectant
(36:36):
and new moms, given how here in the United States,
the vast majority of births do occur in hospitals, and
we know that Medicaid is the number one payer, and
so I would think people listening would think, wait, hospitals
aren't collecting data, like Medicaid isn't collecting data, Like why
(36:57):
isn't this happening? Okay, So what's going on is that
for a death to be counted in most communities as
a pregnancy related complication, the cause of death needs to
explicitly list the pregnancy or explicitly list something in the
maternal health space. And so that is problematic because in
(37:20):
our country and around the world, the metric to recognize
maternal death is up to a full year postpartum, and
so there are a variety of causes of death that
a corner may not explicitly linked to that pregnancy on
the death certificate. So we have a bill within the Mommibus,
the Data the same Moms Act that congressmom Insurise David's
(37:42):
has introduced for us to make sure that we're cleaning
up and standardizing this data collection and reporting. We're making
it really easy and straightforward for local officials to capture
this information and giving our federal partners at CDC resources
to make that data available sooner so that we can
(38:03):
tackle this problem and be precise in our interventions. Well,
I think, Lauren, that's the important point. As much as
more data and more specific data is generally a good
priority and a good area of focus, it matters because
it then enables the type of precise interventions that you
were talking about earlier. So maybe you know, you could
(38:24):
just talk about how you help explain to your colleagues
or to your constituents that this is a big problem,
but actually a problem that contains a multitude of smaller
challenges within it. That's right, and so wow, I want
to start out at the macro level. We call this
the Black internal health Mommy Must Act. But everything is
addressing disparities related to the broad coalition of race and ethnicity,
(38:49):
because we know in certain communities there actually isn't the
disparity for black moms. It might be Hispanic moms, or
a PI moms or indigenous moms. I encourage people to
not be turned off or dissuaded thinking that this is
just a black problem. The second thing that I think
is really important is there's a lot of places where
we've just started looking away, and we can't look away.
We can't turn away. So, for example, I introduced one
(39:12):
of the bills about veteran moms. The v A is
a federally run health care system, and this is a
responsibility that we have when governing to make sure that
our nation's heroes are not dying because they want to
have babies. Right, this is something that we are responsible for.
The Federal Bureau of Prisons, same type of problem. Just
(39:34):
because people are incarcerated does not mean that they should
not have dignity and their health care. They shouldn't be
able to have their babies and be alive afterwards. Right.
We shouldn't see these level of disparities and death happening
with people in federal custody. And those are just the
federal examples. Then we have the challenges of healthcare providers.
(39:57):
But Chelsea, you're a mom. I can imagine that when
you found out you were expecting, it was a big choice.
Who do you see? Who do you want to be
on that birthing team with you, and you took it seriously,
most likely picking your provider, whether it was a midwife
or an obie. You picked the health care system or
the birthing center that you use. Many families don't have
(40:20):
that choice. They don't have that choice between obie's or
midwives or nurse midwives. They don't have the choice to
even pick a doula. They don't have a choice of
obtaining a lactation consultant. And then when you get down,
drilled down, they don't have a choice to pick somebody
that shares the same language or cultural background as they do.
They don't get to pick somebody who has maybe the
(40:42):
same race or ethnicity or religious practices as they have.
And so we want every birthing person in this country
to have a choice and providers to feel confident and
entering into that space again, whether it's a hospital or
not at home, a clinic, whatever, entering that space with
confidence that they will be heard and listened to and
(41:02):
responded to and safe because, as we know, during COVID,
there was an instruction, explicit instruction that told people to
stay out of our health care systems, and for birthing people,
that meant that their partner, their spouse, there's best friend
or mom, their dula was not welcome into that delivery
room or birthing space with them. And so now they
(41:23):
were alone and isolated and fearful, recognizing that even pre pandemic,
the disparities existed. And what do we find out that
there's this combination between COVID infection and being black or
brown that yielded significantly more negative birth outcomes. And then
to be alone and scared is something that should not
(41:46):
be happening in this country. And so we responded really
quickly developing COVID specific maternal health legislation. And yet even
right now we don't have a nationwide recommendation around vaccination
and treatment for pregnant, postpartument and lactating people. It's unacceptable. Well,
I certainly agree with that. I would also say this,
(42:07):
a lot of the progress that we have been making
in the maternal health space has happened at the local level.
There are many geographically focused groups that are leaders, who
are trusted voices, and we need to be seeking them out,
flooding them with resources, and centering them in these conversations.
We have these resources that are small, It might just
(42:30):
be a collective a duelists that are vocal and organized
and are watching the trends on the ground. But then
there's also an opportunity at the health system level for
them to be examining their data and making that available
more publicly, initiating community conversations based on trends that they're seeing,
and you know, being leaders, being leaders, that's what this is.
(42:52):
This is a leadership challenge, and there are roles that
we can all play. One of the things that I've
been really excited about is we have this great convening
power and Congress. Right everything doesn't require a legislative solution.
Sometimes you just need to bring folks together around a
table and illicit commitments from industry, from local electives, from
(43:12):
you know, state and local public health, and then work
together in this collaborative way. And I think that will
be able to move through this COVID recovery, especially in
this maternal health space, on the strength of those relationships,
those coalitions, and those commitments. I do want to ask
about the ways in which we can I think be
(43:32):
comfortable in asserting with certainty what we know and also
being clear about what we don't know. Because I do think,
especially when it comes to expect it and new moms,
we actually still don't know a lot and we do
need to be candid about that because often pregnant women,
new moms, lactating moms are excluded from clinical trials. So
(43:57):
how do you, both with your nurse hat On and
your Congresswoman had On, think about asserting with certainty what
you and we the broader public health community know, and
also being honest and forthright about what we don't. You
are absolutely right, there's been some challenges around vaccination in
general with expectant moms, and so we actually put in
(44:19):
the Mommy Bus and Maternal Vaccination Act that Terry stew
will introduce to do some really focused and targeted public
health communication and education campaigns about the safety of just
vaccines at large during this important prenatal and postpartum period.
And I think that as clinicians we need to be
(44:40):
very clear about the importance of vaccines for mom and baby.
You know, the conversation around vaccines I think in this
space has always focused on baby, right, and that initial
conversation with the pediatricians keeping the vaccination schedule, making sure
that everybody is comfortable but not about mom's help well being.
And I think that this is an opportunity for us
(45:04):
to broaden that conversation and make sure that if there
is a need for you know, remedial education so to speak,
that that we're taking advantage of it, especially while people
have healthcare coverage, right because we're talking about sometimes in
some states this is the only opportunity that someone will
have healthcare is during the time that they're pregnant and
that postpartum period. Or The last question I want to
(45:27):
ask is, if you're able to really pass the and
I hope you are, the twelve Bill, Mommy Omnibus Act,
do you think that then as a template for other
forms of big coordinated public health leadership from Congress in
other areas of health inequity, especially as it relates to women.
(45:50):
I absolutely think it could be a template. One of
the things that I think people assume is that Congress
works on the most important issues facing our country. That's
not That's not true. Congress works on the issues that
members raise. And this is why representation matters, because if
you change who is serving in a body, you're gonna
(46:11):
get different issues put onto that agenda. And what I
have found is as immediately. As soon as we elevated
this issue, maternal health, maternal mortality, these disparities, people were
excited about the solutions. They wanted to help and be involved.
Some people didn't know, some people had forgotten, some people
didn't know it had gotten this bad. But people care
(46:34):
that these issues just need a champion. It's been overwhelming
the support around the country from industry, from providers, from clinicians,
from moms, from nonprofit space, and leaders. We've had leadership
outside the government for so long, it just hadn't had
a home, hadn't had a hub in government. And so
I am very optimistic that we're going to be able
(46:55):
to solve a lot of these problems. But I do
think that we are going to have to continue to
be committed to electing a Congress that looks like the
American people if we continue to count on other people
to solve our problems when we're waiting a long time. Well,
Lauren Congress underod You're not my congresswoman, but I'm very
grateful that you're in our Congress. Thank you so much
(47:17):
for your time and even more for everything you're doing
every day. Thank you for having me, and thank you
for continuing to speak truth on these issues where we
can do better, and I believe that together we will.
You can keep up with Congresswoman Underwood on social media.
At Rep Underwood today, we talked about just a few
(47:40):
of the way sexism and gender bias in fact health outcomes.
We can't solve the public health crisis that is sexism
until we name it in China, light on it. That's
why I'm so grateful to Caroline Creata Prez and congress
Woman Underwood for bringing attention to this topic and for
calling for the changes we so desperately need. I started
this podcast because more people than ever before or are
talking about public health right now, and I hope that
(48:03):
we could use this moment to broaden our understanding of
what public health is. Yes, it encompasses things like pandemics,
and it also includes vaccines, mental health, gun violence, prevention,
reproductive rights, environmental justice, climate change, substance use disorders, HIV AIDS,
racial justice, and so much more. I'm so grateful to
(48:24):
all the guests who have joined me this season to
talk about the lessons we can learn from other important
moments in public health, And of course I'm grateful to you,
our listeners for being part of these conversations. So thank
you so much for listening. Please keep lifting up the
voices of scientists and public health experts. We look out
one another, and please stay safe. In Fact is brought
(48:46):
to you by iHeart Radio. We're produced by Erica Goodmanson,
Lauren Peterson, Cathy Russo, Julie Subrin, and Justin Wright, with
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(49:08):
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Apple Podcasts.
Hi, I'm Chelsea Clinton, and this is in fact a
podcast about why public health matters even when we're not
in a pandemic. We know that misogyny and sexism affect
the way women are treated every day, but the problem
is even bigger and more systemic than it might seem
(00:23):
as well. Here today, sexism is baked into everything from
how cars are tested for safety to the way women
and especially women of color, are treated by doctors and hospitals,
and the results can be deadly. We don't often talk
about sexism as a public health crisis, but that's exactly
what it is. Later, I'll be talking with Congresswoman Lauren
Underwood from Illinois, who has made maternal health one of
(00:45):
her top priorities. But first, I'm delighted to be speaking
with Caroline Creato Peretz. Caroline is a writer and advocate
whose best selling book Invisible Women, exposing data bias in
a world designed for men. It's the many mind boggling
with is that sexism shapes the world around us and
puts women at risk. As you're about to hear, I
(01:08):
was recovering from strep throat and we spoke, so my
voice was a little horse during our conversation, thank you
for being here and having this conversation with me, even
with my raspy voice. Well, thank you for having me.
So I know your expertises on data and gender, and
I just thought maybe we could start with you explaining
(01:29):
what that means and what you do. What I really
work on is what's called the gender data gap they
like the gender pay gap, but in data. And basically
what that means is that the vast majority of information
that we've collected globally and continue to collect, everything from
(01:49):
transport data to economic data to medical data, has been
collected almost exclusively on men, both male bodies and typical
male lifestyle patterns. And that means that the vast majority
of pretty much everything you've come across in the world
has been designed to work better for men. So I
work on the gender data gap and also both its
(02:10):
causes and consequences. And I'm particularly interested in its causes actually,
because the cause I've identified is one that I identified
in myself, first of all, which is our tendency to
when we think of a human being, to think of
a man, and how subconscious that is that we don't
notice that we're doing it. And so it ends up
with ridiculous situations like using a car crash test dummy
(02:34):
based around the average male body and thinking that is
a good fit for the average human body for everyone, right.
And so I find this bias fascinating because it's not malicious,
it's not deliberate, it's just something we don't even notice
that we're doing. And yet it has these huge ramifications.
And Galan, how did you first notice that in yourself?
You said you first got interested in this when you
(02:54):
realize that you had this default to human equals male,
and so of human equals well, all of us. I
discovered it in myself when I was in my mid twenties.
I went to university as a mature student, and prior
to this point, actually I've been pretty anti feminist. I
instinctively felt that it wasn't for me, and that it
(03:15):
was just kind of embarrassing that it was painting women
as victims, and I didn't like it. And I had
to read this book called Feminism and Linguistic Theory. I
was studying English language and literature, and the author of
the book, Debbie Cameron, referred to this issue with generic
masculine in grammar. So in English that would be he
to mean he or she man to meet humankind using
(03:37):
the male form as the gender neutral form. And I think,
like a lot of people, I had heard about this
before and just dismissed it as just incredibly stupid and facile.
Who cares what prow noun you use. Everyone knows it's
gender neutral. But then she pointed to studies that show
that actually, when people read or hear these words, they
picture a man. And that just completely blew my mind
(03:58):
for two reasons. One that I realized I was doing that,
but also I just thought, how have I never noticed
this before? You know, it's just staggering to me that
despite having heard these conversations about generic masculine excluding women,
it had never been something that I've noticed in myself
that I was picturing men. And then gradually I started
(04:19):
realizing how it went much further than that. And actually
it was when I was picturing anyone, lawyer, doctor, professor, writer,
I was just always picturing men. And it has to
be said, actually I was picturing white men. That was
my standard default for what a human looks like is
a white man. And I just found that incredible. And
so I think because that's the way I came into feminism,
(04:40):
I was really primed to notice it when it cropped
up in other areas. So the next thing that I
studied was behavior economics and feminist economics, and economics is
just riddled with the default mail. The way that we
count GDP is set up to wholly exclude the unpaid
work that mainly women do that props up the formal economy,
(05:01):
for example, but we just don't count in. As a
result of not counting it, we undervalue it, and then
we design economies and allocate resources in a totally skewed
way to the detriment of everyone. Actually, so I was
just noticing all of these examples building up and starting
to see that this was just entirely systemic and entirely
hidden because all of these things are presented as gender neutral.
(05:23):
And then eventually I came across the fact that it
appears in the medical profession as well. So it first
came across my attention when I was researching my first book, actually,
and I came across this paper talking about female heart
attack symptoms, and I just thought, wait, what isn't an
heart attack pain in your left chest and down your
(05:44):
left arm, And yeah, it is for men, and it
can be for women, but actually a lot of women
don't experience that. A lot of women present very differently exactly.
Women tend to present more with what feels like indigestion, breathlessness, fatigue, nausea,
and women aren't reckoned. I think that they're having a
heart attack because we have this very strong public health
message that it's painting the chest down your left arm.
(06:07):
But even more shocking to me was that doctors are
misdiagnosing women as well, because we're not necessarily training all doctors,
you know, it's not part of the curriculum to teach
a whole host of different symptoms for various diseases that
do exist, and it's not just heart disease. And so
discovering that you had this default male even in medicine,
even in medicine, it was just so so shocking, It
(06:30):
was so shocking, and at that point I just thought,
I have to write about this. This is just too big,
This is too huge, and so can you just share
some other examples that you probably found equally shocking of
the ways in which medicine, public health, and science have
effectively excluded women. You know, I could go on all
day giving you examples. They're really shocking. I think for me,
(06:55):
one of the things that was most frustrating was the
excuse use that I heard time and time again for
why women and female animals and female cells, because it's
not just in humans were excluded from research, and Karlin,
I think that's an important point, right, like that for
anyone listening to us who also may not know that
(07:17):
the majority of animal studies that are the precursor to
human trials you have historically been done on male mice
and other male animals. So the gender bias starts from
the beginning of a research design and experimentation. But Chelsea,
even in cells, we test on male cells. And that's
(07:41):
just staggering because one of the main excuses is, well,
there's too many excuses. One is women don't want to
participate in research, and the other is do people actually
say in it, Yeah, yeah, that women. You know, it's
just too difficult to recruit women. Interestingly, not when it
comes to cosmestic research. Their women dominate. That is the
one area I found that actually apparently you can find
(08:03):
women to take part in trials. But yeah, the big excuses,
it's really difficult to recruit women, and also that female
bodies are too complicated, and basically what they mean by
that is they're too hormonal. Congratulations us, Yeah, I got
this menstrual cycle and nobody knows what's going on there.
Better not look into that box because who knows what
you might find. And so that is why they have
(08:25):
historically excluded females and continue to exclude females. But as
you start going from humans, you're like, right, you've got
the sort of women. Women are actually more busy, they
have less leisure time because they're doing a lot of
unpaid care work. So there are ways around that of
designing the times that you do it, of making the
centers more accessible so it's easier for women to get to.
(08:45):
But that is a legitimate issue. But then you start
looking at mice, and we'll like, mice don't have any
care giving responsibilities, so that excuse goes out the window.
But they've still got, you know, these pesky hormonal bodies.
And then you look at cells, Right, cells do not
have a menstrual cycle, and they definitely don't have care
giving responsibilities, and yet still we are using male cells.
(09:07):
And let me give you an example of why this matters.
There was a really fascinating study done, I believe in
twenty sixteen that I reported on an invisible women, where
they exposed male and female cells to estrogen and then
exposed them to a virus. It was the flu virus
in this case, and what they found was that the
(09:27):
male cells didn't respond to the estrogen and they weren't
able to fight off the virus, but the female cells
were able to use the estrogen to fight off this virus. Now,
if you think about the fact that the vast majority
of cell stage research is done in male cells, it
just blows your mind to think of how many medications,
treatments that could have worked for women have we missed
(09:49):
out on because we excluded them at the cell trial stage.
And one of the things we know about COVID is
that women have been more likely to survive it than men.
But crucially, we don't really you understand the mechanisms behind it,
which has seriously and definitely hampered our ability to fight it.
When I wrote the book, I started from the position
of this is very bad for women, but now we
(10:11):
see from this pandemic, actually it's not just bad for women.
You know, it hampers our understanding of humans overall and
the human body and treatments that could work. And of course,
on the other side, when you think about vaccines and
the fact that women are represent the vast majority of
those who suffered side effects, including the more serious anaphylactic reactions.
(10:31):
But we did it take into account the menstrual cycle
when it came to vaccine research. We didn't investigate sex
specific dosages, even though we have known for a really
long time actually that women may require lower dosages, both
not just because of the size, but also because of
the far more active female immune system. What do you
see if you see any point of progress here or
(10:55):
not yet, there has been progress. I mean that cell
study that are of heard too. That is progress that
was led by this amazing woman called sab Recline, who
has done a lot of this kind of research, and
actually a lot of this research is being led by women.
It's a really interesting study that found that actually the
gender makeup of the researchers does actually make a difference
(11:18):
to whether or not they do sex analysis and whether
or not they sex to saggregate their data. And surprise,
if you have a female lead researcher you're much more
likely to find that the research has done this sex
analysis that is so important. On the other hand, I
have never seen so much media coverage of this as
an issue, from looking at the impact of lockdowns on
(11:41):
domestic violence, to reporting the fact that the vaccine hasn't
been researched in pregnancy, to reporting about side effects differential
side effects between men and women. That's been a huge,
huge difference. If you look back at a Bowler and Zeeker, actually,
both of which had very very obvious sex differential impacts.
(12:01):
Women were more likely to die during the Ebola epidemic,
not because they were more susceptible, but because their care
giving roles, and of course in Zeka it particularly affected
pregnancy and fetal development. But only one per cent of
published studies on Zeker and Ebola looked at sex or gender.
And yet here for COVID that's not been what I've
(12:22):
witnessed at all. I've never seen such huge coverage of
these issues, and I think that is huge. I really
think that's huge. We'll be right back to stay with us.
(12:44):
You spoke earlier about how during COVID you've seen more
coverage than ever before of how women have been affected
by the disease, but affected by treatments for the disease.
Are there other way is that you've seen the pandemic
affect women, and even more, have you seen the gender
(13:06):
data gap positively or negatively affected by the pandemic. I
wouldn't say I was surprised by the differential economic impact,
but from the perspective of gender data gap, I think
it has been positive to see a this being reported
in a way that I've never seen before. I've never
(13:27):
seen so much awareness of how crucial the care industry is.
And I say industry, but i'm including of course unpaid
care work, but how things come to a grinding halt
when there's no one there to take care of the kids,
and how crucial it is to have childcare provided if
you want women to engage in paid labor, and of
(13:49):
course countries do need women to engage in paid labor,
and so seeing those conversations happen has been kind of amazing.
But then, on the other hand, felt hopeful at the
beginning of well the earlier stages of the pandemic, that
perhaps this was going to signal a shift. But then
you know, if you look at several types of economic
(14:11):
recovery plans. It just feels like we're falling back on
old ways of doing things without having learned the lessons
of the pandemic, which is actually care and health are
really important and maybe we should pay them better. So,
for example, in the UK, we had our recovery plan
in the summer of and then of course we had
another wave and another lockdown. But the slogan for that
(14:33):
recovery was build back better, And basically it was all
focused on construction, literally, built back back, literally, build back better.
And what do we know about construction, Well, we know
the construction is heavily male dominated. And what do we
know about the economic fallout of COVID, Well we know
that it's been heavily dominated by women. Right, women are
(14:53):
the ones who are much more likely to have lost
their jobs to have had to go part time, both
because of the types of jobs women are more likely
to be working in. And again this has been doubly
or trip lely so for women of color, and yet
there has been little to no recognition of that in
terms of the recovery. And by the way, this is
(15:14):
not a new problem. There has been research looking at
the US various European countries finding that if you invest
in the care industry as opposed to the construction industry,
you will create as many jobs for men, but far
more jobs for women, and you'll get as good a return,
if not better, on GDP. So there's the economic argument
for investing in the care industry. Was already there throwing
(15:37):
COVID and suddenly how important the care industry has become,
and it makes zero economic sense to immediately fall back
on jobs for the boys and construction. And yet that's
what we end up doing. And how much of that
do you think has to do with inertia? And how
much of that do you think has to do with
who's better specifically largely men, white men, And how much
(16:00):
of that do you think has to do with construction
is more visible, and often care is more invisible, even
though it's clearly a part of, if not all, of
most of our lives. It definitely will also have something
to do with whose in power. There is very good
research on this going back decades showing that the more
(16:20):
women you have in a country's parliament, the more money
gets spent, for example, on education, or the more time
gets spent discussing issues that affect women, right, It's very
clear that women have a different set of priorities to men,
and therefore it makes sense to have a balance of
people in power so that the balance of citizens is
(16:41):
adequately represented. So that will be part of it. But
I think also, and this is probably the hardest one
to address, is inertia, the status quo bias. We don't
like change. We do like doing the same thing over
and over again, even we know it doesn't work. It's infuriating. Oka,
And we've talked a lot about medicine science from a
research perspective. I wonder, though, if you could share other
(17:05):
areas where you've seen the gender data gap. Well, I'll
start with the crash test dummies, because I feel like
that one's almost the most blatant example, because it's like
a literal man. Right. So, historically, the only car crash
test dummy that was used, and it's still the most
commonly used car crash test dummy in tests, was based
(17:26):
on the body of an average American male, and that
body is obviously too large and too heavy to represent
the average female of any country. But it's more than that.
Women aren't just small men essentially, and so they have
created a very very scaled down male dummy, which they
call a female dummy, but it doesn't represent differences, for example,
(17:50):
in spinal flexibility. It doesn't represent differences in muscle mass distribution,
so for example, men tend to carry more muscle on
their shoulders and their necks than women. Doesn't represent pelvic differences,
all of which are very important when you're coming to
preventing injuries in a crash. Seatbelts, for example, as well
haven't been designed to accommodate breast tissue. We haven't designed
(18:11):
a seatbelt that is safe for pregnancy. And the result
of all of this is that women, if they get
into a car crash, are more likely to be seriously
injured than a man in the same car crash and
sevent more likely to die. Essentially, that comes down to
not having tested it on a body that represents the
(18:32):
female body. But you will find some people saying, oh, well,
maybe the female body just is I don't know, naturally
weaker or something than that's why they die. But there's
a really interesting example if you look at whiplash prevention systems,
and there are two main types which were introduced in
the past couple of decades, and one of them reduced
(18:53):
whiplash frequency for men, who, by the way, were less
likely to suffer from whiplash than women. Anyway, reduced it
for men, but actually increased it for women, whereas the
other most common whiplash prevention system, which was used in
Volvo and Toyota, I believe, decreased it for both men
and women. So there are clearly design issues going on
(19:14):
here that if you account for the female body, you
can create a safer car for both men and women,
but if you don't count for the female body, you
can end up creating a safer car for men that
ends up being more dangerous for women. Karlin, that's just
shocking to me. I know most people don't know that
this is a problem. Well I didn't know this was
(19:35):
a problem. And I think I'm like a pretty well
educated person and consumer. So are there other kind of
equally egregious examples, And I want to depress you, but yes,
most things. So one example I came across recently that
made me pretty infuriated. I'm a runner, and I'm a runner.
(19:57):
You buy women's running shoes, right, I do buy women's
running shoes. You don't. You don't buy women's running shoes.
You buy scale down men's running shoes, and that is
why women are more likely to suffer from injuries, because
the vast majority of shoes are designed around the mold
of a male foot. But actually women's feet aren't just
small men's feet. So women have narrower heels in proportion
(20:18):
to their toe box. And so if you have a
shoe that is designed around a male lust, what women
find is if it fits their heels, it's too narrow
on their toes, and vice versa, it fits their toes,
it's too wide on their heels. There are, however, some
companies that are actually designing around a female, but the
vast majority say that they are women's shoes, and they're
(20:39):
actually just scaled down men's shoes. And the more you
look around, the more you sort of it's going to
start to drive you crazy. I'm sorry, You'll start looking
at things and going does this not work for me
because I'm a woman. Okay, So crash test stummies running shoes.
What about are built environment and where we spin time
(21:00):
or our homes, our office buildings or parks. Two of
my favorite examples. One of them is quite quick to
tell if you've ever worked in an office, you may
well have noticed that in the summer the men are
all wandering around in their shirts and the women are
snuggling under blankets because they're freezing. And there's a very
good reason for that. The formula used to determine office
(21:21):
temperature was based around you'll never guess the average American
mail Yes, the metabolic resting rate of an average fort
to year old man. And it turns out that women's
metabolic resting rate is lower, and so the average office
is about five degrees too called for women, and the
(21:42):
other one actually is also it's also about being cold,
specifically when it's snowing. And this is just such a
fascinating example, I think because I'm going to talk to
you about snow clearing, and the idea that snow clearing
could be sexist just sounds so ridiculous. But as soon
as you start thinking about it, you sort of realized, yeah, okay,
that actually does make sense, So let me make the
case for you. It came about in Sweden in a
(22:04):
town called carlst Skoger, and they were doing a gender
audit of all their policies, which you know is so
Swedish we all just need to move to Sweden. Anyway.
They're doing a gender of all their policies, and someone
actually made a joke about the snow clearing, and we're like, oh,
we should check the snow clearing because they'll never be
able to find anything wrong with that, But actually they did.
They were clearing the roads in an order that privileged
(22:25):
male typical travel over typical female travel. So this is
something that holds around the world. Men and women tend
to travel differently, So men are much more likely to drive,
women are more likely to use public transport. That's partly
like women are more likely to be poorer than men,
but also if a household has a car, men tend
to dominate access to it. And men also have a
(22:48):
much simpler travel pattern of basically commuting in and out
of work A to B. Women, because they are usually
combining unpaid work with paid work, have a much more
complicated type of travel, which is lots of short, interconnected trips,
and that's called trip chaining, and that's things like you're
dropping the kids off at school before you go into work,
maybe you're picking up some groceries on the way home,
(23:10):
dropping in on an elderly relative they're dotting around the place.
This sounds very familiar, I'm sure it does. And so
women as a result basically are more likely to be walking,
and they're more likely to be using local roads, whereas
men are more likely to be using main roads. And
the way that the town council in Calstkoga had always
(23:31):
cleared their roads was clearing the main thoroughfairs first and
then the sidewalks and the local roads. So they decided, well,
let's switch it around. It's easier to drive a car
through three inches of snow than it is to push
a buggy or to walk. Not only did they find
that it didn't cost them any more money, it actually
saved the money off their healthcare bill. And the reason
(23:52):
for that is that, yes, it is harder to push
a buggy or walk through three inches of snow. The
majority of single person accidents during the winter months were pedestrians,
and the majority of those pedestrians were women, and the
entire cost of those injuries was three times the winter
(24:14):
road maintenance. So just there's little shift in the schedule.
By paying attention to how men and women travel around
the city, save them this huge bunch of money on
the question of gender audits. Since you mentioned Sweden was
conducting a gender audit, are other countries taking a similarly
(24:36):
clear eyed view to really determine where there are biases
against women effectively? Really interestingly, and this is on my
list to look into. Hawaii came up with a feminist
economics recovery plan from COVID which seems to have quite
broad based support, thankfully from women and men. Right, it
(24:56):
should because it just makes sense, Like it's called feminist
deacon mix, but it's actually economics that accounts for how
people actually live their lives. Like that's the less catchy titled, right,
which is good for everyone. What would you say, maybe
to your younger self, for two people today who might
be cynical and think, like, why does this matter? If
we invest enough money in enough places, all boats will rise?
(25:21):
What do you say to people who have that perspective
to help them understand, No, actually, we really need to
be investing in places where women and particularly black and
brown women have been historically excluded, because that's good for
you too. I turned the question on its head and say,
why wouldn't you want to collect all the data before
(25:41):
deciding where to invest your resources? It just doesn't make
sense that we're not collecting all the information, that we're
only collecting half of the information and making decisions based
on that. But it's just common sense, isn't it. You
want to have all the information at your disposal and
then you make your decision. And at the moment, we
are consistently making decisions based on only half of the
(26:03):
information that we need, and therefore we're making bad decisions,
we're making expensive decisions, we're wasting money. So essentially, I
would just challenge someone to defend the position that it
is better to make decisions without all the information at
your disposal. Well, I have something new to work on. Caroline.
Thank you so much for all your time. I'm hugely grateful.
(26:24):
Thank you very much for having me. Caroline's book is
Invisible Women, Exposing data bias in a world designed for men.
I was so inspired by Lauren Underwood's campaign for Congress back.
She's a registered nurse who has worked in public health policy,
(26:45):
and she beat in a cumbent to become the first
woman and first person of color to serve her district
in Illinois. She's also the youngest black woman ever to
serve in the United States. House of Representatives. After taking office,
she co founded the Black but Nal Health Caucus, which
is working to raise awareness about and solve the crisis
of black women's maternal mortality in America. I was thrilled
(27:08):
and honored to speak with Congresswoman Underwood, So thank you
Congresswoman Underwood, who assured me that I not only can,
but should call her Lauren for being here with me
today to talk about the real crisis that is sexism
as a public health issue. Before we dive into that,
(27:30):
I'd love if you could just share the story of
your career in advancing health care, which started well before
you came to Washington. Yes, well, thank you for having me.
I in third grade was diagnosed with the heart condition,
and that is really what sent me on a course
of interest in healthcare and improving the health and well
being of my community. I ended up picking nursing as
(27:50):
my career path, and during my second semester of freshman year,
I the course that changed my life Policy and politics
and nursing and health care. And I discovered this whole
field of health policy and was really fascinated by the
idea that we could change some laws and some policies
and improve the health and well being of people. We
could end disparities just by making some different policy choices,
(28:12):
and so I said, on this path that took me
to the Department of Health and Human Services, whereas a
career employee, I worked to implement the Affordable Care Act
for four and a half years. We love the a
c A. Over here. I joined the Obama administration, where
I worked on public health emergencies and disasters. We did
a Bola, we did Zekea, we did the water crisis
in Flint. And then I had this wild idea to
(28:34):
run for Congress after my Congress and then made a
promise during the time of Obamacare repealed the spring of
Seen that he would only support a version of repeal
to let people with pre existing conditions keep their healthcare coverage.
So here, I am a nurse who worked on the
a c A with a pre existing condition. I believed him.
And then literally two weeks later, he broke his word
(28:54):
voted for the American Health Care Act. I got really
upset and decided, you know what it's on, I'm running
and I want And so now I'm here in Congress
and I get to do this amazing work to improve
health and during the time of a pandemic. Obviously, I
think that my background and skill set have been a
value add to our nation. We know the pandemic isn't
(29:14):
the only public health crisis that we're confronting in our country,
and we have long had a maternal mortality crisis in
our country. One of the things my mom and I
talked about today is that it is far more likely
for women my age to die while giving birth than
it was when my mom gave birth to me. And
that reversal of progress and the burden of pain and
(29:36):
loss and grief has fallen most heavily on black and
brown mothers and families in our country. And I know
that the maternal mortality crisis, and especially the black women
maternal mortality crisis, has been a major focus of your
work in Congress. Is that something that you expected to
be a focus of your time in office? How did
(29:58):
you come to connect to this issue so passionately? Are
we doing now what we need to do to ensure
that everyone is able to deliver a child safely? Or
are we not there yet? So when I was I
was in graduate school in two thousand nine at Johns
Hopkins and I had a great friend. Her name was
Dr Salon Irving. She was a sociologist and gerontologist that
(30:19):
wanted to get an MPH and we connected and stayed
in touch after graduation, and while I was finishing up
my service in the Obama administration, she was preparing to
deliver her first child in January, and she gave birth
to a beautiful baby girl named Sleigh, and then three
weeks later we lost her. So we were talking about
a highly educated federal employee. She was a lieutenant commander
(30:42):
in the United States Public Health Service Commission Corps, had
a doctorate, had insurance, had healthcare, she got all her
prenatal care. She did everything right, and yet we lost her.
And that experience was so shocking, horrifying, devastating for me
because as a nurse, we learned that, you know, black
(31:02):
women were more likely to die of a pregnancy related complication.
In my clinical education, it was presented, oh, there's just
something about black women which is not quite right, but
and also not really science. E No, And then I
lost my friend. And then I made this major decision
right to run for Congress, And so I knew that
if I won my election that this would be an
(31:23):
issue that I wanted to tackle because the more and
more than I learned about this problem, that this disparity
has persisted my entire lifetime. I'm thirty four years old,
and we have not seen any kind of change or
progress in this disparity where Black birthing people are three
to four times more likely to die of pregnancy related complications,
(31:47):
and for every death, we have seventies seven zero near misses.
And so when I think about all the things that
we've tackled as a country, all the innovation and resources
that we have leaned in and problems that we've solved,
the idea that we would have this maternal health crisis
that has just been allowed to flourish, it's something that
(32:10):
I found unacceptable. And so when I was elected, I
was elected and became the youngest Black woman to ever
serve in Congress, and I knew that we had an
incredible opportunity to save lives, and we decided to jump in.
So I co founded and co chair the Black Maternal
Health Caucus with Congresswoman Alma Adams from North Carolina, and
(32:32):
together we drafted and introduced the Black Maternal Health Mommy
Bus Act, a comprehensive set of twelve bills to um
end our nation's maternal mortality crisis. We introduced it in
with then Senator Kamala Harris, and we've reintroduced it this
year with Senator Corey Booker, and we've already seen one
of our Mommy Bus bills past the House, and so
(32:53):
we're really excited about the progress that we can make
to save lives and this disparity. Do you inc if
this crisis affected men, just to be really blunt, there
would have been the same apathy effectively in our public
health discourse, in our lack of interventions that we've seen
(33:15):
in the maternal mortality crisis. I absolutely think that we
would have had more interventions, more solutions, and that the
disparity certainly would have been narrowed if this was something
impacting men only or the population at large, men and
women together. We live in a society and you know,
(33:37):
receive our health care in a system that by and
large views pregnancy as in many ways pathologic, that there's
something wrong and it requires these aggressive interventions. But we're
not necessarily seeing the kind of innovation and investment in
pregnancy and delivery and postpartum care as we do in
(34:00):
other areas of medicine, and so then when we see
something go wrong, we're not getting the investment to really
be precise in the data collection. We're not seeing the
level of investment and trying to figure out the evidence
based solutions that work across geography, because there are solutions
that are better in rural areas than in urban areas. Right.
(34:20):
There are solutions that work better for maybe tribal indigenous
communities than they do in suburban white communities. There are
interventions that work regardless of what language you speak, but
we don't have that kind of research being done to
understand this issue, or it's only more recently that that
kind of research is being done and implement at scale.
I think a lot of people are surprised when we
(34:42):
put forward the Mommy Bus and it was so big, right,
there are so many solutions and they weren't deplicative, right,
So we didn't even in the Mommy Bus. For example,
we didn't even touch Medicaid, which we know is a
major opportunity to save mom's lives because they are the
number one payer for for and deliveries in this country.
But there are so many areas requiring intervention that have
(35:06):
to happen in order to save lives, because this problem
is multi factor world. It's not just any one thing.
And I would have thought over the years we might
have been able to tackle a few of those. We
shouldn't have to put forward a twelve bill solution plus
everything else related to medicaid in order to really make
(35:27):
a dent in this problem. And yet here we are.
And I just want to say one other thing, Chelsea.
You mentioned that this is a crisis that's gotten worse
over time, and you're absolutely right. The United States leads
the industrialized world and maternal mortality, and that is not
an acceptable place to be. In my state of Illinois.
Last year, black women were six times more likely to
die the The new data just came out and now
(35:49):
black women are three times more likely to die because
white women started dying more, and so the disparity narrowed.
Not because not because health status improved, it's because it
got worse for everyone. We are moving in the wrong
direction and it's happening right in front of our faces.
(36:10):
We're taking a quick break. Stay with us, Lauren. I
want to go back to the importance of data collection.
I imagine for people listening to us, they might be
surprised to realize how little data we're collecting on expectant
(36:36):
and new moms, given how here in the United States,
the vast majority of births do occur in hospitals, and
we know that Medicaid is the number one payer, and
so I would think people listening would think, wait, hospitals
aren't collecting data, like Medicaid isn't collecting data, Like why
(36:57):
isn't this happening? Okay, So what's going on is that
for a death to be counted in most communities as
a pregnancy related complication, the cause of death needs to
explicitly list the pregnancy or explicitly list something in the
maternal health space. And so that is problematic because in
(37:20):
our country and around the world, the metric to recognize
maternal death is up to a full year postpartum, and
so there are a variety of causes of death that
a corner may not explicitly linked to that pregnancy on
the death certificate. So we have a bill within the Mommibus,
the Data the same Moms Act that congressmom Insurise David's
(37:42):
has introduced for us to make sure that we're cleaning
up and standardizing this data collection and reporting. We're making
it really easy and straightforward for local officials to capture
this information and giving our federal partners at CDC resources
to make that data available sooner so that we can
(38:03):
tackle this problem and be precise in our interventions. Well,
I think, Lauren, that's the important point. As much as
more data and more specific data is generally a good
priority and a good area of focus, it matters because
it then enables the type of precise interventions that you
were talking about earlier. So maybe you know, you could
(38:24):
just talk about how you help explain to your colleagues
or to your constituents that this is a big problem,
but actually a problem that contains a multitude of smaller
challenges within it. That's right, and so wow, I want
to start out at the macro level. We call this
the Black internal health Mommy Must Act. But everything is
addressing disparities related to the broad coalition of race and ethnicity,
(38:49):
because we know in certain communities there actually isn't the
disparity for black moms. It might be Hispanic moms, or
a PI moms or indigenous moms. I encourage people to
not be turned off or dissuaded thinking that this is
just a black problem. The second thing that I think
is really important is there's a lot of places where
we've just started looking away, and we can't look away.
We can't turn away. So, for example, I introduced one
(39:12):
of the bills about veteran moms. The v A is
a federally run health care system, and this is a
responsibility that we have when governing to make sure that
our nation's heroes are not dying because they want to
have babies. Right, this is something that we are responsible for.
The Federal Bureau of Prisons, same type of problem. Just
(39:34):
because people are incarcerated does not mean that they should
not have dignity and their health care. They shouldn't be
able to have their babies and be alive afterwards. Right.
We shouldn't see these level of disparities and death happening
with people in federal custody. And those are just the
federal examples. Then we have the challenges of healthcare providers.
(39:57):
But Chelsea, you're a mom. I can imagine that when
you found out you were expecting, it was a big choice.
Who do you see? Who do you want to be
on that birthing team with you, and you took it seriously,
most likely picking your provider, whether it was a midwife
or an obie. You picked the health care system or
the birthing center that you use. Many families don't have
(40:20):
that choice. They don't have that choice between obie's or
midwives or nurse midwives. They don't have the choice to
even pick a doula. They don't have a choice of
obtaining a lactation consultant. And then when you get down,
drilled down, they don't have a choice to pick somebody
that shares the same language or cultural background as they do.
They don't get to pick somebody who has maybe the
(40:42):
same race or ethnicity or religious practices as they have.
And so we want every birthing person in this country
to have a choice and providers to feel confident and
entering into that space again, whether it's a hospital or
not at home, a clinic, whatever, entering that space with
confidence that they will be heard and listened to and
(41:02):
responded to and safe because, as we know, during COVID,
there was an instruction, explicit instruction that told people to
stay out of our health care systems, and for birthing people,
that meant that their partner, their spouse, there's best friend
or mom, their dula was not welcome into that delivery
room or birthing space with them. And so now they
(41:23):
were alone and isolated and fearful, recognizing that even pre pandemic,
the disparities existed. And what do we find out that
there's this combination between COVID infection and being black or
brown that yielded significantly more negative birth outcomes. And then
to be alone and scared is something that should not
(41:46):
be happening in this country. And so we responded really
quickly developing COVID specific maternal health legislation. And yet even
right now we don't have a nationwide recommendation around vaccination
and treatment for pregnant, postpartument and lactating people. It's unacceptable. Well,
I certainly agree with that. I would also say this,
(42:07):
a lot of the progress that we have been making
in the maternal health space has happened at the local level.
There are many geographically focused groups that are leaders, who
are trusted voices, and we need to be seeking them out,
flooding them with resources, and centering them in these conversations.
We have these resources that are small, It might just
(42:30):
be a collective a duelists that are vocal and organized
and are watching the trends on the ground. But then
there's also an opportunity at the health system level for
them to be examining their data and making that available
more publicly, initiating community conversations based on trends that they're seeing,
and you know, being leaders, being leaders, that's what this is.
(42:52):
This is a leadership challenge, and there are roles that
we can all play. One of the things that I've
been really excited about is we have this great convening
power and Congress. Right everything doesn't require a legislative solution.
Sometimes you just need to bring folks together around a
table and illicit commitments from industry, from local electives, from
(43:12):
you know, state and local public health, and then work
together in this collaborative way. And I think that will
be able to move through this COVID recovery, especially in
this maternal health space, on the strength of those relationships,
those coalitions, and those commitments. I do want to ask
about the ways in which we can I think be
(43:32):
comfortable in asserting with certainty what we know and also
being clear about what we don't know. Because I do think,
especially when it comes to expect it and new moms,
we actually still don't know a lot and we do
need to be candid about that because often pregnant women,
new moms, lactating moms are excluded from clinical trials. So
(43:57):
how do you, both with your nurse hat On and
your Congresswoman had On, think about asserting with certainty what
you and we the broader public health community know, and
also being honest and forthright about what we don't. You
are absolutely right, there's been some challenges around vaccination in
general with expectant moms, and so we actually put in
(44:19):
the Mommy Bus and Maternal Vaccination Act that Terry stew
will introduce to do some really focused and targeted public
health communication and education campaigns about the safety of just
vaccines at large during this important prenatal and postpartum period.
And I think that as clinicians we need to be
(44:40):
very clear about the importance of vaccines for mom and baby.
You know, the conversation around vaccines I think in this
space has always focused on baby, right, and that initial
conversation with the pediatricians keeping the vaccination schedule, making sure
that everybody is comfortable but not about mom's help well being.
And I think that this is an opportunity for us
(45:04):
to broaden that conversation and make sure that if there
is a need for you know, remedial education so to speak,
that that we're taking advantage of it, especially while people
have healthcare coverage, right because we're talking about sometimes in
some states this is the only opportunity that someone will
have healthcare is during the time that they're pregnant and
that postpartum period. Or The last question I want to
(45:27):
ask is, if you're able to really pass the and
I hope you are, the twelve Bill, Mommy Omnibus Act,
do you think that then as a template for other
forms of big coordinated public health leadership from Congress in
other areas of health inequity, especially as it relates to women.
(45:50):
I absolutely think it could be a template. One of
the things that I think people assume is that Congress
works on the most important issues facing our country. That's
not That's not true. Congress works on the issues that
members raise. And this is why representation matters, because if
you change who is serving in a body, you're gonna
(46:11):
get different issues put onto that agenda. And what I
have found is as immediately. As soon as we elevated
this issue, maternal health, maternal mortality, these disparities, people were
excited about the solutions. They wanted to help and be involved.
Some people didn't know, some people had forgotten, some people
didn't know it had gotten this bad. But people care
(46:34):
that these issues just need a champion. It's been overwhelming
the support around the country from industry, from providers, from clinicians,
from moms, from nonprofit space, and leaders. We've had leadership
outside the government for so long, it just hadn't had
a home, hadn't had a hub in government. And so
I am very optimistic that we're going to be able
(46:55):
to solve a lot of these problems. But I do
think that we are going to have to continue to
be committed to electing a Congress that looks like the
American people if we continue to count on other people
to solve our problems when we're waiting a long time. Well,
Lauren Congress underod You're not my congresswoman, but I'm very
grateful that you're in our Congress. Thank you so much
(47:17):
for your time and even more for everything you're doing
every day. Thank you for having me, and thank you
for continuing to speak truth on these issues where we
can do better, and I believe that together we will.
You can keep up with Congresswoman Underwood on social media.
At Rep Underwood today, we talked about just a few
(47:40):
of the way sexism and gender bias in fact health outcomes.
We can't solve the public health crisis that is sexism
until we name it in China, light on it. That's
why I'm so grateful to Caroline Creata Prez and congress
Woman Underwood for bringing attention to this topic and for
calling for the changes we so desperately need. I started
this podcast because more people than ever before or are
talking about public health right now, and I hope that
(48:03):
we could use this moment to broaden our understanding of
what public health is. Yes, it encompasses things like pandemics,
and it also includes vaccines, mental health, gun violence, prevention,
reproductive rights, environmental justice, climate change, substance use disorders, HIV AIDS,
racial justice, and so much more. I'm so grateful to
(48:24):
all the guests who have joined me this season to
talk about the lessons we can learn from other important
moments in public health, And of course I'm grateful to you,
our listeners for being part of these conversations. So thank
you so much for listening. Please keep lifting up the
voices of scientists and public health experts. We look out
one another, and please stay safe. In Fact is brought
(48:46):
to you by iHeart Radio. We're produced by Erica Goodmanson,
Lauren Peterson, Cathy Russo, Julie Subrin, and Justin Wright, with
help from the Hidden Light team of Barry Lurry, Sarah Horowitz,
Nikki Huggett, Emily Young and Humanity, with additional support from
Lindsay Hoffman. Original music is by Justin Wright. If you
liked this episode of In Fact, please make sure to
(49:08):
subscribe so you never miss an episode, and tell your
family and friends to do the same. If you really
want to help us out, leave us a review on
Apple Podcasts.
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