Protecting Moms and Kids (with Dr. Diana Ramos)

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California is making a $4.7 billion investment in improving children’s mental health, and the state’s Surgeon General, Diana Ramos, will play an important role in the program’s success. This week, we meet Dr. Ramos and learn how she’s working to help kids recover from the damage of the pandemic. Dr. Ramos also tells Andy about her experience as an OBGYN and the importance of improving maternal health outcomes, especially for BIPOC communities.

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Dr. Diana Ramos, Andy Slavitt

Andy Slavitt  00:18

This is in the bubble with Andy Slavitt. Welcome to the show. We have a really interesting one for you today. We’re gonna bring Diana Ramos, who’s the Surgeon General of the State of California. And wanted to take a deeper look at a question that I know many of you have, which is you gotten exposed to the public health system? Over the last few years, some of it is flattering, some of it not so flattering. But there’s a big question about how’s it happened behind the scenes who’s doing the work? And what does that like, if you woke up every day in charge of public health for a state like California, where so many babies are born and born into poverty, where you got to make sure you’ve got a healthy mom and a healthy baby, you got to have healthy water and enough water. You’ve got to have a system where the climate events don’t bowl you over, get mental health crises, we had all sorts of things. And I want to talk with Dan about how she approached those things. Start with her personal story, which I think is a fascinating one, and give you an angle on all these things before you even see a pandemic hit with public health. So that’s the episode today. I’m very excited about it. Stick to the end. And we’re gonna talk a little bit about a preview of some of the things that are upcoming in the next few weeks. But without further ado, let me bring in Diana Ramos.

Andy Slavitt  01:53

Surgeon General Diana Ramos. Welcome to the bubble.

Dr. Diana Ramos  01:56

Thank you so much. Such a pleasure to be here with you.

Andy Slavitt  02:00

So tell me a little bit about how you grew up. Where I went to understand is how your life has sort of colored your perspective on how you look at health and how you look at the population.

Dr. Diana Ramos  02:13

You know, that is a really good question, Andy. And I probably fit the mold for about 40% of what Californians have experienced throughout their lives. I am of Mexican American background, and I grew up in Los Angeles born and raised. And I was raised by a single mom, from May he go, she came here when she was 16 years old. And my mom just wanted the best for me, she would work up to three jobs. And I just saw what hard work looks like. But she always reminded me of the importance of education. And just always said, I won’t be able to leave you any thing materialistic when I die. But the one thing I will be able to leave you will be a college education.

Andy Slavitt  03:07

What did she want for you, when she came to the country when she was a young person herself, to achieve dreams, for how you grew up and what you do with your life.

Dr. Diana Ramos  03:17

I think she just wanted me to go to college, and would just always support me with whatever I wanted to do. But I can tell you, as long as I can remember, I always wanted to be a doctor. So I always wanted to be there to help people to heal, to make a difference. And I saw that medicine was one way to do that. And I was able to go to a private high school and thankfully was eventually able to go to college than medical school. But all of it having grown up in like I said, what a good percentage of Californians experience and here in California 40% of the population is Hispanic. So now having this role, it really is so nice to be able to share similar backgrounds, similar stories.

Andy Slavitt  04:14

Here’s what’s changed when you were when you were growing up in Los Angeles, which was, you know, a multicultural place back then. And certainly, it is today in California. Did you feel like becoming a doctor, let alone becoming the Surgeon General of the State was within your grasp. Did you feel like that was available to you?

Dr. Diana Ramos  04:35

Andy, it felt like nothing was really available to me. You know, I didn’t even know how I was gonna go to college. But all I knew is I need to finish high school. That was it. That was it.

Andy Slavitt  04:49

You were determined and you got your motivation somewhat from from your mother. That was a dream for you. But was there something intrinsic or something you saw something which gave you this rings, to say, You know what I’m gonna I’m gonna do this and and take those next steps.

Dr. Diana Ramos  05:05

You know, I grew up near South Central Los Angeles, and really looking to see what the struggles that we had sometimes to get health care. Sometimes that make ends meet really wanted me to make a difference I grew up with, with my cousin who was like a sister who was always very sickly. And I always remember going to the emergency room to get the care that she needed. And thinking, Why do we always go to the emergency room and not to the doctor to get that preventive care. And it’s just very similar struggles that that many people have is that they’re working hard to make ends meet, but don’t have the time and sometimes the medical coverage to get the care, the preventive care that can many times keep them out of the emergency room. So the it was that desire to come up with solutions to help my cousin to help other people that really drove me to make that difference?

Andy Slavitt  06:07

I think most people today feel very distant from the people who serve in government. And I think they therefore believe that the people who serve in the government are distant from them, that they don’t know how they live. Get your story, as you said, is that a lot of similarities to the people you think about every day? Is that something that, first of all, does it make a difference? Is it tangible? How do you keep it that way? And, you know, do you notice that as things move in government, which by definition, you know, big things are slow, and they take time to take consensus? Do you think people’s own interests often get lost in the course, of people trying to make policy?

Dr. Diana Ramos  06:54

You know, I am just so grateful for this opportunity. This is really a dream come true. For me, I oftentimes feel like Cinderella, because I think, wow, if anybody knew where I came from what I went through to get to where I am now, it really is Cinderella. And really, that has resonated with many of the people that I’ve had the privilege and the honor to meet and to speak with, because they will come to me and they say, Wow, I can’t believe that they’re there actually is hope that one I can go to college to I can be a doctor. And three more importantly, I can maybe be somebody like you and I and I encourage them. And that for me has been the biggest honor to be here as California Surgeon General is to be that example of the fact that nothing is impossible. And the fact that here in California, the vision is there to support those of us who have really struggled and made it and are here to serve and be part of the solutions that are needed.

Andy Slavitt  08:03

I want to talk about some more tangible things, including some of the major health issues going on in the country. But I want to just stop and ask you one question first, which is this view of health and what it means to people today? You know, I think there was a time decades ago, when the healthcare system was supposed to be there for you and when you get sick, and it was there for some people and not for others. But but it did a pretty good job of that. Today, I think our understanding of health is a little bit different. The things that affect us physically, biologically, genetically, they they can either trap us or allow us to do certain things. And of course, our health is tied up in so many other things, our access to basic health care, of course, or access to insurance, our ability to sit somewhere our ability to speak the language, how intimidating the system is and the cost of the system. And So said another way if people don’t have their basic health and they can’t afford basic healthcare and I’m a believer that that knocks off a lot of dreams of even being possible. How do you think Calif as you as you think about your role and around the governor’s point of view here in California, that that plays out in how you think about the work you’ve got to do every day.

Dr. Diana Ramos  09:33

You know, you bring up a really good point, Andy that in the past we saw that we went to the health care setting that was a part of our community and and they took care of us. But really with time and with really looking at more and understanding more of what really influences health. We have to realize that 80% of health happens outside of the doctor’s office at percent, really. And that’s so critically important, because it really is only about 10%. Really, we have to look at the bigger picture impacts our health. So the physical environment, do you live in a community where you can walk? Do you live in a community that is not going to increase your risk for asthma? We also have to look at the social and economic environment, Are there jobs available, are there opportunities, and the health behavior as well. So this is all that’s called the social determinants of health. And it really is this, the social determinants of health, the housing, food insecurity, education, transportation, economic resources, that all come into play into our physical and mental health. So you bring up a good point, we now have to look at health as it’s it’s being influenced by our environment influenced by what is happening outside, because I can tell you, when I saw patients in my prenatal clinic, and I had maybe 1015 minutes to do a quick prenatal care check, there is so much more that is happening outside of that one visit that really is going to be impacting their health, more so than my one visit. And I would hope that they would understand and listen and more importantly, communicate with me. But oftentimes, I know that’s not what we hear, we oftentimes hear patients saying, I don’t feel heard.

Andy Slavitt  11:30

I want to come back and talk about childhood, maternal health, and really the significance of you, who is trained OB GYN being the Surgeon General, but maybe the right place to start around healthcare to talk about the thing that most of us have just lived through and gone through in the after effects of the pandemic. I’ve had other guests on and have asked this question recently. But I’m curious, your take on a look back at kind of the last few years of the pandemic. And what we learned and what we saw and how we did. It’s interesting, as I’m interviewing you today, there were some data published, which showed that we are now at a point where excess deaths from COVID-19 were really back to a almost a normal state, we still have people, of course, dying by from COVID-19 Every day, but we have 97% of the country, either vaccinated or prior infections, we have good, both vaccines and therapeutics, then we’re back to a life that we didn’t know when that would occur. So it’s an interesting day to reflect back. Obviously, there’s been a lot of loss both of lives, businesses, closed, schools closed, etc. And now we’re just beginning to deal with some of the other issues that are emerging as a result of the pandemic like the mental health issues, which are capstone of the last few years.

Dr. Diana Ramos  13:01

You know, I think the, the really important thing we need to remember is that, yes, COVID disrupted our healthcare system. COVID brought many of us to our knees. I personally lost three relatives to COVID. And I know many of our listeners shared similar experiences. But the other thing that I would hope we keep light of and and motivate us going forward is that there was a lot of innovation, there was a lot of expansion, realization of what can be done in a virtual world, what can we do to improve the care of healthcare for everyone, that the disruption brought opportunities, and who would have ever known that or believe that you would be comfortable getting a telehealth visit, for the convenience of not having to drive to your doctor’s appointment, or maybe you may not even have the transportation to get that to that healthcare setting. But now COVID prove to us that we can actually provide care in a quality way in in an effective way for many of the common illnesses that we experience. So when I was a kid growing up, and we would go to the emergency room at midnight, one o’clock in the morning, now you can actually go online and get that the care that you need. So that’s some of the positive stuff that I hope we continue on and expand and use technology to improve not only health care, but health, health access and health quality.

Andy Slavitt  15:13

Let’s talk about specifically the impact of mental health on kids during the pandemic. And I wondering if you could give us either by way of some examples or, or some other vivid way of helping us understand what’s going on with kids and what the impact has been with kids. Let Of course, as I think I’m sure you’d say, what’s happened here, it’s only on top of, I think, a pre existing set of challenges among adolescents. And kids and young adults with mental health already.

Dr. Diana Ramos  15:49

Yes, I think of it as COVID, pulling the curtain on things that were already happening, things that maybe we were not aware of, or willing to talk about. But we really have to realize that mental health is is a common denominator for so many other mental health challenges that that we live live in. And the prevalence is so much higher. We just didn’t talk about it.

Andy Slavitt  16:16

So well. So what is happening? Can you give us a feel on the ground? What kids are going through the prevalence of mental health issues, the type of mental health issues?

Dr. Diana Ramos  16:25

Yeah, so so a lot of our kids are suffering from anxiety, they’re suffering from depression. And and the health now is really being developed. So California has stepped up, Governor Newsom put the investment in the children youth Behavioral Health Initiative, which is a historic five year 4.7 billion initiative to reimagine what the transformation the way that California should be supporting our youth and our family. This is huge. So this is just for our youth, our mental health, because we realize that the help is needed to be provided. There’s over 1 million that we are, have developed a trauma informed training for early educators and personnel. But there’s many other opportunities that are happening. The other initiative that we’re focusing on is a $24 million campaign that is focusing on how do you deal with adverse childhood experiences? And where can you get some of that support some of the healing, we’ve all need healing as a result of COVID. I think every single one of us, nobody, nobody has been spared.

Andy Slavitt  17:42

So Governor made a $5 billion, I’m rounding because that’s what I do. But you said 4.7, but the Governor made substantial commitment to children’s mental health. Now, as someone who’s been part of government, I believe in government. But I also believe in our ability to spend a lot of money and not get outcomes. And I think a lot of people who look at government programs and say, Well, how is that really gonna move the needle? So tell us how you see it working? Because it is a pretty extraordinary commitment. There’s no question it’s needed. But a lot for a lot of us, we wouldn’t know where to start. We don’t have enough care providers. We’ve got systemic issues, that even with care providers are hard to solve. The schools don’t have resources and are deficient. And so there’s probably a lot of need. And not for nothing, but there’s a lot of politics involved, whatever, there’s money, there’s people want their allocation, they want their so before you know it, sometimes money, which could sound like a lot cannot get to its goal, how do we make sure that we make a real difference and moving the needle here?

Dr. Diana Ramos  18:49

So you just brought brought up the right points. So what are the metrics? What are the outcomes, who’s going to be impacted? And so that’s the beauty about how the program was invested is that it truly is a multi tiered, interdisciplinary initiative. It is really pulling on the information from from young people from parents from educators, and making sure that there’s no wrong door. So at the school level, supporting the teachers and improving the access to mental health support while at school, there is going to be virtual support that is being developed for for youth and community. health workers are being increased by 40,000 40,000. There’s increased investments in training for those who want to go into mental health, whether you’re a psychiatrist to a social worker, community health worker, so it really has been thought out everything all of it has been developed. up to with equity as the key mindset because we want to make sure that everyone has access, no matter where you live in California. And I know many times people think, Well, you’re in California, that means there’s care everywhere. No, California is so diverse, you know, you can live in a rural area of the state where there is no, no access to a health care provider. So all of these things are being taken into consideration and how the children youth and behavioral health initiative outcomes are being framed and developed.

Andy Slavitt  20:32

So can you give us maybe a vivid sense of some of the programs that we think are going to be effective here, and other evidence based programs and with these resources that we could say, you know, these are the kinds of things that we can do for kids that will move the needle, because it’s trying to get past the generalities. We’ve talked about a lot of anxiety and a lot of depression. There’s also a lot of kids that have been in interstate generational poverty and something you talk about, have lived through trauma, even before the pandemic. So what are the types of things you think we’ll be seeing that we’ll be rolling out throughout the state that will make that kind of different to talking about.

Dr. Diana Ramos  21:15

Until honestly, I think the the, the lowest hanging fruit is what’s going to be available at the schools. Because if you think about it, where to kids spend most of their time outside of their home? It’s in schools. And so there are a lot of initiatives that are being developed for the schools. And in particular, our office has developed a safe spaces curriculum. And that’s a free online opportunity to really help those who work in the education or early care setting to incorporate trauma informed practices into their work. And we know that when we address trauma, we have the potential of decreasing up to 44%. I mean, that’s what’s published 44% of mental health issues. And so for me, that’s exciting.

Andy Slavitt  22:04

What does the evidence, say the 44% can come through through school based initiatives.

Dr. Diana Ramos  22:09

No, if you address the adverse childhood experiences, which is a trauma, toxic stress that a kid can develop, you can decrease mental health problems by 44%. So I mean, that that’s amazing. If you stop to think about it, we know that by age 14, half of mental health problems would will be manifested. So if we can get an early diagnosis and early treatment, we’re really starting to help that child and put them on a more positive trajectory, long life.

Andy Slavitt  22:43

Let me switch topics on you. Tori Bowie. She was an Olympic athlete, Olympic star for the US TrackSTar 2016. She had the designation as the world’s fastest woman, I think you get that by running the 100 yard dash super fast. I don’t have if you ever ran that in school. But I never ran it that fast. But she did. 32 years old. She was retired from the Olympics, and was eight months pregnant, and was to do to deliver obviously in a month, and she was found dead at her home, sadly. Now, I don’t know how many people remember her from the Olympics. But she was this just kind of wonderful, bright, young person, African American. And the latest in kind of the steady reminder that we’ve been getting that women in this country and particularly black women, and Native American women run much higher risks of dying either before pregnancy during labor, or in the year after labor. You’re an OB GYN as well as the senior, both public health officials, the surgeon general in the largest state in the country. Help us swallow this information, this fat.

Dr. Diana Ramos  24:14

Yes. And so Andy, that is a tragic story. And unfortunately, like you highlight it, something that is not unique, and we keep on hearing more, more stories that are very similar. And for us here in California, that is a red flag very similar to everybody else in the country to really do something about it. And like you mentioned, I’m an OBGYN and I have been working in the area of improving maternal health outcomes and decreasing maternal mortality my entire career. And California has been doing that as well. So since 2006, California, saw have the opportunity to do something about it. And one of the first investments that was made was providing a grant to develop the Stanford California maternal care quality collaborative. And through that initiative, an assessment, maternal risk assessment of all of the death certificates for mothers in California was conducted, because we needed to understand what are the causes what is killing our moms. And from that started an amazing cross collaborative public private community initiative. And since then, the California maternal care Quality Collaborative has developed toolkits for physicians, now working with communities to really promote and empower pregnant potential pregnant people and pregnant people, what they can do what they should be aware of the health care system in California, what can we do to improve our maternal outcomes. And so as a result of all of those efforts, we here in California have the lowest maternal mortality rate in the country. So we deliver in California, one in eight babies in the US, so it makes a big difference. And we are always open to continue sharing and bringing this to light. So as an OB GYN, improving the maternal morbidity or the illnesses that sick pregnant moms have, and the maternal mortality is one of my initiatives. And and I pulled together a group of key opinion leaders here in California to help us think of Bigger Bolder ideas, what can we do better? Yes, we’re, we have a better maternal mortality rate than the rest of the country. But we still have the disproportionate two and a half times increase mortality rate of black moms. So that is unacceptable. And so I’m happy to share that, really, the the group came up with three areas that we really need to work on. And one of those has to do in the health care setting. So assessing that a patient who is pregnant and being cared for is high risk, so that we know they’re being cared for in the right health care setting. The other is empowering patients to know, giving them the knowledge, the opportunity to have a conversation, that they aren’t going to be high or high risk pregnancy if they become pregnant. We haven’t done that well enough. So the group is, is developing that and Dr. Sis out by the out of Stanford is is leading that patient initiated risk assessment. And then the third outcome, the that we’re going to be starting on is building trust. Because we know that there is a lot of well founded historical trauma from the African American and the American Indian populations, that we really need to build a bridge and build that trust and build a healing. And COVID Hasn’t, hasn’t helped either. So so we’re getting started on all of this.

Andy Slavitt  28:43

I’ve heard you say before, that, unlike what most friends are standing is that a lot of the risks and issues or concerns occur even kitten care even before someone is pregnant. But as I understand the data, when I look at there, so 700 women across the US every year that died as a result of pregnancy, it splits roughly into a third year before they deliver, presumably with CLABSI, or some sort of preeclampsia, which is what happened with Tory belly, a third actually during labor, and then a third in the year after delivering her baby. You know, and I think we don’t think about in the developed world as delivering a child anymore in the 21st century, as a medically risky event or a risky experience. And in fact, if you go around the world, to most developed countries, most places where there’s no guinea worm and severe poverty and all of those sorts of things, but most of the world it is indeed very safe. And you also see in other parts of the world, probably things that we don’t see as much here and I’m hoping you can Epicenter to And what some of those gaps are, whether some of it is prenatal care, some of it is in almost every other country, I think except the US. There are home visits. But you have done. You know, as you’ve said, for the last almost 20 years in California, California has established a track record of sort of defying that trend. But help us understand if you would, what are the the linchpin gaps, the big differences that occur both in the US and other countries? And also, you’ve talked, I’ve heard you talk about their differences, even among different populations, the kinds of things that afflict them?

Dr. Diana Ramos  30:44

Right? Well, one of the most common denominators that we know, that is contributing to a higher rate of maternal deaths is that women are waiting to, as they’re older to have their first pregnancy. And we know that as you get older, you start to have more medical problems, medical complications, increased risk of obesity, and maybe there wasn’t that preventive visit that has happened, you know, before becoming pregnant. So not knowing that you may be at high risk, because you have high blood pressure. And sometimes we forget to take our medicine or for diabetic, if there’s asthma, or if there have been surgeries, because of uterine fibroids, all of these things are increased risk for complications during pregnancy. And so that’s why education and awareness of what risks potentially, each person may have when they become pregnant is so critically important. And sometimes that information is not so easily obtainable. So working with our partners, not only here in in government, through the public health departments, with the health care systems, but working with communities, it is so critically important to get the message out to get that understanding of what folks can be on the lookout, that may increase their risk for the negative pregnancy outcomes. We want a healthy mom and a healthy baby, all of us. And so we just need to be on the same page as to how we’re going to do this together.

Andy Slavitt  32:36

Well, that is an appropriate kind of place to put put our attention in the conversation. Let’s let’s finish up. I mean, I guess I just want to push on a couple of points. You know, the literature says that 80 to 85% of the deaths are preventable. maternal deaths during pregnancy. And of course, people do a lot of other things that are had a lot of other things that happened in them besides just dying. You know, there’s a lot of trauma that that can go on a lot of situations which can cause real pain and discomfort. So I don’t I don’t think we are just focusing on or should be just focusing on deaths. But you know, that beginning of that first year of life, as you said, Were with a incredibly healthy mom and baby feels like a kind of a basic obligation to society, at least to me, it does. I’m sure people have their own definition of what makes a good society. But beginning life, right, feels like well, at the very least what we owe people. And, you know, we living in the country now that today is saying, Nobody deserves any other additional advantages over anybody else. And yet, we know not enough goes in to making sure people in certain communities are thriving. We’re also a society that looks for like the single push button, easy button solution. So tell us the one thing we can do. To fix everything is a sort of trap I think we get into in these situations. But but maybe just in the closing bit of the conversation, can you help us see some of the very specific actions that we can take to help address both the pre pregnancy period and the post pregnancy period where we have some of these preventable deaths that are right in front of us?

Dr. Diana Ramos  34:32

Yes, you know, I think the most important thing that we all can do is just awareness and education. So critically important. So even though your listeners may be hearing us right now, and they may be saying, well, I’m done with child caring, or we’re, you know, we’re not going to have any more babies. You may not but you hear you’re hearing this information, and I I would challenge you to share it with somebody that potentially may become pregnant. And just to remind them, look, you know, maybe you should have a well, a well exam before you become pregnant. Because because of the fact that 80% of maternal mortality causes are preventable. The leading underlying causes of pregnancy related deaths up to one year postpartum 23%, are mental health conditions 23%. So if we stopped to think about it, that’s all that’s like, one in five people. 14% is hemorrhage, and 13% are cardiac and coronary conditions. So you now know the information, share it with with those you love, I can tell you when I was seeing patients in East LA, I know that I would give a brochure or a piece of information to a patient. And she would tell all her neighbors, she would tell her in Spanish will be called her grandmother is her love friends, and just share the information. So I would encourage everyone, you know this information, share it, I think that is a start. Because then you can direct the patient or that friend to the resources that are available, because there are a lot of resources, but it’s just the first step is is awareness so that then education can follow.

Andy Slavitt  36:33

Before we close, is there anything else that we didn’t cover? that’s on your mind, that’s in your plans in California that you think we should cover?

Dr. Diana Ramos  36:41

You know, I think folks need to realize that California is doing a lot of innovative work, we have, really, we’re trying to leverage all of the resources that we have here. In particular, the human resources that we have in terms of the our population, we have the largest American Native population in the country, we deliver one in eight births in the US, we have the lowest maternal mortality rate, although we can do much better in closing that gap with our black population, and American Indian population. But I would say, partner with us and look to see the programs that we are developing, because as California goes, so does the rest of the country because the investments are being put into improving the health care of Californians. And our impact is is so great. And you can see us as a perfect test for some of the programs that folks may be looking to implement in their states.

Andy Slavitt  37:50

California Surgeon General Diana Ramos, thank you so much for being in the bubble today. And congratulations on this amazing progress and the really the hope for the future. That all of the not just the funding, but the commitments and the real plans to addressing mental health, improving child health are giving us.

Dr. Diana Ramos  38:13

My pleasure. It’s been an honor. Thank you, Andy.

Andy Slavitt  38:29

Thank you today, Diana, I want to tell you about the next four shows we have, because they’re special. We’ve designed them thoughtfully. And the first two speakers the next week, and the week after are with two incredible thought leaders, David Leonhardt from the New York Times. And Matt Iglesias who now is from substack. But before that has been in Vox and a bunch of other places. These are people who challenge conventional wisdom, they challenge our thinking. And they’re very interesting things to say about things that we have long held belief that I’m very excited for both those shows. And then the two episodes following that are going to be very special shows will tell you more about them. But I’m collecting for both of those shows a group of people that matter to me, many of whom I think matter to you. They’ve been on the show before. They’re some of the best thinkers around public health and what’s happened in the pandemic, as well as people in my life including my family. So we look forward to bring you those shows. And have a great week. We will talk to you on Wednesday with David Leonhardt.


Thanks for listening to IN THE BUBBLE. We’re a production of Lemonada Media. Martin Macias and Kyle Shiely produced our show, and they’re great. Our mix is by Noah Smith and James Barber, and they’re great, too. Steve Nelson is the vice president of the weekly content, and he’s okay, too. And of course, the ultimate bosses, Jessica Cordova Kramer and Stephanie Wittels Wachs, they executive produced the show, we love them dearly. Our theme was composed by Dan Molad and Oliver Hill, with additional music by Ivan Kuraev. You can find out more about our show on social media at @LemonadaMedia where you’ll also get the transcript of the show. And you can find me at @ASlavitt on Twitter. If you like what you heard today, why don’t you tell your friends to listen as well, and get them to write a review. Thanks so much, talk to you next time.

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