Amanda Skinner: Navigating Reproductive Care after Roe

Harlan Krumholz: Welcome to Health & Veritas. I’m Harlan Krumholz.

Howard Forman: And I’m Howie Forman. We are physicians and professors at Yale University. We’re trying to get closer to the truth about health and healthcare. This week we’ll be speaking with Amanda Skinner, but first we like to check in on current health news and Harlan, and I hear you have something new to say about ChatGPT. So tell me what we can learn.

Harlan Krumholz: Oh my gosh, I feel like every week we could be talking about what’s going on in the AI community and there are things happening every week which are worthy of people’s attention. This week you started to see this drumbeat of growing concern among AI experts. And this really kind of chilled me a bit. One of the experts is a person by the name of Jeffrey Hinton, and Hinton is a luminary in the field. He’s won the Turing Prize, a sort of the Nobel Prize of the data science and computer science community. He’s widely acclaimed. Many of his breakthroughs were fundamental to getting us to where we are today. He’s a real pioneer and widely respected. And this week on Monday, he sort of officially joined this group of critics who say that companies who are racing toward the sort of this AI future may be creating products that could ultimately be harmful.

So Hinton worked for a long time in academia and had then joined Google, but he’s quit now. And in a New York Times article, he was quoted as conveying that he now regrets some of his life’s work. And he said, quote, “I console myself with the normal excuse: If I hadn’t done it, somebody else would have.” But this is extraordinarily disturbing, Howie, because he’s reflecting back on what’s going on and saying that he’s seeing changes within the industry that are giving him great pause and concern. And this is something which I think I was unprepared for. As thousands of people signed a note that said that we should be putting a pause on the development of this generative AI, these LLMs, large language models like ChatGPT. And many people thought like, “Well, yeah, people like Elon Musk are signing this because he wants the winners, the people who are ahead to slow down.”

But I think increasingly it’s beginning to feel like it’s actually more than that. And when you see someone like Hinton say that for years he believed Google had been a proper steward of technology but now thinks that that’s changed. And he thinks that there are things afoot. And I have the feeling that there are things afoot that we don’t even yet see, which could be quite disturbing to society. It goes from misinformation, people not being able to tell what’s true or not to the effect on the job market, which I think we could manage ultimately. But then the way in which bad actors could really, with these now new tools could fundamentally reshape the ways in which society is organized. And especially in authoritarian societies. This could give a certain power over people that is really unfathomable. And Google’s response was to say, “Well, we just want to thank Jeffrey Hinton for his work over the past decade” and that they’ll miss him.

But they really didn’t confront the issues that he brought up. There was a very interesting paper that was published in JAMA Internal Medicine about a week ago in which they were trying to test whether or not ChatGPT responding to simple patient questions, could it rival the kind of responses that physicians might give. So they went on Reddit where patients were posing questions and physicians answered them and they’re just rapidly responding to kind of questions. And then what they did was they posed those questions to ChatGPT, and they got responses, and they went to a third group, actually a group of several people, and had them grade the responses and said, without telling them which ones are from ChatGPT, which ones were from physicians, but just to try to get some sense of which ones seem to be better responses for patients both for content and tone.

And believe it or not, ChatGPT won. So this is just another piece to this. I think that there’s lots of upside. The technology could really help us communicate with patients better, could extend us, could increase access. But I’m juxtaposing my excitement about the positives with the messaging that’s coming from a lot of experts who don’t seem to be driven by trying to manipulate this for personal gain but rather are trying to raise a flag of warning about what this could potentially cause in catastrophic ways. I find myself sort of split now—excited, but also a little anxious and concerned.

Oof. All right. Let’s go on to Amanda. This is enough in intensity around AI for now, but I’m really so excited that we’re going to have Amanda Skinner on today.

Howard Forman: Amanda Skinner is a nurse-midwife who is now the president and chief executive officer at Planned Parenthood of Southern New England, as well as president and CEO of Planned Parenthood Votes! in Connecticut and Rhode Island. Skinner practiced as a nurse-midwife for almost a decade before transitioning her career toward population health pursuits. Her first stop after her clinical career was at the Chartis Group and then to Yale New Haven Health, where she served as executive director of clinical integration and population health, among other coveted positions. In addition to her current responsibilities at Planned Parenthood, she’s also a member of the Board of Directors for BetterHealth (a Planned Parenthood partnership), the Universal Healthcare Foundation of Connecticut, and Planned Parenthood Federation of America. In the wake of overturning of Roe v. Wade, Skinner has advocated for increasing healthcare equity and reproductive rights access for women.

In 2022, Ms. Skinner was awarded the Donaldson Fellowship from the alumni of the Yale School of Management, the highest such award given to our alumni. And she’s also the first executive MBA graduate to be so awarded. Skinner graduated with a bachelor’s degree from Rice University, and she later obtained a master’s of nursing from the Yale School of Nursing as well as an MBA from the Yale School of Management. So first I want to welcome you to the podcast. You are, as I’ve mentioned, a much-honored alum of our program. And so your connections to Yale are very vivid for me, and I’m very proud of all that you’ve done. But I want to hear about the beginning at Rice University and what happened during that time that focused you to the career that you have today.

Amanda Skinner: So first of all, hi Howie, hi Harlan. Thank you for having me today. So when I was a student at Rice, I was a member of Rice for Choice, which was the campus pro-choice organization. I was a college student from 1988 to 1992. I went to college with sort of already formulated perspectives on abortion rights and access. And so that was just one of my campus activities. My senior year of college, there was a march on Washington called the March for Women’s Lives. And for folks who don’t know, Rice is in Houston, Texas. I piled into my 1986 Toyota with two friends from college, and we drove from Houston, Texas, to Washington, D.C., to attend the march.

And it was at that march where I heard Faye Wattleton speak for the first time. She was then president and CEO of Planned Parenthood Federation of America. And that was a really pivotal moment for me. I heard Faye speak, and I was a senior in college and I thought, “Oh, that’s what my life’s work can be. I can go to work for Planned Parenthood someday. I could become a Planned Parenthood CEO.” And so that’s really what really connected for me, the possibilities of connecting what was so meaningful to me and so important to me personally, to the possibility of a career path.

Howard Forman: And before I turn it over to Harlan, I just want you to take us forward then to that moment when you decide to do the MBA degree, you’re already a nurse-midwife and then also decide to actually leave clinical practice. How does that fit in?

Amanda Skinner: So just as a side note, Faye Wattleton was also a nurse-midwife, so I’m sure that informed my decision to choose midwifery as my profession. But I was also informed in that choice around the philosophy of autonomy and patient provider partnership and decision-making for people. I always knew based on my college dreams that I was going to leave clinical practice someday. And because I was an alum of the School of Nursing, I actually got an alumni email about the MBA for Executives program, and I had just completed service as the chair of the American College of Nurse-midwives chapter in Connecticut. I had just led a legislative effort through that service, and mostly it felt like prominent timing. It felt like this is the opportunity for me to make the next step in my career and to move from clinical practice into how I can have an impact in a broader way and sort of put myself on a path towards leadership opportunities to be more upstream and more transformative around healthcare.

Harlan Krumholz: Amanda, I was thinking, you talk about being at Rice and having that sort of point of view. I was just wondering: where’d you grow up?

Amanda Skinner: I grew up in Waltham, Massachusetts.

Harlan Krumholz: Did you?

Amanda Skinner: Yeah, I did. And my mom was, if she were still alive, I think she would be a liberal activist today. She was sort of a liberal activist then. I can remember her campaigning for John Anderson for president. So I’m sure she informed me without me necessarily always being aware of how she was influencing my decisions. But yeah, I grew up in Waltham, Massachusetts, so going to Texas for college was like a complete aberration.

Harlan Krumholz: It seems like a long way. And that’s what I was wondering whether there were certain things that happened in your childhood that sort of got you turned towards this commitment in your life towards social justice and equity. Were there any things that you think kind of triggered that for you before even you went to college?

Amanda Skinner: I’m not sure if I was very conscious of it. I think there were probably things. So one is that I was baptized in the Catholic Church, but I ended up growing up in a Unitarian church. And the Unitarian church is very oriented towards justice. And I also went to a Catholic high school, and it was a fairly progressive Catholic high school. Even today, while it was an all-girls Catholic high school, they print, for example, in the alumni magazine, my professional achievements—which, you know, I work in Planned Parenthood!—it’s actually a statement about this school and their values around women and people, even though the Catholic Church’s position on abortion is quite clear, that they would not shy away from the work that I do. And then there’s this other, there’s a family history around women and ability to have dominion over our own choices. My great-great-grandmother was forced into a marriage against her will after being kidnapped by her brothers and...

Howard Forman: Oh goodness.

Amanda Skinner: Yeah. And there was sort of a series of women in my family from my great-great-grandmother, my great-grandmother, my grandmother and...

Harlan Krumholz: What country was that in? Was that here?

Amanda Skinner: That was in Italy.

Harlan Krumholz: In Italy. Wow.

Amanda Skinner: And all of them had significant life choices taken away, and I was not conscious of any of this in terms of its direct impact on me, but as an adult and sort of reflecting on my family history, I am a hundred percent certain that family history influenced me deeply and subconsciously.

Howard Forman: Can you give our listeners some sense of the scale of the operation? Because for me, who lives in New Haven, I know the headquarters are about two blocks past the School of Management, and I think that’s where your office sits, your official office sits. But my understanding is the scope of what you have covers the state of Connecticut and Rhode Island in very different services including abortion services, but also a lot of other services. Can you give us an idea about what that scope looks like?

Amanda Skinner: Sure, sure. So first, Planned Parenthood, our structure is that there are 49 Planned Parenthood affiliates across the country. We are one of those 49 affiliates, and each one of us is an independent nonprofit 501(c)(3) organization. And we are members of Planned Parenthood Federation of America. My affiliate, Planned Parenthood of Southern New England, we cover, our service area is Connecticut and Rhode Island. And that means that we are responsible for the delivery of healthcare services, sexual and reproductive and primary care healthcare services in those two states, along with advancing policy in those two states through advocacy that supports access to sexual and reproductive healthcare and all healthcare and being the primary sex ed educator in those two states. From a size perspective, my affiliate, we have 15 health centers in those two states. We have 14 health centers in Connecticut and one in Providence, Rhode Island. More than 90% of people of reproductive age in Connecticut and Rhode Island are within 30 minutes of a Planned Parenthood health center.

And while I think we all thought that with the pandemic that healthcare would be taken over by telehealth, it turns out people actually still want to go see their healthcare provider in person a lot. And that bricks-and-mortar presence and that physical accessibility is really important. In addition to having digital accessibility, because we do have a telehealth service we provide comprehensive sexual and reproductive healthcare at all of our health centers. We provide primary care limited at all of our health centers. We provide comprehensive primary care at two of our health centers. We provide in-clinic abortion services at five of our health centers. Those are procedural abortions, and we provide medication abortion at all of our health centers. Abortion makes up about 10% of our services. And then again, as I said, we are the primary sex educator. We do a lot of youth engagement work, working with young people to ensure that they have good, high-quality, accurate information about sexuality and sex and consent and gender and identity and safer sex practices.

And working with educators to ensure that they are providing good, high-quality sex information, sexual health information to young people. And then we maintain an advocacy presence in both states with a focus, truly a focus on state-based policy.

Howard Forman: And I want to just add, we are not surrounded to the best of my knowledge by any states that have a substantial abortion ban in place right now.

Amanda Skinner: Correct.

Howard Forman: But there are a lot of states that do have a variation of abortion ban in place. And so we’re seeing other states across the country having to provide healthcare for people from out of state. Are you seeing any of that right now? And how do you as an institution working with all these other affiliates, at least sharing an information, how do you support one another when one area might all of a sudden be deluged with demand?

Amanda Skinner: So there are 19 states with abortion bans in place, 13 near-total bans that’s getting, it might be 14 by now, I’m thinking about Florida. And we have seen an increase ever since actually SB8 passed in Texas. We have started to see an increase in people traveling to Connecticut or Rhode Island for abortion care from out of state. We don’t have hub airports here, so we’re not seeing what Illinois might be seeing where they’re in the center of the country surrounded by ban states with a hub airport. But we are seeing an increase in that demand for our services. We have done a couple of really important things to ensure that patients who need the care that we have to offer at Planned Parenthood are able to access it with at least as few barriers in place as possible. Those things are things like a number of Planned Parenthood affiliates have gone on an integrated version of Epic.

So we have a shared medical record across Planned Parenthood affiliates that enables us to, when necessary, be able to ensure that people’s healthcare information is available to the provider who is going to see them. We have instituted at my affiliate a role called an abortion navigator. Her job is to work with people seeking services, even if they’re in Connecticut or Rhode Island or outside of Connecticut and Rhode Island, who might need support or assistance in seeking those services. So she connects them to helping them get flights or hotel rooms or seeking financial support resources to be able to actually take the flight or get the hotel room. Sometimes it’s financial resources for abortion care. We have an abortion fund within our affiliate. We also partner more broadly with other organizations within the sexual health and reproductive health and rights movement like abortion funds to ensure that people have access to their resources they need.

We can’t take down all the barriers. And I think if you have to travel from Texas to Connecticut for an abortion, there are significant, challenging, painful barriers that you are facing even under the best of circumstances, even if you have a flight and a hotel and the time, it is still difficult. It is ridiculous. It’s just ridiculous to ask people to travel three thousand miles to get healthcare. But we are trying to make it as barrier-free as we logistically can. And those abortion navigators are being instituted at affiliates across the country, working with each other, helping each other to make sure that we’re getting people to the best site of care for them.

Harlan Krumholz: Even in a state like ours that is supportive of abortion rights, what are some of the challenges that Planned Parenthood faces today and how are you helping to navigate these challenges? Because it seems to me that there are attacks coming on all sides, even in a supportive state that make it hard. What do you think are the key challenges and how are you able to navigate them?

Amanda Skinner: Yeah, that is, again, thank you for that question. I think there are two lenses on that. So one lens is the challenges we face are actually rooted in the challenges that our patients face. And so one response to that would be focused on the experiences of our patients and the things that we are working on addressing for them. And they connect very much the challenges that we are facing, for example, around affordability of healthcare and access to coverage for healthcare services. And that is, again, even the case in states like ours, and this is in Rhode Island, not Connecticut, but I’ll just offer this as an example. Right now in Rhode Island, there are bans in place where if you’re on state health insurance, the state health insurance cannot cover abortion for state employees. And there is a ban, Medicaid in Rhode Island does not cover abortion care.

That’s actually our primary advocacy effort in Rhode Island this year is to have those policies changed in Rhode Island and Connecticut. Medicaid does cover abortion care. This is an issue of equity for our patients. We should not be asking the people who are in most need, who struggle the most to access healthcare, to also be the people who have to pay out of pocket for healthcare and don’t get access to coverage that people on commercial insurance get. So that’s one example. Specific to Planned Parenthood, I would say we’re an interesting nonprofit organization because we are a healthcare provider and we are an advocacy and education organization.

We are heavily reliant on philanthropic support to be able to deliver our mission. But we are also a healthcare provider in the middle of a very challenging time for healthcare providers. I just read an article, I think it was late last week, that hospitals are facing record losses and hospitals have things like high-margin services in their service portfolios that help them navigate difficult financial circumstances. While we are competing with those hospitals for staff, that is the market that we are competing in to hire healthcare providers, to hire clinic assistants.

They are facing some of those challenges that they’re facing specifically because they have had to accelerate pay. That means for us to be an equitable and fair employer in our communities, we need to do the same thing. But there is no such thing as a high-margin service in sexual and reproductive healthcare in an organization that exists to serve community where 85% of our patients live at or below 250% of the federal poverty level, where we are committed to providing care, no matter what, to our patients, regardless of their ability to pay. So we are facing some significant market and financial challenges that are driven by the healthcare market that we operate in and informed by our values. We want to be the best possible place to work for our staff because if we have thriving, happy, fairly treated staff, they will create a great healthcare environment for our patients.

And of course, again, sort of circling back to the people who are relying on us for care, these are also often people who experience marginalization in the establishment healthcare delivery system. They come to us often because they feel safe with us. We are their only healthcare provider for a large majority of our patients. And knowing that they face that, we want to make sure that in our organization we really are living up to our values around our patients having the best possible experience with us feeling that they are treated equitably, respectfully honored in who they are when they come in our doors. And that again requires that we do that for our team as well.

Howard Forman: Abortion services are a core part of the training of OB-GYNs in this country. And I presume that’s true also for nurse-midwives, but you can tell me more about that. What role do you play or do other centers play now that there are some states where trainees will not be able to be trained in that?

Amanda Skinner: Yeah, so there are a couple things there. So the first is that there’s the physician in residency training. We are a residency training site. We partner with the academic medical centers that are near us to provide abortion training to residents in OB-GYN practice residency, sometimes in family practice residencies as well. And we are seeing that people in ban states in those residency training programs are seeking partnerships where they can come and get abortion training in more favorable states. And I think it will be really interesting to see—this will take some time—but if we start to see patterns emerge in where people pursue OB-GYN residency training connected to the abortion laws in those states. Again, there were sort of an interesting piece recently, I believe it’s Iowa, where they were starting to see an out-flood of OB-GYN hires.

Howard Forman: I think Idaho. I think I saw Idaho is... Yes.

Amanda Skinner: Idaho. Thank you, Idaho. Thank you for correcting me. I knew it was an “I” state. So for advanced practice clinicians, nurse-midwives, nurse practitioners, there are now 16 states in the country where nurse practitioners, nurse-midwives, and physician assistants can provide first-trimester aspiration abortion. Connecticut is one of those states. We just changed our statute last year in Connecticut in the legislative session 12 months ago to include language that enables nurse practitioners, nurse-midwives, and PAs to be able to provide first-trimester aspiration abortion. And we are a training site for our own clinicians at Planned Parenthood of Southern New England.

Our training is modeled on a training program that was developed in California. It is evidence-based and is very clear that this is a procedure that advanced practice clinicians can provide with equivalent quality outcomes to physicians. And it’s an access issue. Just one more comment on that if you don’t mind, Harlan, is that there are a lot of different studies on this, so you can find different numbers, but they all get to the same thing, which is that a massive number of OB-GYNs encounter patients seeking abortion care up to 85 to 90%, depending on the study that you look at. And only about 15% of them provide abortion care. So we have a shortage of abortion providers compared to where people are seeing the need. And so expanding that to advanced practice clinicians is also an important step in expanding access to care.

Harlan Krumholz: Well, it’s such a delight to have you on and to hear about your story and what you’re doing. Let me just ask you here at the end, what message would you like to share with both the supporters of Planned Parenthood but as well as those who may be skeptical about your mission in work when you’re just trying to concisely convey to people why they shouldn’t be scared of what you’re doing and why it’s important? How do you message that?

Amanda Skinner: For me, fundamentally, abortion rights are about our ability to have dominion, freedom, and agency over our own lives. That if we can’t control our own bodies, it is hard to envision our ability to be truly free or have agency over the rest of our life. I think it is important for people to recognize that abortion is healthcare. It is a healthcare procedure. They’re exactly at most two people who should have anything to say about that decision. And that is the person who is pregnant and their healthcare provider who is partnering with them in making a healthcare decision that is the best decision for them, for their family, their life, and their future. And that is I think what I would want people to take away.

Howard Forman: Well, I want to thank you so much, Amanda. You are the most deserving Donaldson Fellow. You are somebody that we all talk about it proudly as to what you’ve already achieved and what you will continue to achieve on behalf of all marginalized minoritized populations and particularly those that are seeking reproductive health services and abortion services. So thank you so much.

Harlan Krumholz: Yeah, thank you for sharing it.

Amanda Skinner: Thank you both.

Harlan Krumholz: Well, Howie, that was a terrific interview, and I’m so glad that we were able to have her on the show. But let’s pivot to another favorite part of the podcast for me, which is to hear what you’re thinking this week.

Howard Forman: Yes. I want to talk about another alum of our programs this week, our nation’s surgeon general and our graduate of the Medical School and the School of Management, Vivek Murthy issued a major report on loneliness and social isolation. He launched this report with an op-ed in The New York Times that I would encourage all of our listeners to read in full, but here are the highlights from the report and why I think he is spot-on to be highlighting this as an already major public health issue, but one that’s going to get worse if we don’t start paying attention. So a few points. One, loneliness is systemic with more than half of all adults experiencing measurable levels in the past year and social connections are on the decline with nearly half of all Americans reporting three or fewer close friends. That number has been climbing over the last decades.

While social isolation is the most common among the oldest, young adults were more likely to report feelings of loneliness—two distinct features. Humans thrive on social connection. There’s a lot of evidence, and it’s not just humans among mammals, but humans particularly thrive. They despair and suffer physical health consequences from loneliness and social isolation. Examples are poor social connection is associated with a 29% increased risk of heart disease, a 32% increased risk of stroke, and a 50% increased risk of developing dementia. These are not inconsequential changes. Lacking social connection is equivalent to smoking 15 cigarettes per day, and it’s worse than having six drinks per day in terms of premature death. And the report goes on and on to make this case that we individually and collectively suffer harms from this trend towards social isolation and loneliness. So what can we do? He suggests six pillars to a national strategy.

One, communities need to invest in physical and tactical needs of bringing people together. Again, all public policies need to prioritize and/or address social connection. Just as we’re trying to encourage people to think about inclusion and health equity when we’re talking about policies, we should also be thinking about social connection. Three, train public health and healthcare professionals to identify loneliness, social isolation, and the means to address it. Four, we need to counter the profit-driven efforts of digital media companies to drive us toward greater isolation. This may be the hardest part. It ties in with what we talked about in the intro, but it’s also so entrenched and it’s growing and worthy of our efforts. Five, we need to actively perform ongoing research to detect, prevent, and address social isolation with evidence-based strategies. And lastly, in all of our communities, we individually, each one of us needs to model, support, and expand efforts to build connections.

So this report forced me to pause and consider how loneliness presents itself in my life, just as Dr. Murthy raises his own challenges with loneliness in the op-ed from this weekend. And again, I encourage people to read it because he’s deeply personal in there, but it also reminds me that addressing social connection can be just as much a virtuous circle as the spiral to isolation in loneliness may be a vicious one. If we reach out to more of our friends, our family, and even our coworkers and community members, we’re not just improving our own potential for better health and wellbeing, but also someone else’s.

Harlan Krumholz: Both of us are great fans of the surgeon general and love the great work that he does. I don’t know what to do when a piece comes out about addressing loneliness because it’s great to cheerlead the idea that we should all seek greater social connection. It would be better for our health. There was a report out of Harvard that suggested that people who live the longest actually have the strongest social connections. And one of their strongest recommendations was that we really invest in those kind of relationships. But the question is, how do you actually change the trajectory of a society which is hurtling towards more social isolation?

Howard Forman: I do think the six pillars address that. I think they point by point say exactly what you just said, that you have to be able to talk about the structures of our communities. You have to be able to address inclusion when you’re thinking about interactions on social media. We don’t have to ban social media, but we can start to think about how we use it to our advantage as opposed to obstructing us.

Harlan Krumholz: Yeah. But how does this actually happen? It’s one thing to say these are the areas, but how does it happen exactly?

Howard Forman: I think just as we’re trying to encourage building walkable communities, I think we also want to build socially connected communities. And just as we talk about maybe banning social media during some hours for young people, we may want to invest in how do we create meetup situations? There are apps that are now created to encourage people to meet up for exercise, to meet up for social connection. These are emerging areas that we could use to our advantage, not just concede to it.

Harlan Krumholz: I’d like to see investments in built environments where we really do look at our communities and the way in which they’re structured.

Howard Forman: Yeah.

Harlan Krumholz: But now—I don’t want to say—I obviously really believe this is important. It’s just a question of how can it get done? And by the way, I mean the surgeon general’s got lots of things to look at. We’re still interested in a whole wide variety of areas. And anyway, I know this is very important and personally, I’m glad that he’s articulating it, and I hope we can make some progress.

Howard Forman: Me too.

Harlan Krumholz: You’ve been listening to Health & Veritas with Harlan Krumholz and Howie Forman.

Howard Forman: So how did we do to give us your feedback or to keep the conversation going? You can find us on Twitter.

Harlan Krumholz: I’m @hmkyale, that’s H-M-K-Yale.

Howard Forman: And I’m @theHowie. That’s at T-H-E-H-O-W-I-E. You can also email us at health.veritas@yale.edu. Aside from Twitter and our podcast, I’m also fortunate to be the faculty director of the healthcare track and founder of the MBA for Executives program at the Yale School of Management. Feel free to reach out via email for more information on our innovative programs where you can check out our website at som.yale.edu/mba.

Harlan Krumholz: And Howie, you’re using LinkedIn more often too. Aren’t you kind of spreading the word by LinkedIn often?

Howard Forman: I find, yeah. I’ll just tell you, LinkedIn is probably the way we’re reaching a lot of our listeners. And if any of you want to respond to our posts on LinkedIn, we’re going to be paying attention to that.

Harlan Krumholz: Yeah. That’s great. Health & Veritas is produced with the Yale School of Management and now the Yale School of Public Health. Thanks to our researchers, Sophia Stumpf, and to our producer, Miranda Shafer, they are amazing. And welcome to Sophia. Thank you for joining us and appreciate your support. Talk to you soon, Howie.