Dr. Kristin Mattocks: Advancing the Health of Women Veterans

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 Dr. Kristin Mattocks, a professor of population and quantitative health sciences and associate dean for veterans affairs at UMass Chan Medical School. But first, you can’t begin any discussion right now without discussing the tragedy that is going on in Ukraine.

I just want to say.... You said it last week: This is the type of crisis that has vast health impacts. Some of those are short-run. Some of those can be very long-run. But today a women’s and children’s hospital was bombed. You can’t not think about this in the context of war crimes and in the context of deep humanitarian and health impact on a population is rapidly evacuating their homes. I’m just curious to know what’s on top of mind for you right now?

Harlan Krumholz: Well, I think it is a time for humanity to come together and exert its values. And we know that this isn’t just a thing about... I mean, Ukraine is the moment, but there are other countries where people are also experiencing immense tragedies that are being inflicted human on human in the course of war zones and really what is unethical killing of civilians. And we need to, as a society, as a world, think hard about this. The Ukraine issue, in part because it’s right up close to us and we understand the threat that’s being exerted by Russia and, seemingly, willingness to attack nuclear power plants.

I mean, Howie, we could be on the edge of a catastrophe, a health catastrophe for large swaths of the continent if these power plants are breached. And then today we were seeing a maternity hospital bombed, people being killed, people being told that they’re safe passage and then being targeted. It’s just heart-wrenching. I’m glad to see the world coming together. I really don’t know. I can’t say I’m smart enough to know what the endgame is here and how we get through this, but we have to know what we’re standing up for and when it’s really basic decency, the ability of people to live their lives. The stark contrast here between the attackers and those who are being attacked is so bright and so galvanizing. It’s something to see the world come together. But as you know, supplies are short. I was seeing someone having to go across the country because she could no longer get her chemotherapy.

I mean, there’s many tragedies within the macro tragedy. And then, like I said, looming real big catastrophes like the nuclear issue. So anyway, I think we’re all watching with bated breath, trying to figure out what we can do to help. I will say it was great to see Yale New Haven Hospital contribute $1 million worth of medical supplies. And I know many others around the country are doing the same.

In addition, I like the ingenuity, like we’ve bought some Airbnb rooms. It’s a way to transfer cash to people in Ukraine so that they can have some ways of doing that. There have been others who have thought of other creative ways that we can be supportive of just individuals on the ground. And what I mean by that is no one is staying at the Airbnb. Airbnb as a company set it up so that you could essentially rent a room as a means to be able to transfer money.

Howard Forman: Without any administrative fees, to the credit of Airbnb. I mean, they really made an extra effort.

Harlan Krumholz: And these are very creative, very creative ways of doing things. Meanwhile, we’re seeing Russia shut down, right? Really become isolated and information flows limited. So anyway, we had to start here. I don’t know we have thoughts, but what do you think?

Howard Forman: Now, I would just add one more thing, which is, to me, a sad side effect is we have a lot of students at Yale and throughout the country at university who are of Ukrainian descent and of Russian descent. In different ways, they are all affected by this tragedy. And they absolutely are not complicit in anything. I feel equally sad for our Russian students that are on our campuses as I do for the Ukrainian students.

I can see on their faces the tension and strain. And I see a lot of them rising up to activate and help with this cause. There was an event in front of the Medical School this week. There was an event on the New Haven Green and an event in front of Yale University, all in the last 10 days, all organized by our Ukrainian students.

Harlan Krumholz: Yeah, no, I think that’s a really good point, and especially I want to protect our Russian students who shouldn’t be bearing the consequences of this, and we should be engaging and making sure they’re okay too, while they’re here with us. But the other thing just finally is, still, it’s remarkable to see Zelenskyy. And I think for our students, for us to show what leadership can do and how it can galvanize. I think it’s an entirely different story. This unfolds entirely differently if they’re different leaders. Someone that fled had not been able to inspire a nation, and for all the times we think that individuals can’t really make a difference, this guy is making a difference and it really should inspire us all to know that values matter.

Howard Forman: Amen. Excited to introduce Dr. Kristin Mattocks. Dr. Mattocks is a professor of population and quantitative health sciences and associate dean for veterans affairs at the University of Massachusetts Chan Medical School. Her research focuses on improving veteran health and Veterans Administration care coordination, especially for pregnant and postpartum women veterans. She is the co-director of the VA Community Care Research Evaluation & Knowledge Center, which helps share high-quality, high-impact research on VA community care.

She’s also a double alum of our School of Public Health, earning her master’s and her PhD here. So Kristin, you have contributed an incredible amount to the literature on health and healthcare for veterans populations and particularly women veterans. Let me just point out for our listeners, we’re talking about dozens of papers each year that you’re either contributing to or leading. So you’ve really made a mammoth contribution to this area. Can you tell us a little about what drew you to this work and what you have found remarkable?

Kristin Mattocks: Yeah. So it was actually very accidental that I got into women’s health. I did my PhD at Yale in HIV stigma, discrimination types of things. So when I took my first job at the VA basically, a year after I graduated from the PhD program, I was working with Amy Justice in her HIV and aging study. I thought that is where my career would go, thinking about things like stigma and discrimination and special populations.

I’d been there about a year and realized that, I don’t know, it just wasn’t sticking. I felt like I wasn’t a clinician. And for some reason, that felt like it wasn’t working as well in that particular study. I felt a little bit disadvantaged that I didn’t have a clinical background. Somebody introduced me to someone who was doing women’s health in the VA and encouraged me to talk to them—ironically, that person, I think at least Howie here…Harlan knows her, Becky Yano, who is in Los Angeles. So basically one thing led to the other, and I started to do more women’s health. And this was back in around 2008. I began to study in a very interesting area, which seems archaic now, but it was called “fee basis care” back in the day, which was basically this very small amount of care that the VA paid for that was not provided in the VA.

So one of the most interesting things about my work and what has drawn me to it over these years is that women only make up about out 8 to 10% of the VA veteran population that we care for in the VA. So when you want to talk about underserved populations where it’s just a whole set of services that women need, that men don’t need, I got very interested in that area.

Fee basis care was basically that, as wonderful as the VA is, there are things that the VA just doesn’t do. And one of the things that the VA doesn’t do at any of its 164, whatever the current number is VA facilities across the country is that we don’t provide pregnancy care. So once a woman gets pregnant, it’s gotten better, but we used to say, “Good luck. Go out in the community and find a provider and we’ll pay for it. And then come on back when you’re done with that pregnancy.”

So I’ve basically sort of built my whole career on understanding that experience for women veterans, trying to figure out if there’s a provider in your area that will care for you, if they take VA insurance which has been a whole nightmare in itself. And then just kind of balancing, receiving all of that care outside of healthcare system and then having to come back into that healthcare system.

So I think what has kept me in it these years is just that real commitment to understanding how to serve this very small population and to make sure that they have access to the same services and the same benefits that male veterans do.

Howard Forman: And just to add one more point to that I was just noting, it looks like women veterans will be doubling in numbers relative to the overall veteran population over the next 20 years. So this is an issue that the VA does need to address. It’s not going to stay small, if it is small now.

Kristin Mattocks: Yeah, it’s not. I mean, when I started in 2008, the number of women veterans we had in the VA wasn’t very big. I don’t even know that it was probably 200,000 yet. And the latest numbers I’ve seen were basically well over a half a million women veterans are now using the VA. So you’re absolutely right. I mean, we’re still women in terms of the larger male population of veterans using the VA. That number hasn’t moved much, that 10 percent-ish number. But there are more women coming to the VA.

And because women come after their military duty, many of them have thoughts or plans or are actively pregnant. So it’s been that sort of little niche that I’ve been interested in learning more about.

Harlan Krumholz: I’m so happy to have you here, Kristin. We had the opportunity to work together early on, and I wanted to share with the listeners about actually what an amazing contribution you made to my career in the course of it. You were a PhD student, and we were working together. I was working on a project that was attempting to reduce the time to treatment for patients coming in with heart attacks. There had been a long legacy of delays that had led to higher rates of mortality than could have been achieved if we had higher-quality care.

We were in the course of pursuing this largely as a traditional quantitative research project, and you turned to me and you said, “Well, what about involving Betsy Bradley, who has been on this program and is now president of Vassar and became a very close colleague of mine.” I knew Betsy. We’d worked together. I’d actually worked with her when she was a PhD student. But we’d kind of gone different directions. It’s an interesting thing.

By you leaning in and actually actively making a suggestion that I hadn’t thought of, it kind of sparked an entirely new direction of the research, because I reached out to Betsy and we transformed this project from largely a traditional quantitative research project into a mixed methods project, one that combined, melded together both quantitative and qualitative research, the sort of nuts-and-bolts statistics in epidemiology with listening intently to people and trying to derive insights from those discussions. I had never been really trained in that, and I had a lot to learn. Anyway, I want to thank you publicly for that. That was such an important thing to do. Betsy was so receptive to the idea and then became really a partner, a really tremendous partner in this.

You’ve continued to do actually qualitative research in a lot of your work, as I’ve read through it. There’s a lot of insights you’ve derived from talking, listening, and channeling the people that you’re talking to. So I wonder if you could share little bit about your experience with qualitative research. The mainstream medical research community is still reluctant to embrace the idea that qualitative research is up to snuff.

Our major journals still make it very difficult to publish that work. What’s your experience of doing it? Why do you continue to do qualitative research, and where do you see it in the future?

Kristin Mattocks: Well, it’s great. I have to thank you because when I did introduce you to Betsy, both of you very graciously allowed me to work on that project, and I hadn’t done qualitative research either. I didn’t know anything about beta blockers. And it’s funny.

Harlan Krumholz: Oh, that’s right. You started on the beta blocker approach. I forgot about it.

Kristin Mattocks: You started on the beta—

Harlan Krumholz: First of all, you were great. You were just so great, the way you jumped in. But that’s right; that preceded the time—actually, I forgot how far back this stretches, that was actually the beta blocker project, the med that slows the heart rate, and we were looking at it. It had been recommended, and many people hadn’t been using it. I forgot about that. That’s right. It started way back then.

Kristin Mattocks: Oh, absolutely. It blew my mind because I remember thinking about the methods at that time that you and Betsy had decided upon. And you had this whole list of hospitals across the United States. Some were high-performing. Some were low-performing. We made the decision that we were going to interview some stakeholders from high-performing hospitals; some stakeholders from low-performing. I think we might have done mid- too.

But it’s interesting because that methodology has always stayed with me in terms of really thinking about different ways to get at kind of what’s going on at a variety of different places and kind of sampling in a way accordingly to performance. That’s how I got my qualitative start is on that beta blocker study. Again, not knowing anything about beta blockers. But it’s funny because that has continued over my career.

I was at the West Haven VA until I think 2009 and then have been up here in North Hampton ever since. I continued to be the qualitative lead on so many different types of research projects. I mean, definitely I do my own women’s health research, but I’ve been doing a ton of pain care research over the past couple of years with collaborators at the West Haven VA in Yale.

Over the course of my career, I’ve had the opportunity to talk to so many different people about so many important clinical issues. I oftentimes have to laugh because I go into these interviews, and I may not know anything about beta blockers or the VA’s pain management strategy or things like that. But over the course of the interviews by the time I’m done, I consider myself an expert in that area because I have the opportunity to talk to all of these different stakeholders all across the country and all kinds of different fields.

I think that I always tell people that I train that if you keep working at it and you really commit yourself to qualitative research, it just opens up so many avenues in your career because everybody, as you know, probably, Harlan, everybody is looking for a qualitative expert of some kind on their grant. I feel like the phone rings off the hook constantly about people wanting help on this or that. And I’m always happy to help them because I always feel like it just broadens my knowledge and my horizons as well.

So I’m going to put that back on you. That’s all thanks to you back in the year in 2000. Twenty-two years ago, Harlan, you helped me learn about—

Harlan Krumholz: Oh my gosh.

Kristin Mattocks: ... qualitative research. So it goes both ways, actually.

Harlan Krumholz: Oh, that’s true.

Howard Forman: Let me step in, because what you’re saying about Harlan I think is true, but it’s really true about you. Now, you assemble teams of researchers to do large projects across a large spectrum. I realize some of them you’re involved in, but maybe not leading, but an awful lot of them you’re leading right now. How do you build a team of scholars that are going to help you create a methodologically sound study that’s going to impact policy? How do you think about that?

Kristin Mattocks: I think just to bounce off something you said at the very end there, Howie, I mean, one of the best things about being in the VA—and the VA I know has its pluses and minuses, I’ve had a tremendous experience over my 16 years—but I think the biggest reason is because I was trained in health policy at Yale, and more than any other place, I feel like the work I do in the VA really does impact practice and policy.

I mean, knowing that is incredible. So you have this incredible community of VA researchers across the country, and we’ve built a strong community. To answer your question about building teams, I mean, I don’t just have my small team in western Massachusetts, I have access to this just very collegial group of investigators across the country. And whether it’s cardiologists or pain care specialists or people who focus on obesity, there are so many people that I can always choose from to build that team.

Yeah, I would say that one of the other things that I think really led to success, and I’m going to credit VA Connecticut for this, is back to that first study that I worked on with Amy Justice. She had a very large cohort study of HIV-infected veterans, and it was a study on HIV and aging. But it was a cohort study.

I didn’t know anything about cohort studies but had the opportunity to watch it up close for a couple of years and see all the different things you could do with a prospective cohort.

When I started my work, I decided to build this prospective cohort of pregnant veterans across the United States. So back in 2013, we built this study that’s called COMFORT [Center for Maternal and Infant Outcomes Research in Translation], which was a prospective cohort study of pregnant veterans, to try to understand healthcare utilization but also healthcare conditions. But the also, very first study to understand kind of what happened to the babies of women veterans.

So we built this incredible cohort study of 15 sites across the country ranging from Los Angeles to Dallas to Tampa. I wanted some rural sites like Fargo, North Dakota, and Iowa. Even included San Juan, Puerto Rico. So that cohort is now well over 1,200 pregnant postpartum veterans. And we’ve been able to leverage that cohort to ask so many different types of questions over the years that really nobody has posed before.

So I feel like we’ve really pushed the study forward. We’ve pushed the field forward in the VA of understanding women veterans and pregnant veterans. And I think it is thanks to that, to understanding the importance of cohort studies, to understand populations and how things work.

Harlan Krumholz: I think such a great topic this week, where we have International Women’s Day, to be talking about women’s health like this. When I look at your work, Kristin, I sort of think you’re making visible what has been commonly invisible or hidden in plain sight. I mean, there have been increasing numbers of women veterans, and yet when people think of veterans and when the veteran services were configured originally, that wasn’t... I mean, pregnancy, wow. That’s very different than what most people think about when they think about the VAs or they think about veterans getting care.

And then you’ve written about sexual victimization and particularly among lesbian and bisexual veterans. You’re really bringing to the forefront the perspective of a lot of people who, again, may not be seen in the sort of traditional ways but actually really are what makes up our military today. And we need to be able to have a broader vision about who they are in their risks and so forth.

As you do this work now, what do you think is the most important thing next to be doing to try to make sure that we’re looking out for all of our veterans and particularly, for you, the women veterans who are, it does seem like incurring a lot more risk, a lot more hazardous behavior, and sometimes when they get back, it affects outcomes.

Kristin Mattocks: Yeah. Well, actually we just got funded to do the next thing. So I’m really excited about this project. So recently, probably about a year ago, we wrote a paper looking at racial ethnic differences in C-sections among veterans in the VA. We found just insane differences in terms of C-section rates when you compare basically women of color with White women. As you know probably across the United States, C-section averages are about 31% higher for Black women, but Black women are about 35%, White women maybe 31%. At some of our study sites, particularly in the South—Durham, Little Rock, Dallas—we were seeing C-section rates for women, Black women, veterans of 70%.

Harlan Krumholz: Wow.

Kristin Mattocks: So Durham, Little Rock, New Orleans—just ridiculous rates. And across the board, they were never that for White women. So we poked around the literature a little bit to think about interventions. And it turns out that there’s this idea that’s been growing over the past couple years about supporting particularly women of color in pregnancy and delivery with a doula. So basically a trained professional who’s not a medical professional but a labor support person who can help negotiate, help communicate, that type of thing.

Now, the interesting thing about this is that technically in the VA, this is not something that the VA pays for. It’s never been done in the VA. But we made a convincing case that we really need to tackle this and with nationwide rates of maternal morbidity and mortality among Black women, we thought we need to really go after this. So we got funded. We are actually, in the next week or two, launching the first ever doula intervention for pregnant veterans. And we’ll be focusing on women veterans in Durham, North Carolina, and New Orleans, which were some of the biggest disparities we saw.

But by all accounts, talking to pregnant veterans, this is absolutely something they want. Some of the interviews we’ve been doing lately with Black veterans, it turns out that they really feel like they are not given a choice about whether or not to have a C-section. They’ll go in to the doctor. Some of them will be told this practice only does C-sections, which is the most ridiculous thing I’ve ever heard. If they want to try a vaginal birth after C, they’re really not allowed to do so.

So it gets at those issues of structural racism and discrimination that I’ve always been interested in. But I feel like now we’re really going to be able to tackle this, I think, which is I think a real service to our pregnant veterans.

Harlan Krumholz: That’s great.

Howard Forman: Yeah. Early on in the podcast, we had Mary-Ann Etiebet from Merck for Mothers talking about the importance of access to doulas and the extraordinarily high rates of maternal mortality that occur particularly in Black women and notably in the South, just as you mentioned. So this is a population that we just do not do well by, and particularly among our veterans, where we owe them so much.

Kristin Mattocks: Right, right. Remember, we kind of in some ways lose track of them. I mean we don’t lose track of them, but because they leave the VA healthcare system, we have less ability to oversee what happens in the community. So again, that’s just something that we have to really focus on and fix because it’s an injustice to these women.

Harlan Krumholz: Kristin, I wanted to just take you on one little other detour here in terms of the things that you’ve been working on. You’re one of the nation’s experts on community care programs in the VA and have written extensively on this. For people listening, since around 2014, the Department of Veteran Affairs really dramatically shifted the ways in which veterans can receive care. And the notion was that really, people should have more choices. It wasn’t just a matter of providing care in one of the, I don’t know, what is it, 170-plus VA medical centers, but that people could have a choice to go to other sites of care.

So they passed this thing, the Choice Act and the MISSION Act, that would provide veterans with more opportunities to receive care with community providers that were partnering with the VA. I know you’ve written extensively about this, and especially in the last couple years just before the pandemic, I guess we were like almost 3 million veterans had been referred for community care.

I’m sure that in the pandemic that’s continued to grow. What’s your sense of... Has that program been successful? What are the issues with it? What are you thinking about it now?

Kristin Mattocks: We’re in a tricky place right now in the VA. So the MISSION Act from my perspective was a really incredible opportunity for veterans to get care in the community. And there are definitely people who feel like all care should stay in the VA, but we also forget—as you both know, I’m from Montana. The closest VA in Montana is always going to be eight or nine hours away.

It used to be back in the fee care days that we wanted people to drive eight or nine hours to the nearest VA. And it’s just, veterans don’t want that. It’s not practical. So both Choice and MISSION gave veterans the opportunity to get care in their community if it was sort of closer and made sense.

So it was a great piece of legislation. However, what has happened, and this was, I think, part of the turning point of why we’re a little bit conflicted now, is part of that MISSION legislation was an urgent care benefit, which basically allowed veterans, like the rest of us, to go to CVS or Walgreens or whatever if you had a sore throat or something like that.

As you can imagine, costs just went crazy. Just our community care budget went through the roof with urgent care. And also there were some changes in emergency care that made that a little bit easier to get to. So we’re now in a situation where in the VA, we are re-looking at the way that we do things, and there’s initiatives in place to encourage veterans to stay in the VA to rethink some of those choices.

So, honestly, I think that we’re at this point where there’s a lot of tension between sending veterans out and keeping them in. Lots of budgetary sort of reasons. So it’s hard. I think the VA is really struggling with this right now. There’s offices in DC that used to have... We had a separate community care office and a separate access to care office. And now those two major offices are merging, which we’re going to figure out what that’s about.

So I think it’s a great question, Harlan, and I think that we’re in a hard place right now. And the thing is, those veterans who have enjoyed the opportunity to go into the community for the past couple of years, many of them want to continue to enjoy that opportunity.

Harlan Krumholz: I bet you don’t see us turning back on that. Right? That would be hard.

Kristin Mattocks: Yeah, no. That’s not part of any sort of legislation I’ve seen, but to have those conversations with veterans. I mean, this whole thing started back in 2014 because there were really important issues in the VA related to wait times and people died and terrible things happened. So remember, this all started eight years ago because of wait time issues in the VA. But now the thing that we’re struggling with, I’m sure, is cardiology. There’s wait times in the community too. Right?

So now we’re in this funny place where, is it going to take longer to get care in the community because of wait times, or is it going to take longer in the VA? And it’s a toss-up.

Howard Forman: I want to say, you started off by saying that you’re not a clinician, but clinician or not, you’re an incredibly empathic and compassionate person who is ideally suited to look out for these populations that don’t often have people looking out for them. You’ve made a huge impact on the veterans populations to date, and I expect you’ll continue to do that. We’re just so thankful to have you sharing your experiences with us on the Health & Veritas podcast.

Harlan Krumholz: Yeah. Couldn’t agree more. It’s so great to be on with you, Kristin, and to reminisce also about the past. It’s great to see you.

Kristin Mattocks: Yeah. Thank you so much. I’ve enjoyed it.

Howard Forman: So, Harlan, COVID has seemingly fallen by the wayside as the war on Ukraine wages on. But it’s not disappeared. We’re still counting more than a thousand deaths per day. Those are far, far above levels that we ever imagined possible before this pandemic. And by the way, this Friday, March 11th, is the two-year anniversary of the World Health Organization declaring this an official pandemic. So we’re two years into it, and we still got a lot of work to do.

You and I had the great privilege of working with a group of academics, former policy leaders, and other scholars on what we’ve called the COVID Roadmap, the “next normal.” And it was, I think, fairly well received by both the administration as well as the public. It was released publicly just two days ago. I was curious to know what type of feedback you’ve gotten about it over the last 48 hours that it’s become more public and what you think are the biggest take-home messages from it?

Harlan Krumholz: Maybe it’s good to give people just a little bit of perspective on this, is led by Zeke Emanuel and brought together so many people. And it was really quite a lesson to me. Almost a master class in how you could assemble a large group and find a path towards a constructive contribution to the administration, the government officials. Find something that might be helpful to them. There may be points where we’re trying to push the government, but we’re certainly not trying to embarrass it.

We recognize this is a very hard job, to try to manage a country with very diverse opinions and for whom much harm has been incurred. It was just such a privilege to be able to work with people and bring in lots of opinions and then distill it in into a set of recommendations.

I found that people who’ve sat down with it and spent time with the report have been responding very positively. They’ve thought that it helps consolidate our current knowledge and has a set of recommendations that are helpful in setting the path forward. We also have found that the administration has had what I think is a wonderful attitude, sort of embracing external input, trying to figure out how that fits with regard to what resources they have and other constraints that they’re dealing with.

Although the war is taking a lot of attention in the White House, there’s a lot of smart people who are still working very hard every day, trying to figure out this path forward with regard to the pandemic. I find that gives me confidence that this isn’t being let go, it’s not being forgotten, but instead these people are still dedicated towards making the right choices.

So it was a good experience, and I was happy to see the administration embrace external input. Not just from us but from others as well. But I thought that was really terrific.

Howard Forman: Yeah, I was impressed, first of all, that I think the news media understood that this was not meant to be, “Do you wear a mask or don’t you wear a mask?” That this is a longer-term plan, mostly for government but also for the private sector to think about, what should our priorities be, so we don’t keep making the same mistakes over and over again, looking back and saying, “Oh, golly gee, this happened again, and we’re just as unprepared for it now as we were 18 months ago.”

I agree with you, Zeke Emanuel pulled this together with a group of other people who really were great organizers of this effort and facilitated a discussion and a collaboration. I got to meet people that I hadn’t really known before, and it was a two-month effort. I think we all put our best selves forward. And I think the product is something to be proud of. I hope that our listeners will take a chance to look at the executive summaries. Only a couple of pages. It’s at covidroadmap.org. And we’ll hopefully link it to our transcript for the podcast.

Harlan Krumholz: Yeah. That’s terrific. A lot of busy people who made time, uncompensated, yet, who’s able to assemble a lot of people, well-intentioned, just wanted to make a contribution. Yeah, it was nice how people will take a look at it.

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 this on Twitter.

Harlan Krumholz: I’m at H-M-K-Y-A-L-E. That’s hmkyale.

Howard Forman: And I’m @thehowie. That’s at T-H-E-H-O-W-I-E.

Harlan Krumholz: Health & Veritas is produced with the Yale School of Management. Thanks to our researcher, Sherrie Wang, and to our producer, Miranda Shafer. Talk to you soon, Howie.

Howard Forman: Thanks very much, Harlan. Talk to you soon.