Margo Harrison: Women’s Health as a Path to Empowerment

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

Howard Forman: And I’m Howie Forman. We’re physicians and professors at Yale University. We’re trying to get closer to the truth about health and healthcare. We’re excited to welcome Dr. Margo Harrison today, but we usually check on the current hot topics in health and healthcare. You and I had a conversation last night about the things that are irritating us right now, and so we decided you’re going to talk about your topic now, and at the end of the program I’ll tell you mine. So what’s on your mind?

Harlan Krumholz: All right, well, I don’t know if irritating…. Unlike you, you’re much more erudite than I am. So sometimes I’m sitting around with my wife and we’re watching TV, and you can imagine the channels we must be watching because the ads come on about memory loss. So I don’t know, that’s because we’re watching Everyone Loves Raymond or we’re watching Frasier or something. I don’t know. We’re watching old shows. But the commercials come on and, oh my gosh, there’s these testimonials where somebody comes on and says, “I’ve been getting up there in age, and I was having trouble remembering things, and then all of a sudden I started taking Prevagen, and things are so much better,” and people listening may... we’re inundated with a lot of drug ads. By the way, we’re one of the few countries in the world that allows direct-to-consumer advertising for drugs. Well, this is how—

Howard Forman: Only two! Us and New Zealand.

Harlan Krumholz: New Zealand? New Zealand or some—

Howard Forman: Yup. That’s it. That’s it.

Harlan Krumholz: Yeah. So it’s kind of crazy. And by the way, I don’t know what the evening news would do without the drug ads. I mean, the news programs are replete with them, but if you see an ad for an actual drug that’s approved, it’s had to go through quite a lot of scrutiny in terms of—before it gets approved, the studies that it has to present, the approval itself. And then in the direct-to-consumer advertising, there’s a lot of requirements about what they can claim. On the other hand, nutritional supplements, if you’re in that category, you’re kind of “get out of jail”... I shouldn’t say it like that, but you kind of are able to avoid all of that. And so you can have people come on the show, you don’t have that rapid-fire, all the complications and side effects thing, and you’ve just basically got someone saying, “You know what? I took this, and it’s amazing.”

And so I was interested in this Prevagen because after I’ve seen so many of these commercials, and as you dig into it, basically it’s this component of a certain kind of jellyfish that causes bioluminescence, and that is important in calcium handling. And this group in Wisconsin, Quincy Biosciences, about 20 years ago—and so I guess they started selling in 2007 or something like that—started having this idea that this might be important in cognition, but it’s marketed like crazy. Actually. There’s a Prevagen ice skating championships I saw. There’s all of this stuff. It’s heavily, heavily marketed, heavily branded. There are no information on sales because it’s a private company. It says it’s the number one recommended memory supplement by pharmacists, but that probably just means it’s the main one they’ve heard of. I mean, it doesn’t mean anything more than that. And the literature is very, very light.

And there are no... let me say this, there are no major trials of it. There are some small studies. We’ll put one in the notes that said there was some improvement. There are other studies says there’s not. There’s some surveys that are having trouble finding studies that support it. But let’s just say this, it has not undergone any fraction of the kind of scrutiny that a drug that came out and said, “We’re effective in treating cognition,” would have to undergo because it’s in this supplement category. Maybe can you explain to folks how does that work at the FDA? I mean, how is it that there is this pathway that people can be promoting this over the counter, but without having to go through that regulatory scrutiny?

Howard Forman: So we did talk about this on an earlier podcast, and I may get it slightly wrong, but basically if it comes in the category of an already readily accessible food product, and I think jellyfish fit into that category, if it’s extracted from jellyfish, if it’s extracted from a tree or a leaf, it can be sold in that format and then it’s sold as not... It’s not FDA-approved. They have to actually say it’s not FDA-approved. But you can make claims that are based on testimonials. You can make claims based on broad sweeping things like “it has been shown” even if it’s one paper. It’s basically just about truth and advertising at that point. And a drug like this is remarkably, as you said, very thin. And the best evidence is a company-sponsored, very small trial that when it went under greater scrutiny, was found to have only a small subcategory that might have had some benefit.

Harlan Krumholz: And in not a very prestigious journal, let’s say in the outer bounds of academic publishing. There was a New York federal jury trial that was conducted that looked into the statements of this, that the reason this is timely is it was just a couple of weeks ago that this came through. And the interesting thing is that the jury found some of the statements were misleading, but they couldn’t find them on all. And I think the reason is because if someone makes a testimonial and they really believe it, even if it’s one, it’s not rigorous science, they can get away with saying that. And if there’s ambiguity... I mean, proving that it’s not effective is harder, I guess, than you might first appear. But it was interesting to say that the jury didn’t, was sort of mixed about it.

And some of the claims that said were not misleading. And I think it’s because the kind of criteria you and I would use for something that is actually coming out and called safe and effective for cognitive decline, is that a very different standard than somebody standing on a street corner said, “I took this, and I feel better.” And is that misleading or not? Maybe that’s not misleading because that person believes it. I mean, they aren’t in those commercials claiming a large randomized trial showed this. They have one person saying, “I took it, and I feel better.” And anyway, I just think this needs to be cleaned up because if people see these side by side, they’ll see a drug ad from a company that’s very circumspect, and then they’ll see one side by side where it’s really over-the-top promotion, and they may not realize that they’re under different rules and that they may think that, “Wow, that one must really be good.” And then I’m watching a lot of life sciences companies who are killing themselves—

Howard Forman: Right. To prove, right.

Harlan Krumholz: ... to produce the evidence, they can go through the regulatory pathway, and be approved, and be prescribed for benefit for patients. And then you’re seeing this as a whole another pathway that can be utilized that some of these things that go through nutritional supplements may have undergone a lot of study, but for the most part they don’t.

Howard Forman: Yeah, certainly not this one, but my topic is going to be somewhat related, so we’ll come to that after Dr. Harrison.

Harlan Krumholz: Great. Let’s get onto our guest.

Howard Forman: Dr. Margo Harrison is an OB-GYN doctor by training with years of experience in research and the healthcare advisory world. She currently works as an adjunct professor at the University of Colorado Anschutz Medical Campus and serves as vice president of strategy and commercialization at Mate Fertility, a startup providing affordable fertility care. Aside from her impressive clinical research and teaching experience, Dr. Harrison has also advised many healthcare startups, such as Solace Space, Rosy Wellness, Poly, and Fertile AI, with their business development research and strategy. She’s also the founder and principal consultant of Dahlia Ventures, a femtech company focusing on startups, and some are work centers on the nexus of healthcare equity access and women’s health. She received her bachelor’s degree from Yale University, when I first met her, and she completed her MD at Albert Einstein College of Medicine and also completed an MPH at the Johns Hopkins Bloomberg School of Public Health.

So first of all, I want to welcome you to the podcast. It is great to see you in person, even if virtually, over a very long period of time. And the last, we had a lengthy conversation. You were graduating Yale and going off to work for MedPAC, the Medicare Payment Advisory Commission. And I’m curious to hear when you became passionate about going into women’s health and what are the issues that have motivated you along the way?

Margo Harrison: Well, so grateful to be here. And yes, thank you for getting my career started by helping me get that very first job and getting me interested in health economics. The story of when I got interested in women’s health actually starts when I was 15 years old. My mom used to work in the library at my high school, and she was trying to look for summer programs and she was like, “Oh, I found this program where you can go to France, an exchange program,” but the date had already passed. So I wrote some essay, tried to get it in, and they said, “You can’t get into the France program, but you can pick any of these other countries in the world to go to.” So I ended up choosing Kenya. So I went to Kenya as a 15-year-old and part of the trip... It was an exchange program and part of it was living with a family.

And so I was living with this family. They had some cousins living with them, they had multiple kids. Their oldest son was actually married and he had brought his wife home. And so over the course of the 10-day family stay, I was kind of hanging out with her going to get water, making dinner, doing stuff around the house. And over the course of the 10 days, I mean, her English just started cursory and by the end was incredibly good. She was clearly super bright, and she was like, “I just don’t understand why I’m college-educated and working on this property doing domestic work, and you were able to come across the world and visit me and do this amazing experience.” And that was kind of this incredible lesson in privilege and being grateful and obviously honestly was the defining moment of the rest of my career, including my time at Yale.

But I really at that time became very committed to women’s liberty and was very affected by the fact that this person with so much human potential, just felt like her human potential was being wasted. And I felt like, well, if somebody’s going to just be the best person that they can be or contribute or fulfill their own life goals, especially if they’re a woman, really needs to be divorced from their ability to reproduce. Because in a lot of situations, like your role in society is really dictated by those organs that you have in your body. And so I became very committed at that time to women just sort of being in control of those organs and using them in the ways that they want to use them when they want to use them or if they never want to use them so that they could achieve other life goals. So that was really the defining moment that got my interest in global health. I ended up having a long career in global health research, and obviously I’m still active in women’s health, and it came from that experience.

Harlan Krumholz: First of all, this is the first time I’ve gotten a chance to meet you. It’s very nice to meet you.

Margo Harrison: Nice to meet you as well.

Harlan Krumholz: It’s always amazing to see the large number of people that Howie has influenced over his career when they come back here and all the things that they’ve accomplished, which I know is not all because of Howie, but—

Howard Forman: Yeah, it takes very little to make gold shine. I always say that: very little, if anything.

Harlan Krumholz: But it’s very nice to meet you and to see what you’ve been doing. I’m very interested in your entrepreneurial activities. You seem to be involved in quite a lot of things. I mean, you start a company that advises femtech companies. You are part of a startup now. I don’t even know when you stopped calling it a startup as you start to get out of the gate, but I wonder if you could just say a little bit about how that transition occurred for you. And I don’t know, what has it meant for you? I mean, it’s just very interesting because you’re involved in so many different things. Just wonder if you can talk a little bit about your activities.

Margo Harrison: Yeah, I would love to thank you and so nice to meet you as well and grateful to be here. And yeah, as we said before, how starting careers off right at the beginning, such an important time in people’s lives. But I think I was always interested in having a big impact. So I went into medicine, as Dr. Forman said, I got my MPH when I was in med school. So for me it was always like I’m going into medicine, but my goal is to impact women like Rhoda in Kenya. It is to have a larger impact, which is why I wanted to learn about impacting millions at a time, which I think is the Bloomberg School of Public Health motto, is “Impacting Lives Millions at a Time.” So I always had a big vision for myself. I never thought that I was going to be a physician, like a practicing clinical physician forever.

But I think what’s really interesting is the moment I graduated from residency, I did inpatient OB-GYN, so I did labor and delivery care and then got some training in family planning and abortion care. But the moment I graduated residency, I was 50% committed to research. And to me, research is entrepreneurship. Everything about research is analogous to entrepreneurship. It’s understanding the context of something you’re interested in, identifying the gap, developing an innovative solution to what you think, what you hypothesize is that gap, learning how to be an incredibly good writer and to convey to funders, this is what I’m trying to do and why I’m trying to do it. And what’s important about it—getting the funding, hiring people, managing a budget, firing people—the research was moving so slowly for me, I actually taught myself statistics so that I could write the papers and analyze the data faster.

And in four years, I published 50 papers doing secondary analysis of low- and middle-income country datasets and was funded on four grants to do research around labor delivery and pregnancy spacing in low- and middle-income countries. So when I look back, I consider myself to be an entrepreneur since the first moment that I started medicine, which was in committing my time to thinking about innovative solutions to women’s health problems. And then I think the academic path was just not the right fit for me. It was too slow. Obviously I was doing things, but I was just worried I’m not going to get another NIH grant for three years. I can’t believe I was sitting there in Ethiopia collecting data, doing dissemination and implementation sites about mobile surgical units. And I was like, “I’m not going to be back here for three years. It’s just the way the grant cycle works.”

And I was like, “This is not the right way to do this for me.” I was even thinking in my head, “What’s the willingness to pay in this setting for this intervention?” There’s some willingness to pay. People don’t want to die in childbirth. People want to live and they want to get good care. So this is not the right way to be framing this issue. It’s certainly advancing generalizable knowledge and contributing to other people solving other problems. But that’s when I left and I think I was looking for something so different. I went to a pre-seed startup, and it failed. Immediately, it failed. And I had just left this prestigious successful academic career, chose the earliest company that I could possibly choose. The startup promptly failed; the economy promptly plummeted. I promptly could not get a job anywhere and was reaching out to all these CEOs in the women’s health space, what’s my value prop?

How could I... I realized I had a huge value prop, I could help... They all wanted me, none of them could afford me, and I could work with all of them. So that’s when I started the consulting firm. And I obviously brought the clinical background piece, and I think the piece that I brought most uniquely was the research approach, the mental approach, helping them with their apps and the backend dataset and how to do secondary analysis. But found I was so much more interested in strategy and business strategy and learning where they fit in the field and what was their differentiating features. So really sort of fell in love with the strategy piece as opposed to more of the operations piece. And yeah, founded my own consulting firm and then actually have also founded in my own company as of November. So always just looking for... I think maybe my problem is the shiny object syndrome. Everything’s cool. Everyone’s doing cool stuff. The consultant setup is a good one for me because there’s always a new interesting problem to think about.

Howard Forman: Can you tell us a little about Mate Fertility? Because on the one hand, it’s a relatively early-stage startup in terms of funding. On the other hand, it has pretty broad geographic reach and it’s growing even faster. And I’d love to hear what is its place in reproductive health?

Margo Harrison: I’m so happy you asked that question because I personally think Mate Fertility is the future of fertility specific healthcare. And as I’ve joined the company, what I’ve sort of brought onboard or what I’m most interested in is how do we smooth the entire fertility experience from the moment that you are 20 years old and want to understand what your options are all the way through the moment when you’re 42 and you realize you had wanted to be pregnant and to grow your family. And so for me, it’s really about using technology, using artificial intelligence, building a tech stack that allows you to start someone at one spot and smooth that experience along their entire fertility journey, whatever those goals are, and to be able to leverage the technology to jump to different places in the patient journey. Like I started off talking about, depending on where people want to be with their reproductive health, Mate Fertility is particularly interested in secondary and tertiary markets and increasing access to care. And I think the technology piece really allows us to increase access and to reach out into rural areas where people may not have access to care. So we’re interested in access, affordable care, supporting people, and being able to achieve their fertility goals regardless of where they come from, who they’re trying to grow a family with, whether or not they’re trying to grow a family independently, regardless of who their partner is, regardless of what their gender and sexual orientation is. We’re opening a clinic this year in Pennsylvania that will be focused specifically on trans care, and I don’t think anybody else is actively engaging in that space like we are.

Harlan Krumholz: I wonder if you could just talk a little bit about the journey. So you got the idea—I always think the interesting journey is how do you convince anyone to invest in the idea? How do you make it so that people find it attractive and are willing actually to put down some money? What was the journey like for that as you—

Margo Harrison: Well, I’m currently fundraising right now for my own company, so I’m very actively in this experience right now.

Harlan Krumholz: We’re happy to be a platform for you to talk about that because—

Margo Harrison: Thank you. I would love to, I mean, just talking about the fundraising piece this early, I’m actually pre-revenue, pre-product in my own company. You’re selling yourself, and you are selling your story. And I think it’s the exact same thing with NIH. With NIH it’s like, “This is my idea.” They care about the approach. They want to know the methodology. They want to understand that you’re actually cutting-edge in your methodology, in your approach. And then after that, they want to know that it’s the right team. They want to see the right bio sketch, they want to see the right patient... I mean, papers having been written—it’s all about telling the story. Grant writing is a story.

Howard Forman: She told me about this company just two days ago, and I understood it immediately. So she does a great job of that. Do you want to just briefly say?

Margo Harrison: So the company is in the menstrual pain and symptom space. We are repackaging supplements and over-the-counter medications in blister packs to leverage the experience of the birth control pill, to time and dose evidence-based intervention so that people start the products before the period starts to statistically significantly improve pain, bleeding, and headache in terms of the first two products. It’s a consumer-packaged good company that is an entrée into my raison d’être as a human being, which is that if you understand when to take things with a relation to your period, you start to understand your cycle. Once you understand your cycle, you understand your sexual and reproductive health. Once you understand your sexual and reproductive health, you are liberated, and you will do what you want with your sexual and reproductive health. So it always comes back to that big vision and the mission of this particular company is really to improve that experience.

I mean, I don’t know why there are no over-the-counter medications targeted towards menstrual pain except Midol, which came on in the early 1900s. It has been a hundred years. And Advil and Aleve, which are out there, first-line treatment for period pain, have not made a product to properly use their own product to treat women the right way to improve their life. I mean, it’s a social justice issue. The product is available over the counter in every store, in every bodega in New York City, you can walk in and buy a little Advil packet. So why are they not building the right product that’s user-centered for women who lose nine productive days a year of going to work, going to school, participating. Why don’t they care about women’s pain in that way? Why don’t they care about women’s liberation?

Harlan Krumholz: So this is a point that actually Howie and I talked about in the intro, we’re going to talk about in the outro about these consumer products. How much work will you have to do to prove... So you said it’s marketing, but how much work will you have to do to prove the effectiveness of the product?

Margo Harrison: None. It’s already proven effective. It is first-line treatment. There’s Cochrane meta-analysis that say this product is the right product. It reduces pain this much. It is more effective than these other interventions. And to use it the right way, you use it like this.

Harlan Krumholz: It’s the timing, right? You want to go—

Margo Harrison: It’s just the timing.

Harlan Krumholz: Right. It’s the timing.

Margo Harrison: It’s just the timing. And so I’m starting to wrestle with things in my mind. Do I put a reusable container that people put the Aleve in, and they could buy the Aleve wherever they want and it just ticks through and helps them take it? Or do I do these blister packs, or do I do both? Do I meet the woman wherever she is and whatever’s the right solution for her? Because it really came from this blister pack concept, but now I’m like, “Oh, well, there’s other ways that different women are going to want to interact with the product.”

Harlan Krumholz: Is it just the nonsteroidal or something else?

Margo Harrison: It’s a nonsteroidal. I will in the future. I mean, it leads to an entire scope of prescription products. I’ll have to go to FDA to make a combined product with the over-the-counter medication. But the supplement products are combined. They have a lower threshold for regulatory involvement. Our supplement product will be vitamin E, magnesium. Vitamin E has randomized controlled trials behind it. It works just above NSAIDs on the pathway of elaborating prostaglandins, so the two products can go together. But vitamin E works on arachidonic acid, which is just higher up in the pathway, and it will be timed to dose exactly the same way. So it sort of meets different people. Fifty percent of people in life I’ve noticed with other companies and data collection want their doctor to tell them what to do. And 50% of people want a nondoctor, a nonmedical intervention for the solution. So we’ll be providing both, no product that we ever put on the market will not be evidence-based for period pain or symptoms. So we start with these smaller products.

We will have SMS, like a QR code on the box, so that we can text with women about when they should take the medication to properly time and dose. We’re going to put a little sheath on the back of a cell phone where you put your blister packs. So when you get the SMS, the blister pack’s right there with you—you take your medication. But eventually we’ll get our own period-tracking app. In the period-tracking app, we will get into education; we will get into research. I’ve already published two papers on behalf of my company. So all of the consumer data that I collect or the future research projects that I do will be given back to the consumers and fed directly back to them to disseminate the information that they’re providing. And then we’ll have some social interaction on the app as well, and really building a community around menstrual pain. So I think there’s just a real opportunity here to then—again—achieve that vision of empowerment and liberty, which is taking control of the very first moment you realize that you’re a woman.

Howard Forman: You’ve done amazing things. I know you’re going to continue to do amazing things. I hope you come back for your 20th reunion this year, but if not, I hope I get to see you soon, and good luck with everything you’re doing.

Margo Harrison: Thank you. Thank you, guys, so much for the opportunity.

Howard Forman: Thank you so much.

Harlan Krumholz: Really interesting. You know, her insight into herself and what she’s trying to do and the way she speaks. I wish her the best of luck. She’s quite a remarkable person, honestly.

Howard Forman: Yeah, no, she has a lot of talent, and she’s had great experiences. And really proud to see what she’s accomplished.

Harlan Krumholz: Yeah. So what’s on your mind this week, Howie?

Howard Forman: Yeah. So after talking about Prevagen, I want to talk about something related. Someone I know went to a hydration spa, and there’s lots of different names for it, but I’ll just call it a hydration spa at the moment. Ironically, they went after having Norovirus, literally after the episode where you talked about Norovirus. So this person had become dehydrated after having Norovirus, wasn’t feeling great, went to a hydration spa, and got some IV fluids. I had vaguely heard about these things in the past but never paid them much attention. It turns out to be a fairly huge and growing industry. I mean, $15 billion or more right now. It is lightly regulated, if at all, in some locales. And by that I mean there are rules and regulations, but the companies that operate them seem to skirt or avoid them. My words, not theirs, obviously. So what are these spas?

There are many types, and some include things as aggressive as subcutaneous injections of various molecules and supplements, as we talked about. But I’m going to be concerned with what you or the listener might think are the safest of these. The ones that infuse or inject IV fluids into your body that add things like vitamins or other minerals, and they’re primarily used to treat a migraine; helping your athletic performance; detoxifying your blood; reversing your aging, Harlan; treating obesity; or merely helping you recover from a migraine or hangover. These treatments can be hundreds of dollars a treatment—hundreds of dollars. And by the way, Harlan, there is zero evidence that they work. Zero evidence, right? But what could go wrong, right? The answer is a lot. So compounding, a term that we may have mentioned once before in the podcast is the process of combining, mixing, or altering ingredients to create a medication tailored to the needs of an individual patient.

It is not FDA-regulated. It is up to state law. And while a spa may say that a physician or practitioner is prescribing the therapy, which most states actually require, they’re most often not on site or they’re very lightly available. And the FDA has even convened industry groups to study and discuss these risks. But their authority is limited. As I said, they don’t regulate this, and there are big risks. These include serious infections, including deaths from injections at these centers. So to our listeners, I say, and then I want to hear your thoughts, Harlan. Whether it’s Prevagen or a hydration spa, caveat emptor, consider the known benefits and please ask about them. And also consider what risks you are partaking in even beyond the risk of just losing your own money.

Harlan Krumholz: Well, and this stretches all the way to stem cells. There’s ads in our local newspaper about physicians who are offering stem cell treatments that I know, again, are sort of regulated in very different ways.

Howard Forman: That’s right.

Harlan Krumholz: I think I told you the story about my father, who was getting a knee replacement, and the orthopedic surgeon said, “For 5,000 bucks we can inject stem cells in and help you.” Without any evidence about it, and so forth. So it’s very interesting that there are these very uneven regulatory, there are holes where things are getting through. And I couldn’t agree with you more when you say caveat emptor. People need to realize that there’s not uniform regulation. Of course, devices are different than drugs, but these supplements and now the hydration therapies is quite amazing….

Howard Forman: I saw on one of the sites right in your area, Harlan, they’re offering semaglutide for $400 infusions. $400 for a month of semaglutide. So they are getting non-FDA-approved semaglutide. They are infusing it in you. Very light physician oversight. The center that I just looked at does not have a physician. They have a physician associate and a nurse. They’re prescribing semaglutide, they’re infusing it. It’s off-label, non-FDA semaglutide. That’s Ozempic or Wegovy. And I’m just aghast at this, and I think this does not end well.

Harlan Krumholz: There’s lots of holes. How about off-label? How about ivermectin for COVID, though? That’s-

Howard Forman: Yeah, right, exactly. No, that’s right. Good point. Good point.

Harlan Krumholz: So there’s lots of holes. Thanks for bringing that up today. Yeah, I saw that, and the charge is something. I mean, if you’re entrepreneurial, there are lots of places you can run that kind of leverage people’s interest in health that are just not evidence-based.

Howard Forman: You call it “entrepreneurship.” I call it “grifting.”

Harlan Krumholz: Gosh, I can’t argue with you, honestly. 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, email us at health.veritas@yale.edu or follow us on LinkedIn, Threads, or Twitter.

Harlan Krumholz: And we very much want to hear your feedback, questions, or your own experiences on these topics. Just this week, we heard someone from my hometown of Dayton, Ohio, who kindly wrote us a note and made us feel good, and we appreciate that. If you like the podcast, please rate and review us on your favorite podcastapp. That helps us. We always read the reviews, and honestly, if you’ve got reasons to suggest or you’re concerned about the podcast, we’re welcome to hear that too. It also helps people find us.

Howard Forman: And if you have questions about the MBA for Executives program at the Yale School of Management, reach out via email for more information or check out our website at som.yale.edu/emba.

Harlan Krumholz: Health & Veritas is produced by the Yale School of Management and the Yale School of Public Health. Thanks to our researchers, Ines Gilles and Sophia Stumpf, tremendous Yale undergraduates, and our producer, Miranda Shafer, an amazing producer. Thank you, Miranda. Talk to you soon, Howie.

Howard Forman: Yeah, thanks to all of them. Talk to you soon, Harlan. Thank you.