Menopaused with Susan Dominus

To learn more and to nominate yourself or someone else, visit Debeaumont.

Org.

The F.D.A. approves an RSV vaccine. The WHO officially ended the COvId global health emergency as the U.S public health emergency expires this week. A new CDC report shows that overdose deaths among Black folks skyrocketed in 2020, driven largely by fentanyl.

This is America dissected. I'm your host, Dr. Abdul El-Sayed.

Friends, before we get started, a quick call. If you're graduating from a public health program this year, we want to hear from you. We're putting together an episode about the future of public health, and you, well, you're that future. If you're graduating in 2023 and want to talk, send us an email at americadissectedatcrooked.com. that's americadissectedatcrooked.com and our producers will be in touch.

Now on to the show. Today, we're talking about menopause and the general disservice wrought upon people who are going through it. By a scientific establishment that fundamentally discounts the suffering that comes with the experience. If you haven't caught on by now, there are a lot of ways that our healthcare system discounts the experiences of women. We talked a few weeks back about the differential experience of puberty, particularly early puberty, and the ways that our silence on the matter has done way more harm than good. We've talked about our failure to take the experience of birth seriously, particularly among Black women.

Our society has full-on discounted the dangers of pregnancy and dismissed the many other reasons women seek abortions. So much so that national policy favors allowing people to force it on you. Which 24 states have now gone ahead and done now? Look, I don't think I need to put my cards on the table on this one. But menopause, it's not something I've had to think much about. I'm a 38-year-old cis man.

I'm never going to face menopause, and while plenty of women I know and love have experienced it, the script they've been taught discounts their pain and discomfort as something to suffer silently. And certainly not to speak to a young man about. Of course, menopause was part of my medical school curriculum, but like most things we talk about in medical school, it was sterilized into science-speak. As if the physiological phenomenon was all I needed to know about. Ovaries run out of Ova, and, with them, stop producing the monthly pulses of estrogen and progesterone that animate the ovulatory cycle. Never mind the ways that estrogen withdrawal leads to a host of painful symptoms, from hot flashes to pain with sex to dry skin.

And we absolutely did not talk about the ways that the constellation of symptoms experienced and the parts of the bodies they affected targeted. The fundamental way someone perceives a core part of their identity. Nope, none of that, but we did talk about the women's Health initiative. It's a landmark study that fundamentally altered the course of menopause treatment in the early aughts.

There was a before women's health initiative. Menopause symptoms were treated with hormone replacement therapy. This should make sense. Menopause symptoms well. They stem from the body's abrupt ceasing to produce the hormones estrogen and progesterone, simply replacing it. Well, it allays those symptoms.

And then there was a after women's health initiative see in this study, researchers thought that the hormone replacement therapy would have secondary benefits, particularly around preventing heart disease, too. So they embarked on the largest known study of its kind, enrolling 160,000 women to test that hypothesis. But then one of the key arms of the study was abruptly halted. Women should not start or continue this therapy to prevent heart disease.

The findings show it doesn't work. In fact, the therapy increases the risk for heart attack or stroke. It was the shot heard around the world. Researchers found that estrogen and progesterone therapy increased the risk of a number of maladies, including stroke and breast cancer. For example, hormone replacement therapy increased breast cancer risk by 26%.

But a note here, those numbers can be tricky see. The baseline risk of breast cancer between 50 and 60 is about 2.33. that means 2.33 of women in that age group will develop breast cancer. So when we say that number increased by 26, it means that that baseline risk, it jumped from 2.33 to 2.94. So, out of 10,000 women, the number of cancer cases would go from 233 to 294, an increase of 61 cases in 10,000..

But that was enough to have them cancel the study altogether and warm the world now. Look, I'm not discounting those 61 cases, but I am saying that 61 in 10,000 may force us to think about, well, all the costs of untreated menopause. See. A recent study from the Mayo Clinic of more than 4,000 women in four states found that the symptoms of menopause cost nearly $1.8 billion.

Yes, billion with a B dollars through missed workdays, cutbacks in hours or frank resignations, or, worse, layoffs. And that doesn't even include the pain, discomfort and dysfunction of the symptoms of the people experiencing them. Since the Women's Health Initiative, hormone replacement therapy has been reserved for only the most extreme symptoms. And folks have been told that menopause is just a part of life, that they just need to grit and bear it.

Like childbirth or menses, early puberty and all the other things women go through and are routinely told to ignore. See. As a man, I would have gone on ignoring menopause if it weren't for a breakthrough. Article in the New York Times magazine, written by our guest today, Susan Dominus, in which she goes back to the moment our understanding of menopause flipped. And asks why. I wanted to have her on the show. To dig in, Here's my conversation with Susan.

Dominus, can you introduce yourself for the tape?

And you write very movingly and convincingly about how. This represents a sort of failure to take into account, or to fully account for the full lived experience of menopause. I want to ask you, stepping back, you talk about it a little bit in the article. But what led you to write about this, or to take it up as a reporting project?

It was a spectrum, but everybody wanted to talk about it, and everybody was baffled by how little we knew, we didn't even know. What is the difference between perimenopause and menopause, and are we in it? And do you have symptoms before you're actually in menopause, and how do you treat them?

And why isn't there more, and is it safe to treat menopausal symptoms? And we were pretty well-educated, well-resourced women, and we were baffled, and I was sort of hesitating, I wasn't sure.

It seemed like a very big topic to take on. I ended up focusing a lot on menopausal hormone therapy, but my friends really felt like. This is such an important topic and that there is a stigma attached and people need to write about it to reduce the stigma.

What is that experience like?

You start waking up in the middle of the night and you're sweaty and you're hot, and you think, like, Okay, I guess I'll open the window now, or I'll try to take a nap during the day. And then it's very hard to know. Okay, well, I'm feeling these things, but are these things that are happening because I'm going through menopause, or is it just that I'm stressed?

Or is it that I can't remember anything anymore because I'm not sleeping well? And am I not sleeping well? Because I'm worrying about my kids? I'm worrying about my parents? I've got so much on my mind. Or is it menopause, is it hormones?

You don't really know, and no one's really talking about it, nobody's telling you there's anything you can do about it, and so you just kind of deal with it. It is also an intense moment. Because I think when you realize you're going through menopause, like every time you have a hot flash, frankly, you're kind of reckoning with the inexorability of mortality.

I mean, I don't think I'm exaggerating to say that. That's part of it. It's also being confronted by your own aging, and for some women, even more than that. I think a sense of like, not universally. But I think for some women, it can be interpreted as there can be a fear of losing one's femininity, one's womanhood. And there are a lot of things going on in the lives of women who are in their 50s, who are, you know, maybe they're in the prime of their careers.

Maybe they have children, maybe they have older parents they're dealing with. You know, everybody is facing a lot of existential stress right now.

I think it is an unfortunate time in your life to be hit with a new set of symptoms. You know, for some women, it's even joint pain. Like, you want to exercise, you want to feel fit, but if everything creaks and aches all of the sudden, you know, that can be. It can be a hindrance, for sure, to your feeling like your best self, right?

When you need to be your best self, right?

That's kind of the nature of the conversation, and I just feel like there's so many parallels. And they all sort of point back to, you know, gender norms and assumption about gender norms. To what degree do you feel like the failure to have taken the question of menopause as seriously as we ought to, given how many people this affects? How profoundly, is centered in a ongoing, you know, frankly, misogynistic approach to the way that we think about women's health.

You know, the other thing I will say in defense of the research industrial complex is that, you know, menopause, it affects your quality of life, but it's the rare thing that affects your quality of life that actually doesn't really endanger you. You know what I mean? So I think you're not going to die of menopause, you're going to die of something, but it's unlikely to be. I mean, it is true that you have higher, you know? It's possible that if you have good menopausal care, you are less likely, for example, to get a fracture.

And like, that's really important, but otherwise, it's not a fatal disease, it's just a quality of life issue. Hot flashes, You know, there is some research that suggests there's an association between more than four hot flashes a day and high rates of cardiovascular disease.

But it's unclear whether the hot flashes are causing that or whether they're just a reflection of the fact that there is cardiovascular disease. But for the most part, hot flashes don't. We don't think that they do any damage, right? They're not dangerous, they're just really, really uncomfortable and disruptive. So I think that that is a less compelling symptom for doctors and researchers to, like, you know, throw money at.

Think about how much money is made treating erectile dysfunction.

But our experience, for the most part of puberty as males, doesn't involve one day as a child, bleeding from your genitalia.

The simple way I think about health is it does one of three things. It either causes you pain or discomfort, it takes away your function, or it has the potential to shorten your life. And menopause takes two of the three, and, you know, erectile dysfunction only takes one.

I mean, it's not just that, it's not a crisis. That women who are in their 60s, you know, might be having painful sex, but it's like, the idea that they would even want to be having sex, I think, is an uncomfortable idea for many people. I mean, I think there's this whole brand of humor around how, you know, appalling it would be for a younger man to have sex with an older woman. You know, there's a real, almost like, visceral revulsion that people have around that idea. It's a trope that you certainly see in comedy.

And I think it reflects a larger societal discomfort with the very idea of a woman's sexual value once she is of a certain age.

We're all painfully aware of the attacks against Black studies happening across the country.

Last year alone, more than a third of elementary and high school students lived in a district that suffered a campaign to ban. A quote unquote. Critical race theory. These efforts happen because the people in power know that Black studies fuels action that can shift the balance of power. And that's why podcast sponsor Marguerite Casey Foundation is excited to help get Black studies into as many hands as possible. They're supporting Kaepernick Publishing and Haymarket Books in a joint effort that will be released this month. Edited by Robin D..G.

Kelly Keonga, Yamada-Taylor and Colin Kaepernick. Our history has always been contraband in defense of Black. Studies will be available for download as a free e-book in late May. American Dissected is brought to you by Bookshop..org. Understanding people is one of the most important parts of my job.

And so I'm reading a book called Surrounded by Idiots now. Look, I'm not a big fan of pop psych books, but it's always helpful to get your mind around. Different ways to understand people. And the book by Thomas Erickson. Well, it gives you a different way to understand how different people think. Whether you're searching for a buzzy new memoir, riveting true crime, or a fantasy novel that sweeps you away, Bookshop..org has just the book you're looking for. Their online bookstore is stocked with compelling titles that will keep you entertained for hours.

From Mary Roach's Stiff to Spare Parts by Paul Craddock, there's something for everyone. Book recommendations on Bookshop..org also come from real people who love books, not algorithms. And the best part, when you purchase from Bookshop..org. You're supporting local independent bookstores, so they'll be around for all of us to enjoy into the future. Bookshop.org has raised over $25 million for local bookstores.

They're unapologetically anti-Amazon and believe local bookstores are essential community hubs that foster culture, curiosity and a love of reading. Join them in helping local bookstores survive and thrive. Use code AD to get 10 off your next order at Bookshop..org. That's code AD at checkout for 10 off your next order.

You know, we talked about puberty and we're talking about menopause. We have a three-month-old at home and having just watched my spouse go through a second pregnancy, I mean, we don't even talk about that, right?

And it's at every level of a life course where the pain, the frustration, the discomfort of women is taken for granted. And, you know, obviously there's a whole field of women's health, and yet it's been underfunded, under-resourced. We don't have a big, broad public conversation about it, so, you know, and as someone who's—I've never had to deal with these things. But as someone who thinks a lot about these questions of what do we choose to treat and what don't we choose to treat? It's rather astounding to me that the sort of biases, the structural bias of the past, we've just sort of carried forward. In terms of what we choose to invest and what we choose not to. I want to jump now just to the sort of state of medical management of menopause.

And can you walk us through how menopause was managed before the Women's Heart Initiative study?

And it was one of the most commonly prescribed medications that there was, and doctors also did regularly prescribe it to much older women. Which is now something that, I think, with good reason, doctors still do, but with more caution.

And when that starts to go away, the experience is extremely uncomfortable. And that's what sort of explains menopause, and so we used to treat that, we used to treat with hormones until this 2002 study. And I'd love to hear a little bit more about what the study did, and maybe not just what the study did, but also how the study landed.

That's what a cure-all people thought it was going to be. So. The National Institutes of Health launched this major randomized control trial, still to date the largest randomized control trial of women only that has been conducted. And contrary to the idea that it was going to lower the risk of cardiovascular disease. It actually found increased incidence of coronary heart disease, of strokes, of clots. And this was in the estrogen and progesterone group, the women who still have uteruses, and that was really shocking to the researchers.

They also saw increased incidence of breast cancer, and basically they did something that was pretty unusual. What was pretty unusual is they called a huge press conference where they announced that they were bringing the estrogen and progesterone arm of this trial to a crashing halt. Because it was deemed to be, they had passed a threshold of risk that was unacceptable for a trial. And even though they emphasized in this press conference that the risk to each individual woman was extremely small, that it was sort of an epidemiological. That you would see these numbers across a population. But for the individual woman, it was going to be a really small risk, they emphasized that. But all anybody really heard is we're stopping the trial.

And I think it's pretty clear that people thought how people interpreted that news was they stopped the trial because hormones are dangerous to women.

But the threshold of risk that a trial can tolerate is much lower than an individual might decide. Is okay for her, and also, the trial wasn't factoring in quality of life issues for women. So the doctor who held the press conference actually said, we have found that the risks outweigh the benefits. What he meant was, we found the medical risks outweigh the medical benefits. But that's not the same thing as saying these risks outweigh whatever lifestyle or risks exist in having hot flashes five times a night.

So it wasn't measuring quality of life, it wasn't measuring anyway. So the researchers went on the talk shows and they gave all these interviews and they rattled off all these statistics. That sounded really alarming.

Good God. After five years, we saw a 26 increased risk in women, now they didn't break it down by age. And if you're in your 50s, your breast cancer risk is actually quite low, it's something like 2.1 risk.

It might be a little higher than that. I'm not sure I'm getting the number exactly right. But 26, on top of a risk that low, is really quite small. You're still not going to get to 3 even. But it wasn't presented that way.

I think a lot of women hear, Oh my God. I have a 26 increased risk of breast cancer. I imagine many women heard that as you have a 26 increased risk of breast cancer, or maybe your risk is 26 times higher. I think people just don't know how to interpret those statistics. But if you don't know what the base number is, then you don't know how to factor in what that 26 increase really is.

So the risk was still super-duper low for women in their 50s, by the way. Totally reasonable to decide. One of the other ways that people describe it. It's like for every 10,000 women who take hormones, an additional eight would have breast cancer. Now you can listen to that statistic and think, like, eight, 10,000, that's not for me.

That's too high. I respect that, but I just don't think that. Most women heard it that way, and I think many women, if they did understand it that way, would be perfectly comfortable with it.

And to illustrate again the contrast here, men, on average, die about two years earlier than women. Do we have higher rates of cardiovascular disease, which largely accounts for that difference? Increasingly? Now you're seeing suicidality and drug overdose account for some of that difference. But that is because men don't go through a thing called menopause, so testosterone on its own likely accounts for a big part of the difference.

And testosterone and estrogen, if you look at them chemically, are really, really quite similar. Obviously, they do what we consider the opposite thing. But both of them are what we call steroid hormones, and whenever you hear steroid, think cholesterol. That's the s-t-e-r.

That's the same root, and so our bodies, just sort of, you know, it's a small little difference, and we all have receptors for both of them. But their impact in the rest of our tissue, independent of, you know, the tissue that are primed to look for testosterone or estrogen, the impact on our tissue is probably quite similar. But we don't have a menopause.

And so we're dosed on steroid hormone, right for much longer in our lives, right? Particularly after the age of 50.

And so, you know, if you think about it, you step back and you think about the hypothesis that was being tested, right? If you sort of thought about this for a second, you say, well, if you were in a situation where you really wanted to test the endpoint of cardiovascular disease and that's all you cared about, how would you propose testosterone blockers in men?

Bias, like alarm, is not a thing scientists usually think about. It's, you know, we pride ourselves in being calm, cool, collected observers of the evidence, but that clearly isn't what happened here.

And so they couldn't kind of deal with it, and they just stopped cold turkey prescribing it. Because it was almost as if they were overcompensating for whatever they had done before. But, like, you know again. 26 Increased risk of breast cancer. It's not nothing, but it's, you know, I think, for you know. Many people take all kinds of medications that entail that kind of elevated risk for various bad outcomes because they know it will offset some serious lifestyle impairing symptoms. So it is really, I think you're right. There was a huge psychological component to the way the trial's findings were announced, and to the way that doctors responded. And certainly to the way that women responded. I think women were sort of almost primed to think that, like, surely this is too good to be true?

Like, really, I can just take hormones and it'll, you know, it'll offset. So many of the symptoms of aging and menopause that, you know, plagued women's, for, you know, generations before me. And maybe it just seems, quote unquote, unnatural to say, you know, I still have friends who had unbelievably terrible perimenopause and menopause, just terrible sleep problems, terrible hot flashes, real like, real misery. And we would talk about menopausal hormone therapy. And, you know, some people just want their lives to be very natural.

You know, they just that's, there's a they valorize that, I guess they privilege that, and you can't persuade them otherwise.

There was an irrationality that took over and an infantilizing that came of it. In other words, women weren't even really given the choice to think about the risks and whether they were willing to take them to stop suffering.

It affected people who are over the age of 50, by definition. So you're talking about people who were born in 1950, who were probably young women in the 60s, 70s, 80s, right? And so I do think there was a generational, or like a cohort effect there that, you know, there was a culture of like, what doctor says goes and you're going to listen, you dare step up and second guess what we're saying.

Right, who are you to ask us these questions? And, you know, and I think the press. Decidedly, I was going back and preparing for this, watching some of the coverage, and it just was it was, and it was so profoundly alarmist.

The other thing I wanted to tease out there is the lies that can be told by way of relative risk communication. What I mean by that? When you say this increased the probability of X threefold, and you're like, OK, it went from one case in 10,000 to three cases in 10,000. And it's not that you're lying per se, but you are using the way you communicate that number to aggrandize an effect. That's not very grand, right? And in that respect, it is it is.

It is attaching an emotion that's not necessarily deserved.

That was when the W.

H.

I 2002 findings were released that didn't really get a lot of attention, basically. They eventually found that being on menopausal hormone therapy, if you start it young enough, really reduces your risk of diabetes. And then they found that for women who were on estrogen alone, the women who didn't have uteruses, they kept going with that arm of the study.

And when they finally concluded that arm of the study, after eight and a half years or so? What they found was that the women who were on estrogen alone had lower rates of breast cancer. So this is like, I mean, it's not easy to lower rates of breast cancer. And yet it got very little attention, it was very little known, and there wasn't a press conference held to tell women like, We have good news for you.

If you are one of the 30 percent of women who've had a hysterectomy before the age of 60, which is an incredible number. It speaks to how much of the menopausal population does not have a uterus. Great news we can lower your risk of breast cancer. you can go on menopausal hormone therapy.

And that stuff, somehow, the good news that came out over the years never really garnered the same amount of attention. And there's also research to suggest that one of the things that really alarmed people was this increased incidence of cardiovascular disease. You know, there has been research since to suggest that if you take hormones between the age of 50 and 60, that it actually reduces the kind of the markers for cardiovascular disease. You know, they examine women's arteries, that they see healthier looking, you know, less plaque and healthier vascular systems. So none of this these distinctions, you know? It's much more safe to take hormones between the age of 50 and 60 because your baseline risk is lower.

So whatever incidence risk you have, increased percentage risk is much lower. But also there's some thought that if you start the hormones as you're going through perimenopause or soon after your menopausal, it's much better for your system than if your system. Your body starts to go through all these changes, it's made some changes and now you introduce hormones, you know, 10 years out that is thought to not necessarily be as safe as starting when you're young.

America dissected is brought to you by outer gnome. You know what, I can't stand, I can't stand. When companies that aren't really committed to the planet do one-off things. To pretend, like, somehow they've been green all along, that's called greenwashing outer Gnome, though. Well, they're the first brand founded on a total commitment to sustainability.

Outer Gnome offers extremely comfortable and stylish men's and women's clothing. Every product they make has a planet first mentality, meaning materials are environmentally friendly. And the factories they work with provide safe working conditions and fair living wages for all workers. But here's the thing you don't buy clothes to help the planet. Well, you do, actually, but you buy clothes because they're comfortable.

They look great, and Outer Gnome's got you there. The blanket shirt, for example, closiest shirt of all time available for the whole family.

Sea jeans soft, comfortable and guaranteed for life. And well, don't forget the crooked Media holiday jackets, which were a hit, and they were an instant staple for the whole crooked office. Every Outer Gnome product is comfortable, breathable, and fits great, designed to make you look and feel great and sustainably made for a better planet.

Go to OuterGnome.

Com Slash America today and you'll get 25 off your first order. That's outergnome.com. Slash America spelled O-u-t-e-r-k-n-o-w-n dot com Slash America. To receive the 25 off discount code, check them out today.

Outergnome.

Com Slash America and don't forget to use the promo code on the page for 25 off. This episode is brought to you by Cariuma, the cool, sustainable sneaker company made for life on and off the board. Warmer days.

Well, they're finally here. And you need a staple shoe to carry you through the summer and beyond. When it comes to days spent in the sunshine and on your feet, Cariuma's got you covered with effortless style, unmatched comfort and premium quality. Worn by celebrities like Ashton Kutcher and praised by publications like Vogue and GQ, these are a cult fave.

Look, I love my akka lows in pantone blue and look, there's a version of an akka for you. akka is Cariuma's new school. Take on a timeless sneaker style, it's designed for everyday wear and with breathable organic cotton canvas in shades like green, off-white, rose and pantone blue, it's the perfect pair to prep for summer.

They're sure to have a perfect color for you. We've loved the lace-up akka for years and now Cariuma recently launched canvas slip-ons. Made with organic cotton and natural rubber outsole, this easy-to-wear style provides a timeless look with incredible comfort and ease. It's everything you love about the Akka now, without the laces.

Cariuma is always keeping it fresh with epic collaborations with brands like Deus, Avatar and Pantone. There's something to love for everyone, and sure-to-be shoes you'll never get bored of. For me, it was the Pantone and the Akka for me. Cariuma is B Corp certified and has a dedicated reforestation program based in the Brazilian Rainforest.

Their co-founders, David and Fernando, both grew up there, so this project is especially close to home for every pair sold. Cariuma plants two trees, and they've already planted over 2 million trees to date. Cariuma doesn't just talk about being green, it's baked into their entire business ethos. You can get Cariuma sneakers free and fast in the USA and offer worldwide shipping and 60-day free returns.

They deliver right to your front door, using single box recycled packaging and for a limited time. America dissected. Listeners can get an exclusive 15 off your pair of Cariuma sneakers. Go to Cariuma.com to get 15 off. That's Cariuma.com for 15 off only for a limited time.

A couple questions 20 years on from the Women's Health initiative, have doctors become a bit more nuanced in treating menopause?

Just as their phones were ringing off the hook. When the WHI study came out and suggested that hormones were unsafe for women, doctors are telling me that their practices are. Obgyns have been like, crazy busy lately because women want to talk about this. Women who were too shy to bring it up, or who felt awkward, or who brought it up and felt like the doctor kind of hinted. It wasn't a great idea. Now they really want to hash it out, and it's not to say that this article suggested to them, like, you should definitely be on menopausal hormone therapy. Because I think we made it clear in this article that it requires a conversation and it's not for everyone. It might not be for you if you're over 60 and you haven't started and you're at high risk for breast cancer.

It's almost certainly not right for you. But women want to have the conversations now with their doctors. And I think it's inspired a lot of discussion and a lot of appointments. It's rare that you actually get to feel like something you publish moves the needle on the conversation. I am hearing from Obgyns that it has moved the needle on the conversation.

And for some Obgyns, the effort of overcoming the reservations that women have about menopausal hormone therapy because of years of bad press. The effort was more than they could put in with each patient, even though they often thought that these women should consider it. So there are many OBs who I think think this makes their job much easier because they want women to consider this as an option. But there was so much hesitation because of just misinformation, just flat-out misinformation, that it takes a long time to actually unpack. Well, what is the risk? And like, Well, we're using different formulations now. Are they safer than the ones that were used in the WHI?

Well, they look safer from tons of observational studies, but they're not randomized, controlled trials, so the research isn't as good. These things are complicated and I wish that doctors could say to women. We have three 10-year-long randomized controlled trials that all confirm that menopausal hormone therapy is flat-out safe. There's lots of reasons to think that the new formulations are safer, based on really good observational studies. And particularly that the issue is not that the estrogen was causing whatever adverse health effects they were seeing, but that it was the progestin. Because the women who were on estrogen alone had better health outcomes than placebo, right? So clearly, it seems likely that it was really the progestin that was causing the health problems.

So do we have a better, safer formulation now in micronized progesterone? A lot of observational research suggests yes, but you as a doctor, know that's not quite as good as a randomized, controlled trial.

Which was also studying things like Are low-fat diets healthier for women? are vitamins, you know, do they improve outcomes? It was like a billion-dollar project at the end of the day. In fact, one person told me it was so big that some hospitals, actually, it was the first time that they integrated.

Networked computer systems. Because they had to do that in order to be part of this massive project.

I want to ask you, going back to that trip that you took with your friends. If you had taken that trip after you reported your article, what would the conversation have been?

Just go on the menopausal hormone therapy, it's important and it's safe. And you can also go off of it in a couple of years and there will be no harm. I mean, they didn't even see any increased risk in breast cancer until after five years. It's not that menopausal hormone therapy is the answer for everyone. But we didn't even know how to think about it in that conversation.

So I think that's the main thing is the idea that there is recourse. And this friend eventually did make that choice. But many, many months of suffering went by, you know of needless suffering before she did, and it pains me to think about that. I actually have a lot of. I get very upset when I think about the collective amount of suffering over the past 20 years that women endured. Simply because of misinformation. That snowballed and snowballed, and took on a life of its own and became kind of like the sort of general accepted dogma.

That, like, there was something fishy about this particular treatment. And I mean, if you read the comments to the New York Times magazine article, there are women who say, I think that my marriage ended over how depressed I got. I took myself out of the workforce because I could not function, my alcohol, my memory, my general energy just plummeted. I mean, it's really, really, deeply, deeply sad how much suffering happened.

For, you know, in the WHI's defense, probably. Women in their 70s shouldn't start menopausal hormone therapy. We now know that's not a good idea. And women were doing that not all the time, but it was something that doctors did with some regularity. So, you know, there was a lot of important information that obviously came from this trial, but collectively, when you consider the amount of suffering. Even just women thinking that they were having autoimmune diseases because they were suffering joint pain and not knowing that it could be remedied by hormones or neurologists.

Never considering that. Well, you know, you're 52.

Like, is it possible that this could be related to menopause? It's just it is very upsetting, I have to say.

It's unquestionably good news that we have a vaccine for RSV, for seniors, the vaccine, well, it's about uptake. Only about 40 of seniors have had the Shingles vaccine, which prevents varicella zoster, the virus responsible for chickenpox. That hangs out in the nerve roots, only to reappear after your immune system weakens at older age as shingles. And the disinformation around the Covid vaccine throughout the pandemic, well, it's primed folks against new vaccines in ways that may prevent seniors from taking these too. Notice how I said during the pandemic?

Well, according to the WHO, the Covid global health emergency is officially over, and the U.S public health emergency is set to sunset this Thursday. First, let me explain what ending a global public health emergency actually means. It means that the WHO has determined that the number of cases is no longer more than we expect. Though, it remains high that there's no way to stop cross-border transmission, and therefore that we no longer need a coordinated international response.

Look, whether you want those things to be true or not. They are, particularly as cases, hospitalizations and deaths are at an all time low. But there's something more here. I want you to understand. It does not mean that Covid is gone. In fact, Covid is going to continue to evolve and we're going to continue to have to evolve with it.

And we're likely to see new waves, particularly in the fall every year. But I want to step back and look. I don't mean to beat a dead horse, to be honest. I don't know why people beat horses in the first place, but you get what I'm saying. There is a gigantic lesson, particularly for those of us in the United States, on this pandemic.

For three years, every single public health agency around the world.

It meant that the federal government showed what was possible more people had healthcare than ever before. We invested billions in basic science, public health program implementation, and public health awareness. And though here in the U..S. we still lost over a million people, public health, from distancing to masking, to vaccines, to testing to treatment, saved millions more.

Don't get me wrong, there are parts of the pandemic I never want to go back to, but the part that had government investing in the basic healthcare resources. That for so long in this country, we were told we couldn't afford, and we were told could not be done well. They were to draw all that down. Begs the question What was the real emergency?

Look, a super transmissible, super deadly virus spreading all over the country is certainly an emergency unto itself. But isn't millions of people dying because they don't have basic healthcare in emergency, too? Or the shocking level of homelessness, poverty and mental illness, or our failure to invest in basic prevention across our communities. So, while the Covid emergency may be ending, the public health emergency in this country is not.

And people ought to be asking what it'll take for us to address all of those other causes of death, too. On that note, a new report from the C.D.C showed that while opioid overdose jumped across the board in the first year of the pandemic, it jumped particularly highly. Among Black Americans, among whom overdose attributable to fentanyl accounted for the highest increase in overall overdose deaths. I raise this because since the beginning of the opioid crisis, it's been characterized as a disease of low-income, rural, white folks. And that's meant that we've moved.

Into those communities to tackle it. But as with almost all diseases, they follow poverty and marginalization. And it's always only been a matter of time until structural racism opened the floodgates of our national opioid crisis into predominantly Black communities. But it's not just substance use, it's about treatment, too. And that's where racism has also reared its ugly head.

It's about access to substance use treatment, because Black Americans are far less likely to access buprenorphine, a life-saving medication that reduces the risk of overdose. With a combination of factors, including, well, Frank, racism among doctors who prescribe it, and the exact lack of healthcare at baseline in this country, I just talked about. Meanwhile, rather than invest in harm reduction, that actually saves lives. Conservatives are too busy blaming the border for our fentanyl crisis, because, well, fentanyl can be manufactured nearly everywhere.

But isn't it convenient to blame the border, meaning immigrants on this? Well, if you're conservative, you bet it is, so let's be clear about something you could seal the border tomorrow.

For the millions of Americans currently living with substance use disorder, so can we please stop demagoguing Brown folks over this? That's it for today. On your way out, don't forget to rate and review. It really does go a long way.

And if you love the show and want to rep us, I hope you'll drop by the crooked store. For some America, dissected Merch.

America dissected is a product of crooked media. Our producer is Austin Fisher. our associate producers are Tara Terpstra and Elise Fotopoulos mixes and masters the show. production support from Ari Schwartz.

Our theme song is by Takao Sazawa and Alex Uguiera. our executive producers are Leo Duran, Sarah Geismer, Michael Martinez and me. Dr. Abdul El-Sayed, your host. thanks for listening.

This show is for general information and entertainment purposes only. It's not intended to provide specific health care or medical advice and should not be construed as providing health care or medical advice. If you have any questions related to your own health. The views expressed in this podcast reflect those of the host and his guests. And do not necessarily represent the view and opinion of Wayne County, Michigan, or its Department of Health, Human and Veteran Services. The views expressed in this podcast reflect.