Chronic Illness: Not Actually Female Hysteria!

Quinn: [00:00:00] How do we take a huge chronic disease burden like Lyme disease or long COVID or even long flu and make it so personal that we simply can't ignore it anymore? That's today's big question and my guest is Dr. Mikki Tal. Mikki Tal is an immunoengineer and a principal scientist at the Massachusetts Institute of Technology or MIT for the cool kids.

That's where Dr. Tal leads the Tal Research Group within the Department of Biological Engineering, and also serves as the Associate Scientific Director of the Center for Gynepathology Research. Mikki is working to identify the connections between infections and chronic diseases.

She received her PhD at Yale University in immunobiology. And she's researching how immune responses to viruses are impacted by processes such as aging. [00:01:00] Dr. Tal then did her postdoctoral training at the Laboratory of Irving Weisman at Stanford, where she later became an instructor at the Institute for StelCem Biology and Regenerative Medicine at Stanford, leading the infectious disease team and studying immunomodulatory mechanisms which impact immune clearance of infectious disease with a focus on Lyme disease and then COVID.

Now, look, I've written a bit recently about the lessons we finally need to learn, should we decide to, about post viral and bacterial health issues, the societal and medicinal and health and economic issues and improving our baseline of wellness and community health so that we don't suffer from those quite as much.

Those things are real. These post viral and bacterial health issues, and we've known about them for a very long time and the compounding effects of chronic diseases have just gotten and are just going to continue [00:02:00] to keep adding up the longer we ignore them, and we gaslight people. There has never really been a better time for Mikki's work, so real pros and cons situation, and for this wonderfully inspiring and personal conversation.

Welcome to Important, Not Important. My name is Quinn Emmett, and this is science for people who give a shit. In these weekly conversations, I take a deep dive with an incredible human who's working on the front lines of the future to build a radically better today and tomorrow for everyone. Our mission is to understand and unfuck the future, and our goal is to help you answer the question, What can I do?

Mikki welcome. Thank you for joining us today from sunny springy Boston.

Dr Mikki Tal: Thank you. Thank you for having me. I'm really excited to be here.

Quinn: Well, thank you so much for joining us for all the incredible work we're going to hear about today and why you're doing it. I do like to start with one very important question to set the tone for this little [00:03:00] conversation of ours.

And I've asked like I said, almost, I think almost 200 guests this question. And while we will talk a little bit about your life story and why you're here, I do like to ask, why are you vital to the survival of the species? And I encourage you to be bold and honest here, because it's ridiculous, but we do usually get something good out of it.

Dr Mikki Tal: Okay. Wow. That is a great question.

Quinn: Is it?

Dr Mikki Tal: You know, my number one thing here is being a mom to two really great boys who are navigating their own, you know, challenges through life. And my most sacred task is helping them through that, I think.

Quinn: I love that. I love that. I've got three and it is, my wife and I've talked about this a lot as we've gotten older and the kids, it seemed like they were all the same age for about five years and now they're very much not that. And how we balance all these things, right.

How you [00:04:00] balance the, like some of the world's most important research with being a mom to two boys. It's, yeah it's a daily thing. It's a weekly, monthly struggle.

Dr Mikki Tal: It's a daily thing. It's, you know, there's always that saying if you love your job, you'll never work a day in your life and you'll work every day in your life.

And I feel that so deeply. And I think so many of the puzzles that are kind of always churning in the back of my mind, I, you know, sometimes I just have to shut that off and be in the moment with family, but they're always there. I'm really passionate about my work.

Quinn: Yeah, it's the shutting off is a hard one. That's definitely one we've been wrestling with. My wife is a very hardworking, successful screenwriter and producer and, you know, stuff is just constantly going in her head here. But we've tried to set some boundaries here and there for my stuff, like climate change is not allowed in the house, basically.

You know, and especially now on the weekends, because it's like just be present for a minute, but it's difficult to [00:05:00] escape.

Dr Mikki Tal: It is.

Quinn: How old are your children?

Dr Mikki Tal: So my kids are 10 and 14,

Quinn: Okay.

Dr Mikki Tal: You know, the funniest thing is, my husband has said to me next time he gets a veto on my research topic because I have ruined grass in the outdoors for us. With all the tic checks and, you know, everything we know now about Lyme.

Quinn: Oh yeah. I can only imagine again, like it's me not ruining people's nice days about about climate change. My wife has definitely found me in the early days when I started to take this on, you know, from an incredibly privileged place, but still you know, like hiding under blankets at night.

And she was like, look, bud. You chose this if you want to do this, we got to find better ways to handle it because it's not ideal right now. So, I get that. But what I was going to ask about their age and we can cut that out if you want to. But it's interesting because it seems 10 and 14.

At least those are real human beings. How much of your work do they really understand now? Especially I guess the 14 year old, [00:06:00] not how much of like immunology do they understand, but sort of the scope of what you're working on and the history behind it.

Dr Mikki Tal: Oh my God. So, I mean, my kids are brilliant. They're little geniuses and I know I'm super objective.

Quinn: Yeah, no, totally. Never heard that before. Yep.

Dr Mikki Tal: They are, you know, pretty unbelievable. And they understand a lot, I would say about my, like a surprising amount. I've raised little immunologists. They, you know, there was this time early in the pandemic where I had put out I had given a talk at Sanford and I had put it on, I made the zoom link available for everybody.

And then eventually I put it on YouTube and it just, it took off. And I actually talked to my son. You know, at the time, my 14 year old who, you know, at the time he would have been ten or eleven. And he, I talked to him about putting a talk online because he had such a fantastic [00:07:00] grasp of what was happening, what the, you know, what the vaccines were going to entail, what that would give you, wouldn't give you, you know, so much that really wasn't in the public understanding. We never ended up putting that online, but he gave, you know, I have this recording of him giving this beautiful explanation to his little brother of just they, they know a lot about what I do and what it means.

Quinn: That's amazing. That's besides just Oh God, mom's checking us for ticks for the 12th time today.

It's not, it is helpful once they can connect the two when they're like, Oh no. Okay. I mean, it's still annoying but we get it, you know, we get it. That's fantastic. That's great. It is, I imagine it sounds like we're relatively similar in that if my house was on fire, like I would take that video with me and probably, I mean, I would take the people and a pet if there's a pet, but also that video and just be good to go. That sounds amazing. Okay. So we've already gotten, you know, 5 percent personal with [00:08:00] it, but I want to start here to set some context. We don't always talk about people's sort of life stories or all their prior work or how they got there, things like that.

But as I've gone about all these incredible conversations, I've started to lean towards, it turns out one of the, one of the things that people come to us for and we have gotten better at and we're pretty good at is really helping people answer this question. What can I do about COVID, or Lyme or climate, which is 400 different things, or hunger, whatever it might be.

The make or break stuff. And, often besides asking them, Well, Mikki, what can you do? You know, which is, what are you interested in, what are your skills, and I can point you towards a million incredible people, like yourself, or organizations, whatever it might be, who are already doing the work they can join up with, or be inspired by. But I do find that people can find their way in, and that's what I love about having these conversations, when they can really relate to someone and why they're doing it, even if they're totally different people. So everyone [00:09:00] finds their way into any career that I guess seeks to affect the world back, which is something I think about a lot these days.

One way or another, they find their way in somehow a doctor, an artist, right? A writer, a journalist, whatever it might be. So my version is I got into philanthropic work 16 years ago, something like that, close cousin was diagnosed with leukemia and I thought, I'm a moron. What could I possibly do to help her?

And I found the Leukemia and Lymphoma Society and their fundraising arm called team and training. And I was like, great, I'm just going to run and I'm going to raise a bunch of money and we'll give it to the people who didn't fail flashcards in middle school and high school. Great. And then I loved that.

And it felt like I was doing something and I could see the return on it doing something and I could see how that helped her feel better that people were supporting her and people like her. I really doubled down a few years later when one of my best friends [00:10:00] very quickly was diagnosed and then died of esophageal cancer. Now, I know these aren't infectious disease, we'll get there, but I'm 41 now so I think about this stuff but as we grow older and everybody in history has gone through certain impactful eras, right, from different wars, smoking, HIV/AIDS, COVID, obviously, fentanyl, air pollution. We experience more loss as we get older, right?

And a greater variety of loss. And some of that is expected from older parents and things like that, but also some younger folks. And it's both part of life, but also not great. And it's the part people don't really advertise about real life and getting older. So, again, one of my favorite questions to ask is asking people, Why do you have to do this work? And your Twitter thread forever ago sharing why you had to do this work was so beautiful. And I thank you for doing that. And I wonder if you could share that again and we could talk [00:11:00] about it a little. About why you, Mikki, have to do this work with infectious disease.

Dr Mikki Tal: So, you know, at some point, somebody asked me what was really, what was driving me, because I am clearly very obsessed, I'm deeply obsessed about infectious disease and immune responses to infectious disease. And I gave it some thought and I, I didn't have to go very far because I had some really defining moments in my life that really kind of sealed this for me.

And showed me how, you know, the thing with infectious disease is that things can go so quickly that you don't, I think we get raised with this concept, like if you get sick, you're going to be able to go to the doctor and they're going to figure out what you have and they're going to be able to help you and there's going to be, you know, and we have these kind of promises in our mind about what modern medicine can and can't do.

[00:12:00] And the really scary thing about infectious disease is that some of them, there is no time for that. And the diagnostics are not where you think they are, and you're going to walk into the ER and, I mean, what happened with my cousin is that he got an ambulance. He got to the emergency room. And he passed away before they even figured out what was going on.

Quinn: So sorry to interrupt. Is this your cousin who died of meningitis? Is that right?

Dr Mikki Tal: Exactly. That's right. He died of meningococcal meningitis. And this was like, this was on a Monday where Friday, he didn't feel that great and canceled a date. And Monday he was taken in an ambulance to the ER and died an hour later in the hospital, you know, so this is just, this is, you know, I know there's this whole vibe and some people were just like, Oh, don't worry about it, you know, Oh, you know, tough it out.

And that's not my, that was not my takeaway. And partly because of this experience and partly because of an earlier [00:13:00] experience with my uncle. But I've seen the most tragic outcomes with infectious disease. I know that infectious diseases can kill you. I know that something so small that you never saw it and you didn't even know what was happening can take your life. And even when it doesn't take your life, what I've learned is that it can make you so sick. It can take away so much of what you thought defined you as who you were, that was deeply intertwined with the health that you had. So I have actually grown quite wary of some of these little microbes and especially the pathogens.

I definitely take efforts to avoid them. Because I like to think about it as I, you know, I give them the respect. I think they deserve. And I like to proceed with caution when they're involved.

Quinn: I appreciate that you put that so [00:14:00] wonderfully and thank you for sharing all that. I've been so lucky to hear from, you know, we had a young woman on last year or earlier this year, I don't know, time doesn't mean anything to me anymore. Who she had, I believe it was an aunt who went blind or was born with blindness. And instead of saying, that's it, I'm gonna, I'm gonna figure this out. I'm going to go into ophthalmology or whatever it might be. She said, Oh, one of the things I'm really interested in is fixing a specific bottleneck in all of laboratory science where Research Assistants have to come in at night and spin the bottles and do all this and it holds the whole thing up and what if they break and staffing.

She was like, I can fix a lot of things by working on this specific bottleneck. And so she's building robots who can do this very carefully. And yet we also had on a gentleman, incredible conversation with a gentleman named Sharif he grew up in Iran, whose dad had some muscular dystrophy and just, you know, that is [00:15:00] extremely degenerative in that case and no one could figure it out there where they lived or when they got to the U.S. and he is that kid who grew up and he figured it out and it's too late for his dad but he said I have to do this for him but also for me but also so many other people who, like you said, and this is very impactful to me right now, certainly as people who look around and go, I'm not the person I was. And I didn't think this was going to happen so soon, or really that it could happen to me. That is something we all wrestle with. I mean, I see it with my young boys who think they're invincible, right? They're morons, but I get it. I was the same way. But it's very easy to look around for everyone now, especially and say oh, that's not really the case and you don't want to necessarily live in fear, but you also do have to do your tick checks and you have to give viruses and bacteria who were here way before us and are going to outlast us the respect they deserve.

And I appreciate that. Do you [00:16:00] find that there are similarly minded or affected people that you work with or that you're attracted to those type of people to work with who might have some sort of personal investment in this, in your research or in the, you know, the greater research field?

Dr Mikki Tal: So my research really intersects these two fields. There's microbiology and there's immunology. And in microbiology, I feel like people are split. You know, there's the people who will eat off the floor and they're just like, not concerned.

Quinn: Good bacteria! Yeah.

Dr Mikki Tal: And there's, you know, the, definitely giving microbes the respect they deserve and borderline germaphobic.

And I really feel like microbiologists kinda split into those two. And maybe it has a lot to do with which bugs you work on. Immunologists, interestingly you know, one thing that I noticed during COVID that was really interesting is I saw that the microbiologists were being much more careful immunologists after the vaccines were quicker to [00:17:00] unmask and just kind of trust their immune systems here and microbiologists were in general, you know, the microbiology conferences I was going to, were being much more careful, were using CO2 monitors, were staying masked, keeping doors open where, you know, there were some really interesting differences between the fields and between their different approaches to pandemic responses.

But I do see a whole subset of immunologists who continue to work on infection associated chronic illnesses. Who are still being really careful out there because they know it can happen and they're cautious about it.

Quinn: It seems and I've had a couple of conversations recently, really wonderful conversations about things I truly barely understand concerning the brain and the gut and how they might potentially be related and how every time we pull on the string of one of those, it seems to only get worse which is both amazing and so inspiring, but also son of a bitch we've gotta make some progress and then he tried [00:18:00] to connect them together and go Oh, my God, which way does this go?

If it goes at all, et cetera, et cetera. But the immunology of it again, which I barely grasp here. I'm a liberal arts major from a long time ago. It's fascinating to me because there's plenty of shows and conversations that focus really hard on the science of things and the technology things.

And I always try to bring it back to who's affected here. And when I think of immunology I think of the science writer, Ed Yong, who was at the Atlantic for a while and won a Pulitzer for his work on long COVID writing about how the, this coronavirus and the disease COVID you know, it was a flood that revealed all the cracks in our sidewalk that we already have. And my very poor version of that was, it was a pop quiz on all the medical and health and societal and economic choices we'd made for the past 300 years. And it was like, let's see how you did.

And not great. In some ways, not great. But one thing you really did expose, which we live with every day, but don't talk about enough, is again, coming back to immunology is it's not just this [00:19:00] particular virus or bacteria. It is, and this is where it gets so much more complicated and I imagine where microbiology comes in some, all of the pre existing things that each of us have going on, and especially in America you might have a potpourri of these things, right?

And how that can both just wreak havoc with those things or turn on things that we didn't know were there before or exacerbate them or things like that. This isn't just a, I, again, with long COVID or Lyme, these are really systemic attacks that can really vary in a lot of ways/

Dr Mikki Tal: I want to separate that there, there are two aspects.

Quinn: Please, because I'm definitely, it was definitely wrong.

Dr Mikki Tal: No, it, it is complicated and it is not just COVID, but in two very important different ways. One way is that we've known this about flu for at least a hundred years and we've never done anything about it. So we never even gave it the name long flu, you know, we never really acknowledged, we knew [00:20:00] that you could get flu and it could really mess you up.

And we knew that afterwards you could get a secondary bacterial pneumonia and that could kill you, or that could really do you in. And then that could set you up for a tertiary fungal infection that could also cause it, you know, an even worse pneumonia. But where the timeline breaks, we got really confused.

So the pneumonias were easy cause you had the flu infection. You never really recovered. Then you got this pneumonia. You know, and we understood that was complicated. But the thing is that every year we've watched that the height of the flu, you know, the number of people in the population that got flu, that's going to then impact the number of heart attacks that we're going to see several months later.

And even though we've always seen those line up, we've never managed to draw the line back to that flu infection. We're not even asking you, if you go in with a heart attack. We're not even saying, Hey, did you have the flu this winter? That's not, we've [00:21:00] never even attempted to draw that line. So when the timeline breaks, we have a really hard time piecing back together, what was that triggering event? And what was that infection that set off in motion other catastrophic events in your body? Now, where the other facet of what you were saying, where this is complicated by other infections is that you are not a sterile being you, you know, are walking around with multiple different chronic viral infections and chronic bacterial infections as well as this whole, you're a whole ecosystem for all these microbes that live in your gut.

Some may play nicely together and some may not play nicely together, and they may bring out the worst in each other in a way that you'll only realize upon this new infection that deserves this delicate balance. And so I think those are two [00:22:00] different ways in which this isn't just about COVID or just about Lyme.

This is about a better understanding of how we've never managed to piece together a broken timeline. From what seemed like either a mild infection or an infection that you seem to have recovered from, but that could still later have catastrophic effects and how different microbes interact within you.

Quinn: So I really appreciate that. And thank you for clarifying my, you know, very simplistic take on these things again, as I try to wrestle with just the practical effects of them and how they affect the health care system and all this and people going to work or school. I want to stick a moment with that point you made of we've never been able to connect the dots on some of these things for as easy as it was, easy, to go coronavirus can cause COVID, HIV, you know, can cause AIDS, et cetera, et cetera. Like you said, not asking these questions of, Oh, you're having a heart attack. Did you have the flu? [00:23:00] The whole thing we went through about counting COVID deaths, right?

Did you die with COVID or of COVID all these different things.

But what I really love about your research, and you've been very outspoken about this, is there's also half the population that we have spent a couple hundred years at least ignoring in such a wide variety of ways. And we have talked about sexism in medicine and healthcare and everything quite a bit again, over the past couple of years with guests like Elizabeth Ruzzo who made the company Adyn and Rachel E. Gross and Cat Bohannon and a bunch of others. And on the one hand, you've got something like Lyme disease, right? Very tough nut to crack, ignoring the whole, like we had a vaccine, then we didn't and all that stuff.

But it's possible that's at least partly due to the inherent sexism in research and there's plenty of versions of it, right?

We don't study menopause, all these different things. But let's stick with Lyme and infectious disease. Can you provide a little deeper history and context for how you got there as far as it concerns Lyme and where we are and where we go from [00:24:00] here?

Dr Mikki Tal: Yeah. I would love to, because I feel like that aspect of it is a huge piece of my personal journey and what really made this work so important to me. So I got my PhD at Yale in Connecticut, and I remember that. I used to lay out on the grass and soak in the sun, and I never thought twice about Lyme.

In Connecticut. It's pretty funny. But I moved out to California, sunny California, for my post doc. And in my post doctoral research, I was working on immune regulation and I was doing this work with Irv Weissman at Stanford and actually the big paper that I was working on where I came across you know, some of the big impacts between how Lyme is kind of hijacking our immune response.

That actually just came online yesterday, but the important thing about that was that I was working on an [00:25:00] immune regulatory access where your immune system has the power to kill you. Okay. So that's just full stop. If your immune system is left unregulated and without putting on some really strong breaks, there are these feedback loops that will just amplify.

And so what happens is you start off with these positive feedback loops and they turn on negative feedback loops so that you can shut this down and you take some time to try to knock out this pathogen that's gotten in. But you do it in a controlled way where you're saying, okay, let's do that, but let's not decimate the entire brain or the lungs or that, you know, you pick things that you're not gonna let the immune system destroy because those would kill you.

And so, there's certain, there's these checks and balances in place in an immune response that's [00:26:00] controlling, trying to give you ample ability to control this pathogen, but also really reining that in so that your immune system doesn't kill you. So I was studying that and what was really interesting is I was focusing on a particular checkpoint where that critical negative signal, that break was very diverse in the population and what turns on that break, like the, you know, the foot that hits that brake pedal that can hit that brake is shared across us.

Like it's very similar between you and me. It's very similar, but our brake looks different. And so what was thought was that there was likely multiple pathogens that had figured out a way to hit that break and to be able to push that pedal. And so what I started to do at Stanford is to try to find [00:27:00] these pathogens.

And basically I had a probe and it went around to all these different microbiology labs. And I was like, well, you test my probe. And the one that really took off was our work on the bacteria that causes Lyme disease, where we found that it has clearly mimicked our way of hitting this break.

And it can now it can just, it can hit that break on its own. And I was reading about this and starting to learn about Lyme disease and chronic Lyme disease. And I was reading these review papers that we're talking about that were explaining to physicians how chronic Lyme is not real. How encouraging this would be doing a disservice to your patient, essentially using the fact that this skews female at, you know, at about a 70:30 female to male who will have Lyme disease and then get antibiotics and not [00:28:00] recover and go on to become catastrophically ill and really have this debilitating impact on their health.

That was getting used essentially to chalk this up to hysteria and that meant that this wasn't a real disease, that this very biological difference that we should have used as a clue. You know, I mean, I look at that and I'm like, Oh, does this mean it's testosterone?

Does this mean it's, you know, what is it that's protecting men and that women don't have, you know, but that's not where they took it, where they took it is that means this isn't real. And, I think that's the moment where I said to myself, I mean, at this point I'm a researcher, I've been doing years of immunology research.

I'm looking at this and I'm realizing that among very respected scientists, that are driving our research directions, research funding, things that we think we understand and bring into medicine, that they [00:29:00] are inherently looking at the fact that I am a woman as a way to disregard things that will negatively impact my health, the health of women, like it felt very personal. I've never had Lyme, but this felt very personal. It was years after that we even realized, Sabra Klein did this amazing work. And she was, she started questioning the flu vaccine.

So the flu vaccine has always, women have always reported more adverse events. And that has always been chalked up to a reporting bias. That women are more likely to complain. Now, I'm telling you that I'm pretty tough. You know, and I am tougher than a lot of guys I know. And that just never resonated with me.

It really didn't. And when I saw Sabra Klein present this work that was showing that women are getting twice the dose they need, the dose we chose [00:30:00] is the minimum protective dose for men. Women are actually protected at half that dose. And when you give women a protective dose that's right for them, they don't report more adverse events. Shockingly. This only happens when you give them twice the dose. But yet this got chalked up to be a reporting bias and women complaining. And so at that time I was taking all of this in and I got mad, you know, I got really mad. And honestly, that anger has guided a lot of my research since then.

It's funny because I don't think of myself as this like angry feminist. That's not, that doesn't define me. I'm really, you know, I have so much hope. I really think so much of this can change, but I felt a responsibility as a woman who was able to understand kind of how we got to where we got to where we got and where we are in the tools that we have now that could change that.

I felt a huge responsibility. This is where I have to step in and do something because I can change this. [00:31:00] And I need to for myself, for other women and for people with these chronic illnesses. I mean, men get them too, you know, women get them slightly more. Men also get them, like this impacts all of us.

And I think what you were saying before is that at some point we realize that we have thought this was for the vulnerable, and then one day we realize that we're all vulnerable. Who knows for sure that this couldn't happen to them. Not when we don't understand who gets long COVID and who doesn't, who gets chronic Lyme and who doesn't. You know, without understanding that, you don't know if you're protected or not.

Quinn: Thank you for sharing that. That is it is so, I mean, you can take Lyme disease out and replace it with birth control and you can replace it with menopause and you can replace it with, sometimes I wonder, we were very lucky to have some wonderful OBGYNs when we had a bunch of fertility troubles and miscarriages, and science helped us have three babies, but, you know, you get plenty of shit along the way, of course.

And I do wonder sometimes if an [00:32:00] actual baby didn't come out, which doesn't happen all the time, would male doctors chalk pregnancy up to hysteria? If there wasn't physical evidence of this thing, would they just be like, I don't know, man. It just seems like a lot.

Dr Mikki Tal: I know. I know. The crazy thing about this is that you don't only lose your health as you're going through this process. You lose more than that, you lose, I don't have a word on it, but this is this experience that I've heard so many times where the experience that a patient can have with certain doctors can be night and day, depending on if there was a man in there with them, who was supporting them and pushing back on the doctor. And this is just so unbelievably infuriating. And I think it's a frustrating interaction for doctors and patients as well. I think that nobody walks away from this interaction where there's a patient and there's a [00:33:00] doctor and the doctor's gaslighting the patient. And nobody walks away from that interaction thinking, Oh, great.

You know, I mean, obviously the patient walks away feeling horrible. The doctor, I think also walks away feeling horrible. I don't think anybody who went into medicine and did everything that they did to go into the specialty that they went into wants to have this interaction with the patients where they couldn't help.

They know they couldn't help. They have no idea what's going on. They're throwing something out there, and they see the impact, you know, like I think everybody wants this to be better for there to be solutions. And that's, I really feel like that's where my place is in research.

To try to provide some answers both for patients, but also for the medical community, because I do really believe they want to help and they don't know how.

Quinn: We can talk all day about, you know, Beyonce and Serena Williams, these incredibly wealthy people having nightmare pregnancy stories because the doctor didn't listen to them about [00:34:00] pain and, you know, on and on. But, you know, this all reminds me of, and I'm gonna get to you saying, I think I can fix this.

Again, coming back to this lovely woman we talked to Elizabeth Ruzzo who started this company called adyn, A D Y N, very early on, but essentially it's a it's a test and it's still like version one ish of a test to help you find the correct birth control for your body. And she came at that because going through that process is so awful for nearly everyone. I mean, talking to her I just remembered the girls in middle school and high school going through this and overnight gaining 20 pounds and what that meant to them and mental health and the hormones. What a nightmare. And she was like, this shouldn't be this way.

We've just decided to not do anything about it. And she's like, I had a terrible mental health experience with it. I, you know, tried to take my own life because of it. And then I realized, I think I am the person who has to try to fix this because of not just my interest but my [00:35:00] skills at this. And so let me leave this lateral thing and come work on this directly.

And again, I come back to my friend Sharif who was like, I'm going to fix this muscle dystrophy thing. It doesn't affect me, but this has to stop. And I wonder if you can talk about that now, about why you now are doing this in a world where I've always struggled to define this correctly because it can come off very harsh, which is, we were all susceptible to the original coronavirus.

Now we've all had a variety of shots and boosters and infections from these, all these different versions and it's chaos, but such a huge wide variety of people got at least exposed, at least infected to one of the versions. And whatever this percentage is of people who have some variety of long COVID, some combination of these 12 to 13 symptoms, whatever it might be, including the things that they might've had before. There are a lot of people who are affected by this, or they're just [00:36:00] related to someone who'd love someone who has it, who probably weren't as invested before in viral conditions in the experience of having a loved one with a, as we used to call them pre existing conditions in the old days, right, when we didn't even insure against them. A lot of those are doctors and nurses who are on the front lines. A lot of those are front line workers who, or essential workers as we call them, who we just decide to throw to the wind, or hourly workers who work in meat factories. The spectrum is so wide and so varied and it's a terrible thing. And at the same time, I wonder if you have seen any change because of university presidents in charge of labs or people in corporations, men, who are going, Oh, Hey, we need to work on this. We need to fix this. Who might otherwise not have spoken up. I try to be so tactful about the way I think about this and phrase this, but I wonder if you have seen anything like that.

Where are you getting help that you maybe didn't expect before?

Dr Mikki Tal: Yes, yes, and yes, and I [00:37:00] think, , first of all, I want to say in regards to where I'm getting help that I wasn't getting it before is that I am so, so lucky and privileged that when I was doing this research, I got an award from Bay Area Lyme Foundation. I got this award called this Emerging Leader Award.

And at that gala, and this is, you know, pre-pandemic on my work on Lyme, and at that gala, I met an incredible philanthropist who, you know, we started talking about the problems in the world and the problems with Lyme and she has this personal drive to turn pain into purpose. This is her mantra where she went through, you know, just a horrific experience for herself, with her family, with chronic Lyme, and decided that she was going to change that for other people.

And she has [00:38:00] supported my research so tremendously, given me resources to attack this. And as the pandemic kind of unfolded during this other research that I was working on with Lyme, she really enabled me to also pivot to working on that as well. And to kind of, you know, the way I think about it as this was happening to doctors, to nurses, where long COVID was happening to them, to their colleagues, to people, they knew, people with the vocabulary, the medical vocabulary and understanding to describe what was happening to them with colleagues who knew what they were like before, where there was this very clear triggering event and they were very clearly not the same afterwards and they had a way of understanding what was happening to them, which, you know, is unique in terms of the infection associated chronic illnesses.

That has [00:39:00] never happened in our modern history previously at this scale. Incredibly useful. And I decided that, you know, this was this opportunity essentially, that if people could understand and see and appreciate that long COVID is real that must, if we go back and look at what, everything we know about chronic Lyme.

If these two illnesses are identical in terms of how they present in terms of if the one is real, how could the other not be real?

And I challenged so many people who I then presented to or spoke with to go back and question those old assumptions. To re-look at their biases now, with what they know about Long COVID, with what they think about Long COVID. And this has been a huge, a [00:40:00] tremendously pivotal moment for Chronic Lyme because people are appreciating that.

I was at a conference where the keynote speaker opened with an apology for something he'd written about chronic Lyme 20 years ago. And now with what he knows about long COVID, he would have taken it back, you know, he looks at it differently. And that was just, so this has been such a huge change in our understanding, in our stigmatization of chronic Lyme.

And I'm not saying that doesn't happen to long COVID, it happens still, but long COVID is at least to some extent, getting to appreciate some, you know, understanding in the medical community, a lot of designated research that's getting funded by the government. There's a, it's on a different scale than chronic Lyme, than ME/CFS, than long flu that never even got a name or any of these other, you know, like mono that you didn't recover from, you know, [00:41:00] not that like it's finally these infection associated chronic illnesses, I think are all trying to align with long COVID because it's a new chance for people to look at this again.

And like you said about Ed Yong of reexamining these gaping cracks in the healthcare system that people have been falling through and saying, Ooh, that's not okay. You know, we should really, we should do something about that.

Quinn: It's really about operating with a level of empathy that we didn't have before, and a self awareness that we didn't have it, and a self awareness of how we're using that practically, and putting ourselves out there like that gentleman who opened his talks with an apology, right? He said, look, it's on the record that this is what I said.

And I wouldn't have written it. And I would like to say something different. And, again, you know, on one hand it reminds me of, I remember, this weird memory of, it's like 2009. And, you know, [00:42:00] what became Obamacare, and was there going to be a public option, and were we going to cover pre existing conditions, and talking to someone on a plane who just didn't understand the need to support it, and I just had this thought, and I was a young, I was a moron, you know, I was 24 or whatever, and I just remember thinking, oh, you must not have someone in your life who has one of these, much less yourself, because you cannot possibly love or much less live with someone with any sort of pre existing condition, much less long flu.

You know, I remember my best friend's mom growing up, she was on crutches her whole life because of polio, right? Not a lot of those left. She survived, but holy shit. You know, it's impossible. It's impossible to, of course there's monsters out there, but it's impossible to do that and not have that turnover of empathy and then go, like you said, oh wait it's a, it's the Taken thing.

I have a very specific set of skills. I have this language and all this education. Can I turn that around and apply that here? Especially if I'm a man who has [00:43:00] ignored this, even purposely over a period of time you know, adversely or just through ignorance, whatever it might be like what can I do here, 'cause not only is it incredibly timely, and the flu analogy is such a good one because it's like, it literally comes back every year. Like what we're so keen on oh, was it the right vaccine this year? Will we get a universal one? And it's at, look, everybody do have, it's at best it's 60% and isn't that great?

And then it helps people and it's we don't talk about the fact that what it keeps adding to the baseline of chronic disease over time and in Lyme and all these things.

Dr Mikki Tal: The thing that was shocking for me is the first year of the pandemic, when we were all kind of, everybody was really taking a huge effort to minimize spread.

We didn't have flu that year.

Quinn: Yeah.

Dr Mikki Tal: You know, and that just, flu is actually an easier one for us to, you know, we still had COVID and we didn't have flu.

Because people were really trying to be very good about [00:44:00] ventilation. People were moving things outside that could be moved outside. People were wearing masks and suddenly we realized, wow, we could have a huge effect on our overall health. If we took ventilation seriously.

Quinn: Yeah we could just not do this.

Dr Mikki Tal: We thought about the extent to which we breathe in air that has just come out of somebody else's mouth unfiltered.

You know, and when we had a spotlight on that for a brief moment in time, and when people were taking that seriously and doing something about that, flu wasn't a problem that year, you know, and so I think to me, I look at those things and I'm like, Oh my God, flu is a solvable problem, even with bad vaccines, you know?

So yes, we need to do better and we can get better vaccines, but this mental model that got presented in COVID saying, of this Swiss cheese, right, that, you know, the vaccines aren't perfect, masks aren't perfect, cracking a window isn't perfect, but you put all these things [00:45:00] together and you can protect yourself in a really profound way by compounding different imperfect protections.

I think the takeaway from that for me is that if we really attempted to tackle the flu problem, we could.

Quinn: I have been so lucky over all of these conversations to, you know. not just have one specific conversation about the ocean, right? We've come about it 20 different ways in the same way with women's health or mental health or whatever it might be. And one of my favorite conversations from the last year is with research scientist, Lindsay Marr, who's at Virginia Tech.

Dr Mikki Tal: Oh, yeah.

Quinn: I mean, just incredible. And she's just what are we doing? It's so obvious, like you were saying, look at what we just basically accidentally did. We could do that. The federal government put tens of billions of dollars for schools and offices and basically no one used them and you could level the playing field against all these things.

You know, it's so important to have more and better vaccines in the mRNA platform. Who knows what it could do? [00:46:00] Thanks to folks like Karen Kariko, right? And it's so important to understand the post viral stuff that's gonna happen because these things aren't like going anywhere, right? Especially because we just feel like bringing measles back sometimes. You know, but at the same time, we can do these better things. We can level the playing field and just have to deal with it less with these incredibly basic things and these questions Elizabeth Ruzzo is asking going, Why is it that people just have to try different birth controls until they maybe find one that doesn't make them feel fucking terrible or try to kill themselves?

Why do we, you know, for decades as Rachel Gross's book taught me and Cat Bohannon’s book and all these other conversations, we just, we said, Oh, well, well, we can't do people who have menstruation and clinical trials because obviously they'll screw it up and it's going, what are you doing?

And pregnant people. And on the one hand, you're like, well, we do have to be careful, but excluding, what are you [00:47:00] doing, because then you don't realize we're giving them twice the flu vaccine that they need, and that's why they're having these adverse effects. Jesus Christ, it's not that, it's both complicated and not that fucking complicated.

Sorry.

Dr Mikki Tal: I asked, actually, I asked a really high level pharma exec, you know, who is in charge of a vaccination program. And I said, what would it take for you guys to test a male and female dose in your trials? And he said to me point blank, FDA would have to mandate it, you know, it would double the cost of our trial because currently we're already mandated to test this in men and women to kind of parse the data to be able to disaggregate the data by sex, that's new.

And he was like, but it's not powered to, it's not powered to analyze separately by sex. And so we if needed to analyze just for males and just for females, he was like, that would cost twice the amount and it would have to be mandated. There's no way we would take that [00:48:00] on without it being required. So FDA, please, please go ahead and mandate that/

Quinn: So much of my job is trying to help idealists like myself be more pragmatic about the way politics works in the corporate world, capitalism that we're not going to be able to completely throw away, and all these things. So on the one hand, I'm like, quarterly reports, this guy, like what a nightmare it must be to manage this all this and then there's the vigilante side of me, which is like too fucking bad, bud, like I'm sorry, your computers are gonna cost more, like fucking figure it out.

Like what, listen to yourself. Are you kidding me? So there's that. So I don't want to keep you forever, even though I could have this conversation forever I truly am so thankful for it. Talk to me for a minute about your current research and the trials you've got going on, how you're very strangely looking forward to Lyme season here.

So you can gather more volunteers to your crazy study. I'm going to just send my kids out into ticks today. Talk to me about that and where we are and what you're operating on so that we can get to my favorite question, which is what can we [00:49:00] do? And that's both with our voice, with our dollar, Congress people, whatever it might be.

So set the stage for us here and then we'll get into what we can do to help.

Dr Mikki Tal: Sounds great. So currently my lab is working on two really big things. One piece of what my lab is working on, and this is more, you know, on the deep immunological characterization side is that we're trying to map illness trajectories. So we think that if you can ask your immune system how it's looking at different pathogens, how it's responding, that we could learn so much, that we could separate very early in the response to infection, who is going on to recover and who is going on to not mount a protective response to actually mount a response where everything is going haywire and this is going to, they're going to become catastrophically ill and we think that we can predict those [00:50:00] trajectories pretty early in the response to infection.

And that by looking at these immune features that look very different during a protective response that's going well and properly regulated versus a response that's going off the rails.

Quinn: Wow.

Dr Mikki Tal: That's one focus of my lab. The other big focus of my lab is this huge clinical study that we're running called Maestro at MIT.

And this Maestro study, this thing is all consuming. This is this mission to leave no stone unturned. So Maestro is our humility to say, we have no idea what's happening with chronic Lyme disease, with long COVID, with these infection associated chronic illnesses, we don't know why people are getting so sick.

We don't understand. There isn't a chapter in the medical textbooks about these illnesses and the plan for Maestro is to write [00:51:00] that chapter. So we're looking at everything, every biological fluid people will give us. We're taking it, we're taking saliva, throat swabs, vaginal swabs, rectal swabs, urine, blood.

Quinn: ‘Cause who knows?

Dr Mikki Tal: Where it's literally the theme is constantly leave no stone unturned. We're looking at you know, we're doing this whole slew of neurocognitive assessments, both the kind that we used to know how to do as well as working with these new innovative companies that are doing eye tracking and trying to use your eyes as a window into your brain.

They're using EEGs that you just wear on your head and can measure electrical output from your brain that, you know, video games that you can play and can teach us about things that are happening and even these tests where, you know, you lie down and then you stand up and we're looking at what's happening to your feet or is blood pooling in your feet?

Is it blood pooling in your abdomen instead of going up to your head when you stand up, you know, taking your blood pressure, looking at all these things and we're looking at other [00:52:00] stuff, like we, you know, we used to think that hypermobility was genetic. You were born with it or you were not born with it.

And now we're seeing, oh, it looks like people are becoming more hypermobile after infection. What's going on there? What's falling apart with their connective tissue? What's so, so we're doing, we're characterizing all of this. Basically everything we can think of, we're constantly trying to get more funding for this because we want to profile everything.

We want to bring in an older cohort. Currently, we're only up to 65. You know, we're focused on 18 to 65. So adult, we really want to see what's going on with those older adults. We would, we'd love to be able to bring them in. We would love to follow people out for longer times and bring more people in.

I mean, you know, there was a piece about our study in the Boston Globe and our site crashed after that. I mean, people, so many people tried to enroll. It was just, there's such a gaping hole that people are falling into. Like a crack doesn't even, that doesn't, [00:53:00] it's a chasm, you know? And I feel like.

People are desperate for help to even just to understand what's happening to them, even just to give it a name. So as we write this textbook, we're also giving everybody back their own data so that, you know, it's a study. It's not a trial. We don't have solutions yet for anybody, but at least what we can do is we're trying to give as we're looking for answers, we're trying to give some of those answers back so that at least people can understand a little bit more about what's happening to them.

And yes, as we're looking towards tick season, the population that's been the hardest for us to recruit and the cohort that we're really that we need is this acute Lyme cohort. So we need people who are within four weeks of their tick bite. So while I hope you all do your tick checks, I hope that nobody gets Lyme this summer.

If you do, please think of us, look up, you know, MIT [00:54:00] Maestro, enroll in our study. What we are trying to do is catch people who are having that acute infection, getting their antibiotics where, you know, they were at that time, otherwise healthy or, you know, going about their life, functioning in the outdoors. And we want to try to understand what's happening and that, you know, illness trajectory mapping that I was talking about, we want to do that.

So we want to really characterize those people who are going on to recover versus the people who are not going on to recover. How early can we tell those apart? What are the features that are delineating those? Because that is going to be huge in our ability in the future to prevent this, to recognize it early, to treat it as soon as it's happening.

It's so much harder to fix and repair damage that has already [00:55:00] happened. You know, imagine you break a bone. So it's the same thing. If you break it apart here, your connective tissue, if you're already experiencing brain damage, that's really hard to repair, but it's so much easier to prevent.

And that's kind of, I feel like, always been the guiding light in infectious disease. And I hope it's not something we lost during COVID, but the goal should always be to prevent. It's so much easier to prevent than to treat and to bring you back in. And so if we can see that once you've had Lyme, if we can see that you're going down that catastrophic route, if we could identify that early, it would be so much easier to help you then before everything goes off the rails.

Before you've lost your health, you know,

Quinn: That is so fundamentally helpful and true in so many ways, which is again, because of the way the US medical system at least is completely incentivized and predisposed to being reactionary and to treat you as opposed to encouraging primary care and wellness and community [00:56:00] health and vaccines and all these things and opening your windows, you know, or just I don't know, let's not shut people's water off.

All of that stuff, a hundred percent. Tell me just so, again, people, I want this to be as useful to people as possible. Someone gets bit by a tick, they catch it, they follow the YouTube videos to remove it right, exactly, hi yah, and then when should they go to an urgent care or primary physician, and at what point should I guess, because I, from what I understand, again, correct me where I'm, everywhere I'm wrong here.

It's still pretty tough to diagnose. Is that correct? Or is that chronic Lyme that's tougher.

Dr Mikki Tal: So I'm gonna, I'm going to start from the beginning there because

Quinn: Perfect. Great. Basically, I just want to tell people what to do.

Dr Mikki Tal: Is you've been out in the outdoors, whether it's your backyard, or you've been out camping. When you get home and you get in the shower, take that opportunity to do a tick check. If this is your kids, look for them.

If this is yourself, look for yourself, the places you want to focus [00:57:00] on, you want to look between your fingers, between your toes. You want to check your armpits. You want to check around your groin. You want to kind of feel around in your scalp. I know it's really hard to see a tick there, but you can run your fingers through your hair along your neck, behind your ears, along your ears.

You're feeling for something for a little bump. If this is for yourself, if you're looking and you're looking for something small. So on somebody like me, I don't know if you can see all my freckles. I got a lot of freckles and some of these ticks, you know, these little deer ticks, they could be smaller than a freckle, you know, and especially the little ones.

So you're looking for something very small but you should be able to feel it. So you know, do those tick checks. That's number one. If you find a tick, pull off the tick. That tick, you know, there are a lot of services where they could take that tick. You could mail them the tick and they could tell you if that tick is infected or not or if it's engorged or if it's, you know, and it's so much easier to find it in the tick.

Then to try to [00:58:00] take you apart to look for it. So, you know, that's one thing that you can do. Then you know, the thing that you're watching for is you're watching for a rash, the problem is not everybody gets the rash. So you're also watching for things like a summer flu, you know, and I know that's so hard right now with COVID and with, there's so many things going on, but if you feel like you're suddenly, you know, you had this tick bite and now you feel sick. Over these next few weeks, following that, this is something to take seriously and to talk to your doctor about. So that's definitely something to pursue. Next is, you know, there are some keys to health that are not glamorous, but they will always be true.

You know, your immune system is powered by sleep. Getting a good night's sleep. Getting some exercise, having real nutrition with real food that [00:59:00] has real nutrients that can fuel your immune system. The, these things are so important. They can't be overstated. And I know they're not easy. They're really hard work.

You know, good sleep, exercise, eating right. Like these are hard things, but these are things you can always do to try to maximize your health. And we were talking about wellness and prevention. That's always, you know, really key starting something like this. from a point of view where you're really healthy and you've got all the nutrients you need versus starting it out with a nutrient deficiency, you're going to see that's going to make a really big difference in outcomes.

And you know, then we fall into that hard part where if you are not recovering, you know, so if you can catch this early and get on antibiotics, if you do have Lyme, that's going to go a long way, and that's going to really stack your odds for being in that higher chance group of recovering. If you find that you're, unfortunately, in that group of [01:00:00] people who is not recovering, you've got to manage to connect with, doctors that understand what's happening to you and can help you and are willing to work with you and not, you know, if you're finding yourself just with somebody who is closed to this, even in this world of long COVID, find a different doctor.

There's so many out there right now, I think that, that are very aware of the different things that can go wrong and really do want to help. So, build yourself a community of people who care about you and who, and, you know, doctors who can help you so that you can find your way back to health.

Quinn: Amazing. You want to catch people for this study in the first four weeks post bite. How long should they wait to call your hotline?

Dr Mikki Tal: Call me immediately.

Quinn: Are we talking about like an immediate bite? Hey, I pulled this thing out, www.getmetoboston?[01:01:00]

Dr Mikki Tal: We will do anything we can to get you in. If you can come to Boston, if you can come to MIT, we will do whatever it takes to get you in and seen in that four weeks. But the earlier you tell us about it, the earlier we can bring you in, the better that is all around for the study. And you will be doing so much to help so many.

This is the piece that we really need in order to be able to understand how the other puzzle pieces fit together. We need that triggering event that started it all. So, yes, if you had a tick bite, if you've been recently diagnosed with Lyme and if and if you know of anybody over the summer, if you hear, oh, I just got Lyme, tell them about our study.

Quinn: Put him on a train. Gotcha. Okay. Okay. Send the tick off and then make your way up to Maestro. And maybe you could provide us with some of the reputable tick evaluation services where people can FedEx their little friend off.

Dr Mikki Tal: Absolutely. Some states have, you know, with their own health [01:02:00] departments, labs that are even providing these services for free. Other states don't have that funded, but there are some really wonderful, reputable commercial labs. We're collaborating with one of them very closely.

So, you know, I'll make sure we have that on our website, but I can also provide that information there are places you can send these ticks.

Quinn: Awesome. Anything else folks can be doing besides the very acutely personal things, as far as great resources to get educated on this stuff, besides this conversation and things they could talk to their City Council, Board of Supervisors, state legislators, whatever it might be about things to move along this fabled vaccine we're trying to bring back to life.

What else do you feel is really actionable for folks? And you can always send this to us later as well.

Dr Mikki Tal: Okay, that's an interesting question. I mean, for the medical community, what I would really like to see is I would like to see how we're trying to fill those cracks. So I would like to see [01:03:00] what specialty is going to take on these patients with infection associated chronic illness. Like with MS, that ended up being neurology.

With fibromyalgia that ended up being rheumatology. But they don't, they were never really given the tools, they have, sorry, they have the tools, but they were never given, you know, they don't have insurance approved treatments that they can provide. They haven't been unleashed on these infection associated chronic illnesses in the way that they could be.

And the question is, will rheumatology step up to the task? Are they even the right specialty? I feel like for the medical community, we really have to identify how we are going to treat the overwhelming number of people that now have these chronic illnesses. So that's one, in terms of what people can do.

There is a lot of information out there, but it is hard to sift through the hype and [01:04:00] the, you know, within wellness there's a lot that's real and true and valuable, and there's some wellness industry stuff that is less helpful.

Quinn: I have no idea what you're talking about.

Dr Mikki Tal: Right, of course.

Quinn: You’re putting it so much more gently than I do, but thank you for being a professional. Could you, again, whenever just any amount of, even if you're like, Hey, these are the two or three best resources that we trust.

Great. We'll take it again. That's all we're trying to do is prevent people from having to do the sifting. It's a nightmare. So yeah, anything you can provide would be fantastic on that front.

Dr Mikki Tal: Great. Great. I will give that some thought and send you some resources.

Quinn: I appreciate it. Okay. Last two questions. Are you ready? Who is someone in your life that has positively impacted your work in the past six months? And this is kind of how we call it out. Some people have a [01:05:00] colleague, some people have a dog, some people have a spouse or children or any of the above, a mentor who can know.

Dr Mikki Tal: One of my sons in a very important way has been through his own health journey and the amount that I have thought about that nonstop, every waking moment, the things I have learned for him to try to help him, I think will impact my work tremendously. And I think that people have no concept of what it takes to be a caregiver for somebody who's going through something with their own health and how healthy you have to be and how much you need to do in order to try to help them solve their own problem.

It’s tremendous, but just like being a parent helped me be a better mentor. Being a caregiver is going to make me a better researcher of, you know, [01:06:00] while the problems are different, there's so many similarities and flavors and certainly the empathy and compassion that I've, you know, gained through this experience has very positively impacted my work, even though it's taken me away from some of it to some extent.

Quinn: Sure. Well, I'm sorry to hear that. I hope it improves and I'm sure he's very thankful to have a mom like you.

So thank you for sharing that. Last one. What is a book you have read in all of your free time in the past year or so that has either changed your thinking on something or opened your mind to a, you know, a new idea or principle that maybe you hadn't considered? And we've got a whole list up on Bookshop of wonderful recommendations and everything from Goodnight Moon to, you know, medical textbooks you name it, we've got it.

Dr Mikki Tal: Oh man, this is such a tough one. You have stumped me.

Quinn: By the way, it can also be, and I'm just going to change the question from now on, because I literally go home and read about like dragons at night because I'm like, I can't think about, I got [01:07:00] to turn my brain off. So if yours is romance dragons great. I read that too. And it's very helpful.

I think that's important too. So whatever has been helpful to you, let's put it that way.

Dr Mikki Tal: Honestly, I read so much for work that while I have read some really impactful things, for me that most helpful thing to kind of try to turn work off a little bit and I let my mind keep sifting through it in the background but change my frame. And really, I'd have to say more than any book, this is my husband.

This is my husband in the evenings talking to me about stuff that's not work, forcing me out of that a little bit. Grounding me in the world and in our family. And I'd have to say that more than any book, that's him.

Quinn: I love, what a wonderful answer. I love that. I love that. My wife just doesn't listen to me at night. Cause why would she? Like truly the day is enough. No one needs me now being like, so, she's like please go feed your dragons. Jesus or watch spaceships blow up somewhere. That's [01:08:00] wonderful.

Well, thank you for sharing that. We won't put him on Bookshop. This has been one of my favorite conversations ever. Don't tell my other ones. I really am so thankful for it and your perspective and the work you're doing, which is so immediate. But also you're using all these new things and new moments and tools to answer some very age old questions and issues that we chose very purposely not to deal with.

And that just keep on catching up with us and holding us back and we don't have to do that and we're very lucky to have folks like yourself who are saying no mas, we're gonna we're gonna try to go out these things. So I really do appreciate it and I appreciate your time today.

Dr Mikki Tal: Well, thank you so much. This has been a lot of fun.