Interview: 1 simple question that could improve women's health | Meryam Sugulle

0:01This is TED Health, a podcast from TED, and I'm your host, Dr. Shoshana Ungerleider. Your belly button might seem like nothing more than a small scar or a fun feature to point out to kids, but it's actually a lasting reminder of your first lifeline, the placenta. That incredible organ nourished and sustained you before you were even born. And for the person who carried you, the health of that placenta may still be telling an important story, especially when it comes to heart health. In this talk, obstetrician and researcher Dr. Miriam Sugule invites us to rethink the connection between pregnancy and long-term cardiovascular risk.

0:42She reveals why one simple question about pregnancy complications could be the key to better screening, earlier interventions, and improved outcomes for women everywhere. It's the kind of shift that makes you wonder why we haven't been doing this all along. Sometimes the path to protecting future health starts with understanding the past, belly button and all. Then stick around after the talk for an interview with gynecologic oncologist and founding dean and CEO of the Alice L. Walton School of Medicine, Dr. Sharmila Makija. But before we dive in, a quick break to hear from our sponsors.

1:23And now, Mariam Sugule takes the TED stage. How would you react if I told you that we have an underused screening tool that has the potential to improve women's health substantially? And that this tool only consists of one simple question. Have you had any pregnancy complications? With that simple question, we could identify women at increased risk for cardiovascular disease later in their lives. that means diseases involving the heart, the brain and the blood vessels like heart attack, heart failure, stroke and high blood pressure. By asking that simple question we could seek out the women who could benefit from general health screening already at a younger age that means checkups of blood pressure, body weight and blood sugar.

2:20Based on the results, we could offer personalized lifestyle advice and suggest preventive measures. Why? For this is a fact. Cardiovascular disease is a major cause of early death, apart from cancer, not only for men, but also for women. I hope that all of you now got very curious about what on earth nine months of pregnancy have to do with older women getting heart attacks and strokes. Pregnancy is something younger people do, you might think, even though I would argue that 50 is the new 30. Pregnancy is often described by a well-used quote as a stress test for life. A woman's health gets tested by being pregnant.

3:19Will she tolerate pregnancy and all the involved physiological changes well, or will there be any complications? The most important organ for pregnancy is the one that was once attached to the center of your belly, where your belly button is. We all have a belly button, regardless of gender. You and I, King Charles, the Pope, Beyoncé. We, and where it is, we were all once connected via a lifeline, the umbilical cord, to the most important organ in both our and our mother's life. You and I, we are all here thanks to our placenta. We all survived the single most dangerous event in our life, birth that is, due to our well enough functioning placenta.

4:17We all know that the placenta was our first meal box when we were growing babies inside our mother's womb. Most of us also know that the approximately nine months of growth inside our mother's womb have lifelong lasting effects on our health and diseases once we are outside. But what is lesser known is that the placenta, the one we were attached to, is crucial for the future cardiovascular health of the mother who lent us a room in her womb. That means how healthy our placenta was is very important for the health of our mother's heart and blood vessels. How is that the case? how does our placenta affect our mother's future cardiovascular health?

5:12In order to understand that, we must briefly talk about the makeup of a healthy placenta. This fascinating organ is made early on in pregnancy, when the fertilized egg develops into the baby and into cells that invade the layers of the womb of the mother. This happens early on in pregnancy, before the baby even looks like a baby. After invading the different wall layers of the mother's womb, the cells group together and form finger-shaped tissue. These tissue fingers seem to poke into the layers. finally the healthy placenta includes a special room in where these tissue fingers are showered in the mother's blood in this shower room the growing baby receives different life important nutrients and signals via different transport mechanisms in other words it is very important that everything works well in this specialized room.

6:29It has to be nice and tidy. That guarantees the meal box effect of the placenta, the good effect. But just like almost every other living thing, cells can get stressed and cells can get out of control. This happens, for example, in cancer. But how can a healthy placenta become a stressed placenta? What happens? Placental cells can get stressed when the blood shower in the specialized room gets messy. The placental cells then get out of control. They grow crazy bumps on their surface. In fact, they seem to literally throw up stuff into the specialized room. By that, the stressed placental cells send many different types of signals into the specialized room.

7:31And these stress signals then reach the mother's blood and the mother's blood vessels. And when they reach the mother's blood vessels, they can make these vessels unhealthy. And they can contribute to making the pregnant woman sick, and the pregnancy gets complicated. The placenta is then not really healthy anymore. Maybe you've heard of or even know personally women who have had increased blood pressure from around the middle of pregnancy, who had protein in their urine, or headache, abdominal pain, blurred vision, or all of this. Then they had what we call preeclampsia. a pregnancy complication of varied severity that occurs in 3 to 10 percent of all pregnant women, the rate depending on where we live.

8:30What does preeclampsia have to do with the placenta and with the mother's future cardiovascular health? Remember what I told you about the stressed placenta. According to a widely accepted theory supported by research, in preeclampsia, the stressed placental cells send signals into the mother's blood. These stress signals may cause inflammation-like processes in the inner lining of the mother's blood vessels. This then leads to disturbed vessel function and to the science of preeclampsia that I mentioned earlier. Preeclampsia is only one of several examples for a pregnancy complication related to a not well-working placenta, but I will stick to this example.

9:27In a way, the placenta and the mother talk to each other. And since our earliest cells formed both us, the babies, and the placenta, we talked to our mothers even before we could speak properly. And it turns out that this may well be one of the more important talks we had with our mothers. So back to the concept of pregnancy as a stress test for life and how stressed placental cells can impact on a mother's future cardiovascular health decades after she was pregnant and had a preeclampsia. How do we know that women after pregnancy complications are at increased risk for future cardiovascular disease.

10:24In Scandinavia, we have unique access to large population-based data sets containing health information. For many decades, these databases have provided important medical knowledge. They tell us that women who have had preeclampsia towards the end of pregnancy have a doubled risk for future cardiovascular disease compared to women who have had uncomplicated pregnancies. I mentioned the meal box function of the placenta. I explained the effect of stressed placental cells and how they send signals to the mother. If the placenta gets even more stressed, the meal box function may be affected. That means the baby has a lower weight than it should have in addition to the woman developing preeclampsia.

11:25Some babies may even, for various reasons, be born too early prematurely. For these women with a very, very stressed placenta, the databases tell us that the future cardiovascular disease risk is even higher, up to four to eightfold higher compared to women with uncomplicated pregnancies. So to sum up what we have talked about so far, we have databases that give us information on pregnancy complications and future cardiovascular health risks. We know that the baby and the placenta and the mother send messages to each other, talk to each other during pregnancy. But we do not know the exact mechanisms by which complicated pregnancy and the placenta contribute to future health risks for women.

12:25And this is my point. Much research remains to be done, and the placenta is still full of secrets that need to be unveiled. But why should we bother anyhow? And how can we identify women at increased risk? And what should we do then? As I said in the beginning, why? Because cardiovascular diseases are a main cause for early death also in women. Heart attacks are known to present differently in women compared to men and may be recognized too late, and that might prove fatal. This is also another good reason for identifying women at increased risk earlier, at a younger age. This is because the earlier the risk factors are dealt with, the better the effect on the blood vessels and the heart.

13:26how can we identify women at increased risk by asking the right questions about pregnancy at the right time and whatever the exact cause and the precise mechanism for the association between pregnancy complications and cardiovascular disease prove to be our mothers sisters aunt's pregnancy history may provide important information for future health needs. And what should we do then? We could take action at the right time. Women could be offered general health screening at a younger age, including checkups of blood pressure, body weight and blood sugar. We could give personalized advice on lifestyle and try to influence other risk factors, such as weight gain, obesity, smoking, or type 2 diabetes.

14:29This could be done even before women enter their 50s. Is this new medical knowledge? The answer is no. Has this knowledge been acted upon? Not really. Placenta-related pregnancy complications have officially been acknowledged as sex-specific risk factors for cardiovascular disease by the American Heart Association 11 years ago, and other cardiologic societies have followed their lead. Many guidelines suggest or call for follow-up after pregnancy complications. But we are not aware of any country in the world having a systematic cardiovascular follow-up for women after pregnancy complications already at a younger age.

15:24We think such follow-up is of extreme importance for equality in health care and society's survival, since women are important for society's survival. We think that it should be possible to integrate a simple cardiovascular risk factor assessment, measure blood pressure, body weight and blood sugar, at the general practitioners into existing screening programs for cervical dysplasia or other comparable, available screening programs around the world. Tomorrow, when you stand in the shower and look at your belly button, remember the placenta. Remember the one simple question that could improve a mother's health.

16:21The one simple question that could improve cardiovascular health. Have you had any pregnancy complications?

16:40That was Miriam Sugule at TEDxArendahl in 2022. And now, on to our interview. Dr. Sharmila Makija is the founding dean and CEO of the Alice L. Walton School of Medicine in Arkansas. She's an international gynecologic oncology expert, and she works with partners to enhance medical education and prepare students for future health care roles. Today, we'll be digging into the shifting landscape of reproductive health, the evolving role of medical education, and how each of us can make a difference in advancing women's health. Dr. Makija, welcome. Thank you so much. Pleasure to be here today. You've dedicated your career to women's health, from caring for patients with gynecologic cancers to shaping how future doctors are trained.

17:29Given everything happening right now around access to reproductive care, what's top of mind for you as both a physician and an educator? You know, it's a challenge. It's a challenging time right now. So I'm originally from Alabama, so I'm used to being in the South. And moving to Arkansas, we really saw that women's needs were even greater here with less providers in the area for women's health. And so we've had to be not only the provider of care, but really the voice for women to talk about the concerns that they have, whether it's directly listening to them and bringing it to our legislators' awareness, to working on policies and being a support in that arena.

18:14What are some of the biggest gaps in women's health that still exist today? And why should all of us, regardless of gender, care about closing them? You know, maternal mortality is one of the biggest problems for women's health. Women shouldn't be dying in childbirth, and that was our biggest problem that we saw across the country. And, you know, I happened to be on the board of Every Mother Counts, and we had just done a film on the state of maternal health in Arkansas right when I was starting here as dean. And so that has brought a lot of attention to the state. I'm now on the governor's maternal health task force, and she has now invested into the state to address these issues for maternal health.

18:59So I saw that within less than two years of me being here, coming across and unifying with the legislators to the other health systems, looking at the policies, looking at how do we address the health needs of the state for the women here. And she has invested, I think it's now over$40 million into improving health outcomes for women. Not only providing more doctors or looking at better access points, but what we call the whole spectrum of health care providers. So doulas, midwives, that are really necessary to work as a team to provide more access points. It's shocking to me, even as a physician, you know, hearing about maternal mortality rates and the fact that in the U.S.

19:46like we face these issues. So I'm very glad to hear that you're doing what you're doing in a state that has some of the biggest challenges and shining a light on this. You know, a lot of listeners, I think, want to support better health care for women, but they don't know where to start. So what are some simple but hopefully meaningful ways that anyone can get involved, whether it's in their community, at the ballot box, or even just around the dinner table? Yes. Well, it's funny you bring up dinner table. I've shared this before, that both my parents are educators. And so we would sit at the dinner table, and it started with, what did you learn today?

20:25And sharing that as kids with their parents. and then it shifted to what have you done to make someone else's day better? And so that shifted our mindset of learning what are problems that people are having and how can we try to help, even in a small way. So I think that for women out there, knowing that you have that trust with your doctor, but with your close group of friends, to be able to talk about things openly and not be embarrassed or ashamed that you have a problem and you're having to bring it up. You know, I think there is a lot of pressure on women to be a certain way, to be, you know, perfect.

21:05There's a lot of societal pressure. So I think having a group that you can confide with in a safe space, I think, is a start. I'm absolutely in favor of community support networks. You have to know that that is some place that you can feel safe to talk about things. And I think doctor's offices, again, you're very stretched for time, but there are more community networks that are being formed out of doctor's offices because there are needs from women that are asking for this, especially in this day and age. I think it's even more important to just be up front and ask whoever you trust, whether it's where you get your hair done or going to daycare and talking to the other moms.

21:48And you're going to find out pretty quickly if they're not the right group. If they're not making you feel welcomed or invited in, you know to turn and keep looking elsewhere. And I know you've said before that medicine isn't just about science, right? It's also about trust. With reproductive health becoming a flashpoint and DEI programs under pressure, how do we protect trust in our health care institutions? You know, I think what we saw during the pandemic, as much as we were really trying to improve access and dealing with the issues around COVID and care, I think it really exposed the issues that we have with just trust amongst patients and providers.

22:33And, you know, one of the things that we really worked hard at was just open communication and bridging that trust as much as we could. It's front and center with how we train medical students to bring back that area of trust and how we communicate, how we empathize. You know, back when I trained, we did talk about this a little bit more. we had our mentors bringing us into the clinics and talking about, you know, how we build that trust. And it was openly talked about. And we saw how they did that. And then I think now, with the pressures that are on a physician with all the productivity measures, you have 15 minutes to create that bond.

23:18It's very much a tough challenge. And we're trying to change that paradigm at the medical school. Yeah, well, good. I think that's so important. But such a challenge, right? And sort of building on that, it feels like scientific and medical guidance is being questioned more than ever. How do we, meaning how do the consumers of healthcare decide who and what to trust when it comes to our health? It was always the challenge already, right, when we have limited to time to build that bond. And then you have the internet, which has been helpful, but also can be confusing, right? So Dr. Google, right, trying to diagnose things for yourself, and then coming into the addition of AI, where if you really look at how that's changing, how we diagnose the patient, maybe even being more accurate than the physicians, that brings up the trust issue again as to who's right and how do we create that relationship.

24:24But also, there's not going to be one set of answers. You're going to have to look at the technology and look at where is it appropriate for what areas. There's not going to be a one-size-fits-all for how we communicate the science behind a lot of the work that we do, the evidence-based practices that we do right now. In times like these, when longstanding rights and public health initiatives are really being challenged or even rolled back, how can physicians, nurses, really all of us in health care show up not as political actors, but really as advocates for evidence-based care and show up for the patients who rely on us?

25:09In my humble opinion, I think it does come back to going to the basics and admitting when you don't know the answer, right? Because that's just human. You know, we're so trained to look at a patient's problem, but maybe not the patient as a whole. And there may be other contributing areas that are leading to the problem at hand. That's one of the premises of why we are changing that medical education piece at the school. I want to talk about that. You lead a brand new medical school. Yes. That's so exciting. Yeah. What's the responsibility of medical education in this moment, not just to teach anatomy and pharmacology, but hopefully equip future doctors to lead with courage and really prioritize their patients and see them as whole people?

25:59That's right. I have to start off by saying we have such a great team, you know, because it does take a team of like-minded, but even those that will challenge the status quo to get that team together to really start to address where we need to improve medical education. And if you look at medical education across the board, it's highly regulated. When you have committees that decide what can be changed, what can be removed or added, that's probably, good or bad, is what's causing a little bit of the stifling of the advancement of knowledge. And so what we're trying to do is create some nimbleness within the curriculum, yet adhering to a lot of the much-needed regulations for producing a doctor that knows how to take care of the illness but also knows how to take care of preventative care.

26:50Because that's not something that's fully front and center. How are you addressing it long-term to be actually put into place in practice? The whole health principles are looking at this whole person care. So it's not just the physical, it's the spiritual, it's the mental. It's that whole care that is the foundation for value-based care. And more and more institutions and health care systems are moving from a fee-for-service to value-based care. And, in fact, our educational partner is the Mercy Health Hospital System that's in the Heartland. They're our partner that's already practicing value-based care.

27:30So our philosophy is that we're going to teach this and then place them into that system to work and practice it in real time. Well, Sharmilla, you've spoken powerfully about compassion being core to care in a time that can feel divisive. How do we bring that compassion back into the center of health care across lines of belief and background and people's experiences? Even changing how we approach a patient to, instead of asking the question, what's the matter with you, changing that question to what matters to you. And part of the curriculum is called Arches, and the A is for the art of healing.

28:15You know, we're sitting on the campus of a world-class museum, Crystal Bridges, and we are taking those curators and that team, the educational team there, that's already teaching K-12 students improving that it's improving their empathy skills or communication skills, and we're bringing that into the medical education curriculum. And there are many schools that do some courses on this, but we are weaving it throughout the entire curriculum because we feel it's that important to bring in that empathy piece front and center at the beginning. I think that's fantastic. I know you've worked in some of the highest levels of academic medicine and healthcare leadership.

29:00What's your take on how institutions can really stay true to their values when they face pressure to walk back programs that are focused on diversity and health equity? There's no easy answer to this. You know, we are looking at this in many ways. You know, as long as we're doing it the right way and how we are being inclusive, we may not have the label of DEI, but we are practicing inclusivity. There are still racial differences with how women respond to treatments or men. So we do talk about it in cases. We just may not label it. I think that's the start of staying true to the work itself. I think it's a challenge, especially those institutions that have funding that are tied to federal funding that are at risk.

29:51But we are trying to at least stick with the evidence-based practice for now. You're at the front lines of treating diseases that disproportionately affect women and often go undiagnosed until later stages. How do policy and stigma and access intersect and affect outcomes for the women that you care for? I think access is the biggest issue. I think that doctors are trained to take care of patients as they need. But if they can't even get access to those doctors, that's a big problem. And this is a problem throughout rural America. This is what we see firsthand. And so our mission is to improve that access.

30:34I will say, starting with the type of medical students that we're recruiting, we are really looking at those with the rural background because we know those are the people that are going to likely go back into the rural areas to practice. So that's one way of addressing access. Now, that's a long term, right, because we've got to produce students that will go on to residency programs and then come into practice. I think that virtual care networks are going to be really important. That's another piece of what we are working with with Mercy Health System. They have been a leader in virtual care networks throughout the Heartland region, which is what we call this particular area of the country.

31:16And that along with broadband access, those things that are really going to be tied together to improve access, not only for the patient to have more access to us that are in maybe a little bigger city or more urban areas, but even for the doctors that are in rural areas so that they're not alone and they can access the specialists when they need to. That's the system that we're looking at here at the medical school, along with our sister institution, the Heartland Whole Health Institute. They're looking at the rest of the system because you can't just do it as a standalone as a med student is being produced and going on to residency programs.

31:57you still need that system to be built out to accommodate. You've mentored so many young physicians, especially women and those from underrepresented backgrounds. What do you say to the next generation of health care workers who want to be change makers, but they don't know where to start? There are going to be some that want to go and walk and protest, right, to bring awareness. And then there's some that want to focus on policies and making changes at the state level, national level. There's those that are just afraid to say it out loud but want to quietly work behind the scenes. So we really try to embrace everybody's different personas but could work it all together to the same outcome.

32:41And that's how we encourage because I don't think there's one way to do it. I'm someone that wants to support the teams and help build them up and help them learn how to maybe say it in a way that's not putting everybody at odds or in their corners. And so how do you approach having that line of communication to be heard more effectively? In a moment in time that's challenging for physicians, for nurses, for all of us in many ways, what's bringing you hope right now? The fact that we're opening this school, I mean, that is the future. We have a great team here that's had their heads down for two years working on a very innovative, different type of curriculum.

33:24And we are so excited to see them in this come to life. They are our future. Our hope is with them to change the way medicine looks, but really humanity looks. because we want them to be great humans in the community serving others. Just so happens that they're in the field of medicine. That's what gives me hope. Thank you for taking the time to have this conversation amidst everything you're doing to get this school open. And I really appreciate your time and thinking on all of this. Thank you.

34:02And that's it for today's episode. Thank you so much for listening. TED Health is a podcast from TED. And I'd love to hear your thoughts about this episode. Send me a message on Instagram at ShoshanaMD. This episode was produced by me, Shoshana Ungerleiter, and Jess Shane. Edited by Alejandra Salazar and fact-checked by Vanessa Garcia-Woodworth. Special thanks to Maria Lages, Farrah Degrunge, Daniela Balarezo, Constanza Gallardo, Tansika Sangmarniwang, and Roxanne Heilash.

34:38Thank you.