#428 How to fix Global Health without a quantum computer: Madeleine Ballard from CHIC

35:33And the result is the 2023 Primary Health Care Act, which actually guarantees pay insurance equipment for the 100 ,000 community health workers nationwide of Kenya. And so this has been very cool, both because it illustrates what's possible to create momentum to change a policy, but then also because I think this is where advocacy or advocates sometimes make the mistake of thinking like once you win you've won and it's like no once you win you get to then like defend right and so it's also you know I was part of the national policy change when I was living in Liberia like with that that that work that I was describing as talk podcast that was um all being done by volunteer community health workers and we kind of had the the ministry give us permission to say like what if we treated them like the freshers they are, how might health outcomes change?

36:28And that pilot ultimately went on post Ebola at the Minister of Health, made that kind of professional CHP policy a nationwide thing. And she actually then later served on the board of Shikumi and started to take this worldwide. But unlike in Liberia. In Kenya, I think that the bottom-up organizing and activation of networks of community health workers was essential not just to win, but also to perfect the policy. I think we all know that when policy changes, particularly nationally nationwide, it's going to be a bumpy road. We're going to endeavor that it is smooth, but I mean, look at Obamacare.

37:14It's like they passed the policy five years later, they put up a website and it crashed. It's really hard. to do things on a national scale. And it's no different in any other country, particularly ones that have way fewer resources than the US. But having this network of community health workers almost was like the canary in the coal mine or sort of a real-time live dashboard. So like there would be an announcement, okay, you know, the supplies are going out or okay, we're, you know, sending out the first stipends. And then boom, like this county would just light up and say, hey, actually, we never received any backpacks.

37:49And there was almost a real-time feedback loop. Whereas in Liberia, one of the things that happened when community health workers were professionalized, and this sometimes happens, this is a broader phenomenon than just community health, but all of the women that had been providing care for years for free got replaced with teenage men. And because there was not an organized voice at that moment for community health workers in Liberia, that kind of happened. And then the ministry sort of only realized it. And to their credit, like a couple of years in, and then they published extensively on it.

38:28They were like, hey, this is probably a mistake. We're losing a lot of the trust, the knowledge. Like this is not how these transitions should go. This is not just transition. And so here are some things. If you have to go to womenschws.org, it's the results of that. research, just the recommendations for how ministries can make sure that when they do professionalize this workforce, they're bringing in the folks that were involved in some informal way in this care and prioritizing them. And that usually ends up being about 70 % women. So anyways, but I think the difference between

39:07or the importance of not just these top-down enabling conditions, but this bottom-up demand and also feedback and engagement, this is the difference between a policy that is really entrenched versus one that's a little bit more fragile. And I mean, to Liberia's credit, again, I think it's becomes more robust and it's routinely held up as an exemplar of what's possible worldwide with community health workers. But we had the Permanent Secretary of Kenya at an event at UNGA this autumn, the UN General Assembly. And as many might be aware, there's been a rocky road for anybody in health or development.

39:55The just complete shutting off of US foreign aid from one day to the next created a lot of chaos, particularly because if you look at most low and middle income national health budgets, a very sizable portion of that is coming from foreign aid. And maybe it's 20%, maybe it's 30%. You know, it's not all US money. But again, most companies could not survive just like a one day to the next absolute slash in revenue. And so this was a moment where I think governments had every excuse to say, oh, we're putting this on pause. We're taking a step back. This is not the moment. And actually what we heard them say very clearly was, no, we are never going back.

40:46And we already see the benefits of this. And I think that that's been very heartening to see that you used to have$10 spent on health. Now you have seven, but you should still spend one on this, right? Because the value is there and momentum's there. People are seeing the difference that it's making. So I think that to me is like, okay, there's a real resilience and depth in this movement. It's not just a paper tiger. Absolutely. And when a country is doing this, and despite ludicrous moves by other administrations to remove financing, et cetera, they are still doing it. they obviously want to empower those community health workers as much as possible to do as good of a job as possible and so I'd like to give our audience here a view of what a community health workers day might look like the average and perhaps the extreme and then for us to talk about the technology that can help them do their job and what that looks like because like I've talked about many times on this podcast there are various frontiers i think in health tech that are being pushed at any one time there's a technology technological frontier where you know you might argue that things like quantum and stuff are being are being pushed there's definitely an adoption frontier in for example uk secondary care you know what do hospitals adopt and we're trying to push that frontier but there's a frontier that we're talking about here in um community health workers and what they are being armed with and what they can do to make their job easier better and provide data and infrastructure that's perhaps not there in a workforce of people that i imagine around the world globally a paper base they're probably not opening chat gbt although you might actually the ai conversation at that layer might be interesting to talk about and how that's permeating but um let's start let's start with a community health worker and what their day and week looks like and where technology might fit into their job and where you think we're going with that to kind of bolster that workforce i'll just say to start that community health workers are in every country around the world right and so the experience you know differs i'm speaking to you here from you know we're in london there's a community health worker pilot down the street in westminster that's happening right now i'll talk about the day of the life of a community health worker in Liberia.

43:13But I think this is sometimes a misconception people have. Like, oh, it's about malaria in the Liberian rainforest. It's like, well, first of all, no, it's about all of our health, right? Because of pandemics and health workers often being on the front lines of identifying those outbreaks, whether it's Ebola or otherwise, and containing them. But also that fundamentally, we can speak on trust and some of the secret sauce of community care provision afterwards. But that is... those patterns play out all over the world. But let's just say, okay, this is, you know, it's after sunrise in Granjita County.

43:51That's where I used to live in Liberia. This is just on the border with Cote d 'Ivoire. We have a community health worker, let's call her Mariam. She wakes up. She probably checks her phone before heading out. This is something like a basic Android smartphone. Maybe it was solar charged overnight. Liberia is a particularly challenging context because they're, I mean, even in the national, in the capital, uh, there's a very small power grid. Um, so, um, but that phone has probably an app, uh, maybe it's, uh, community health toolkit, calm care. There's a bunch of different, um, uh, community health based apps that, uh, national governments use, but it would guide her through household visits and kind of say, hey, who should I visit?

44:38Who have I not seen in the past month or whatever? And there would be some sort of electronic health record on that phone, which in an ideal world is linked again to like a national system. And that phone, again, if there is connectivity, it would be just beaming that information up right away. If there's not connectivity, we've seen Liberia was really great at pioneering Bluetooth-based systems. So when a supervisor would come, they would just Bluetooth it, grab the data, and off they'd go. There's also a world in which, you know, we really have frequent connectivity issues. And so we carry a paper register as a backup because connectivity is patchy and there's still redundancy.

45:22But, you know, somewhere on that spectrum is what's happening. So she does that before she heads out. She grabs her medicine kit. And this has everything from like malaria rapid diagnostic tests to the ACT, the drugs for malaria, oral rehydration salts, zinc, anything that pregnancy tests, things that might come up over the course of the day. And she's probably visiting a house first with a mother and a child. That child has had a fever maybe since the previous night. So she would, I think a lot of the care that community workers provide is just simple decision trees. Like if a fever, step one or B, test for malaria.

46:05You know, if it's a fever, if a fever, then test the fever, take the temperature. If it's actually a fever, if it's over, you know, then you would do the malaria diagnostic test. And this is just like it's a finger prick test. You take a little blood sample, you toss it in the thing that kind of everyone knows what a COVID test looks like. It's very similar, looks very similar. um and then yeah if treatment if it's positive like she would start treatment actually on uh the spot maybe she checks the child's breathing with a timer to rule out pneumonia um and then she kind of says okay i'll be back in like two days just to see 48 hours 72 hours to see how things are going and she just kind of keeps doing that so she walks to the next cluster of homes and again the frequencies uh and the distance it like it really depends on The epidemiology would have the services coming off of her.

46:56So providing what the if you're in an urban area versus a rural area. But pretty much every household that she visits, she's either doing some sort of preventive or curative or promotive care. um and then she might even at some point like i don't know stop for lunch let's say we're lucky it's mango season you're under the tree you're chopping up some mangoes maybe there's a health talk maybe there's a women's group meeting maybe and and uh because again we know that i mean honestly like even without a community health worker like just women meeting makes kids healthier so like this is to your point about community there's amazing uh uh literature about self-help groups, but with the addition of drugs and a connection to the central health system, also supercharges that.

47:49And then, yeah, maybe she's visited, let's say, that day by her supervisor, right? And that supervisor might observe her providing direct care, would maybe go through records with her, look at whether the amount of malaria or whatever that she's treating is in line with what you'd expect epidemiologically, provide some coaching, provide some correction, maybe do the Bluetooth sync, maybe even do a spot check with community members that she's supposed to have treated and ask them questions. And then by the end of the day, she's back at home, she's charging the phone against Solar Power Bank, maybe the data's uploading.

48:33And then that data ultimately becomes part of a, ideally, right, a national dashboard that policymakers see, that decision makers are seeing. And that is also beamed back to her. So she can be seeing, again, what's her error rate? What's what type of, you know, how many visits? What households like haven't been, you know, she hasn't seen in a while. And off she goes. So, yeah, I think you have like diagnostic tech, you have data reporting tech, like communication, some sort of power, connectivity tech, all sorts of different applications throughout the day. And then who knows, actually, I should say, maybe then she also logs on with her phone and joins the Community Impact Coalition Activate Tactic Meeting, where she's kind of, you know, connecting with other members, you know, the national health leaders from the national health system in Haiti, leaders in the National Health CHV Association in Uganda, and trading notes about, some sort of upcoming policy or influence opportunity.

49:38So yeah, and there you would have technology again for transnational connection, advocacy engagement, and maybe she WhatsApps a friend in a neighboring village. The cwadvocates.app brings in someone else to the movement. So a lot of different applications. They're actually really tech-enabled is the first thing that comes to mind here because actually on some level I was expecting to say a lot of this is paper-based and but I imagine that's part of the work that you guys do is going in and changing that right yeah I think I mean certainly the the order of the day five ten years ago is these giant registers that you have to carry and they're quite they're quite heavy and then you know you have to bring those registers to the clinic and then data entry people on and on but you see actually most countries at this point who are transitioning to professional cfu uh national programs uh the the android phone like the digital uh is baked right in like from from the get-go so when kenya did this for instance yes like everybody gets a gets a phone and it's there's a community health information system that is connected to a um hmis and again not without difficulties like the kenya hmis was like offline for a good chunk of the year earlier this year and you know so the hence like it's i'm i don't want to paint like a super rosy picture at the same time i think a lot of high-income ventures would be like wow i'm sat here going like hold on a minute i need like my period sounds interesting like that okay um why can't i log into the nha well you know this quite there there is actually um yeah a lot of really thoughtful yeah um tech like again national scale tech applications um in many countries the other thing that really sticks out in what you've just described as well is that so much of it if not all of it is about the flow of information and whether tech enabled or not whether it's a human to human interaction and they're going through a decision tree and you know that whether they're documenting that and beaming it hit to someone that then responds technologically or comes in person so much of this is a really interesting mix of the flow of information data and information going into people but then also enabling people to connect with people it seems like this really i'm not saying nice balance it's a balance it's it's a balance of all of that that i imagine is being worked out and and you know best practices of this are being figured out and i just think that's a really it's really fascinating I think with how that parallels with what we're trying to do and you know you mentioned this community house works in London it'd be really interesting to figure out how they're doing that in London actually but it mirrors really well with almost just how our healthcare system is trying to figure out where we put technology and humans as well because on some level the you know on a big level in fact the preventative healthcare conversation here in the UK I mean we've got preventative healthcare being done by youtube influencers that have got a medical degree that are just taking it upon themselves to educate the public and that's the flow of information through technology to them shout out to dr james o'donovan quite absolutely absolutely i mean he's got what half a million more than half a million followers now and you know he's he's deploying all of that information you know and youtube's found a business model for it and there's you know there's our wife i mean he just does it for the love of it doesn't he i mean he just absolutely loves the impact um but it's so it's just so interesting to me that there's this really interesting balance between technology and human to humans but all of it is around maximizing the flow of good information at the most efficient possible i guess cost of doing so and way of doing so i just think that's i don't know if that if that resonates but that's that's what i'm getting from your story anyway yeah i think it's been very interesting actually i spent some time um earlier last month out in california and i was meeting with a number of people kind of on the bleeding edge of ai and i was really struck right like we're living in a world right now where as the American Surgeon General said, loneliness kills like a pack-a-day cigarette habit.

54:10And yet we're just fundamentally obsessed with making machines faster rather than people closer. And if you think about, if you zoom out, we're just living in this moment of rising conflict, of deep fakes, post-truth, just an absolute cratering of trust. loneliness is surging, antisocial behavior is surging. And again, we just keep returning to this question of efficiency, efficiency, opt-out efficiency. And it's like, I think we should be returning to the question of connection, right? If we optimize for speed, and I think the Western highly industrialized world bears this out, we get a sicker, lonelier world.

54:56If we optimize for connection, we get a healthier one. And so could we not use that perhaps as a framework for how we think about technology, right? Like you mentioned your clinician friends, it's like if AI can help them reclaim hours from like discharge letters and data entry, and so they can actually just look patients in the eye when they walk into the consultation room, like that is not automation, that is a form of restoration, both for the clinician and for the patient. Because I think fundamentally, I got its core. What is care? What is health care? It's an act of. It's an act of love and love, famously, gloriously inefficient.

55:41You know, you're not just like, what's the minimum number, you know, viable times I have to tell my wife that I love her before she listen it's like no how can i just overflow love and care onto this part why because i love them you know so time presence listening like all these things that we have we've built these systems that call those things waste when actually they're the things that make us human and technology is offering this the opportunity to either dispense with them entirely which i think It would be a big mistake or to actually finally create the time to do that. You know, and that to me feels like the opportunity of our time.

56:26Let us use technology to connect. And I think that's why we champion community health workers, right? They're the embodiment of real connection. They deserve technology that supports them. And so the goal is not so much. And this is not anti-efficiency. The goal isn't, you know. But efficiency is in service of connection. efficiency precisely yeah no i yeah like that to me is a future but here's the other problem with the system that i that i that i noticed over here that that is in in slight contradiction of that which is that if we don't create that time that desire for love and care and time will be exploited and that's the workforce issue that we have currently is that that's what i think hugely that's what people feel is that the expectations on their time have never been higher yeah and their their expectation to put their love into health care remains and they do so they end up over indexing on the amount of time they're in burning and burning out and this and this ends up being this ends up being the problem how do you combat that with community health worker programs do you do you have self-care as part of this or is their workload managed?

57:40Because I can imagine their patient lists can grow and grow and grow simply as a factor of as families grow and grow and grow and communities themselves grow. And so how is that workforce managed in that way? Yeah, this is a real issue, I'll say. So there are, again, great tools that allow you to model when you're thinking about what is the service package for community health workers? What is the type of care that they're going to deliver versus at the doorstep versus what type of care that they're going to refer. And you just you can easily look at like the epidemiology of a country or different areas and say, OK, for, you know, doing HIV, this and birth control injection, that and malaria, then, you know, for this many people, it should take you approximately this many hours per week for this many households, plus or minus.

58:31And the idea is to try to get that to a reasonable number. I think what we have seen, and this is the tightrope that we walk, right? Part of the way to get community health workers professionalized, to get them treated as the member of the health workforce that they are, is to demonstrate what they can do and to provide more and more complex types of care. For instance, like, oh, community health workers in Malawi provide intramuscular injections. People are like, wow. And it's because if they can do that, then they're definitely professionals that you should definitely pay them and supply them and so on and so forth.

59:06But I think the shadow side of that advocacy tactic, though it does create the results and the respect that we want to see, is that then there's a possibility we're just overloading CHWs with tons of tasks. It's like, oh, and you can do eyeglasses and you can do this and that. And of course, CHWs can do all these things wherever there's a great, there's randomized So the safety, the efficacy, the acceptability of this care being provided by this workforce, then of course they can do it. But obviously, you then have to potentially hire more of them or make sure that that distribution matches the demands on their time.

59:47And we have seen, we actually have a paper out in Lancet Global Health on this that looks at time usage versus time contracted. And the conclusion is basically that, yeah, in many systems, community health workers, there's fundamental labor exploitation happening, right? Because the complexity and the time and like, it's not adding up. So I think, and I think this is something that is not unique to community health workers. I think a nurse, a doctor, a physician's assistant would all be, as you're saying. They're never going to do that study in the NHS. I mean, that's just absolutely. Well, you know, we've all read, this is going to hurt.

1:00:29Work hard. Like, you know, this information is getting out there. And so, but then again, like this is the opportunity. we see all this news stories about companies, you know, saving all this money through AI applications and whatnot. And so it's like, okay, great. Like how, how can we reduce the burden away from the things that direct, because I think the thing about, about time, right. Or about any workforce is that we, we often have to speak in units of time because that's something that we all understand in the same way. But again, I think research repeatedly shows that it's more about energy management.

1:01:10And so it's like, if you were able to say, hey, someone could have an extra five minutes on their five minute consultation, that would be hugely transformative for them and be potentially a very empowering and energizing five minutes for the clinician, versus if you replace that five minutes with like following up on a discharge letter, like, woo, energy levels are plummeting, and we're much less engaged with our job. But the good news is that like, yeah, AI could do the second one and potentially create that that five minutes in a cost neutral a cost saving way like i think that you know this this is a really this is really thrilling um uh but but i think it's also worth saying or sorry just to say it is really thrilling because i've said this a hundred times on this podcast but my friend david neal wonderful soundbite said we're 150 years behind analyzing the value of the human in healthcare because it's always been assumed AI is making us question that but my my thing on this is that if we figure out exactly where to put AI we can really put the pedal down there and reserve what humans are excellent at to put them there which gives us a purpose of pushing AI through beyond just efficiency and if in your framework which I love put everything in service of connection that actually if we then start to identify the areas that we absolutely want a human to do because we know that's what perfect health care is and what it feels like to the patients then we can start to identify well definitely human here definitely ai here and let's have a conversation about the things in the middle to see what what level we want to do at different areas that brings me to the question that uh you prompted me to ask you earlier actually about what good community care provision looks like because you mentioned trust and again humans build trust with each other and off the back of building trust we know evidence-based better history taking shorter hospital stay on a dose dependent relationship with how empathic they feel their clinician is like we know the more empathic they feel their clinician is more trust better history short hospital we know this it's all it's all it's all there in the evidence so So I've got a feeling that the answer to this question starts to plot this path for us a little bit of what do we reserve for humans and what do we perhaps do with AI?

1:03:33But what does good community care provision look like at its best from CHWs that you've learned? Yeah, it's interesting. We were just talking about all the possibilities of AI. And yet I think it's important to temper that with just as observation that, right, like health tech, funding, like we're often chasing the shiny, right? We want the dashboards, we want the devices, we want the AI models, and obviously all valuable in the ways that we've just described. And I think no one, nothing can replace the people who make the system work, like when the Wi-Fi drops, because what technology cannot replicate, and we've seen this, is trust, right?

1:04:25Communion health workers have cred. Part of the reason they're so effective, and again, this has been shown study after study, is because the communities believe in them. And I think trust is the strongest operating system in healthcare. You cannot code it. You cannot buy it. You cannot deliver it by drone it's not a product it's a relationship and it's one that's fundamentally built before the outbreak the upgrade the app and i think we always want it when it's too late like oh covid like who's gonna go because yeah the vaccines and oh gosh there's a specter of ebola and like and it's like and yet that's the thing that you you can't just summon it um it's got to be there in a pre-existing way and so i think fundamentally if you want to scale innovation You have to start by scaling trust.

1:05:16And this is why I would say, you know, AI alone, you know, is not going to help us fix delivery gaps. And in fact, it might multiply them, right? I mean, if we think about the, we were talking about malaria earlier, there's now malaria vaccine, right? This is thrilling. It's going to save countless lives. And more than half of kids in Afghanistan are not fully vaccinated, right? Because technology breakthroughs collapse without the people to deliver them. And AI, I think, is a really interesting use case for us because it risks repeating that same pattern, but exponentially faster. It's like, oh, AI can surpass doctors and diagnostics.

1:05:59That's amazing. That means that health professionals with less training, maybe like a community health worker, could potentially do more than ever before. But again, let's fast forward to the beginning of this conversation. 86 % of key mouth workers around the world are not salaried. Any given day, they're out of medicines one third of the time. So without actually this, you know, these professional CHWs who are salaried, who are skilled, who are supervised, who are supplied, we're taking this what could potentially be an amazing care delivery network, the world's largest, the world's largest pandemic detection system.

1:06:32And we're just leaving it unplugged to use a tech metaphor. And so AI, in some senses, is escalating the cost of not supporting chemo health workers exponentially. And I think there's really good reasons. I mean, just to speak directly to folks who are like, oh, well, let's just ditch the health work in the first place. I think two observations on that. One, care is not advice, right? Like AI doesn't fundamentally deliver care, right? Right now it delivers advice. um and so and we know we've all gotten a lot of advice in life about exercising smoking going to bed all these things um and it's more it's it's it's helpful but it's not sufficient right and if you're thinking about iber conditions like they require a human a test a dose a follow-up so it's like okay let's let's not conflate the two things number one and then number two um yeah again like there's an equity question we're talking about countries that could and should and elasticity city and stuff.

1:07:27And it's like, man, you know, I just mentioned Merriam, CHW in Liberia, who's very tech enabled, but fundamentally women in low and middle-income countries are vastly less likely to use mobile internet. You know, hundreds of millions of people remain offline. These are precisely the populations that community health workers have reached, by the way. And so if you're just going like D to C, your strategy risks widening inequality. And that might not be your problem as a company but it's certainly our problem as a society and something that we should be thinking about uh uh together how do we make sure that ai i think ai plus health workforce um could finally close the health delivery gap whereas ai without it risks are you optimistic on that the big sigh perhaps suggests not it's one of those things where it's like i believe so strongly in this and then you're like but could I be wrong?

1:08:22My sense of where we are, James, is we are surely, again, to circle back to where we started, reaching like peak disintermediation. People are so over, like they just do not want to spend more time in front of the screen. Their work is in front of the screen. They get therapy. It's in front of the screen. They, you know, do their banking. It's like all, it's just, it's too much. And so at what point does the pendulum begin to start? just swing rapidly back to local, in-person, connected, alive? And how are we going to choose to enable that? I feel like people are craving that. I mean, just the other day,

1:09:07I invited a bunch of people from the health and media space just to my house for dinner. And some of them, I'd met them once. It was women, that's why you were invited. but you know they were they were they were like second degree third degree connections i like just the yearning and the appetite for like wow i'm just gonna come sit down and we're gonna just talk and we're gonna reflect on like the prop of something around like women who who um who made us you know people are telling stories about their sisters their mothers their best friends their work you know wives and whatnot it was just a beautiful completely not tech you know I used the technology, I guess, to reach out to them.

1:09:50But at the end of the dinner, somebody said, I won't share a name, but she said, wow, this really restored my faith in humanity, which sounds like a crazy thing to say. But it's like, actually, if you're just spending all this time in these disintermediate spaces that we know, and I mean, Derek Thompson has written so well about this that are much more extreme than our in-person interactions. People are sharing opinions or opinions are being amplified that are way outside of what the vast majority of people think that are fundamentally kind of much ruder, that are much more skewed towards bad news and so on and so forth.

1:10:34like there's a real cost to just being spent so much time in these environments you know garbage in garbage out and so um there i think there's a yearning and people can't maybe articulate what that solution is or what that looks like that it's like oh god it looks like talking to my neighbor like this is not a prescription anyone in the uk wants them but um in jest but uh but i think there but there that that kernel is in there and it's it's like whatever makes this human, like some alarms going off. And so can we, I think for those of us having these conversations, like how do we have them at scale with thousands, with millions of people and decide the type of future that we want to build and say, hey, we've been running this experiment again.

1:11:21It's making us sad, lonely, sick. Like let's run a different one and still reap, you know, the economic returns and all the things that we're concerned about. And I think both is possible. I love this because it also reminds me of one of the things that I think we need to avoid in healthcare, which is a wealth divide also causing a human robot divide. The wealthy get the humans and those who aren't get the AI and the robots. And off the back of that, we know that care is the currency. We know that connection is the currency. see and what i don't want to see is us move to a world where that can be on some level bought and therefore becomes exclusive i think that's that's one of the dangers that it's one of the reasons that conversation like this is actually quite important because um acknowledging where we can get that connection that is business model positive that is global health that is a foundational layer to healthcare in every single country and figuring out how we put connection front of centre and put everything else in service of that.

1:12:31It is just so important that we figure that out and go from there to make sure that we don't head to this world where connection can be bought and then it's something reserved for the wealthy. I think that's, and thank you for bringing that up as well. Although it's interesting, James, it's just on that point, you know, so we've just moved into a council estate here in London. And we used to live in a neighborhood just 20 minutes away in one of these converted Victorian buildings. And we've only lived here for a couple of months. And I know like 15 of my neighbors in this council estate. And I was looking up and there's an interesting piece around this.

1:13:12I mean, this is like a contested, you can tell the PhD is still in there, right? So I was immediately like Googling things. and there's a lot of evidence that folks in lower income brackets actually report stronger local ties right that it's like and you see this across countries and even within countries um uh and uh and there's cultural differences too like my my spouse from germany and everybody's part of a local club where it's like in i used to live in new york now we live in london uh everyone has a side hustle yeah it's true and they it's true they kind of make fun of like the person who goes and like watch the plane lands like oh how quaint it's like well i don't know like who's the loser the one that has hobbies and interests or the one that has none you know like so i almost again i think it's one of those things where um i feel like so what what wealth has done historically has given people the opportunity to opt out right opt out of of seeing who cooks your food of cooking it yourself of opt out of even grocery shopping and being in the same space as your neighbors just get it delivered like just such an opt-out society um and then the folks that can't afford to opt out like are in line you know they're at the library they're they're in like the the the remnants of these third spaces that we still have as community and so i think it's it's almost one of those things um where uh my my question is yeah i think with everything good there's there's this stratification risk that you've just described and it's almost like um yeah i think mariam knows something about community that a lot of people in there very wealthy people in their bunkers might do well to rediscover and what is what does that look like so anyway yeah that's just a counterpoint but uh lots of ways it could go um anyway i love it it's been an absolute pleasure one thing i didn't get to ask you on over and out of time was uh how you guys are funded and if you've got any asks for this community that listen to this podcast but if you've got an extra 10 seconds to let us know any of that that would be wonderful to close us out absolutely movements are built by many people with many skill sets so we invite you to join ours join chic join chic.org see how policy change at scale actually happens see the many people making it work and and contribute, you know, whatever, uh, skillset forms of capital that you have, um, to a healthier world.

1:15:42Awesome. Madeline, absolute pleasure. Thank you so much for joining me. And I will definitely see you again on this podcast. Right on James. Thanks a lot. Hey everyone. Thanks for listening and making it all the way to the end of this episode. Remember to subscribe, rate us, and leave a review. And you can head to the description of this episode to follow me on all of my social media. So you don't miss out on any of the latest health tech content.

1:16:06Thank you.