#101: Code Blue: Arizona Goes to The Emergency Room

Quinn: Welcome to Important, Not Important. My name is Quinn Emmett.

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Quinn: So much-

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Quinn: ... we have no money left. I mean, we never had any. Oh man. Brian, what a great episode this week. This episode is featuring another... for some reason, another incredible human who has decided to give up their regular life to try and fix this thing that's happening outside. I guess it's still called democracy. Tell them about our guest.

Brian:  Apparently. Well, her name is Dr. Hiral Tipirneni. She's an emergency room physician.

Quinn: Check.

Brian:  She's a mom.

Quinn: Check.

Brian:  She's an immigrant.

Quinn: Check.

Brian:  Cancer research advocate.

Quinn: Check.

Brian:  And yeah, she's taking all of that and trying to bring it and her expertise and her empathy to Congress.

Quinn: I would say the only feasible way her incumbent measures up to her in any way is if you take all of her qualifications and you take away like what they are and you take his qualifications for being corrupt, and you just... if it's just basic math, he is as corrupt as she is just infinitely qualified to bring... like we'll talk about expertise and empathy and decision-making skills [crosstalk 00:03:01].

Brian:  So in that, way they're equal. Yeah.

Quinn: Yeah, yeah, yeah, yeah, yeah, yeah. If you just do it that way. Anyways, what's the great baseball statistic wins above replacement value? Something like that. WAR they call it. Basically like Brian, if you were a right fielder, your WAR would be how much better are you than the average right fielder and that's your WAR calculation. And this would just be off the scale. So anyways-

Brian:  Off the charts.

Quinn: Let's go talk to Hiral.

Brian:  Let's do it.

Quinn: All right. Our guest today is Hiral Tipirneni and together we're asking, how the hell did all of America end up in the emergency room? Dr. Tipirneni, welcome.

Dr. Hiral Tipir...: Thank you so much for having me Quinn and Brian. I appreciate the chance to speak with you both.

Brian:  Yeah. No. Thank you seriously.

Quinn: We'll see how that goes.

Brian:  We're very, very excited to have you on. Let us begin doctor by just telling everybody a little quick intro of who you are and what you do.

Dr. Hiral Tipir...: I am Dr. Hiral Tipirneni and I'm the democratic nominee for Congress in Arizona 6, but in my life prior to running for public service, I was a ER, physician and emergency medicine physician. Worked clinically for many years, and then also spent almost nine years working in cancer research advocacy. So my background is medicine and science, and I come from experience of serving others and solving complex problems to make a positive impact in people's lives, which is really what I think we need more of in Congress and in DC. So here I am.

Quinn: I was going to say, what of all of those qualifications makes you feel like you can help? It's crazy. It seems so silly that any of those things would just automatically be a major upgrade to the current situation.

Brian:  Reminder for everyone out there, and so you know also doctor, our goal on this show is to provide some... we're going to provide some quick context for our topic, and then we're going to get into some very action oriented questions and anything else and everything else that everyone out there can do to help support you and your mission. That sound great?

Dr. Hiral Tipir...: That sounds wonderful. Thank you.

Quinn: Awesome. So Hiral, we like to start with one important question to set the tone for this fiasco. Instead of saying, tell us your entire life story we like to ask, why are you vital to the survival of the species?

Dr. Hiral Tipir...: Well, I don't think there's ever been a moment in our political history, at least since I've been alive, that it is more clear that we need more physicians and scientists in DC. I mean, we find ourselves figuratively and literally in this state of crisis, right? And it is an emergency and who better than to jump in and start solving these complex problems than an experienced emergency physician that has been in those situations, having to make rapid, fact-based, data driven decisions, quickly, decisively, intervening, making a difference, stabilizing situations and solving the larger complex problem at hand. We need more of that.

 That's what we need right now on so many fronts, whether it's addressing this public health crisis, or this pandemic, the resulting economic recession that we're in, addressing our climate crisis which continues to show its rear, its ugly head constantly with these wildfires and extremes of temperature. And obviously other things continue to rage on as well. It's not like the opioid crisis has gone away. It's not like gun violence has stopped. It's not like economic inequities or educational inequities have gone away.

 There're emergencies all around us. So absolutely I say, bring in the professionals, bring in the ER docs, bring in scientists, bring in the folks who appreciate a data-driven approach and can be decisive leaders, and let's get to work.

Quinn: Again, it all seems so logical.

Brian:  Just like every guest we have. Every incredibly intelligent guest we have talking, it's like, "How is this not the norm already? How is this not already..."

Quinn: It's just like Hiral should just be in charge of everything, everything.

Brian:  Please, take it over.

Quinn: I mean, why not? Dictator for the day. All right. So just some quick context for our story here. Our wonderful guest seeks to represent Arizona's sixth congressional district. Is that correct, Hiral?

Dr. Hiral Tipir...: That is correct. Yeah. It's Arizona's sixth congressional district, yes.

Quinn: And that's part of the area around Phoenix, including Scottsdale, some other suburbs. I believe it's about 750,000 constituents. Does that sound right?

Dr. Hiral Tipir...: Yeah, it's just shy of 800,000 and it is North Phoenix. Then as you said, the Northeast Valley suburbs, Paradise Valley, Scottsdale, Cave Creek, Carefree and Fountain Hills.

Quinn: Awesome. And I believe, I used to have all these memorized and now my children badger me about them, I believe that's more people than three States, four States, something like that. I think it's like Alaska, Vermont, Wyoming, something... There's a few under a million.

Dr. Hiral Tipir...: Oh yes, yes, yes. Yeah. I think definitely Montana. And I think Wyoming, I think you're right. I don't know the other ones, though. Yeah.

Quinn: And DC of course, which should be a state. Different conversation.

Dr. Hiral Tipir...: Right.

Quinn: It seems like your district has been redrawn a couple times, which is what happens with the census often, clearly over the past 20 years. And hopefully we can make that a little more fair again, everywhere after 2020, the last three representatives have been Republicans. The last five presidential elections have leaned red, but it seems like decreasingly so. Hiral, our listeners know that we are pretty picky about which elected officials we talked to and hopeful elected officials.

 But I think, again, our listeners know that Arizona is not only, well, potentially going blue in a couple of weeks, not just for you, but hopefully overall, but Arizona is hot and it's getting hotter. And for example, in 2018, I think it was something like 120 or 130 days over triple digits. Cities like Phoenix and again like Los Angeles or places in the middle East they're making moves to provide cooling options for folks that don't have any, especially at night when our bodies need to cool down. That in itself is becoming harder, becoming more dangerous.

 But Arizona is actually really, I think, going to be interestingly, the tip of the sword per se, when we talk about climate mitigation and adaptation. And so it's really important to have local leaders and national leaders who are going to help listen and learn and also not be afraid to try and enact policies to both fight this climate crisis, but again, understand that it's important to, at the same time, try to keep areas like Phoenix and the surrounding areas as livable as possible. And obviously also we're all still locked in our living rooms. There's a lot going on.

 But as you said, it seems like it's the perfect moment and you seem like the perfect person to have as someone who has spent so much of their career trying to provide solutions in a data-driven and at the same time empathetic way. So again, our question day is how the hell did basically all of America end up in the emergency room? Hiral, this isn't actually your first shot at a congressional seat.

 And so just again for everyone else's reference, and this was stunning to me, I knew the surface level of this, but not all of it, which is that your opponent, the incumbent, admitted to 11 ethics violations related to improper spending and other financial rule breaking, just a garden variety. Agreed to a $50,000 fine is still in office and quoting the house ethics committee, "Violated house rules, the code of ethics for government service, federal laws and other applicable standards." And they said, "His testimony lacked credibility." So I'm curious what it is about our perfectly functioning democracy Hiral, that keeps you working so diligently to try to become an officially elected part of it?

Dr. Hiral Tipir...: Wow, that's a lot. So I'm going to give you sort of the basic core example of what motivates me to run. So I saw a woman in the emergency department many years back, and this is one patient of many that has a similar story, but she had felt a lump in her breast four months prior to when she came to the emergency department. But she was an hourly wage worker. She had no health care benefits. She did not have health insurance. She could not access the healthcare system. She could not afford to take time off of work where she didn't have paid sick leave or anything like that. And so she just kind of ignored this lump that she felt in her breast for four months. And she was in her early forties. Finally, she presents to the ER, when I see her, the reason she comes into the ER is because she has this oozing wound on her breast bone, right on her sternum. And she can see it on her skin. And so she comes in for that.

 And as I start examining her and I start asking questions, I find out about this lump that she felt prior. And once we started doing some tests on her, we realized her body is riddled now with cancer, riddled. And that's that wound on her chest wall is a metastatic lesion that is now eroded through her sternum. 42 years old and less than six weeks later, she was dead.

 I mean, this is America. This is our country. The infinite resources we have, we are supposedly that shining city on the hill, right? We are the envy of the whole planet, but we can't keep people like her alive because she doesn't have an insurance card because of our broken healthcare system. And until that health care system is repaired and actually functional, I'm going to be in this fight. I'm going to be in this fight because I have that perspective. I've seen it. I've seen the eyes of people who have struggled.

 I mean, when you have a parent come in and they're tearful and they have a child who is sick and they're crying for two reasons. They're crying because number one, they're worried about their kid and they think, "Oh my gosh, I waited too long to bring them in." But they're also crying because they have no idea how they're going to afford any care that this child is going to need. And they are anticipating already being homeless and broken, not being able to put food on the table.

 But yeah, this is a travesty. This is happening in our nation every single day. And the ACA, the Affordable Care Act, helped us take one giant leap forward, right? We didn't get to the finish line, but we took one giant leap forward in the right direction. 23 million Americans are now within our healthcare system with insurance, with access to healthcare because of the ACA. And we are right now in this emergency crisis where that very safety net is being ripped away.

 I mean, you guys know this, I'm sure, that there is a case going in front of SCOTUS, in front of the Supreme Court, that is led by this administration and several attorneys general from several GOP States that are looking to fully repeal the ACA, which will leave 23 million people uninsured. But on top of that, let's be very clear, one out of every two Americans has a preexisting condition, and those folks would either be uninsurable or have astronomical rates that they couldn't afford. And this is in the middle of a pandemic. I mean, it's unconscionable, it's almost unconscionable to imagine any human being would ever push for this.

Quinn: Sure. And I believe we've gotten that, and I imagine because of the demographics of the people who've been affected, especially if people who've really suffered, and further faced higher mortality averages. But, what do we have? What is today, the October 6th, that we're at 7.5 million diagnoses for COVID, which is 7.5 million, no pre-existing conditions. That's probably not 7.5 million new Americans with preexisting conditions. But for a lot of them, it's another layer to it. And I'm sure for a number of them, it's maybe their first one. And guess what? There's a lot more coming and if you strike down the ACA, it's going to be on... It feels incredible. It feels like so many people have forgotten what it was like until that day in, whatever it was, 2010, when pre-existing conditions weren't covered.

Dr. Hiral Tipir...: Right. Well, and realize too, that we still didn't get to the finish line, right? We still have millions of Americans.

Brian:  Oh God, no.

Dr. Hiral Tipir...: Just prior to this pandemic, we still had millions of Americans, families all across this nation that still either were under or uninsured, right? But, we've seen the benefit of the ACA. We've seen the benefit, not just to outcomes and people being able to stay healthier and seek primary care and focus on some preventative care and things like that, but we've also seen the economic benefit. So, it's really important that we realize there's a human toll, there's an economic toll. And the sooner we imprint that inextricable link in our minds and understand that... This pandemic, for example, it has laid bare all the fragility of our healthcare and economic systems. And it's shown how one is directly connected to the other.

 I mean, as soon as the pandemic hit, not only when people got sick and they lost their jobs because they couldn't go to work or because they were in the hospital or they just were too ill to work. But, all the people that lost their jobs because businesses closed down, and production of things stopped and so forth. All of those folks, we have seen how the healthcare and the economic systems are so tightly linked. And if we don't take some decisive action to strengthen our healthcare system and address these economic inequities, we're not going to find our way out of this. Even once the virus is eradicated, we're going to be back to square one. So, we can't go back. We have to learn from this and do so much better.

Quinn: And I think it's important to know, and thank you for that context. It's so true. I mean, again, you go to the Make America Great Again thing, it's like, no, it was fundamentally broken before COVID showed up and exposed everything. But, I want to talk a little bit about, because we've tried to... Look, we are two middle-class, straight white guys. There couldn't be more privilege on planet Earth. And so, we try to recognize that, but also have folks on, like yourself, who look and have different experiences than we do, certainly. I mean, besides the fact that you have 30 years of medical training. Besides those details.

Brian:  I'm close, I'm getting close to 30 years of medical experience.

Quinn: Brian, that's not this conversation, Brian, okay? But, one of the things we've always tried to point out and certainly over the past year have tried to do much better job of is, to help people understand and to say out loud that the inequities in really any of America's systems, they are not broken. They were designed this way. They were designed in a very racist, unequal way. And I want to talk with you a little bit about how that leads to the healthcare system that is also not necessarily broken. It is designed to be reactive and procedure and profit-based.

 So, like you said, Obamacare's is this huge step forward, and it was imperfect from the start, for a lot of reasons.

Dr. Hiral Tipir...: Mm-hmm (affirmative), right.

Quinn: But, it was far better than the previous situation. Now, Trump has spent four years trying to destroy it and that might happen in a couple of weeks, right?

Dr. Hiral Tipir...: Mm-hmm (affirmative).

Quinn: But, at the same time, there's still millions of people with no healthcare, or that they don't know what's included in Medicaid, or they're just lied to. And so, they don't go to annual checkups, they have tons of underlying conditions because of all the toxic air they're exposed to. So, adults get chest pains, or they're a young Latino kid or black kid with asthma. And so, they go to the emergency room, right? They don't have a cardiopulmonary person that they see frequently to check on their asthma.

Dr. Hiral Tipir...: Right.

Quinn: Or like you said, the young woman with cancer, they don't go those first few times because they fear those bills where they blow it off, like people do. And then, they go to the emergency room and it's wonderful as emergency room doctors and nurses and staff are. It is a massive expense, not only on the system obviously, but on the person. And so, I wonder if you can talk about how we translate and pivot from this reactive procedure profit-based system to something that is, like you said, solution-based, that is preventative and we are supporting health instead of constantly treating disease, something that is value-driven.

Dr. Hiral Tipir...: Yeah. Well, that's a great question. And you know, we talk about this a lot in medical circles about moving away from procedure and the number of interventions that tend to drive right revenue. And that's considered somehow the significance of any medical institution. And that's why a lot of hospitals have struggled financially during this pandemic, is because there were a lot of elective procedures, surgeries that were put off right or canceled and delayed, and that was their major revenue stream.

 And all of a sudden we're realizing how important it is to go back to that value-based template of medicine. And so I love the fact that you mentioned preventative care right, because look, so in our country, we spend more than $10,000 per capita, right? So per individual on healthcare every year. Which is almost twice as much as the next closest industrialized nation. And we do not, let's be very clear, we do not have better outcomes, okay? Now that being said, a large proportion of our healthcare dollars are spent in those final weeks of life, right? They're spent in the ICU, they're spent in experimental treatments and those Hail Mary passes in some ways, right. It's just those extreme measures, right?

 Imagine, and I'm not saying critical care is an important, of course it is. And sometimes it makes all the difference in the world. But imagine if we took a portion of that and we used it more proactively in those early years and we used it more in prevention, we used it more in education. We used it more in-

Quinn: In nutrition.

Dr. Hiral Tipir...: Right. And so one of the things I wanted to highlight is, especially from the emergency medicine physicians perspective, is we see firsthand all those social determinants of health come to play. If you've heard that term before, social determinants of health, it's about housing security, it's about food security, it's about education, access to healthcare, access to clean water and clean air. It's about educational resources. It's about all of that, right? Well, we see where all of those inequities come to fruition, right?

 For example you mentioned say a young child, a young African-American kid who's got asthma, right? Now he lives in, assuming a lot of these social determinants, like maybe they live in a congested apartment complex right? They're in a small apartment, several family members. They live in a community that is near smoke stacks, right? They don't have necessarily clean air to breathe. There's also a less quality education this child might be receiving, right? The family is economically struggling. They don't have food security or maybe they live in a food desert where all the parents can access is certain kinds of foods. They're just trying to keep their family alive, but they may not be the healthiest, right?

 They can't take the time off to drive across town to get the fresh produce. They don't have a vehicle. They're already living at this incredible deficit, right? And then on top of it, you put the fact that they can't access regular healthcare. So this kid can't go in for his preventative appointments. They may not be able to afford his inhalers, or they may even ration that inhaler to only use when he's really struggling.

 He can't stay away from smoke because that's in his air all around him. They can't have all the hypoallergenic bedding and clothing and different detergent for him because they just can't afford that. So this child will have a perpetual struggle for so many reasons. So all of those social determinants of health impact that one child. Now magnify that to millions of families, millions of kids, millions of parents out there. That's what we're dealing with.

 So we can't look at this as just, people talk about how our healthcare system is just simply having an insurance card, right? And therefore you have access to healthcare. That's not it, it's about education. It's about housing. It's about economic equity. It's about resources, having food security, having clean air, clean water, clean playgrounds, and safe areas to play and run. And it's about all those things that we just downplay. We don't take those factors into account. And so you could send a kid, a family like that, a health insurance card. That's not necessarily going to lead to a better outcome. You have to address all those factors if you really want to improve that child's quality of life.

Quinn: Absolutely. And I've been thinking a lot and trying to talk about a lot this as much as I can. You said healthcare determinants and another word I've been using is externalities and how we as people with the microphone and legislators, and everyone needs to be thinking about these. Whether it's literally like, "You want to talk about the stock market, fine. Let's talk about what are these things actually exposed to?"

 And it's the same sort of mind map, like you said, for a young black kid with asthma because if you reverse engineer all of those health determinants, like you said, every single one of those things that he or she is exposed to was a decision that has been made in a systemic way in our society. And he was, or she was, always going to be exposed to those things. There was always going to be a food desert, their best options were a pharmacy or a dollar store. And at some point that stuff adds up. And like you said, it requires comprehensive change. It requires upturning the entire thing. We can't just give them a health card because you still haven't fixed anything else yet.

Dr. Hiral Tipir...: And I think this is one of those things where, as emergency physician, I think especially as women, I think there's certain skills that we have that I think make our voices essential to a thoughtful, evidence-based policies. I did a talk at a organization called FemInEM, their national conference last year. And FemInEM stands for women in emergency medicine and my talk the title was Empathy, Equity and Empowerment. And why I bring that up is because I think it is that perspective that allows us to understand how those three things can be utilized to improve these social determinants of health.

 I mean, empathy, number one, is obviously just being able to put yourself in somebody else's shoes and that has to be something that can be done rapidly. And when you think about an emergency department, right, you don't have this longterm rapport with somebody, right? It's not a family doctor. "I've been seeing them for 20 years. I know their family." They come in, they're in a bad moment, a dire crisis, and you have to establish trust very quickly so that they will tell you everything that's going on so that they trust you to take care of them the best way you know how, and that you actually have all the information you need to do your job.

 That takes empathy. And people understand when you truly care. They understand when you are empathic. They know when you're actually listening. I think that is something inherently strong in that field, but I happen to think women have that skill sometimes better honed. No offense to you men.

Quinn: Oh please. No, no. I mean, this is what we've been saying. Well, look older white men have had their shot. At this point, the statistics have bared it out. It didn't work out. We're all locked in our houses here. It's not, great.

Dr. Hiral Tipir...: Yeah. Right. You're right. That's [inaudible 00:28:49].

Quinn: So whether it's proven that women have the empathy gene or not, which I'm pretty sure it has, it's got to be markedly better than the alternative, which is just like, again, we're locked inside and the sea levels are rising. It's not going great.

Dr. Hiral Tipir...: Yeah. Well then that's good. Then you give me that opening to just say we are just more empathic, so. And then it's about the addressing the inequities, right? Understanding the differences of when you can have two... Like this child with asthma. You could have two children who come in with asthma, but their outcomes will be radically different based on all those other factors. Right? Do they have health insurance, but do they have a parent that can be at home with them if they get sick? Do they have access to clean air? Can they afford their medications? Are the parents adequately educated on the warning signs to watch out for when to bring their child in? Are they living in a home where they can have the child with a HEPA filter to clean the air?

 And so the child can have... All of those, right? Those factors have to be considered. You can't treat those two children exactly the same. If you do, you are committing blatant, ignorant malpractice in some ways, because you know you can't send them home with the same discharge plan. One is working with an entirely different set of variables. And then that's where the empowerment then comes in, is that helping them find those resources. Right? You wouldn't send home a patient like that, like that child with asthma, the African-American kid, if he did not have access to all those resources. That's where you stop and you get the department social worker and you talk to them about getting them in the Medicaid program, making sure they have WIC, making sure they understand how to use the inhaler, making sure that they have the educational resources, helping them figure out how to eat healthy.

 All of those things. That is just something we are more in tune to and that is how you deliver better comprehensive care. And that's how we have to approach the whole constellation of problems, that you cannot just put a bandaid on it or put a single solution on this. This is a multi-factorial problem that like you said, has existed for decades, if not centuries. And we got to peel it apart. We got to find all those core weaknesses and fracture lines and discriminatory practices or injustices, and we got to rebuild so it is more equitable across the line. And I'll tell you, that's an investment in our collective wellbeing that is going to not only help us keep our fellow human beings safer and healthier and happier and more productive, but it's going to be economically better for our nation as well, because we spend so much of our healthcare dollars as an afterthought, retroactively trying to put out the fires.

Quinn: Yeah. It makes a lot of... I mean, it clearly just makes them... It's one of those things where you're just banging your head against the wall.

Brian:  So hard. So many times.

Quinn: How are we not seeing this? It's crazy. The president goes to a hospital that is literally designed for him and leaves 48 hours later. I mean, you have spent some time in, correct me if I'm wrong here, on a board of directors for your county's public health care system. Is that correct?

Dr. Hiral Tipir...: That's correct, yep.

Quinn: So there was just some news recently regarding a system like that, but in Los Angeles. Great, great article in the LA Times. And just to quote it here, because I was just thinking about this this week, they discovered that in LA's public health care system, the average wait in that system to see a specialist was 89 days, according to a Times data analysis of more than 860,000 requests for specialty care at the LA County Department of Health Services, a sprawling safety net system that, again, to editorialize, serves more than 2 million people. It's huge, it's complex. Los Angeles has 88 cities, right, whatever, serving again, the region's poorest and most vulnerable residents, but they made a point to talk about so many of these folks didn't wait the whole 89 days because they just died. They just didn't make it there.

 And so I fully understand. I mean, whether we're talking about the VA, which by the way, those numbers are actually worse than the VA, which is hard to do, but look, public health is always been byzantine, right? And by a lot of folks relatively ignored, you've got these healthcare startups and that's all great, but we have to fix this vitally important infrastructure among our increasingly urbanized cities and counties. And yet for a lot of folks, I feel like until they started following 40 epidemiologists on Twitter this year, their understanding of public health is limited to flu shots and vaccinating their kids.

 So, I wonder if you can talk a little bit about what the practicalities of that work is like for you. Why that's important to you, I guess. How that translates both to other counties, but also on a more federal level.

Dr. Hiral Tipir...: Yeah, no, absolutely. Our County Health System is in a perpetual state of struggle to obtain adequate funding. The population of Maricopa County has grown so rapidly that we are now the, I think, densest, fourth largest County in the nation. And yeah and I mean, I've been here for 24 plus years in Arizona and I mean, it's amazing, the amount of growth, right? Where I live, probably about a mile north of me beyond that was all orange groves and desert. Now you could drive for 40 miles and there are neighborhood after neighborhood, after little town after... I mean the growth has been exponential.

 So that being said, our County healthcare system has struggled to keep up in our densest areas. We have tried to expand those services. And I'm really proud of the fact that a couple of years back, we passed a very huge ballot initiative that every Maricopa County resident voted for that funded a huge expansion of our county hospital. So, that was fantastic. It's been expanded. It's been reopened with this new name. They're still tweaking and still adding on a few things.

 I'm really proud to say this. They've also put out these satellite family and community health centers, which I think that is the big piece that is missing for a lot of hospitals, because you can't just have this one centralized hospital. You've got communities where people may not have transportation. They may just not know, how do I get care there? But a lot of it is also about representation. When you have community medical centers in these more Latinx communities for example, and you have healthcare providers who speak Spanish fluently, they are very well-versed in certain cultural behaviors and things like that. That's where people are going to go. That's where they're going to feel a sense of trust and understanding and that's where they're more likely to be compliant with medical direction and guidance, and that's where you're going to get better outcomes.

 So we have to have more of those community health centers that actually feel like they're ingrained into the community, that they are a place where people feel more at home or comfortable, they're more trusting. I tell you, I mean, there's been data on this. There's been study after study on healthcare disparities and shows that actually two of the factors that really help is number one, having more of those on the ground community health centers but number two is having more diversity in those health care professionals, right?

Quinn: Sure.

Dr. Hiral Tipir...: So if you walk in and you see nurses and lab techs and doctors that look more like your community, you're more likely to go there when you need medical care, you're more likely to follow their guidance. You're more likely to bring your family members and anybody else who's sick and it just leads to better outcomes. So I'm so proud of our county healthcare system, Maricopa County Medical Center, which is now called Valleywise Medical Center, that they have invested in this community health centers, which are going to make a huge impact.

 The other area where it really helps too, is with mental health services and dealing with issues of addiction because historically, there's all the stigma that goes along with that. People are less likely to pursue that, nobody's going to drive 20 miles when they just don't think they're going to get the respect and the care and the kindness that they deserve. But if there's a health center in their own community and they get the word of mouth that these are people that you'll be able to relate to and connect with, they're more likely to seek care. They're more likely to seek those services. All of that is just positive feedback into those communities that just leads to long-term better outcomes. So, that investment by our Valleywise Health Center, I think is not just a very thoughtful data-driven investment, but it's going to lead to such improvement in health outcomes for so many members of the community that have been in dire need for good medical care for far too long.

Quinn: I mean, it makes sense, it comes down to trust. If you were a person of color in America, I understand fully why you would not trust your local healthcare systems, which blow even white people in and out the door so quickly these days, much less a black, brown or indigenous person. It's crazy. I think about in right here in Virginia, there's a gentleman running for congress in Richmond, Dr. Cameron Webb and he would be ... This is taking, like you were just saying this, this trust, this representation thing to the next level, in a moment where so many people don't know whether to trust COVID messaging, right?

Dr. Hiral Tipir...: Right.

Quinn: And yet black, brown and indigenous people are suffering just vastly worse than others. You've got before COVID, I think black moms diet at something like ... their mortality rate's like three times white moms. Yet at the same time, Dr. Webb would be the first black doctor in congress. I mean, that is measurable.

Dr. Hiral Tipir...: That's huge.

Quinn: That matters so much.

Dr. Hiral Tipir...: It does.

Quinn: I think his wife is also emergency room physician, which is just like overachievers. I mean, but that matters on-

Dr. Hiral Tipir...: It does.

Quinn: ... I'm sure it has mattered in his community and in her community and it will matter so much to have someone that frankly looks like that, helping with that messaging and someone like you, who has spent ... and I know you were, I believe not born here, you came here, but it doesn't matter. There will be people who look up to you who are getting news from Facebook and Instagram and in 40 different ways but I think they will feel like they can trust you in that. Not just because of your work, it just matters. It just matters and we're just not doing a good enough job with a congress that's full of white lawyers.

Dr. Hiral Tipir...: Yeah. No, and that's why we need more diverse voices in D.C. at all levels. Not just in D.C. at all levels of government. I mean, it's whether it's city councils and school boards, or all the way up to the White House, we need more diverse leaders and voices. When you think about, it's common sense, to understand that that will lead to richer, more thoughtful, more comprehensive and robust policies. If you have a table ... and I think you probably remember, we saw this picture of, I think it was like 12 white men around the table that were discussing women's reproductive health rights.

Quinn: Oh yeah, oh yeah, just, Jesus.

Dr. Hiral Tipir...: I mean, it's comical. I mean, that's almost like you couldn't have staged that any worse, but think about if you have ... you're talking about, say education, let's take something even different than healthcare, education and you put around that table, you put teachers, you put principals, you put a school psychologist, you put parents who've seen their child struggle in different school settings, public, charter, private, whatever. You have students who are now adults who have gone through turmoil at different levels of education.

 Then you have that richness of dialogue at that table. Think about the education policies that will come out of that group. It will be comprehensive. It will be thoughtful. It will address so many of those otherwise forgotten variables and that will be robust policy that will not only have long-lasting benefit, but will more likely have a chance to also receive bipartisan support because it represents such a wide swathe of our population.

 So we need that for everything. We need that for healthcare, we need that ... and that's important. I mean, I'm not going to decide how to do work on a plumbing project without talking to a plumber. Why would you discuss healthcare without having doctors at the table? Without having patients? Without having nurses? I mean, it doesn't make sense, and that's what we have right now. So yeah, we need Cameron. He's fantastic. I'm cheering him on. He and I have been doing a lot of events virtually together because I don't think there's been a time, a moment, that we need more voices like his and mine, and so many other scientists and physicians who are hoping to bring their data driven approach, their empathy, and their problem solving skills to Washington.

Quinn: Yeah, and I think it just makes it personal for voters and constituents to feel like there's somebody that they can identify with because so often that just isn't... And I think that was part of the disappointment of Biden being the choice for a lot of folks. It's like it's just the same. He's going to be great, but it's just the same thing. When we have opportunities to have folks like yourselves out there and standing in for people.

Dr. Hiral Tipir...: Yeah. I'll share a really brief story here. When I first started running, there was some neighborhood community, it was like an India Day or something. It was celebrating Indian culture and food and everything, right? I was at this outdoor park in Scottsdale, and there was all these booths set up, and some booths you'd go to get a little Indian snack or they would have henna painting or whatever.

 Anyways, I had my booth there for my congressional campaign just to talk to people in the community and hear about the issues that matter to their families. I was kind of walking around, strolling around just doing the meet and greet kind of thing. And this was obviously before COVID, and as I start coming back around the circle, back to my booth, there's a little girl who's standing at the side of it, a little Indian girl. She was about nine years old.

 I just see her standing there, and then as I'm walking towards her, she catches my eye and she runs to me, runs to me, her eyes light up. And she comes to me and she gives me a big hug, just wraps her arms around me tightly, and she's just like, "Dr. Hiral. Dr. Hiral." I didn't know her, and she was just the sweet girl who was hugging me. And then she's like... she takes my hand, she goes, "I want to take you to see my parents. I want to take you to see my parents."

 There's this couple that's standing on the other side of the booth that was talking to some of my staff, so she dragged me over to them and she presents me to her parents. And she says to her mom... and I'll never forget this. She presents her mom, "See mom, I could be this. I could be Dr. Hiral."

Brian:  Doesn't get better than that.

Dr. Hiral Tipir...: I mean, tears came to my eyes, the mom gave me a big hug, the dad gave me a big hug, and this little girl is just jumping up and down like, "I could be a doctor. I could run for Congress. I could be a leader." It was exactly that, what you guys said, is when you see... You can't be what you can't see, right? And for this little girl, she was just marveling at the fact that there was a brown woman that was a physician, that was hoping to be a voice in Congress. And it made all difference for her, and that is critical for every kid out there.

 Every young person should be able to look at that composite of our leadership in our most stately halls, whether it's at our state capitals, town, city halls or, in DC, and be able to find people in that composite picture that look like them, that tell them, "You too can be here. You should be here. Your voice is important here."

Brian:  I love that. Holy cow, it must have been a nice moment.

Dr. Hiral Tipir...: It was amazing. It was amazing. There was a lot of tears.

Brian:  Yeah, I bet.

Dr. Hiral Tipir...: It was just a big group bear hug.

Brian:  I remember hugs.

Quinn: We're fans of tears.

Dr. Hiral Tipir...: Yeah. Yeah, I know, right?

Brian:  Those were nice.

Dr. Hiral Tipir...: Yeah, that was all pre-COVID. Yeah.

Brian:  Hiral, I want to ask you about your history a bit. Quinn and I are very big supporters of cancer research and treatment efforts, and cancer seems to have been a major part of your life. Can you talk to us a little bit about what cancer has taken from you and where it has taken you?

Dr. Hiral Tipir...: Yeah. No, absolutely. It's one of these things, right? As a physician, somehow, I don't know why, you'd think it's not going to hit your family because somehow you think because I'm a doctor, that... I don't know, it's irrational thinking, but when my mom was diagnosed with cancer, my whole world fell apart.

 I had just become a new mom. My oldest was... she would have been eight months old at the time when my mom was diagnosed. And my mom was this healthy picture of perfect health practices, she walked three miles a day, she never ate meat, she never spoke, she never drank alcohol. She was just as healthy as could be. You would never... But obviously we know that that doesn't mean anything.

 But anyways, yeah, she was diagnosed with cancer. And after initially getting what we thought was cured, her cancer came back with a vengeance. Her body was riddled with mets. It was primarily in her liver. She underwent a liver resection that was not successful. And just as we were about to initiate some experimental therapy on her, her liver just collapsed. She went into full hepatic failure and she ended up passing away fairly quickly.

 It was one of those things where, again, I had access right to amazing resources. I mean, my parents had good health insurance. My dad was still working, but... Or, I'm sorry. No, they were probably on... Oh, no, they were on COBRA because my dad had retired, but they weren't on Medicare yet. So they were on COBRA, but anyways, they were covered. I had obviously the ability to reach out to specialists all around the country, which I did, to tap into some clinical trials and find out this and that and navigate through our healthcare system, just because I had more understanding of it, but she eventually succumbed to the cancer.

 And then, just a couple of years after that, my nephew who were, at the time when he was diagnosed, he was six, he turned seven shortly thereafter, was diagnosed with ALL, with acute lymphocytic leukemia. And of all the childhood leukemias, and this sounds awful, right? Of all the childhood cancers, this is the one you would prefer to have because it's got such a high cure rate. It's got a really good prognosis.

 As it turns out, my nephew had a very rare form of it. He had a certain cell receptor type that made it completely resistant. He never went into initial remission at all. So he ended up being this incredibly rare case of a highly virulent, untreatable form of ALL, to the point where he ended up needing experimental treatments, very toxic chemo combinations. And ultimately, it was decided that he would need a bone marrow transplant. Well, I'm not sure if you guys are familiar with the national bone marrow registry.

Brian:  For sure.

Dr. Hiral Tipir...: Yeah. But that's the NMDP or National Marrow Donor Program. But anyways, so here's this Indian kid who needs a bone marrow transplant. Well, guess what? When they looked for matches for him, they didn't find any 10 out of 10 matches. And this is interesting. The kid in the room right next door, very similar. He had a different form. I think he had AML which traditionally needs a bone marrow transplant. So he had seven pages of matches, 10 out of 10. Seven. And on every page, there was 20 matches. So we're talking maybe 140, 150 matches that he could have potentially gotten marrow from.

 My nephew had zero, zero. And of course, this is after everybody in our family got tested to see if we can match. I think the highest we got was a seven out of 10. And for people listening, the 10 out of 10 just means that all of these different markers are met so that there's less of a chance of rejection and there's a good chance of actually responding to that. So ultimately, we had to do a whole summer full of bone marrow drives where we were in... We had family and friends and network all across the country that set up these drives to get people of South Asian descent to register in the bone marrow registry so that we could ultimately find a match for him.

 We ended up bringing in thousands of South Asians into the registry thankfully. But unfortunately, the highest he got was still a seven or an eight out of 10. So ultimately, he ended up getting a fetal cord blood transplant which we were just grateful to get. Again, it was not a 10 out of 10. He got that in June. So he was diagnosed in March. He got that in June, and he did not make it to 100 days post-transplant as far as recovery. His leukemia came back with a vengeance prior to day 100, and he ended up passing away that November. So it was like an eight-month course which was just horrific. So he was seven when he passed.

Brian:  Oh, god.

Dr. Hiral Tipir...: Yeah. And I'll tell you what that did is, after that, after losing him, we had just lost my mom. All I wanted to do was stay home and just hug my children. I just did not want to leave them for a second. My kids at that time were fairly young, and so I just took some time off work, and I just wanted to sit there and snuggle them tight and not let them go. And then I went back to clinical practice for a while, and it was just... Emotionally, it was taking a toll on me. I couldn't walk into a kid's room without breaking down into tears, which was... They teach you in medical school to have this professional emotional distance, because you cannot get drained by every encounter, because obviously that can suck the life out of you, and it can really impact your ability to be professional and do your job.

 But it was just too soon or it was just too harsh. So anyways, I took some time off and then I learned about an incredible opportunity to work, to use my skills in cancer research advocacy where I could help bring research and the funding agencies together for childhood leukemias, breast cancer, prostate cancer. Those are the areas that I focused on, and help vet the science, make sure that it was really impactful research and then make sure we've funded it. It delivered real results for people going through cancer and their families. And to me, it just felt like it was an amazing chance for me to honor my mom and my nephew's memories and to hopefully be able to alleviate a similar burden off of other families that our family had gone through.

Brian:  Thank you so much for sharing that, first of all.

Quinn: I'm terribly sorry for your loss.

Brian:  I think it's so clear whether it's the subject, no matter the subject, we're big believers that numbers and data and all that is great, but it's personal stories that get people to connect. So we very much appreciate you sharing that.

Dr. Hiral Tipir...: Yeah, absolutely. Absolutely. Yeah, sorry.

Brian:  No, we're...

Quinn: Not at all. We've both got unfortunately some connections to cancer and not nearly to certainly the professional extent that you do, but it has galvanized us and needs all the help it can get.

Dr. Hiral Tipir...: Yeah, absolutely. There's no rhyme or reason. We're all vulnerable and that's why we have to-

Quinn: True.

Dr. Hiral Tipir...: And that's why it's important to invest in research. We have to make sure NIH funding is preserved, making sure we're able to get those amazing researchers to be able to do the work so that we can actually really improve the lives of people going through treatment, early diagnosis, maybe genetic testing, personalized therapy. It's just there's so many things we can do to improve the quality of life for people who are going through cancer. And certainly, the ultimate goal would obviously to be find cures. And so, yeah. I just remembered my nephew. It forced him to grow up very quickly, to be in a hospital and be surrounded by adults all the time and all this talk about very complex medical things.

 And I'll tell you, there's one day where I remember taking him for a little stroll with his IV pole out in the courtyard of the hospital, and I had to explain to him why his ALL, why his leukemia was not going into remission. And I told him, "Well, it's just you got a special form of ALL. You got a special form of leukemia. It's not typical. And so we got to find a special treatment." Where he could have said... I don't know. He was seven. Anything he would have said would have been acceptable at that point. But what he said to me was, "Well, maybe if they can figure out what might work for me, then maybe it'll help other kids so they don't even have to get it in the first place.

Brian:  Wow.

Dr. Hiral Tipir...: It just makes you realize-

Brian:  Can I add, I'm so curious about the, you said that the 10 out of 10 and the seven when you were talking about the bone marrow. Why can one person have 150 matches and one person have zero?

Dr. Hiral Tipir...: That's a great question. I mean obviously, look, our South Asian population, although it is a decent proportion in many communities across our country, we're certainly still very much a minority. First of all, just if you look at the number of people that are in our national marrow registry, the vast majority are Caucasians. They're your average White American person.

 South Asians, even African-Americans, certainly Hispanic-Americans, all of those folks are less likely to find matches specifically because there's just less of us. Also, because I think it's just something that I think we have to educate these communities on. We have to make sure that people know that there is this thing called this registry. It's just like we know about blood drives, blood donation, making sure that there are blood types that match certain people.

 Well, we need to make sure people understand that for bone marrow transplants, there has to be matching as well and that requires knowing what donors are out there. It's simple now. I mean, it used to be where they had to take blood, now it's a swab.

Brian:  Oh, wow.

Dr. Hiral Tipir...: So, it's really simple. If you go to marrow.org, www.marrow.org, that is the NMDP website. It has all sorts of great information. For anybody out there who's listening who is not on the marrow registry, whether you're South Asian, African American, Hispanic or White, whatever, please get yourself in that registry because this is the silver lining here. Right, guys? Is that from the marrow drives that we did for my nephew Rajan, we've learned of dozens of matches that have come from that, that have saved people's lives. A cousin of mine actually-

Brian:  Wow.

Dr. Hiral Tipir...: ... was able to give his marrow to a girl who was suffering from aplastic anemia and saved her life.

Brian:  Bam.

Quinn: Oh, man.

Dr. Hiral Tipir...: This work that was done in Rajan's name has left a legacy of hope and of lifesaving intervention. If that's one public service announcement, please everybody become part of the registry.

Brian:  That's [crosstalk 00:59:02].

Dr. Hiral Tipir...: You can save a life.

Brian:  Awesome. There's something so special about somebody who's not only working on the front lines, but trying to pay it forward and you've worked with The Society of Research Administrators International, and correct me if I'm wrong here, but it seems like through that you've spent much of the past decade just trying to train the next generation of research and data scientists. Is that right? Because if so, we'd like to be some flies on the wall when you explain that to the current White House.

Dr. Hiral Tipir...: Yeah. It's really about understanding the value of good science and understanding how to put together good, effective research. Because look, there are amazing bench researchers and clinical researchers out there and there's no shortage of need for all of those projects, but there's clear difference in the impact of certain work over other work.

 That's the element that we always emphasize. The two things are innovation and impact, so let's find new creative ways to solve these problems and then let's really figure out if that's going to make an impact in people's lives. Because there's some research that's fantastically interesting, but it's not going to actually change anybody's life. It might be fascinating to us as scientists and it might make the cover of Time Magazine or Scientific American, but what's it going to do to somebody's quality of life who's dealing with that illness?

 So, it's not just about the innovation. You have to have innovation and impact and when those two things are high quality in research, those are the kind of research projects that we tend to lean into funding, making sure we follow those milestones, whether it's two years, three years, five-year projects and really see how they come to fruition because we want to make sure that we're incentivizing those researchers to do that work.

 I mean, we're talking about really cutting edge stuff, exciting experimental therapeutics, early diagnostic tools, genetic markers. Just so many things that we can really develop that would make huge progress in cancer therapy, cancer diagnosis, cancer treatment. But at the end of the day, it's about improving the quality of life of people who are going through it. When you know that you can help somebody while they're getting chemo to be able to still live a good quality of life, that's everything-

Brian:  Everything.

Dr. Hiral Tipir...: ... to that family. That's everything, that's everything.

Brian:  We are all about that.

Dr. Hiral Tipir...: We got a lot of work to do, guys. We got a lot of work to do.

Brian:  Love it. Let's do it.

Dr. Hiral Tipir...: We got to [crosstalk 01:01:57]-

Quinn: We love work.

Brian:  Love it. We're here, here for it.

Dr. Hiral Tipir...: Well, I'm getting the hook from my wonderful Hannah.

Quinn: Absolutely.

Brian:  Oh. We can wrap it up here.

Quinn: No. Hannah's always trying to get us out of here. It's fine. We understand. We just want to do our most important part here, which is talk about the action steps that people can take here.

Dr. Hiral Tipir...: Yeah, absolutely.

Quinn: Brian, go for it.

Brian:  Like I said at the top, our goal is to find specific action steps that we can take, that our listeners can take, the important action-oriented questions we can ask that help support you. Let's get in on that because this election is already underway with early voting having started in Arizona. So, let's start with their voice. What are the big, actionable and specific questions that we should all be asking of our representatives?

Dr. Hiral Tipir...: Absolutely. Well, so early voting starts tomorrow actually.

Brian:  Okay, tomorrow. Got it. Because this is-

Quinn: This will come out in a week, so we're-

Dr. Hiral Tipir...: Oh. Oh, I'm sorry. Got it.

Quinn: This is basically a time machine here.

Brian:  You're in a time machine.

Dr. Hiral Tipir...: I'm in the future. I did not realize that.

Quinn: So sorry. So sorry.

Dr. Hiral Tipir...: October 7th was the beginning of early voting. There you go.

Brian:  Boom.

Quinn: There we go.

Dr. Hiral Tipir...: And that's when early ballots were mailed and exciting news, by the way, for everybody in Arizona is that they extended the voter registration deadline to the 23rd of October.

Brian:  Excellent.

Dr. Hiral Tipir...: So, the 23rd of October is now the deadline.

Quinn: That's awesome.

Dr. Hiral Tipir...: Anybody who's out there has not registered to vote, anybody who is turning 18 up to November 3rd can register to vote early. If they're going to turn 18 in that time, but please everybody needs to be registered to vote. Your vote matters, your vote counts. I want everyone to know that the procedure of voting is being done so thoughtfully with our County Recorder, with our Secretary of State here in Arizona. Make sure that when you get your early ballots in the mail, you fill them out promptly, you send them back. There's a texting system in place that'll tell you when your ballot was received, when your signature was verified.

 So, that means your vote was counted, so you can sign up for that through the Recorder's office, but we just want to make sure. Yeah. And if you go in person, there are multiple early in-person voting stations all around the county and the state. There's a listing of that. Yes.

 We're going to make sure that obviously everybody wears a mask. They will be doing it very cautiously, using all appropriate public health guidelines, but you can go safely. And we anticipate, because there's so many of those days and stations set around, that we shouldn't have lines or large congregations of people, hopefully. And Arizona we have over 80% of our electorate votes by mail, early voting.

Quinn: Wow, 80%? Holy cow.

Dr. Hiral Tipir...: Yeah, yeah, yeah. We're leaders in this, and we've honestly done a pretty kick-ass job of it. I am very proud of our state, and that number is growing. So, I'm sure after this next election we'll see a higher number, but yeah, we've been doing it for over 20 years and doing it very well, I think. I want everyone to have faith in the system, to make sure you vote, fill out your ballots, get to the polling stations if you're not on the early, the pebble.

 But please, please vote and make sure you research your candidates, and make sure you know where they stand, and how they voted or what they propose to do on the issues that matter to your families. And if healthcare is number one, be aware that there are people out there, like my opponent, who are right now signed on to a Supreme Court case that will go in front of SCOTUS on November 10th to fully repeal the ACA and leave people with preexisting conditions high and dry.

 So, vote like your life depends on it. I'm not saying that hyperbolically. Your, our health, our wellbeing, our children's well-being, their futures depends on this election. Vote like it does because that is the reality we're in. If anybody would like to volunteer for our campaign, they can send an email to field@hiral4congress.com.

 You can follow us on social media. We have an amazing following on Facebook and on Twitter, on Instagram, share, retweet, repost, join the conversation. We want to hear your thoughts, and just tell your friends about our campaign and then tell your friends about important candidates that are running in your communities like Dr. Cameron Webb. We want to make sure we get all of these fantastic candidates up and down the ballots across the nation elected, so we can get to work on these important issues and just do better by our fellow Americans.

Quinn: That's tremendous. Thank you. And what is the URL for your campaign, so that people can just throw dollars at it? [crosstalk 01:06:50].

Dr. Hiral Tipir...: Yes. Yes. Contributions are always welcome. It takes resources to not only pay my amazing staff and keep a great-

Quinn: Hannah's got to eat.

Dr. Hiral Tipir...: Hannah's got to eat. We've got to keep a roof over Hannah's head, and more importantly, or not more importantly, but importantly also is that getting our message out, which means we're sending out mailers or on TV or just... We got to get that message out to every nook and cranny of this district.

 So, you can look us up. It's my first name, hiralforcongress.com. So, hiralforcongress.com. Go to the website. We have the social media links there. There's a contribution link there. If anybody's in the district and wants a yard sign, if you want to learn more about the issues, you want to see our endorsements, you want to see any interviews, it's all there.

Quinn: Are you guys doing phone banking? Can we do that through there?

Dr. Hiral Tipir...: Yes. You can sign up to volunteer. We have phone banking. We have text banking. I think we've written every postcard we can possibly write, but my field team will get you hooked up with whatever you're able to do. We are so, so grateful to every single amazing volunteer out there that has helped our efforts, because this is a winnable seat.

 I want everybody to understand this is within our reach. We're up in the polls, but we got to work hard to get this to the finish line. We got 28 days left, and we're going to work our butts off every single day. And there's so much at stake. We can't afford to leave anything behind. We're going to leave it all out on the field. You got the saying? Leave it all out on the field. That's what we're going to do.

Quinn: Let's go ahead. That works.

Dr. Hiral Tipir...: Okay.

Quinn: Hiral, this has been tremendous.

Brian:  Tremendous.

Quinn: We cannot thank you enough. I know you have to get out of here. So, thank you for your time and all that you're doing and cannot wait to see you out there making some change here.

Brian:  Yes.

Dr. Hiral Tipir...: Thank you both. Thank you, Brian and Quinn so much for this opportunity. It was really lovely to chat with you both. And thanks for the work you're doing in getting these messages out and sharing some positive action items with the rest of our communities. We appreciate it.

Quinn: Thanks to our incredible guest today. And thanks to all of you for tuning in. We hope this episode has made your commute or awesome workout or dish washing or fucking dog walking late at night that much more pleasant. As a reminder, please subscribe to our free email newsletter at importantnotimportant.com. It is all the news, most vital to our survival as species.

Brian:  And you can follow us all over the internet. You can find us on Twitter @importantnotimp.

Quinn: It's just so weird.

Brian:  Also on Facebook and Instagram @importantnotimportant, Pinterest and Tumblr, the same thing. So check us out, follow us, share us, like us, you know the deal. And please subscribe to our show wherever you listen to things like this. And if you're really fucking awesome, rate us on Apple podcasts, keep the lights on. Thanks.

Quinn: Please.

Brian:  And you can find the show notes from today, right in your little podcast player and at our website importantnotimportant.com.

Quinn: Thanks to the very awesome Tim Blaine for our jamming music, to all of you for listening. And finally, most importantly, to our moms for making us. Have a great day.

Brian:  Thanks guys.