In This Episode
DeRay, Kaya, Sam, and De’Ara cover the underreported news of the week, including voting rights, police overtime, eating disorders, and corporate profit from racial justice. DeRay interviews Dr. Elizabeth Mayer about biostatistics and what they reflect about cancer across demographic groups.
DERAY MCKESSON: Hey, it’s DeRay. Welcome to Pod Save the People. In this episode, it’s me, Sam, Kaya, and De’Ara, as usual, talking about all the news that you don’t know from the past week. We learned a ton. I learn a ton every week. I love it myself.
And then I sit down and talk to Dr. Elizabeth Mayer about biostatistics and how cancer research and treatment have disproportionate effects between races, genders, and sexual identities. Here we go.
My advice for this week is to ask the questions yourself. Let me tell you that I realize that I should– there’s a project. I should have been asking a lot more questions.
Ask the questions yourself. Trust people and let people do the work they do, but make sure you show up in the room and ask the questions so that you understand things really well yourself. Ask the question. Let’s go.
DE’ARA BALENGER: Family, welcome to another episode of Pod Save the People. I am De’Ara Balenger. You can find me on Instagram and Twitter @DeAraBalenger.
SAM SINYANGWE: I’m Sam Sinyangwe, @samswey on Twitter
KAYA HENDERSON: I’m Kaya Henderson, @HendersonKaya on Twitter.
DERAY MCKESSON: I’m DeRay, @deray on Twitter.
DE’ARA BALENGER: So clearly, a lot of the conversation should be and has been Afghanistan. What’s going on in Afghanistan, what the implications of the United States government pulling out of Afghanistan have been, whether or not there was a plan to evacuate people in a timely fashion, whether there should now be an extension of getting folks out. Because still up in the air how things are going.
We’re seeing images of empty planes that are leaving the airports. Obviously, the chaos and these now compelling iconic photos that are lasered into our minds of the suffering and the people just in Kabul, waiting to get out, desperate to get out.
So many things obviously surface when– just in the conversation around Afghanistan and this government and its military. It’s interventions in places. It’s colonialism in places. All of that aside, though, really trying to get an understanding of, what is the plan, and how are we going to get– I think there’s still 300,000 Americans in Afghanistan, but then also the people who the United States government has employed the 20 years that we’ve been in Afghanistan, and their families and all– being at risk now with the Taliban in power.
So lots of thoughts, lots of things. As someone who worked at the United States State Department, I do not envy our colleagues and friends who are there now. It is a very difficult job. It’s a multi-agency coordination that’s happening. It’s a day and night job to really answer all the questions that are happening now.
So yeah, just kicking it off with that. What are we thinking about Afghanistan, y’all?
DERAY MCKESSON: As many people have said, it was sort of wild to see Bush, Trump, just completely erased from the narrative about how we got here. It was like all of a sudden, Biden made these mistakes. And you’re like, uh, Biden didn’t put us there, right? It feels like there should have been a better plan for the rollout of leaving, for sure, but he didn’t get us there. It was frustrating to watch the media just allow Bush to be off the hook.
I also just– it made me– I mean, the thought that there were so many people who helped the Americans out, and that we did not do everything humanly possible to help them is just heinous, bad, just every type of word that is.
KAYA HENDERSON: And that is going to have repercussions for us far into the future. Because any other place that we want to work that we need help, people are going to be like, nah. I’ll take the pass on that, because I see how you treated the Afghan folks who worked for you.
DERAY MCKESSON: I don’t know. And they worked for us for a long time. It wasn’t like you did some weekend work last weekend. It’s people who have been translators for the Americans for a long– it’s like we just didn’t even– the planning on that was just not there, so that was also wild. And the last thing is I’m reminded that Trump made a deal with the Taliban.
KAYA HENDERSON: Say it now. Say it.
DERAY MCKESSON: That feels like it really did just get swept away in the conversation that he was actually talking to them and not the Afghan government in a way that, I think, really set us all up. So remember that part of the Trump deal was that the US will release 5,000 Taliban prisoners, and that the Taliban will release 1,000 of its prisoners. It makes sense to me that the army probably did stop fighting.
Could you imagine locking 5,000 people up, and then in one fell swoop, Trump is like, hey, just let them all out. I wouldn’t come back to work either. I’d be like, get me out of here, because those people definitely remember all the people that locked them up. They remember that. Biden should have had a better rollout, but he did not make this.
SAM SINYANGWE: So the only thing I’ll add is that war is just not– it doesn’t work, right? I don’t know how else to say this, right? There’s this idea that war is going to solve things, and you go back to 2001. And I was 11, right? I was this kid, right? So this is a 20 year period. This is a generation, a generation of just war.
And in the end, you see it all topple in like a week, right? All of that investment, billions, billions, trillions of dollars, people died, hundreds of thousands of people died. Afghans, Americans, all kinds of people died.
And in a week, the whole thing just collapses. The Taliban takes over. They obtain that military weaponry and are now using it against people.
What was this for? Why– not only did this fail, and we should say this was a failed war, a lost war again, not the first. Vietnam we lost. We lost this.
And we probably shouldn’t be doing future wars, because we’re not good at winning them. So we probably should think about– there’s this– I’m not trying to be a hater. I’m trying to be real, right?
Because I think there’s this idea after World War II that America is capable of doing anything and is this dominant power, superpower that nobody can mess with and that can just run roughshod over any country, any group, and face no consequences and be successful at achieving an objective. That sounds good, and I think some of us believe that, right?
And I think the reaction to the Taliban retaking Afghanistan has been having to come to grips with the fact that that’s a myth, that that is a lie. That war actually doesn’t achieve the objective that we set out to achieve. And that if anything, we have now restrengthened the Taliban and given them more equipment than they had before.
The last time, we gave the Mujahideen equipment, including Osama bin Laden, in the same area when we’re fighting the Soviets. So we did this again. So I don’t know. It’s like, how many times are we going to keep doing this with our own taxpayer money?
And then in the end, I mean, there was a lot that was accomplished in terms of creating space for a different society, creating space for removing a regime that was egregious and totalitarian and just barbaric in so many ways. But long term, did all of those– were all of those things sustainable? Will all of those things ultimately be what 10 years, 20 years down the road Afghanistan looks like?
And it’s an open question, but it’s not looking good. And we ought to reevaluate our foreign policy with that in mind. We ought to course correct and not think about America as this colonial power that can just step in and impose a particular type of system, a particular type of arrangement that clearly was not sustainable. That was not something that, frankly, had the power or the legitimacy to defeat the Taliban, and that’s what we’re seeing.
So it’s just– almost like a growing up where as a kid you see 9/11. There’s all of this going to war. And now you’re seeing the end of that, the conclusion of that, what was it all for. And I think that the facts speak for themselves.
KAYA HENDERSON: One of the things that’s interesting to me is that people are entering this conversation about Afghanistan without having a clear sense of the history. We’ve been there for 20 years. Before that, Russia was there for 20 years, right? The desire to stabilize Afghanistan as a key country in the Middle East to prevent terrorism and a bunch of other things has been a long standing concern. And now two superpowers have tried and failed.
SAM SINYANGWE: The Brits tried too and failed.
KAYA HENDERSON: Yep, absolutely. . And in fact, what we’ve done is completely destabilize the Middle East at this point. And the same was true with Iraq, right? Part of weapons of mass destruction, OK, sort of, but also, how do we stabilize a country that was literally on the brink in the middle of a bunch of other countries on the brink?
And to your point, Sam, this is not– we’re not good at this job. And so I think it does bring about questions in terms of our future foreign policy. But one of the things that I feel is really important in these kinds of things is truth and reconciliation. Saying really clearly, we didn’t do a good job here’s why. Here’s what we can do to help moving forward since we have pulled out, I think, is really important as soon as we get the rest of these folks out.
I think the other thing is watching this humanitarian crisis is heartbreaking. I came– I flew back into the US yesterday, and I flew into Dulles Airport where literally there were thousands of people in the customs line, and many of them are Afghan refugees. I was in the baggage claim area, and there are bags everywhere because the customs line is backed up.
And there are just tons of garbage bags, people who had their belongings in garbage bags. There’s people who literally had the clothes on their back and one garbage bag. And these are the lucky ones who’ve gotten out.
You watch video of folks who are literally begging for food. You hear about girls and women being told to stay inside because the soldiers haven’t been trained how to not snatch them and rape them. I mean, this is a full out humanitarian crisis, and our response is, we just got to get out of there.
And so I believe we got to get out of there, but it really feels yucky to watch this thing go down. Oh, yeah, now we’re just going to bomb. The whole thing is a cluster, and I don’t know what the answers are.
Clearly, we don’t know what the answers are. We like to think that we are better than this, that we’re more coordinated than this, that the military minds who have put this together might have done something different. It’s heart wrenching to watch all of this stuff go down and to watch us be like, we just got to get out of there.
DE’ARA BALENGER: All of that is so right, Kaya, and I think the only thing that I’ll add just on the larger picture in terms of how we’re engaging with anyone that we are trying to, quote unquote, “help or develop.” Most Western nations, their approach to development, it is so bureaucratic. You can say, we’re going to have a 10 year program to build democracy in country X, but if you have a change in administration, that program can go away.
One, it’s just how the whole entire system is set up. But then also to the core of the system, Americans can’t agree on what democracy is.
KAYA HENDERSON: Say it.
DE’ARA BALENGER: So how are we going to go somewhere and build democracy, right? So I think we saw with Trump. I was following foreign policy and following development in a lot of places, particularly on the continent where we had tons and tons of resources and programmings for family planning. They took that away because they don’t believe in that.
So I think even as we’re doing this working– yes, we’ve been in Afghanistan for 20 years. But it’s also been multiple administrations with multiple points of view on what democracy is, and that’s why there hasn’t been consistent progress. Because it’s been incremental, and it’s been incremental in ways that’s like, OK, we’re going to pivot this way, or now we’re going to do this, or now we’re going to do that, or resources are going to go here and not there.
So I think back to the programs that I worked on at State, and I would go to a country where they spoke one language, but they had– they’re given equipment where the instructions are in a different language. How that supposed to work?
So my news this week is about the House debate that happened this week on the John R Lewis Voting Rights Advancement Act. I just wanted to zoom out, because what’s been heavy on my mind is that it’s the 58th– this past week was like the 58th anniversary of the March on Washington where they, guess what, marched for voting rights. And here we are in the summer of 2021, and guess what we’re marching for? Voting rights.
Guess who’s speaking at the march? So we all know Reverend Al, National Action Network. Our aunties, uncles, cousins, cousins cousins, put together this march, and we are grateful for them.
Martin Luther King the Third spoke. The descendants of the people who were marching in 1963. And John Lewis, for whom his skull was busted crossing the Selma bridge, here we are 58 years later, still trying to get some voting rights.
And the things that these Republicans were saying on that House floor about voting rights– I mean, it’s like Strom Thurmond has been resurrected and put back into the House chamber. I just am so confused. Sam, you talked about being 11 when 9/11 happened. It’s like, this has been people’s entire lifetime.
SAM SINYANGWE: So what’s wild about this is just seeing the escalation from Republicans in terms of voter suppression. It’s not just that we’re still talking about voting rights, and we still need voting rights. It’s that the Republicans are getting even worse.
DE’ARA BALENGER: That’s right. They still think, now we gonna do this.
SAM SINYANGWE: They get even worse. They’re doing new things now. They were on voter ID. We’re talking about voter ID. We’re talking about barriers to voter registration, purges on lists.
We’ve been talking about that for decades. It’s been happening. They’ve been getting worse with that. We saw how Brian Kemp used that to cheat and get himself governorship in Georgia against Stacey Abrams.
So, again, those are common tactics. We’ve seen those. But now they’re passing laws that allow them to just say, even if you get the most votes, well, now we might be able to just completely overrule the result of the election anyway. We might be able to just replace the person counting the votes.
So that’s a whole other thing. That is not even just voter suppression. That is like, it don’t matter if you vote, don’t matter if you suppress, don’t matter if you turn out. It doesn’t matter, because we’re just going to change the results anyway, just going to fudge the numbers, just going to delete these votes. It doesn’t even– like, you don’t even have an election.
So that is what they’re on now. And so this is why we need legislation, federal legislation, to empower the federal government to intervene in these states, most of which are in the South, most of which are the same exact states that were doing the same exact things back in the ’60s and the ’50s and the ’50s, et cetera. So the same problems, adding new layers of systematic barriers to voting on top of the existing layers that we’ve been talking about and that past generations have been talking about and that legislation hasn’t fully fixed.
So this isn’t a problem that’s getting better. It’s a problem that’s getting worse, and we need to be able federally to intervene and stop this before it gets to the point where you don’t have an ability to even elect somebody who can stop this. You don’t even have the power to turn out and vote, because your vote can just get tossed out. The numbers– the counting– they can just choose not to certify.
And they tried it already. We know that’s what they’re going to try again. So, again, it’s wild to see the urgency of this. It’s clear, and yet it comes down to the same tactical conversation every time.
Is Joe Manchin and Kyrsten Sinema going to eliminate the filibuster and pass this? That’s the question. That’s all we need to know.
Are they going to modify, eliminate, reform the filibuster so we can get those 50 votes in the Senate to pass this? Because it already passed the House. That’s what we need.
And we don’t know. We still don’t know. They signaled that they might be willing to at least vote for the legislation, even though they might not be willing to end the filibuster in order to pass it, which isn’t good enough. So we’re still stuck with the same two people standing in the way.
So that’s the political conversation. It’s part of the same problem. I mean, we’re talking about it’s not a coincidence who these people are.
It’s not a coincidence that they are folks who– a white Senator from West Virginia, a white Senator from Arizona, folks who are not necessarily going to come through for us, and that we need to be thinking about, how do we put enough pressure on them to fall in line with the rest of the party to make this possible? Otherwise, we might be staring at another four years, eight years, 26 years, et cetera of Republican rule and imposing these restrictions again and again and again at the state level, refusing to intervene at the federal level, and bringing us back to where we were in the ’60s.
So my news is about Los Angeles where you might recall that last year the LAPD, among many other cities across the country, in Los Angeles, there was a big push to cut the police budget. There was an announcement that there would be $150 million cut made to the LAPD budget. But it turns out that at the time there was a lot of questions about whether these cuts would ultimately bear out in the future, in part because they relied on some gimmicks.
And one of those gimmicks was the calculation of overtime. So in LA, one of the ways in which they were able to propose a cut to the police budget was by proposing to cut the amount of overtime that officers work. Now it turns out that in 2020, the 2020 to 2021 fiscal year, there was a reduction in overtime among officers.
However, it turns out that because of the budget shortfall that the city had, they basically charged that overtime, that extra overtime that officers worked, about $47 million, to basically the city’s credit card. So what that means is it’s not just that they’re going to have to pay for that overtime. It’s that they’re actually going to have to pay more in the future, because they’ll have to pay at the rate of the officer’s current salary when they ultimately pay out that money. And they still haven’t announced when they’re going to pay out that money.
So this is a practice that I didn’t even know that LA was doing or other cities, basically charging overtime hours to a credit card, giving officers an IOU that you worked overtime last year, but because of budget cuts we’re not going to pay you now. We’re going to pay you at some point in the future, as much as 20 years in the future. So essentially LA is racking up a debt, and that debt is ultimately going to cost more than the total cost of the overtime hours that officers are working because of those increases in officer salary down the road.
So all that means is the $150 million cut that was proposed is not ultimately going to be $150 million cut. At best, $47 million of that is not going to the $150 million. But it’s actually going to be some amount more than $47 million that actually ends up getting paid out anyway because of the method in which the city went about this.
So all of that is to say that we heard a lot from cities across the country that they were going to cut police budgets. Some cities responded to that. Others did not. But there were a lot of gimmicks involved in that, and some of these are so political that it sounded like they were going to be making moves and doing big things.
But it turns out that they just charged this on the credit card. That is even worse than if they just paid the overtime right now. They actually are going to end up paying the police more because they pushed this down the road.
So this is part of a broader conversation about the direction of policing in this country. We’re seeing a lot of pushback and a backlash to defund not only in LA, but also in Austin where one of the largest cuts that was made to any city’s police budget was in Austin. They cut the police budget by a third.
The state backlash to that passed a law that actually not only requires Austin to reverse those cuts, which they have proposed to do, but essentially bans any city within Texas from cutting the police budget without a special waiver from the governor. So that’s already in place in Texas. Florida has already done something similar.
We’re seeing in LA that what was proposed ultimately isn’t going to be what is going to be cut. So it’s important to keep tabs on what’s happening. A lot was announced last year, but a lot of that is not ultimately coming to pass. And folks’ feet need to be held to the fire to ultimately be held accountable to making good on the promises that they made last year.
KAYA HENDERSON: I think that this is actually true of a lot of the simple calls to action that we have around these very complex problems. These problems aren’t so intractable because people haven’t thought about them. In fact, there are lots of ways to deal with– I mean, this is schools. This is policing.
This is housing. This is health care. It’s like whack-a-mole. You might do something on one hand and create other opportunities with another hand.
One of the things that piqued my interest is my history with labor negotiations. And when the city owes policemen or teachers or whatever outstanding money, that is the best bargaining tool that labor has. Because they will extract not just that money from you, but four or five other things that they want because you owe them.
And so not only does this put the city in a precarious financial position, but it puts Los Angeles in a precarious labor negotiating position because they owe these folks money. And you can believe that the police union is going to make good on what is owed. And I think that it’s really important for other folks who are making these kinds of cuts to look at what’s happening in Texas, in Austin, to look at how states are backfilling even courageous individual decisions to look at the implications on labor, to look at the implications on the city’s future financial picture.
This stuff is complex. And while I appreciate the calls to action and the urgency and whatnot, and you’ll hear this come up as a theme in my news later on, protests will get us only some of the way there. Deep policy change is really necessary if we want to see the kind of change that we are fighting for. But I know you all know that better than me.
So my news is on a similar theme around unfulfilled promises as a result of the protests and racial reckoning that has happened over the last year or so. There– this is a fascinating study that was just released by The Washington Post called “Corporate America’s $50 Billion Promise.” And what The Post did is they analyzed the corporate commitments after– in the wake of the George Floyd murder and after all of the other things that were happening last year.
As you know, every company worth their salt made commitments towards racial justice and reducing inequality and all of these other things. And this analysis is looking at data and the commitment statements from 44 of the 50 most valuable companies to see how they have done over the last year. It is a fascinating study.
I’m just going to say straight out the gate. There is so much here that you need to read this study for yourself. We’re only going to sort of skim the highlights. The biggest takeaway is that America’s 50 biggest public companies and their foundations committed $49.5 billion, with a B, so roughly $50 billion since George Floyd’s murder last May to addressing racial inequality.
More than 90% of that amount is allocated as loans or investments that they could actually stand to profit from. So, again, DeRay, this is– the people who know the game know how to play it. I’m making $50 billion in commitments and $45 billion of it, I could stand to profit from. Fascinating.
Two banks, JPMorgan Chase and Bank of America, accounted for nearly all of those commitments, nearly all of those commitments. And in that $45 billion, only $71 million went specifically to criminal justice organizations, which that was the whole thing, right? Police, policing, et cetera.
In fact, when you look overall, the amount committed is actually less than 1% of the net income earned from these 50 companies. So, A, we’re going to give you a teeny little bit. $50 billion sounds like a lot, but when you look at net income of these 50 big companies it’s actually less than 1% of their income. Some of these commitments are over 10 years. And at the end of the day, the vast majority of these companies that are making the commitments stand to profit.
There’s also no real way to measure the results of these commitments, and nobody is accountable because there’s nobody who is tracking all of this stuff. And corporations aren’t required to report where all the money is going or what its impact looks like. So big dollar amounts being committed, no idea whether this money is being dispersed or where this money is going, and there’s no way overall to actually measure the impact of this commitment.
37 companies responded to– 37 of the 50 confirmed that they have disbursed $1.7 billion of the $50 billion. Did you hear me? $1.7– they committed $50 billion, and only $1.7 billion has been dispersed based on the data that The Post could compile. And seven companies refused to provide any data or to outline how much they’ve already spent.
Many of the commitments were made around homeownership, were made around business loans, were made around banking, education, and additional commitments, like diversifying their C suites at these companies and buying from Black businesses. And largely, I think what the report shows is these are more unfulfilled promises. These are more ways that folks who know the game are actually using the game, even though they have made these big commitments.
There are a few organizations who have benefited tremendously from this. So they have an analysis of the organizations that have gotten the most corporate donations as a result of these pledges, and they are the Urban League, the Equal Justice Initiative, the NAACP Legal Defense Fund, and historically black colleges and universities. But only eight of these 50 companies gave to Black Lives Matters groups, and only three companies gave to the Center for Policing Equity.
DERAY MCKESSON: I’ll just add that I am always shocked at how little people are both willing and ready and frankly capable to do the structural change. I had a call with a big firm, and they were like, we believe– and I was like, do something about the police. And they were like, well, we’ll have to take it back to the committee and think about the risk– I’m like, well, what’s the commitment?
The police killing people. That’s the only reason you even know who I am. Like–
KAYA HENDERSON: Say reparations. Say reparations to abort and see what happens.
DERAY MCKESSON: What did you think I was going to ask you to do? I don’t– Don’t fund me. I don’t need– DeRay doesn’t– like, I need you to do something about police. And they’re like, well, you know the committee has to approve. I’m like, OK, OK, OK.
The second thing is I do think that if money could fix it, it would have fixed it. It’s like, I’m not convinced that the money only strategy is a strategy. The third thing I’ll say around the structural piece is that I don’t know where people got hoodwinked about like individual success.
So I like Lil Baby, the rapper. I like him. He just did a bicycle giveaway, and he does all these giveaways in Atlanta that are really powerful.
My worry is that all of us on this call know that there is no amount of bicycles we can get people in the hood that’s going take them out of poverty. It just is not– there’s no amount of turkeys on Thanksgiving. There’s no amount of book bags or back to school.
That is– it literally is not the strategy, and people are just hoping to believe that if we give people tennis shoes, that is the structure. You’re like, it’s not the fix. Money might help, like direct cash. There are a million ways to do reparations at the structural level, like child care, like– things that would have a meaningful impact at scale.
And we have got to figure out how to popularize those things, because I saw Lil Baby give away those bicycles. And I, at once, was like, this is dope, and like, goodness can we help him understand some of the structural stuff? Because if he leaned in on that, it would actually be– it would have a scalable impact that was far greater than whoever walked into the park that day and got a bike.
OK, so my news is taking us out of these conversations and really talking to something that I was just fascinated by and wanted to bring it here is muscle dysmorphia. So this article in Insider Magazine talks about eating disorders is a conversation that most in the public conversation is confined to white women. It’s like, white women have eating disorders, and that is how we have told the story in public.
And I had never even thought about the way that eating disorders show up for men. And what the article goes on to talk about is muscle dysmorphia. Part of one of the consequences of COVID is that there’s an 88% increase in the people who before the pandemic would exercise one or two times a week, with 60% of the men saying that their top reason was for their mental health.
But they go on to talk about how some men suffer from what they call muscle dysmorphia. That they’re hyper-fixated on building muscle and looking ripped with a weight and muscle goals that can ruin their lives. And I just literally– I hadn’t heard about it, hadn’t thought about it. This idea of the danger of exercising.
And the study or the article goes in to show that for a lot of men, it really does become an obsession or becomes a part of the performance of hypermasculinity, this idea that it’s not enough to be healthy. You actually need to have an eight pack or a six pack and all these things. And how the conversation about body positivity or about eating disorders really has been so confined in public to just focusing on white women.
And I thought that was interesting. I think it has implications for how we think about the health of communities. I think about my time in residential life in college, and how we didn’t really have a lot of supports to even identify people that weren’t women. I remember getting trained on how to spot girls who had eating disorders. I remember that.
We never had a larger conversation about it, and I think about how we’ve talked about before on the podcast how some of these things become taboo in communities of color so we really don’t talk about them. And how do we make sure that we give people the supports that they need? How do we make sure that we have the public conversation? And I just wanted to bring that here.
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DERAY MCKESSON: And now my conversation with Dr. Elizabeth Mayer. I learned so much from her about the status of cancer research, what’s going on, what should we be thinking about, how do we understand it. Hope you learn, too. The one and only Liz Garrett-Mayer, Dr. Liz Garrett-Mayer. Thanks so much for joining us today on Pod Save the People.
- LIZ GARRETT-MAYER: Thanks, DeRay, for inviting me. I’m thrilled to be here to talk with you.
DERAY MCKESSON: I’m excited to have you, because you are an expert. And I feel that I’ve had a lot of questions about but haven’t had an expert in. So can you talk to us first about how you got to the field of medicine and science that you study, and then why cancer? Like, what was the journey to this field?
- LIZ GARRETT-MAYER: So I’m in oncology biostatistician. So as DeRay well knows, I went to Bowdoin College where I studied mathematics, statistics.
DERAY MCKESSON: Whoop whoop.
- LIZ GARRETT-MAYER: Yeah, Bowdoin College, shout out. And from there I wasn’t really sure what I wanted to do. I was generally good at school. I found the problems that I was solving in my probability and statistics classes really interesting.
And then when I heard about the areas of biostatistics and epidemiology, I thought that that sounded like a really interesting area to pursue for me. So I ended up enrolling in the PhD program at the Johns Hopkins School of Public Health and Biostatistics. My research and my dissertation focused on mental health research.
But at the end of my PhD, when I was looking around for jobs, I wasn’t necessarily drawn to cancer, but I was drawn to working with a bunch of really accomplished biostatisticians and epidemiologists who were in the Johns Hopkins Cancer Center. So I really joined the Johns Hopkins Cancer Center group of biostatisticians to work with– Steve Piantadosi, Giovanni Parmigiani, and Steve Goodman as mentors, because I felt like I was still very young and green and new. And it really grew my love for working in the area of cancer.
And one of the things that’s really interesting and exciting about being a biostatistician in cancer research is there’s just such a breadth of different kinds of things that we study. We study epidemiology. We study basic science. We study prevention.
We study survivorship. We study quality of life. We study drug development. So it’s just so rich with different topics to explore from a research perspective, and that’s how I got into it.
DERAY MCKESSON: And what part of cancer do you study?
- LIZ GARRETT-MAYER: As a biostatistician, we tend to work in all kinds of different types of cancer. So we work in prostate cancer, breast cancer, leukemias, all different kinds. Some biostatisticians focus specifically on one kind of cancer, but many of us span the breadth of types of cancers.
There are some statisticians that really focus more on the drug development component. That’s the kind of thing where it’s really taking a drug, and it’s an early phase and working with trial designs to develop it to the point where it goes to the FDA for consideration for approval. So those would be developing clinical trials, phase one, phase two, phase three clinical trials.
So I’ve been involved in many different aspects. And like I said, it’s a fun job because all of it’s interesting and it’s all quite different. So it’s always something new.
DERAY MCKESSON: Now let’s zoom out before we zoom in. Are we learning more about cancer today than we did before? Are we essentially at the same place?
Is a cure off the table? Is it– I don’t know. What’s the feel? And I feel like it’s one of those things that I–
- LIZ GARRETT-MAYER: Yeah.
DERAY MCKESSON: –I hear people talk generally about eff cancer and stuff like that, and I just still don’t– I don’t really know what ground zero is or where we are.
- LIZ GARRETT-MAYER: A lot of people will say things like, when are we going to find a cure, or what’s going to be the silver bullet? Or what’s the status, like you just said. Now, it’s complicated, because cancer is really many different diseases.
So cancer develops when normal cells in your body develop mutations, and then they mutate in such a way that those cells can spread essentially throughout your body if they’re not found early and controlled. So that’s when we talk about metastatic disease. If you have metastatic cancer, that means that it’s spread from the place where it started to other parts of your body.
So in terms of where we stand with cures, it turns out that we do have cures for some cancers. So, for example, a number of years ago Dr. Druker, who’s an oncologist at Oregon Health Sciences, he came up, with, of course, help from other people in his research team, with the drug called imatinib that can be used to treat chronic myeloid leukemia.
What that has done, it is transformed that particular kind of leukemia from what was a fatal disease into a manageable condition. So if patients who have that leukemia take imatinib, essentially potentially for the rest of their lives, that will keep that cancer in check and they can live essentially a long normal life. So that’s one example where there has been a cure that’s been developed.
Now if you stop taking imatinib, then, yes, your leukemia may come back. But that’s clearly a win from the patient perspective.
Now where things stand going forward, I’m sure everybody is familiar with the concept of chemotherapy. Chemotherapies are toxic drugs that often makes people with cancer feel really bad. The goal there is, really, to try to kill the cancer cells without killing the patient with toxicity. So those are developed in a way that we try to give as much as we can to get rid of the cancer without harming the patient.
But in the past several decades and even more, people in the cancer research have been working on other kinds of therapies, targeted therapies and immunotherapies. And the most exciting area I think now that people are really spending a lot of time and energy on is the area of immunotherapy. And the concept there is that cancer cells are smart cells. What they essentially do is they trick your body’s immune system into thinking that they’re normal cells when they aren’t normal cells. If we can stimulate the body’s immune system to help the immune system identify cancer cells and go after cancer cells and attack the cancer cells, that is a great way to try to eradicate cancer from a person’s body.
So, for example, what has been very successful in many cancers in recent years, they’re called immune checkpoint inhibitors. There’s been many successes where they have been given to patients, and they’ve had great responses in areas such as melanoma, which is a skin cancer, or kidney cancer, or even lung cancer, for example. So people are really enthusiastic about that idea of not just giving these drugs to people, but can we come up with approaches that can harness the patient’s immune system to help the patient’s immune system get rid of the cancer.
DERAY MCKESSON: Are there racial disparities in what we find in how cancer is impacting people? Or you talked about trials, and I’m so interested in that. Because we haven’t– I’ve heard that trials probably were impacted by COVID. I heard that there are probably some racial disparities in who has access to trials or socioeconomic disparities, but I don’t really know anything about that. So I thought I’d ask.
- LIZ GARRETT-MAYER: The organization that I work for is called ASCO, the American Society of Clinical Oncology. And just to be clear, I’m here not as a representative of ASCO. I’m here as a friend of DeRay’s and happy to share my experiences with you all. But it has, overall, been at ASCO and across the country in many different areas dealing with cancer, a focus of disparities in cancer.
There is disparities in screening. So, for example, racial minorities are less likely to get recommended cancer screenings. And we know that the best way to have good outcomes is to catch cancer early, so that’s a big concern.
We also know that racial minorities are not well represented in cancer clinical trials, meaning that if the population in a certain area is, let’s say, 20% African-American, then the trials at those institutions should have 20% African-American patients on their trials, and they just don’t. And some of the disparities have to do with issues of what you need to do to be part of a trial.
Sometimes they take more time. Sometimes they take issues of needing to get transportation more frequently to a site. Sometimes it has to do with implicit biases that people think that, well, I don’t think this patient’s going to want to go on a trial, so I’m not going to bother inviting them to be on this trial. So we struggle with that, because what we need to have is that the patient populations on clinical trials should be reflective of the patients who will receive the therapies.
The other real challenge with cancer treatments is that they’re really expensive. If you don’t have insurance, they are prohibitively expensive. And even if you do have insurance, because the treatments sometimes are so expensive that people really just can’t afford some of the therapies, especially for later stage cancer.
So when we talk about disparities, sometimes it has a lot to do with the financial ability to pay. And in the world of cancer care, there are many conversations about what’s considered financial toxicity. The fact that it’s not even necessarily the cancer that causes toxicity, that people actually end up going bankrupt because they can’t afford the treatments for the disease.
DERAY MCKESSON: Wow. And what about gender? Like, are all genders represented? Is there a similar problem with recruitment?
- LIZ GARRETT-MAYER: There’s not as much issue with recruitment across gender. We do see disparities, however, with sexual orientation and gender identity, and some of that has to do with patients of sexual and gender minorities not feeling comfortable going to care providers. And, I mean, I’ve had a number of conversations with people about this from a research perspective and also from a personal perspective.
When you go to a care provider, you have to feel really comfortable and trust that individual. If you’re going into a care provider’s office and you’re not sure how they’re going to respond to you divulging, having a sexual orientation that they might not be comfortable with, that could hinder you from going to the doctor in general, which would hinder you from getting cancer screening, from general preventive visits to physicians. So I would say men versus women representation, that’s really not an issue. But I think the broader issue of sexual and gender minority is a problem in cancer clinical trials in addition to disparities in care in general.
DERAY MCKESSON: Got it. Now how do you– and this is so basic, but I definitely don’t know it. How do you get in– like, can I go to like www.joinatrial.com, or does a doctor have to refer me, or I don’t know. How would I even know? Do you get paid to be in trials?
- LIZ GARRETT-MAYER: So there are a couple of questions there. Number one is, how would you get on a clinical trial if you had cancer? So many cancer centers or oncology practices will talk to you about trials that they have available. Many of them also know about trials that are available at different centers.
If you go to an academic Medical Center, so, for example, like Johns Hopkins or Dana Farber Cancer Institute in Boston, they make a big effort to try to match patients to trials. And just to be clear, physicians would never recommend a trial for you that they think you would not potentially benefit from. So they would never say, there’s a great standard of care option available for you, but we want to put you on this trial with something that we think might not work for you.
So there’s always the ethical issue. And these studies go through rigorous, ethical review to ensure that the patients that enroll in trials are getting optimum care. So that is one thing to think about.
If you go to a place and they have trial options for you and they talk to you about them, that’s great. On your own, you can search up clinical trials at a place called clinicaltrials.gov, which is essentially a national repository that we have the United States that provides for you information about clinical trials. And you can search by cancer type and location and all sorts of things to get an understanding of what trials are available and where they’re available.
You might live in an area where there is not a research cancer center that is providing a lot of clinical stuff, or you could have a rare cancer. And even though you’re near a research center that has trials for the rare cancer that you have, they might not offer any for that cancer. So it’s not unusual for people to live in one place and travel to a cancer center across the country to participate in a clinical trial.
And let’s talk about a disparity there, right? You have to have the resources to be able to fly across the country potentially every month or so, and rent a hotel or an Airbnb or whatever to be able to do that. So that is an issue of disparity that you’d have to have the resources to be able to do that kind of commute.
And then in terms of the payment component, as you asked, do you have to pay to be in clinical trials? The way that it works and it kind of varies from trial to trial. But if it’s an experimental therapy, IE, one that hasn’t been approved in the United States by the FDA, that drug would be provided for you as part of the trial.
Now all of the regular other care, blood work that had to be done, or X-rays and scans of your body, your cancer, and MRIs and things like that, it would be part of regular clinical care. Those would not necessarily be covered, unless they were specifically for research purposes.
DERAY MCKESSON: So if I had a rare cancer and I lived in, I don’t know, the middle of Iowa, how do I participate in the trial? Will you mail the stuff to– I don’t know. What–
- LIZ GARRETT-MAYER: This is a conversation that’s being had across the country by places like the FDA and the NCI and other organizations that are interested in making trials more available to patients. And the concept is called pragmatic trials, and it’s really this idea of bringing the trials to the patient instead of making the patients travel to the trial.
So depending on exactly what kind of study it is, what kind of things they need to measure, it’s quite possible that from your home base in the middle of Iowa, that you could go to local facilities to get scans, to get tests done, and they could be remotely sent to the center where the trial is being run. And you could receive the treatment potentially remotely as well. You wouldn’t have to go all the way to Johns Hopkins or all the way to the Mayo Clinic in Minnesota.
DERAY MCKESSON: How is it 2021 and we are just talking about this? That is scary. Do we find– I’m interested in whatever the formal name is for like trial outcomes maybe. Do we find disparities in trial outcomes?
And I ask, because you know we’ve had on the Pod people talk about seat belts and how test dummies are not the size of women. Like, all this stuff where you’re like, wow, we didn’t even design the test to support all body types.
- LIZ GARRETT-MAYER: Right.
DERAY MCKESSON: Do we find that there were disparities in outcomes? Like, do we know anything about race, gender, or–
- LIZ GARRETT-MAYER: Yeah.
DERAY MCKESSON: –class in terms of trial participation and outcomes?
- LIZ GARRETT-MAYER: The way that it works in trials is that we have an eligibility criteria. We might say that, for example, all patients with this specific kind and stage of cancer are eligible as long as they’re over age 18 and meet these safety characteristics, for example. What ends up happening oftentimes is even though there may not be an upper age limit, what ends up happening is we end up enrolling relatively few patients, let’s say, over age 75.
So what ends up happening is the patients on the trial aren’t representative in the same way we talked about race a little bit ago. People over age 75 might not be able to tolerate the treatment as well as patients younger than age 75. And so when we talk about things like disparities and outcomes, what we’re doing– maybe a technical term is we’re– we end up sort of extrapolating and saying things like, well, if you go on this treatment, we think you’re going to live six months longer than on this other treatment.
But that’s based on a population that it was selected by their physicians to be enrolled on this trial. So we refer to that as a problem of generalizability that we end up giving the treatment to all sorts of patients after the trial is done, and many of those patients were not well represented by the patients that were on the trial. So when we talk about how well the treatment works, the information that we learn from the trials doesn’t always translate into the treatment benefit that we see when we start giving it to patients after approval.
DERAY MCKESSON: And after drugs are approved, when you give the drug out to doctors for the first year, do they have to send you all a status update about– how do you know how it’s being received, do you know what I mean?
- LIZ GARRETT-MAYER: So that’s called the post-market setting. And in the post-market setting what ends up happening is there is information that is transmitted back to the FDA so that they can keep tabs on what we would call adverse events, and if patients are having serious toxicities that might not have been identified in the trials. Sometimes the FDA, if they have concerns based on what they saw in some of the trials, they can say that we are requiring the company to do additional studies to ensure that the drug is safe, or we need to collect more information.
They might even say you need to do a study that looks at a different dose, because we think that the dose could be improved from what we approved. So there’s a lot of still discussions that happen after the drug has been approved by the FDA about how to potentially monitor for safety, and how to potentially learn of better ways to give the drug to patients. And it’s challenging. In oncology, it’s very challenging.
Not that it’s not challenging in other areas, but understanding what is the right dose and the right schedule can be very hard. There’s not a strong enough emphasis in that component of drug development, and I think it’d be hard to find somebody who would disagree with that.
Usually those studies that look for what’s the right dose are small studies, meaning they have relatively few patients. And the way that they consider what the right dose is to move forward in drug development, sometimes it’s not based on the most relevant outcomes.
DERAY MCKESSON: And what is a– you said a small trial. Can you just help us understand what’s a small, medium, and big trial. Is a big trial 500,000 people, and a small trial’s 100,000 people? Or is it a small trial like 20 people, and a big trial is–
- LIZ GARRETT-MAYER: Right.
DERAY MCKESSON: –1,000 people?
- LIZ GARRETT-MAYER: Yeah. So it kind of varies, and it depends on a number of components. So when we were talking about dose and I was referring to it what we call phase one, it’s usually called the dose finding phase. Sometimes those trials can be as small as 15, 20, 30 patients, and they’re looking at different doses of the treatment and enrolling a relatively small number at different doses. So at the end of the day, you might have only treated 6 to 10 patients at the dose that ends up going forward into these later phase trials.
A large trial in cancer would be in the order of thousands. Now, again, it depends on really what you’re looking for. Sometimes if you’re doing something like a prevention study, it could be 10,000 patients. But if you’re looking at patients that have cancer, in the world of oncology, it’s usually hard to get more than a few thousand patients on a trial and have it be done within a reasonable amount of time.
I mean, that’s one thing that’s been really challenging in oncology in recent years. What we used to think of cancers as being defined by the place in the body in which the cancer started, so breast cancer is a cancer that starts in the breast, and prostate cancer is a cancer that starts in the prostate. In recent years, we have been much more focused on what we would call precision medicine, which is less concerned about where the cancer is and more concerned about the genomic makeup of the cancer cells.
Which is good, because we’re focusing really on what is driving the cells here to make them be replicating and potentially spreading throughout the body. And if we can target that, we could stop that from happening. But what ends up happening is a lot of times these targets we’re looking for are relatively rare.
So it’s become actually harder to do trials, because we’re getting better at identifying these cancer subtypes. And we’ve just taken a big issue, like cancer, like lots of people have cancer, but we’re getting better and better about identifying all these very small subtypes of cancer. And so they end up being relatively rare in the grand scheme of research, and finding enough patients to participate in trials to learn about them ends up being really hard.
DERAY MCKESSON: Well, we appreciate you. Thanks so much for being here today, and we can’t wait to have you back.
- LIZ GARRETT-MAYER: Yeah, that’d be great. I’d love to.
DERAY MCKESSON: Well, that’s it. Thanks so much for tuning in to Pod Save the People this week. Tell your friends to check it out. Make sure that you rate it wherever you get your podcasts, whether it’s Apple Podcasts or somewhere else. And we’ll see you next week.
Pod Save the People is a production of Crooked Media. It’s produced by Brock Wilbur and mixed by Bill Lancz. Our executive producer is Jessica Cordova Kramer and myself. Special Thanks to our weekly contributors, Kaya Henderson, De’Ara Balenger, and Sam Sinyangwe.