What is the vaginal microbiome, and why is it crucial for women's health? How does bacterial vaginosis (BV) and its treatments impact women's lives? Dr. Craig Cohen, a leading expert in obstetrics, gynecology, and reproductive sciences at UCSF, explains the importance of the vaginal microbiome and its role in women's health. Drawing from years of experience and extensive research, including his work in Kenya, Dr. Cohen discusses the challenges of treating BV, the necessity of innovative treatments like live biotherapeutics, and the urgent need for better diagnostics and widespread education. He emphasizes the importance of advocacy for research and funding to improve women's reproductive health outcomes.

Check out the shownotes to learn more!

Takeaways:

• Understanding the vaginal microbiome is essential for women's reproductive and overall health.
• Bacterial vaginosis (BV) is a common condition that many women may not be aware of.
• BV can increase the risk of preterm birth, HIV, and other sexually transmitted infections.
• Proper education and awareness about BV can help women take proactive steps for their health.
• Routine testing for the vaginal microbiome is not standard but can be requested from healthcare providers.
• Advocacy for better diagnostics and treatments for BV is crucial to improve women's health outcomes.
• The vaginal microbiome plays a significant role in maintaining optimal health and preventing infections.

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A huge thank you to Evvy for sponsoring this episode! Evvy is a women's health company that is unlocking precision healthcare for women & people with vaginas. Their mission is to close the gender health gap by discovering and leveraging overlooked female biomarkers — starting with the vaginal microbiome. Learn more about them at Evvy.com.

A portion of today's episode was donated to the Society for Women's Health Research - a nonprofit with a mission to advance women’s health through science, policy, and education while promoting research on sex differences to optimize women’s health.

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This episode was created in partnership with Resolve Global Health.

Make sure to check out the Planet People Podcast if you love this podcast! :)

If you have a vagina, here's a question for you. Do you really know what's going on down there? I'm serious. As a woman with a vagina, I didn't know what the vaginal microbiome was.

I didn't know that not all bacteria is bad bacteria, and that there's a possibility that some women may be living with bacterial vaginosis and not even know it.

Hey, and welcome back to another episode of global health Pursuit, a podcast for beginner learners, seasoned public health professionals, and fans who just love hearing inspiring stories from leaders working to make the world a better place. I'm Heddal Bahman. I'm a social entrepreneur, storyteller, and your host.

Today, we're talking about vaginas, how it can affect your health and even mental wellbeing, with doctor Craig Cohen, professor of obstetrics, gynecology, and reproductive sciences at the University of California, San Francisco. Make sure you're subscribed to the podcast, leave a five star review, and share this episode with someone who might find it valuable.

Your support helps me keep this one woman show going and makes it 1% better every single day. This episode is proudly supported by Evie, a women's health company that is unlocking precision healthcare for women and people with vaginas.

Their mission is to close the gender health gap by discovering and leveraging overlooked female biomarkers, starting with the vaginal microbiome. Learn more about evvy by clicking the link in the description or visiting them on the web@evvy.com.

that's e v y.com dot doctor Cohen, thank you so much for being here. You know, this conversation is something that kind of opened my eyes up.

I didn't know about any of this before even reading the articles that you wrote, as well as the articles on resolve. So I'm very excited to be here. Welcome.

Thank you, Hetal

It's a pleasure to be here and have this opportunity to have this conversation, because I think that's one of the issues, is we need more women to understand what the vaginal microbiome is, why it's important for them and their health, their partners, their children, and just the way of life.

You know, you spent so much of your career studying bacterial vaginosis and just, you know, the vaginal microbiome in general. What drew you to this field?

Yeah.

Yeah, the interesting question, I mean, I can think back to during my training in residency, when I spent my first year of residency at the University of Washington. Later on, did my fellowship there as well.

I remember specifically, Doctor David Eschenbach, who later on became the chair of the department at the University of Washington.

I remember him helping me as an intern to take care of one of my earliest patients who complained of a vaginal discharge and really just took me through step by step, like going what sort of questions to ask her, and then the laboratory evaluation with the microscopy and so forth, and then the treatment. And the reason I bring up David Eschewak is he's one of the leaders of this field.

If you take a look at some of the earliest publications on BV, a lot of them emanate come from the University of Washington. King HolMes, David Eshvak, two of my really amazing mentors during that earlier period of my life.

It really, it came about through my taking care of women, seeing that the treatment that we had was okay for getting rid of symptoms initially, but that the majority, in the majority of these cases, women would start complaining. They'd come back and say, Doctor Cohen, you know, I have these symptoms again, what can you do? And essentially I would re prescribe antibiotics.

And that was just not feeling good.

But in addition, it came about as I became interested in helping women to prevent them from becoming infected by HIV, but also those who are living with HIV to improve their quality of their lives. And that came about through my work, predominantly working in Kenya. I've now worked there for almost 30 years.

But in doing that, understanding the associations of the vaginal microbiome and HIV, preterm birth and many other problems that can emanate from having Bv.

Right. So I want to start off very, very beginner. I guess my question is, what is the vaginal microbiome like? What does that mean?

Like, what is a microbiome first?

Yeah, I think there's increasing over the last decade or so, been a lot in the media about the microbiome, mostly focused on the gut microbiome, because it's probably the microbiome that the scientific community, medical community knows most about, but also because we kind of know how to manipulate it.

But there's been an increasing interest just in understanding that human beings, we're not just who we are like those walking around, but we harbor, you know, trillions of microbes, whether it be on our skin, I mean, throughout most, not the entire body. I joke around sometimes. I say, you know, you think about, you know, why do human beings exist?

And you could say we, you know, we essentially we co evolved with these microbes, right? But you could say maybe we exist as an opportunity for the microbes to be able to live, you know, you can flip it, right?

Instead of being human centric, you can think of it, you know, micro centric. And also it's important to understand that these microbial communities, that they truly are communities, right?

So we talk, commonly thinks, I think people talk about bacteria and they say, oh, I don't want bacterial infection. But the reality is there are bacteria that help us to stay healthy, and we in turn actually provide the bacteria nutrients that keep them healthy.

We are part of that community, if that makes sense.

Now, in the vagina, women have co evolved with the microbial community that we think of as optimal, which predominantly are dominated by a certain species of bacteria called lactobacillus. These aren't the lactobacillus that you find in your yogurt.

So just to dispel that there are four dominant lactobacilli species, probably one is the best of the bunch, called lactobacillus crispatus. Interestingly, to my knowledge, humans are the only species that have a vaginal microbe that's dominated by lactobacillus.

So the other animals have vaginal microbiome, but they're distinct from the human vaginal microbiome.

Okay.

The human reproductive tract is relatively unique, even amongst primates, although there are primates that have some similarities to the estrus cycle, the monthly cycle that women have. But there are unique aspects to it.

So it's so interesting that these bacteria, these optimal vaginal microbiome, they really have co evolved with us and essentially have supported health and well being and reproduction and birth. Right? I mean, that's a lot of responsibility for these microbes.

The focus, a lot of my work is I try to stay away from the word healthy and use the word optimal. It's maybe semantics, but not everyone, and that's what we'll start talking about.

Bacterial vaginosis or vaginal dysbiosis, essentially an aberration of the vaginal microbiome. Not everybody has that lactam cells, crispatus.

And so that's part of what our work is about, is can we then help those women to move their microbiome to a more optimal vaginal microbiome?

So what would an optimal microbiome look.

Like dominated by one of the four species of lactobacillus crispatus, lactobacillus crispatus, lactobacillus gasri, lactobilis jansenii.

And then there's another lactobacillus that's much, much less common, like one or 2% those lactobacilli an optimal vaginal microbiome comprise of 90% of the bacteria within the vagina. Still, they're living within community. They're not living by themselves.

There are other bacteria that will be part of that community, and it's thought that those other bacteria, in many cases, are supporting that community.

The lactillus are supporting the other bacteria, and those other bacteria most likely are providing nutrients which are required for the lactobacillus to be able to survive and sustain in the vagina long term. Also, if you think about it, think about what these lactobacillus are going through. Okay. You think of the vagina. Our dinner table, by the way.

So I have teenage kids. Actually, my daughter just turned 20. She's not a teenager any younger. But we talk about the vagina. We talk about the microbiome.

We talk all these things all the time.

So I hope it's not like you, dad.

Absolutely not. In fact, my daughter has educated her friends a lot. Yeah. Like the hpv vaccine, for example.

It's a painful vaccine, and she got it, and she told her friend, but most people don't understand, like, why do you need this vaccine? Educated all of her friends in middle school, and they all got it anyway, so.

Wow. In middle school, too. That's great. That's impressive.

Yeah. Middle school. The vaginal microbiome. Oh, so think about the vagina. Right? Okay. But think of everything that the.

I mean, think about what the vagina encounters, right? So, I mean, there's. For women who are menstruating, there's the menstrual cycle, right?

So here, once a month, here comes the blood, which obviously, we know changes the microbiome. So at least transiently, the lactobacillus usually decline and other bacteria can increase.

And, in fact, when women develop BV, it's a very common time for them to develop. Bacterial vaginosis is immediately after menses. So that's something that the microbiome has had to adjust to over time. Then there's pregnancy. Right?

And then there's sexual intercourse as well, and exposure to semen. Right.

And then there are other conditions that can happen, sexually transmitted infections and yeast infection and those sorts of things as well, which the microbiome has to contend with if it wants to sustain itself long term, which is usually the goal, at least, the optimal vaginal microbiome. But oftentimes, these perturbations, these changes will alter the microbiome and the lactobacillus. We don't know what comes first.

Do the lactobacillus decrease and then allow the other bacteria to then increase, especially those associated with bacterial vaginosis. And or is there an exposure to this microbiome, which is suboptimal, which then essentially kills off or dominates the lactobacillus?

It's probably both that happen, and there's some other possibilities that may be causing this change from optimal to suboptimal vaginal microbiome.

Okay, so what I'm hearing is that there can be multiple ways of a woman getting bacterial vaginosis, right?

So, that's right. So we think of sexually associated causes and non sexually associated causes.

So it's not technically a sex transmitted infection, but it's definitely associated with sex. Does that make sense?

Say more.

Okay, so, for example, there have been studies that have shown that among women who have sex with women, that if one of the partners has BV and they share sexual toys, so essentially they're sharing the bacteria from one person's vagina to another, that it's highly likely that if the initial woman partner had Bv, that the penis can also be a way of sharing bacteria between vaginas. A male partner with more than one partner can share the bacteria from one woman with another. Okay, so that's a sexually transmitted element to it.

We know that there are other factors that also put a woman at risk of developing BV, certainly multiple sexual partners not using a condom, those sorts of sexual aspects. And then there are also associations with hormonal contraception. So the non sexual transmitted elements that also increase a woman's risk.

Menstruation, as I mentioned earlier, also puts a lot of women at risk. For example, a colleague of mine has recently completed some really interesting work among teenagers in Kenya. Her name's Supriya Mehta.

She's at Rush University. So she's done a very interesting study among teenagers in western Kenya using the menstrual cup during menstruation, and has demonstrated that.

So, essentially, catching all the blood at the cervix, not allowing very little of it, then goes to the vagina and demonstrating that those young women, those teenagers who are using the menstrual cup, have a significantly lower chance of developing BVD. Super interesting. So it's not related to sex, it's related to menstruation. Right.

So there are other factors that are associated with having the abnormal vaginal discharge and microbiome.

So how does this show up women? Like, what are the first symptoms that somebody might show and say, okay, this is not normal?

Yeah. So the majority of women who have BV are asymptomatic. They don't complain of symptoms.

Okay, now, if you do a detan, you know, for those women who do have BV. Don't have. Are not complaining.

Remember, I'm using the word complaining of symptoms because you may have something for your whole life, but you think of it as normal. You're not gonna complain about it, right? Because everybody has it. And this is really an important point because.

And this is also an interesting point for your listeners, is that BeV affects women of color in the US much more likely than women who identify as white. And it's also much more common among women in sub saharan Africa as well.

It's probably a combination of genetics, behavior, and behavior around menstrual hygiene and genital hygiene practices. So, for example, douching or use of products in one's vagina is a significant risk factor. So I want your listeners to know, do not douche.

But a lot of times, women are trying to dress. They have a discharge that is smelly. It's bothersome, it's embarrassing. And so they'll go. They don't know what to do.

Maybe they've gone to the doctor, and then they get the smell back again. And so then they go to the drugstore, and they see these femme fresh, all the names of these various products.

Women spend billions of dollars a year on these products. So it could be due to different genital hygiene practices between different ethnic and racial groups as well.

But imagine in some communities, like in Africa, 35% to 50% of women can have BV. Okay? So imagine you have it.

Your older sister has it, your mother has it, and you've had this discharge ever since soon after you went through puberty. And you've had this right almost the entire time. So it's not something that you see as abnormal. It's part of what you think of as normal.

But you're not aware that it's not. It's not optimal for you or your family members or your friends. So a lot of women don't complain.

But if they do have complaints, the most common complaint is having abnormal discharge. It can be gray or white. It's usually thin, and then it has, like, a. It can also oftentimes have a fishy smell.

And oftentimes, this fishy smell is most pronounced if a woman is having sex and has exposure to semen immediately after ejaculation. If the discharge can have a real malodorous smell, very fishy smell. So that's usually the most common.

It can also be associated with general itching and burning sensation as well. But the majority of individuals who have BV, majority of women have BVD, don't have any symptoms.

So I could have it and I wouldn't even know. Wow.

You wouldn't know. And why. So why is that important? I think it's truly important. In fact, I wouldn't be.

I would be doing this work, but not with the same urgency, if it wasn't for these. That bvs associated with poor reproductive health outcomes. Right. So if a woman has BV, she's more likely to have a preterm delivery.

If she has BV, she's more likely. If she's exposed to HIV, she's more likely to become HIV infected.

And if she's living with HIV, she's more likely to transmit HIV to an uninfected partner, and she's also more likely to be infected by other sexually transmitted infections like Goddarin, chlamydia and herpes.

So there are many reasons why there's a real need, I believe, I think an urgency to help women to understand the importance of knowing about their vaginal microbiome.

We haven't talked about testing much yet, but knowing about the vaginal microbiome and then working with their medical professionals to work towards optimizing the vaginal microbiome.

And then a lot of my work is the research to develop new products that can help women to optimize a vaginal microbiome and that we call the field called live by therapeutics. It's separate from probiotics. It's similar, but separate.

Probiotics are usually comprised of bacteria, but they can't have any medical claims because they have not been rigorously tested in clinical trials.

Live by therapeutics, essentially are bacteria as well, but are going through very rigorous testing, both for how well they work to prevent the recurrence of bacterial vaginosis and also safety, which is of utmost importance, too.

So now I want to go into the testing part, right? So when we go to see our Ob Gyn for our annual checkup and all of that, is that included in the annual checkup? Like, what do we have to ask for that?

Or what does that look like? I mean, we usually just, like, we just go and trust our physician and then, okay, we're good, and then we just move on. Right.

So usually most of that checkup with your gynecologist or primary care physician or provider is going to be symptoms based. Right?

So if you don't complain of a vaginal discharge, the clinician is probably not going to look now, if, when your clinician does an exam and sees copious discharge that has a smell, they may take some swabs and do a test, which would help to identify if you have BV or yeast or whatever, even if you don't have complaints.

Again, based on what I told you earlier, someone may not complain of things because they don't see it as not being normal, because they've had it most of their life since puberty. So, yeah, this is a kind of interesting area. So it's really been symptoms based.

The other part is, and this is a little technical, but I hope your listeners will understand, the treatments are good. The antibiotics usually use metronidazole, also known as flag or clindamycin. They're good at taking care of reducing symptoms initially.

First month or so, they're relatively good. Anywhere from 70% to 90% of women will have a cure. Up to 70% to 80% of women will have a recurrence within a year. So the treatments are not great.

Right. So you can get rid of your symptoms initially. That's good, but it's a high likelihood that this is going to come back.

The reason is that the antibiotics are decreasing the bacteria that are causing the BV. But remember, I told you about the lactobacillus species, it's not bringing back the optimal vaginal microbiome.

And that's why I'm working on the development of live by therapeutics. So you would use them in conjunction with antibiotics.

So you would take the antibiotics, get rid of the bad bacteria, and then you immediately bring in the good bacteria to hopefully replace an optimized vaginal microbiome.

So the part of the reason why the diagnostics are the way they are is because the treatment is suboptimal until we get these new treatments approved by the Food and Drug Administration.

So that's, you know, speaking to what you just said.

And now kind of building on that, can you just speak a little bit more about like, or the wins or like, the things that you're seeing in the research that could really improve the state of BV?

Yeah, yeah, exactly. Because it really hurts me when I'm taking care of, I do work clinically in San Francisco.

So when I take care of my patients and they had me, I diagnosed with BV, I tell everything. I'm telling you. I tell them, like, I'm going to give you antibiotics.

It's very highly likelihood that it's going to get rid of your symptoms, but it's also very high likelihood you're going to get this again, and you're going to come back. And this is what I can offer. This is what I can offer you right now. And so, yeah, it's definitely problematic from that perspective.

So because of that, I've been, you know, I've been working in others as well to develop, we call them these live biotherapeutics. So the idea is, if a woman has BV, she has a lot of aberrant bacteria that are growing instead of the optimal vaginal microbiome.

And so we use antibiotics to get rid of those, really decrease those bacteria, and either you can use the antibiotics in the vagina once nightly for five nights, or you can take a pill twice a day for a week, and then immediately after. The idea is that we give the live biotherapeutic, the lactam crispatus, live by therapeutic, to replace and replenish the optimal vaginal microbiome.

All of that is just like, you know, I've just blanked our paper.

I mean, I was happy the New England Journal, of course, New England Journal published, but when I was very happy, we were one of the very few manuscripts, papers that were published that were not Covid related during that period of time. So, but in that study, we enrolled 228 women from four different locations in the US. San Francisco, San Diego, St. Louis, and Chicago.

We chose our sites on purpose so that we could have a large proportion of our population which identifies african american and or hispanic. These are two groups in the US that have a higher chance of having BV than other populations. So, and then we randomized them.

So, like throwing a dice. But we did it two to one. So there was two time chance you would get lactin V and a one time chance you would get a placebo.

All the women got treated with the five days of the topical metronidazole, and then they got treated then for eleven weeks of either lactin v or placebo.

And what we found is that the twelve week visit, that the recurrence of BV happened in 45% of the placebo arm and in only 30% in those who got lactin V. So we significantly reduced the risk of the recurrence of BV. It was essentially the first study of the live bar therapeutic to show that.

And then we followed these women for additional 13 weeks.

Some additional women got BV in both arms of the trial, but we saw a significant reduction of recurrent BVD in the lactin V arm in comparison to placebo arm. So that's fantastic, right? And a lot of interest in our study and in the field, but it's not sufficient to get the product to the market.

Remember, I was trying to explain the difference between a probiotic, which you can go to your whole foods or your pharmacy, or you can Amazon, you can buy lots of probiotics, but live biotherapeutics with an indication to prevent recurrent BVA, you can't have, because the FDA at this point in time, is requiring additional, what's called phase three trials. So phase three trials essentially demonstrate, confirm that the product works, it reduces recurrence of pv.

And then we always continue to follow safety. So we have never seen any sort of safety problems with this product at all.

But that additional testing, and this is what, hopefully your listeners can be part of the solution. We really need to create an advocate.

That's crazy.

That makes sense. There's not an advocate, but there's not an advocacy group like, name the advocacy group for around BV or the vaginal microbiome.

Some of these new diagnostic companies are trying to fill that void.

Like Eby, they're trying to fill that void, but they're trying to educate women and they have a educational mission and research mission as part of their company, which is fantastic. Ideally, this would be a grassroots sort of advocacy, because there's just a lack of investment a lot.

Most of the funding that we've had to date to develop Lactin V, that's the name of the product, has been public money through the national, US national institutes of health companies are not investing at this point in time, have chosen, at least at this point in time to invest at least in Lactin V.

They may be funding their own research, but if we had the proper funding for Lactin V, if we had it today, like you said, craig, I'm giving you, I'm not going to give you the amount, but I'm giving you this amount of money. Our listeners have contributed this. I'm sounding like a politician, and we had all the money today. Within three years, the product is on the market.

So we have a plan in place. We just need the resources. But really there's not.

I think advocacy is definitely one of the missing ingredients because at least so far, I'm not finding that the pharmaceutical industry has been fully vested in this field for a variety of reasons. Maybe they'll change when we get our new president, the US at least.

Who knows?

We'll see.

This year has been crazy. Let me just tell you that.

Although I have to say it's exciting to them.

Well, yeah, there's two. Yeah, you could describe it two different ways. Why do you think there hasn't been much investment in this, in this field?

I just learned about BV literally like a month ago, so I had no idea. And it feels like for me, what else? Like, what else is out there that I don't know about?

Yeah.

As a woman and trying to, you know, be healthy and take care of her body, there are a lot of.

These diseases that women, I mean, people don't talk very much about. Again, I told you, our dinner table, we talk about the vagina and diseases and health and so forth, but that's not every dinner table in America.

It's good also, I have a teenage son, too. It's good for him to learn about these things to, and ask questions. So I think there's a lack of awareness.

I also think your providers as well, are not necessarily very well trained in how to take care. That's part of what I do in our medical school with our residents and our students is train the next generation.

But it takes a lot of individuals to be able to do that, to really raise awareness and then to discuss it with our patients. Part of it's around time and other interests that people have again.

Over the last four years, people been focused on health, but mainly, like, on Covid and those sorts of things, and not as much on reproductive health. I hope that's changing. So people say, well, I have a vagal discharge, but it really does. I know this is one of the, you wrote this in the email.

How does this affect women's lives?

I mean, it has, it may have really negative consequences for women's lives, not even the preterm birth and HIV and sexually transmitted infections, but the embarrassment, the quality of life. Imagine if when you have sex, if you have BV, you have this fishy smell and how that might be off putting to your partner, right?

And you might be afraid to be intimate with your partner because you're afraid of how your partner is going to react, whether it's a male partner or female partner. So I think that's that. We know that BV is associated with poor quality of life.

So in regards to get back to your question around investment, I mean, overall, and there's quite a bit written on this, there's just, there's a lack of investment in women and reproductive healthcare, period. Right. There's just a lack of investment. And I've been learning, as I've been working on lact v now for 15 years, doing four clinical trials now.

We just finished our last clinical trial outside of Durban in South Africa. That was great study as well, is that I'm learning that you have to, essentially, you have to work through the regulatory agency.

So in the US, that's the FTA, every country has their own regulatory agency. You have to also get support of providers.

They have to see that, okay, if your product does what you say it's going to do, then I'm going to prescribe it like the result will be better than the current standard of care. You also need to get patients, in this case, women, who are going to desire this additional treatment.

Because imagine right now you're taking a pill twice a day for a week or using something in your vagina for five days.

Now we're asking you to take eleven additional weeks of using a vaginal applicator, which looks like a tampon applicator, and apply the product twice weekly. Okay? I mean, that takes some commitment. You have to know that you're going to benefit from using this product.

And then the last one, and this is particularly unique to the US situation because of. It's the role that third party payers, so you mentioned your history working the pharmaceutical industry.

I'm sure you understand the role then of third party payers.

And so they have to see there's going to be a value to them because you're getting extra treatment to spend the extra money in order to justify you developing this product.

Right.

Right.

The benefit to then that the patients are going to end up with a better outcome and I guess, I mean, I don't want to speak for third party payers, but maybe that it's going to save them money because now your patient is less likely, that's being covered by your insurance, is less likely to come back to the provider for care because now she has an optimal vaginal microbiome. All right, well, that's going to save us money because they're going to have fewer clinic visits.

All right, we'll spend the extra dollars for this additional treatment, but if you're the pharmaceutical industry trying to decide are you going to invest money here on some other product, you have to look at all of those factors. So it's not just the research that drives us.

That's why when I mentioned your listeners can play a very important role here in developing like an advocacy network to understand more about the vaginal microbiome and demand better diagnostics and treatment, what would.

Be a call to action for our listeners here? Y'all? Listen to this episode. What's the next step?

The one little next step.

The one little next step would be to see if, I don't know if there's already an established organization, but essentially to establish a advocacy group that could use this podcast but also could have other speakers come to educate themselves and then to start advocating at the national level, global level as well. I mean, I mentioned the BV is more common in Africa than it is in any other region in the world. So it's really an equity issue.

Health equity, reproductive health equity issue as well.

So combining efforts with the global health community and with women's health community, reproductive health community, I think finding affiliations with like the March of Dimes, which advocates for new treatments prevent preterm birth, for example.

So finding the other groups that might be aligned with your interests, but really pushing forward, because to me, it all comes down to optimization of agile microbiome. If we can do that, we can prevent preterm birth. Not all, but a lot.

And we can prevent HIV acquisition, STI acquisition, we can improve the quality reproductive health for women. I mean, we get it all.

We get it all.

That would be my ask.

And then also I think my ask to my listeners is to ask more questions to your physician.

I use the word clinician because not all clinicians are physicians. So just to be mindful of that, we have excellent nurse practitioners, physicians assistants and other providers.

I use the more generic term, and sometimes it's a physician, sometimes it's not.

Yeah, your healthcare providers, healthcare providers.

Exactly.

Ask more questions and that will push them to learn more and be more educated and hopefully educate their patients more as well about this very important topic.

Amazing. Well, thank you so much for being here.

My pleasure.

Thank you for listening to this episode. If you'd like to learn more about today's topic and guest, head over to the show notes linked in the description of this episode.

There you can get access to resources, links, and ways you can get involved in the pursuit for global health. And if you loved this episode, don't forget to write me a review on Apple podcasts and rate the podcast on Spotify.

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