When Racism goes “Systemic”

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The Supreme Court reverses a lower court ban on the abortion pill, Mifepristo. Moderna announces a new combined COVID and flu vaccine. The FDA issues a warning on paralytic shellfish poisoning. And federal agencies come together to form a new enforcement unit to tackle illegal flavored e-cigarettes. This is America Dissected.

I'm your host, Dr. Abdul El-Sayed.

Wednesday is Juneteenth, a federal holiday commemorating the moment that enslaved people in Galveston, Texas, one of the last bastions of slavery in the U.

S.

, heard about the Emancipation Proclamation. Commemorating days like this is absolutely fundamental for a few reasons. First, it's a day that commemorates a moment of genuine joy for people from whom joy had so assiduously been stolen. But second, if done right, it protects us from a certain tendency to forget the worst things about our history. Commemorating the end of slavery forces us to remember that there was once slavery, and that should press us to tamp out all the last vestiges of the essential racism that enabled it.

And, as much as we'd like to ignore it, that racism persists today, written into the bodies of black folks across this country. It shows up at the very first moments of the transition of life. According to data from the CDC and others, black mothers with college degrees still die at higher rates in childbirth than white moms without them. Overall, black moms are three to four times as likely to die giving birth to a baby as the national average. Their babies?

They're two to three times as likely to die before their first birthdays as the national average. If they survive into childhood, they're up to two times as likely to be exposed to lead, and three times as likely to be hospitalized for asthma. In adolescence, black teens are more than twice as likely to be shot to death, and that's all before their 18th birthday. Heart attacks, strokes, most types of cancers, all higher among black folks. Why?

Racism. Racism that robs folks of opportunities like good schools, college degrees, good jobs, owned homes in stable neighborhoods, clean air and water. All of it is a function of racism. We've covered the consequences of racism quite a bit here, because we could literally do the whole podcast on this singular topic, and it still wouldn't be enough. But I was particularly interested in learning from our guest today, because she brings such a multifaceted perspective to these issues, and taking a bit more time with this type of question can unlock new insights, and, hopefully, new ways of addressing it.

Dr. Lael Liverpool is the author of the new book, Systemic, which explores the ways that racism gets under our skin. Her background is unique. She did a PhD in virology and immunology at Oxford. She then decided to pivot into a career in journalism.

That cross-disciplinary approach unlocks a unique perspective on these challenges. Couple that with the fact that she's of mixed Lebanese and Ghanaian heritage, and she's lived all over Europe throughout her life, it all means that she has a unique international perspective to what is a global problem. So I knew I had to speak with her. My conversation with Dr. Lael Liverpool after this break.

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All right, let's get started. Can you introduce yourself with the tape?

So my Ph.

D. research was in Oxford, and I focused on investigating how viruses are recognized when they first invade the body. So looking at, yeah, that intimate interaction between viruses and our immune systems.

was in the public health sciences, and most of my colleagues were bench scientists, and it's rare for the bench scientist to come out of the laboratory. And that's one of the things I really appreciate about your background. So, as you did your work and as you thought about the implications of that work for society, what led you down this path to thinking more broadly about social dynamics when it comes to our health?

And he's the one who said, oh, it looks like you just have a classic case of eczema or atopic dermatitis, which is obviously a really common skin condition. And I was really surprised because I'd assumed I must have some really rare, difficult to diagnose condition. But he thought that the reason that doctors had kind of missed that is because of difficulty recognizing that condition on darker skin like mine. And that kind of got me thinking already about how there are these inequalities that can affect our health. And then, in the course of researching the book, I got to know a lot of people who shared their stories and their experiences in health.

And there was an experience, for example, of a young British Nigerian woman living in London who also has brown skin, but she actually almost died because of the failure by health care workers to recognize a very serious condition called Stevens-Johnson syndrome on her skin. And then, looking into that, I came across a case report of an African-American woman, so this is in the U.S. now, who experienced something very, very similar. And again, there was that difficulty of health care workers to recognize that. So, you know, being a scientist, I wanted to kind of look into the research in this and understand why is this happening.

and is this, you know, a more widespread problem. So I can share a little bit. You know, I found that there was research showing that 75% of the images in medical textbooks, for example, in the U.S., showcase images showing conditions on lighter skin. Just 5% show how those conditions look, on darker skin tones, for example. But also it affects the confidence of health workers to recognize conditions.

So there's work showing a survey of medical professionals internationally found that only 5% said they felt really confident to diagnose health conditions across diverse skin tones. So that was surprisingly low to me, and I think that's what kind of led me to think, okay, this is a more systemic problem. It's not just about one or two doctors, but it seems like there are wider problems, maybe in medical education, that are affecting our health.

S.

, spent a lot of my time abroad in Egypt, and then did some of my graduate education in the U.

K.

, is that you've traveled in the world, in your body, in a number of different spaces. And I always think that that gives you a sort of sense of you're constantly running an N equals 1 trial of what the experience of racism feels like and looks like in different places. And then you're also an observer of how that interacts with other people. You know, it's fascinating for me. When I go back to Egypt, I'm biologically 100% Egyptian, and people can sniff the fact that I didn't grow up in Egypt very quickly on me.

And there's all these questions about, like, so where are you actually from? And here, my whole life, it was like, oh, wait, so where are you actually from, from? And then you get this whole different tone of, okay, but, you know, it was fascinating here. It was like, yeah, but you don't look Egyptian. I asked why.

I was like, well, your hair is, there's this word na'im, which is like soft, meaning it's not very curly. My father has very curly hair and looks more traditionally, you know, Egyptian for that reason. And, you know, then you start to realize that, like, this is sort of a very implicit sort of form of colorism about, like, where you can actually be from as a function of, right, your hair texture or the color of your skin. And I want to ask you, right, because every book doesn't just start as a exploration, nonfiction books. They don't just start as an exploration of a particular topic.

They're usually motivated by something a bit deeper. And you shared this experience of not being able to get this diagnosis in the Netherlands and then, you know, having this diagnosis in the UK. From your experiences in your travels, what are the goals and ideals you really wanted to plumb when you decided to write this book?

And that shows us that, you know, race doesn't exist in a biological sense. But, unfortunately, race is a very real thing that we experience as we travel around the world. It changes how we are perceived, how we're even believed or treated in medicine might change because of how we're racialized. So I think it's a very real thing in a social sense. I think that's why people say, you know, race is a social construct.

But in the book I also argue that even though it is a social construct, it can affect our biology. You know, it can harm our health. So I think it's important to make that distinction, that race is a social construct, but racism can affect our biology and harm our health. And that's something I've come across. I think, in the book I give the example that when I travel to Ghana, which is where my parents are from, I'm sometimes called a Brunei, which is a term that refers to foreign people or white people.

But then in the Netherlands, I'm very much black. I've traveled to Brazil. I have a friend from Brazil. And I've also experienced the way that race is used there is different, or in South Africa. So I find that quite interesting.

And I think it just underlines this point that race is a social construct. Because if something is scientific, you know, scientists, we like clear definitions, which should be consistent in time and place. And race is nothing like that. It's messy, it's chaotic, it's social. And I think that just illustrates how it doesn't have a basis in science or in medicine.

In the beginning, like early on in the scientific endeavor, when you think about original science, you just had this very plain-faced racism that was about trying to, in effect, justify a lot of the social construct that drove racism by trying to create some science around it. And then, in a moment when we started to appreciate the fact that racism is a terrible, awful, unethical, immoral, just scab on our existence, people then just ignored race. They were like, OK, we're just not going to talk about this and we're going to pretend like it doesn't exist. And then what happens is that there's this iteration, I would argue, in the 70s, 80s, and 90s, where, rather than explicitly try to bastardize science to demonstrate why racism is justified or ignore race altogether, we tacitly started to include it in our models as just a feature that you would want to adjust for or engage with. And the mistake there was essentializing race rather than racism.

And we're getting to this new position. I think one of the challenges.

that I try to think through and I know you try to grapple with in the book, is how should we be thinking about it and operationalizing it in work. Those last three iterations kind of sucked. They were terrible, did a lot of damage. But what is the right way forward in the way that a scientist should engage with this and interrogate it when it's not the exact or focus of the research?

So I think you're so right. And I think it's a great question to think how should doctors consider race. I would love to see doctors think more about racism and not race. So what I mean by that is thinking about the way that systemic racism, for example, the structures, systems, institutions underpinning our societies, how that affects people's health. But also interpersonal racism.

In the book, I look at racism-related stress and even racial trauma, how that affects our health just on a day-to-day basis. Or indeed, interactions in healthcare, in medicine, and then biases that have been incorporated into algorithms. There has been, unfortunately, in the past, this effort to incorporate race into algorithms, but without really reckoning with the cause of racial disparities in health. And so, in effect, you're automating inequality or making it seem like it's inevitable. And that was something that was so important to me to get across in the book.

It was also empowering for me, as a black woman, that there's nothing wrong with me. You keep hearing these statistics that black women are more likely to die in childbirth in the U.S., but also here in the U.K., where I am right now, as we're recording this.

Or you hear about black people experience more cardiovascular disease, die more from cancer. There are so many of these statistics, and it can sound like it's a permanent thing that we can't change. But when you say that racism leads to these problems, when you say that it's living in a racist society, that's harmful, suddenly you've changed the framing slightly, but it makes such a big difference, because racism is something that we can do something about, right? So I would love for doctors to think more about racism rather than race and think about how racism affects their patients, the environments they live in, the air we breathe, what they're exposed to, and also how that operates in that doctor-patient interaction.

is that you have two very large minoritized communities that tend to be black African, either from the African diaspora or from the Caribbean, or South Asian, right, from Pakistan, India, Bangladesh. And if you think about, like, original automation, when we think about automation in research or algorithmification, you tend to think about it in terms of AI tools, right, and you have to have a computer behind it. But, like, BMI is the way that we've tended to measure adiposity, and it's not a very good measure for adiposity, and it's particularly bad for both of these groups, right, because if you look at the South Asian community, you find that BMI tends to vastly underestimate adiposity, in large part just because of bone density or muscle density. And then in the African population, it's exactly the opposite, right? And so you end up having this automation where you're systematically mismeasuring this idea of adiposity and all the downstream consequences.

And, you know, we've had several episodes about whether or not adiposity is actually a measure of the things that we really want to measure downstream, whether you're talking about diabetes or cardiovascular disease. But even leave it there. If you think you're measuring a certain thing and you've got two minoritized populations that you are systematically mismeasuring relative to the sort of, quote, white normal in the UK, you start to appreciate that, like, we've been doing this for a real long time, and it tends to embed a certain level of inequity in terms of who gets treatment or who gets cared for, right? Because in theory, you walk into a doctor, and they say, oh, your BMI is perfectly fine. Or you walk into the doctor, and, you know, you've got a bodybuilder, and like, oh, yeah, well, your BMI is super high.

We should do something about that. Neither of those things really work out well for that patient for a number of reasons. And I guess the question I want to think through with you is, the tough part is, too often, the challenge with racism is that it is an exposure that is ubiquitous, but the people who are affected by it, by definition, are the ones who are of the race that is racist against, right? So it's like saying, you know, a couple of folks, it's raining outside. Some folks have umbrellas.

And you're like, well, we're going to measure who's wet. And you're like, well, actually, you probably want to either do something about the rain, right? And this analogy is not quite right, because, you know, you can't really stop the rain, but in this case, you do want to stop it, or you want to give everybody an umbrella, right? Like, there are a couple of different approaches here, but we've always just focused on, well, like, well, the wet ones, like, let's think about and measure that. And I think the tough part, you know, in terms of thinking about that is, when you're trying to measure, to your point earlier, is that science beckons us to have very clean, crisp, comparable measurements.

And when you know that you have a ubiquitous exposure that literally everyone is swimming in, right? You know, if you live in a society where there's racism, it's there for everybody. You're just not feeling it if you're not a member of the minoritized race.

And so it tends to violate a lot of the way we think about science. A lot of what I was trying to do in my dissertation was to get us to think beyond, like, simple, clean metrics, and think a little bit more about complexity and the way we measure complexity. But one point that I think a lot of, you know, that's pointing us potentially in the wrong direction is that I think we're headed back into a colorblind phase, because people are going to be like, oh, well, racism, can't really measure it, so let's just ignore it. And then there's going to be, like, a bifurcation, and then there's a whole other literature that's, like, all about race. But the challenge for me is, what happens when you want to bridge these?

You want to talk about, you know, some clinical algorithm, but you want to engage the experience of racism because it's meaningful, but you run into this inference problem around how to measure something that only some people actually feel the exposure of, even though it's ubiquitous.

And I think, yeah, capturing more of people's experiences will be really valuable. Like, there's work looking, for example... So there's been work. looking at the literature in general on racism and trauma, for example, that's found a positive association between those two. There was a study that I found really interesting.

I highlight in the book in Australia in 2017.

. It found a link between childhood trauma related to racism and then late-life dementia. That was among Aboriginal and Torres Strait Islander peoples who experienced higher rates of dementia. So that study found that participant scores in a childhood trauma questionnaire were linked to a few indicators, but including separation from family by omission, the government, or welfare. So this refers to a series of racist policies that were put in place by the Australian government in the last century, separating many Aboriginal and Torres Strait Islander children from their families.

But also, you know, racial disparities and dementia exist in a lot of countries, including the US. And there's also been interesting work there, where, you know, the prevalence of Alzheimer's-related dementia is greater among black people compared with white people, for instance. And there was a study in 2019 that found early signs that this could be related to racism. So I thought that was really interesting because, as you say, it's a very difficult thing to capture, to measure. But it's really important, I think, that we go beyond just saying, OK, there are these health gaps, and looking at why they exist, what can we find.

So, in that study, the researchers surveyed a group of African Americans about their experiences of racism. And then they scanned their brains later using MRI. And they were able to show that, among older African Americans, self-reported lifetime discrimination burdens, so racism across a lifetime, was associated with an increase in what they call white matter lesion volume in the brain. So that's an early sign of cognitive decline that's been linked with dementia. So obviously, measuring the effects of racism in the brain, it sounds, you know, difficult.

It's not easy. But I think this type of research, and also just listening more to people's lived experiences in medicine and healthcare, it does show that it's worth investigating. And, you know, dementia is a condition that affects, I believe it's, more than 55 million people globally. It's expected to affect almost 80 million people by 2030.. So it's a condition that I think this affects everyone.

You mentioned that, of course, it affects minoritized people. But in the book, I really make the case that it's an issue that we should all care about, because, you know, racism, it permeates medicine and science. It makes healthcare systems, of course, deeply unfair. And that's a huge injustice. But it also makes healthcare inefficient, right?

You're wasting time, money, resources of medical professionals. And we would like our healthcare systems to work efficiently and in a logical way. So I think it's an issue that affects us all. And in COVID, that was very clear, right? I mean, I think racism, in the book, I make the case that it kind of acts as these fault lines in our society, these cracks in society through which health problems can creep, like infections, right?

Like infectious disease, epidemics. And again, that can affect all of us. at some point. Of course, some of us might be disproportionately impacted. But eventually, even if you think you're more privileged and this isn't your problem, I would argue that this is everyone's problem.

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The point that you do a great job making and one of our previous guests wrote a made a very similar argument. Heather McGee is that in a society where there is racism, where we have to engage in collective action, when one group of people wants to deny others a service, they, by definition, are denying themselves the service because the service either exists or it doesn't. And the other part of it is, even if you were to be able to say in a racist society, actually we get the service and they don't. So long as you're all living in a collective space, right? Especially when you're talking about an infectious disease.

Well, every single person who gets the disease is a risk for other people getting it. And so this idea that when we ascent to a level of racism in our society that it destroys the firmament within which we can even think about collective goods, whether you're talking about a healthcare system or a public health system, or even a transit system, right? To be able to get places so you can walk on your way to work rather than having to hit the gas pedal and drive for 30 minutes and waste your life in the back of a car. These are all things that all of us benefit from. And when one group decides that another group is not worthy of having those things, there are real consequences to it.

I want to also just sort of zoom in a bit on this.

question of scale, right? You talk a lot about the ways that we've embedded this in healthcare. Part of the challenge, I think, is that when someone is a, and let's use the word victim, right? You talked a lot about the cognitive implications, right? So much of racism happens, it's mediated through one social experience in the world of being treated that either through a series of traumas or being treated as perpetually less than, right?

That that's going to induce a certain amount of stress, and stress we know has all kinds of hazardous consequences in the body. But so much of that happens before anyone gets into the healthcare setting. And I've thought a lot about if we were able to perfectly eliminate all racism inside of healthcare, right? And we're a long way from doing that. But even if we were to eliminate all of racism inside of healthcare, I think the most caustic consequences of racism happen before anybody ever even gets into a hospital, right?

It's like. so much of it is the job you can get, the access to a walkable community, the quality of food that you can get access to, whether or not you are treated as an esteemed member of society simply because of the color of your skin or how you look when people see you, the ability to, you know, afford proper housing. All of these things are a function of a systemic racism that is well beyond anything that happens in our, you know, especially talking to the US, our broke-ass health system, right?

I mean, it's what I try and think about most days, but, you know, I'd love your insights on that.

and again, that's not something that a doctor has really any influence of where you live or what kind of air you're breathing, so I do think that a lot of the solutions to these problems are also kind of upstream of healthcare, and, you know, I won't get political, but

. Oh, you're welcome to get political.

This seems like a small thing, but I think in the course of writing the book it's something I've recognised as actually quite important. You talked about stress and we talked about racial trauma, which is, you know, really traumatic experiences, but there's also just more day-to-day things. There are things which I've even dismissed, that I experience, that, you know, I go into a shop and I'm being followed by security because there might be stereotypes that black people steal more, or like in the airport or travelling and experiencing that you're being randomly checked. I think it's something that a lot of people may have experienced, these kind of biases, and those things do cause stress. It seems like maybe trivial and small, but I think, day in and day out, again and again, having that kind of low-level stress, there's also research showing that that's harmful to health, that it can lead to high blood pressure, which again is more prevalent, for example, in black communities in the US, in the UK, so I think, yeah, that we can also think about just how are we treating each other, how are we treating our friends, colleagues, neighbours?

Could we actually be impacting each other's health just by interacting with each other? That's something that's been really powerful for me to think about how we live our lives, but of course, there are going to be many layers, and healthcare is important, because when we do need that urgent care, we want to make sure that it's equitable. So I think there's a lot of layers to this, but absolutely I agree with you that looking upstream of healthcare at our society and policies that will make our society more equal will of course be beneficial to our health.

when I teach, I often ask people, I'm like, okay, so what is the most important resource you have? And folks are like, well, water, right? If you didn't have water, you wouldn't live for three days. That's it. And other people are like, well, food, right?

You need that. I'm like, well, you have three weeks without food. And rarely do people say air, right? And you've got about three minutes without air.

We don't think about it that way.

She developed a very severe form of asthma. And it's just so, so sad. You just can't comprehend losing a child like that and what she's been through. But she's managed to really turn that into such an inspiring campaign, trying to improve air quality here in London, but also around the world. And I was talking to her and she said that she's been looking at the US and that environmental racism in the US, she said it's something else, that there's just so much inequality in not just air, but, yeah, also water, pollutants, what people are exposed to.

And of course that affects our health, but sometimes we just don't see that. As you say, we think about, okay, I'm in the doctor's office, or I've collapsed, I need urgent care, and we think about health care. But what got us to that point? So no, I agree. I think it's a really important point.

And you see the consequences. When there's a bad air day in Michigan, it's the worst in that community. One point that you made about health care that I think is really important is a lot of it is what happens in health care. And then there's this juxtaposition between what's happening in society and what happens in the clinic and it's who gets access to health care. And, of course, what's interesting, I think, about your experience is you're writing about systemic racism in health in a number of different contexts.

And one of the important differences between the UK and the US is the NHS.

There's been studies to demonstrate that the quality of the NHS differs substantially based on what community you're serving. But there is health care and it is something that you have guaranteed access to as a UK resident. Whereas in the US, we have a number of safety net systems, Medicaid being the predominant one, that reimburses at nearly half the rate. And because our health care is entirely privatized, that makes you a second class health care citizen. And I wanted to ask, in your research, in this book, there are, of course, health disparities because of what's happening in society and what's happening in the clinic.

But that's a really big difference between these two, and I wanted to ask the degree to which you're able to suss out the impact of who gets access to the health care system across these two societies in terms of the disparity that we're seeing in health status as a function of racism.

So I know that this is a very political issue in the US, but in Europe it's considered in many countries as just, you know, health is a basic human right. And I think providing that kind of improving health care access for everyone will certainly improve many of the issues that I touch on in the book. Having said that, I think that even in the UK, which is a great kind of case study for this, we do have universal health care access and still we do see racial inequalities in health. And I think that perfectly illustrates how it's not just about health care, it's about the lives we lead outside of that setting. And it's, you know, it's.

what do I eat for breakfast in the morning? What kind of air I'm breathing? What's my job? And so all of those things play a role as well. But I do think that, of course, improving access to health care is beneficial in terms of addressing racial health disparities.

and treat is going to be fundamentally different versus somebody who's only ever really spent time thinking or reading in a book that doesn't even share anything about skin that looks like yours. One of the big challenges we have is because of these systematic differences in who gets access to go to a high quality school or extra tutoring, or you guys call it tuition there, to be able to excel at your, in our case, AP classes or A levels in yours. Those questions, they make a big difference. I remember I was in the UK and in the summer to make some extra money I would actually tutor A level biology and chemistry. There was the most promising student in my class.

I had asked him, I was like, so what do you want to study? He's like, I had intended to study medicine and this was the year that they instituted university fees.

To me, it was such a shocker.

We don't often think about that, but can you speak to the importance of having a clinician that shares your experience and comes from that same experience of understanding the wiles and the methods of racism, to the kind of care that you might get?

There is actually research showing that there are benefits of physician race concordance with the patient. There was research, I think, in California, looking at black men who saw black physicians and they had better outcomes when it came to cardiovascular health. In the book, I also talk about maternal health inequalities and infant health gaps. Black infants in the U.S. are sadly more likely to die before the age of one.

Those inequalities were also reduced in a study when black infants were treated by black physicians. There does seem to be an effect, but I actually think that it's more important that your physician is, as I mentioned, aware about racism and treats patients in an equitable way. I think that's more important than their race, because I think a lot of the problems in medicine are systemic, which means that even if you are a clinician who is from a marginalized group, you might still be ending up perpetuating that legacy of harm, because there are guidelines telling you that black people's kidneys work differently, you need to adjust their test results, or lungs function differently and you need to adjust them. And if you're following the rules, as it were, then no matter who you are, you might still be perpetuating that. So I don't necessarily think that it's not that every black patient must see a black physician.

Having said that, of course I've experienced the benefit, because I think black physicians in particular are underrepresented among clinicians. It seems like almost a special thing or a benefit when you see a clinician who looks like you. I think if there was more equality, then that wouldn't have to be such a special thing. And if all physicians were better trained to treat diverse populations, then of course we wouldn't have to be worrying about this. But given the context that we're in, I do think that diversity is so important, and I think just that training and understanding and having confidence to, for example, diagnose across diverse skin tones, that's something that in the survey I mentioned earlier, that's not even there.

So I think that there's a lot of work we can do to increase diversity, representation, but also train physicians of all backgrounds to be able to care for all patients. I don't think the onus should not only be on marginalized groups to take care of each other. I think that everyone has a responsibility. If you're a doctor, it is your job to learn how to care for all patients.

Thank you so much for joining. Thank you so much for.

His ruling ultimately reversed the FDA's approval of the drug more than two decades ago, not just putting its access at risk, but preempting the FDA's entire remit as an agency that uses scientific evidence to make decisions about medication safety and efficacy. When the case was appealed, the appeals court tried to find what we'll call an unhappy medium, allowing the drug to continue to be used, but severely restricting access by, for example, banning it from being sent by mail. The Supreme Court had put a stay on that ruling pending their ultimate decision last Thursday. Let's be clear about something. The case was specious from the jump, and I'm glad that even this ideological accord ultimately saw through it.

Think about it. If a doctor is called upon to care for someone, regardless the circumstances, they are doing their job. To claim damages would create a really problematic precedent. But while this particular threat against abortion medications may be over, I wouldn't assume that efforts to curtail access to them are behind us. ID logs have made it absolutely clear that restricting abortion medications is in their crosshairs.

And while this case was thrown out, they'll bring others. And we'll be watching. As a proponent of vaccines, I have to be honest with you all, I absolutely hate having to get them. I cannot stand the idea of somebody poking me with a piece of metal. And now that I have to get vaccinated for both flu and COVID every year, you can imagine how that makes me feel.

Which is why I was pretty excited about this. Just one shot.

The hope is that offering these two together may help close that gap. Importantly, the vaccine currently known as mRNA-1083 also uses mRNA technology to vaccinate against the flu. A new approach for a vaccine that has relied on more traditional vaccination platforms. We'll keep you posted. Meanwhile,

The algae doesn't have a specific taste or smell, so there's no way to know if your shellfish is affected, and the toxin isn't removed by freezing or cooking. However, it can be identified in testing, which is what prompted the FDA's warning. Finally, as we've discussed here previously, illegal vapes continue to penetrate the U.S. market, hooking a whole generation of young people to nicotine addiction. Not to mention the fact that unregulated vapes coming in illicitly can often be contaminated.

Remember back in 2019 and the before times when there was a spate of deaths attributable to cannabis cartridges? Yeah. To crack down on this, a suite of federal agencies, including the Bureau of Alcohol, Tobacco, and Firearms and Explosives, the U.S. Marshals, the FTC, and the U.S. Postal Service, yeah, the mail folks, have come together to form a cross-agency law enforcement team.

Up until now, most of the focus has been on enforcing at the distribution level, through letters and penalties for gas stations and convenience stores. This represents a much more concerted effort to tackle the problem at a much higher level, and to target the inflows of these products before they ever hit the street. While teen nicotine use is down from five years ago, vaping still remains common. Nearly 10% of high school students in a recent survey, reported vaping in the last month. Interestingly, legacy tobacco companies, who've now pivoted into the e-cigarette space, have been urging government action against what they see as an encroachment into their market.

Locally manufactured vapes are far more limited regarding flavor than the illicit vapes coming from abroad. Those come in flavors like Juicy, Peach and Strawberry Ice Cream. Too bad. the same companies crying foul sell similarly flavored products in dozens of other countries. But I digress.

While I think enforcing the law on illicit nicotine is an important step, we should also be thinking more about how to take on demand for these products. Remember, Juul, the original vaping king, made its name targeting kids on social media. And while teen vaping may be down, other nicotine formulations, like the Chew Pouch Zin, is on the rise. To that end, we need to engage the tech industry to assure that kids aren't being exposed to undercover marketing for nicotine products, whether vapes or tabs or whatever comes next. Before we go, just a housekeeping note, I'm going to be away on vacation next week, but we'll be back right here the week after.

See you all, then. That's it for today. Thank you so much to Dr. Leah Liverpool for joining us. If you have guest recommendations for the show, share them with us at info at incisionmedia.co.

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America Dissected is a product of Incision Media. Our producer is Andy Gardner-Bernstein. Video editing by Nar Malconian. Our theme song is by Takashi Zawa and Alex Higuera. Sales and marketing by Joel Fowler and Nick Freeman at Big Little Media.

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This show is for general information and entertainment purposes only. It's not intended to provide specific healthcare or medical advice and should not be construed as providing healthcare or medical advice. Please consult your physician with any questions related to your own health. The views expressed in this podcast reflect those of the host and his guests, and do not necessarily represent the views and opinions of Wayne County, Michigan, or its Department of Health, Human, and Veteran Services. Thank you for listening.