Transcript has been lightly edited for clarity and readability.  

RyLee Curtis: Welcome back to part two of Preventing and Treating HIV/AIDS in Utah. Again, we're joined by our guests, Adam Spivak, who's the co-founder of Utah's only free HIV prevention clinic, and Ahmer Afroz, who's the Executive Director of the Utah AIDS Foundation. 

[music] 

Ahmer Afroz: Not much, no. I think it's like you said. And I think when Adam and Susana come with such a brilliant idea, I think it's hard to turn them down. And so, I think what we're missing across the nation, and particularly, in Utah, is more of a focus on direct services and interventions that we know work. So, while you can say the PrEP Clinic is just a PrEP clinic, it's so much more than that. This is a perfect marriage of public health and medicine and mental health and medical navigation. There are so many components to this. So having a one-stop shop where you feel comfortable, and I have worked with many providers in Utah, and I think Adam and Susana are the go-to within HIV, and because of the trust that they've built within the community of people living with HIV. And so, you know it's going to work. 

AA: And we've seen similar, and not in the US, I will say. I think the one place that comes to mind is Thailand has done quite a bit of these studies, but it's a lot of times cause they're breaking the patents for the medication because they don't care, and they are going to get people what they need, which is brilliant and power to them. But yeah, I think it... I'm trying to think of how I can say this and not get in trouble, but you do look at a lot of what is dictated from the state and the Federal government, and it's not what people need.  

AA: And so, it's hard to communicate that because from the public health side, which is funding a lot of things, they don't want to think in terms of that. They want to think in terms of beautiful words that sound great, and ticking boxes, and making the CDC sound great, and other Federal agencies sound great. But yeah, I mean I think it just takes really being passionate and knowing what to say to who, and making them believe it's their idea, and then you sit back and let it happen. 

[chuckle] 

Peter Weir: Well said. So, I didn't know that connection between the two of you, and so for me, that was serendipity. Someone like RyLee saw this connection and saw this coming, but that was a fun story to see, where you guys connect. I got a couple other questions about the PrEP Clinic. One, just for listeners, there are ways to get PrEP with different means, and there are plenty of physicians, myself included, that have done PrEP for patients, and so... But this is unique, this is a unique clinic in that it's for patients who have insurance or don't have insurance. I'm assuming the majority don't, and they don't have the means. And so, this is unique in that they're getting patients free meds, just testing. So, I'm assuming no out-of-pocket cost for patients. It's just impressive, and I love it. And one thing I wanted to ask you, Adam, was: What's your funding status right now? Are you guys looking secure? Or is it worth making a plug out there for some listener who says, "Boy, this sounds like a very important thing for our future as a state?" 

Adam Spivak: Yeah, it's a great question, thanks. We are secure. Let me say that in the sense that we have a strong partnership with the Department of Health, again, thanks to Ahmer. We have referrals and we have support from Utah AIDS Foundation. We've held joint fundraisers together. We found a natural partnership between the two groups. We have other community partners that we share. Financially, I'd like to be in a different place. I think I'm not exaggerating when I say this, and in fact, Rochelle Walensky is the Head of the Centers for Disease Control, currently, but prior to that, was the Chief of Infectious Diseases at Harvard, Mass General. She spent her research career showing, economically, at least in part, in more recent research, that we could end this epidemic, period. I mean you can go into the details, but it's in the papers, so you can read it, and she's got the models. We don't need any more science. We don't need any more research grants. What we need is people like Ahmer, people like Susana, people like our med students that volunteer in this clinic, and our patients that will come, and they keep coming because we have all the science we need, we have all the drugs we need. They work, they're well-tolerated, people are doing great. 

AS: So that's an important perspective, I think, because we like to think about this pathway about some basic science discovery, and then this cool stuff happening in a lab and clinical trials. All that already happened. That already happened. Now, what we need to do is make modern medicine more equitable, and less bigoted, and fairer, and more open, and more tolerant. And that happens when we do that, me included. And that's why the med students really are sort of the beating heart of this clinic. We give away healthcare for free, and that makes me feel very good. I think it would not surprise any viewers to have a sense of what my politics are. 

AS: The last four years were hard for me, and I was angry a lot. Even though I look like the kind of person that's supposed to benefit from the previous administration of a white male, etc., etc. But I was so angry and there wasn't a great outlet for that until Susana and I came up with this idea, and we had such phenomenal support from our partners. But that's not to pat ourselves on the back too hard, because 300, 400 patients are not enough. Ahmer nailed it. We haven't changed the numbers. That's what matters. That's the metric that matters. 

AS: I think this is a nice pilot project that's a nice thing to talk about. But when you talk about public health, you're talking about thousands of people, and you're talking about millions of people, and you're talking about tens of millions of doses of vaccine. You're not talking about individual care anymore. And so, this model, it is public health, but we're too small right now. So, it's a long-winded way of saying that "We're, okay, we survived COVID. We switched to Telehealth; we're going to keep a lot of that. That's worked," and I go on and on. But we need to grow and grow and grow. When you do it fast, and when you do it with open arms, embracing our community partners, and we desperately need funds to do that. 

AS: And what I've tried to sell, and I don't have an elevator pitch because I talk to long, me going up the Empire State Building or something. [chuckle] To the suits is that: What are you buying if you invest in our clinic? And I envision a headline that says, "Utah is the first state with no new HIV infections." Would you want to own that headline? Would that be a nice one? Be on every newspaper in the country. Oh, I don't know if everyone reads newspapers anymore. It'd be on the Internet. It'd be on Reddit. It'd be talked about. It'd be on Twitter. We could be the first state. And we could be the first state, there is no question in my mind. But we need more resources to do it. 

PW: I love that. And that's, again, that's what resonated when I met with Adam a year-and-a-half ago, and it stuck. And I was going to pull that point out, but you did a beautiful job of just really nailing it, which is this idea, and I think everyone, hopefully listening, just pauses and asks themselves because I think all of us have gotten the assumption that this is something we're just going to have to live with. I think it's resignation. And after meeting with Adam and doing a lot of reading on this, I want to ask this provocative question, and Adam just already brought it up, but for our two guests is, can we eradicate HIV/AIDS? And maybe let's answer this question not at a global level because I realize the challenges at a global level, not that we shouldn't be thinking globally, but let's just confine ourselves to the US for the moment. Is that a possibility?  

AS: Absolutely, there's no doubt in my mind. And I think, yeah, this gets back to the politics, unfortunately. [chuckle] But if you go back in history and look at the accomplishments that we've had as a country, and I'm talking about Word War II and immediately after the things that this country has done, and the beacon of light that this country has stood for, for people around the globe, that wasn't salesmanship or marketing; that was real. This is a country that has done things. We've slowed down on that a bit, I think, and they are obviously... The coronavirus vaccines are an incredible thing, and that really, it took international resources and effort and whatnot, so I shouldn't be drawing nationalistic borders. But there's no question in my mind that if we put our minds to this and our political will and our recognition of shared humanity, that we could end this disease, and we've done it before with other diseases. And we have all the tools on the table, all of them right now today. We just have to decide to do it. 

PW: Ahmer, thoughts, reactions?  

AA: Yeah, no, I agree. I think Adam touched on this. I think we have all the tools; we know we can do it, but I think we do need large-level shifts in the way we think about this. Adam talked about having a racial justice lens to this; and in the United States, that's still very much what needs to happen. I think we need to abandon thoughts of equality and focus on equity, and what does that look like. And some would argue, "Forget equity, and talk about justice." And I think that those are difficult things to do, but I think we're there, and I think the PrEP Clinic and UAF are really shining spots on, "You can achieve that. What does it look like to make money, or race, or sexual orientation a non-issue?" So, I think it's large shifts. I think it is getting more players at the table who are impacted by this, who are voices of the community, who are... I mean I am also academically trained. I get into that ivory tower mentality as well, and so you have to acknowledge that sometimes, I'm not the best person to answer or look at something. 

AA: And so, I think if we have more, like Adam said, relying on more people, having more cohesive, collaborative efforts, what makes me nervous is looking at the larger government involvement within HIV and the ebbs and flows with that. The lack of acknowledging equity, injustice, aside from beautiful words on a grant application, and the lack of being able to really calling out racism, which if you look at the community health AIDS service organization, those conversations are at the forefront because a lot of these organizations operate in that manner of really a top-down approach for communities. It's not collaborative. So, a long way of saying yes, I think there's just so much to do, that it is hard, sometimes, to stay focused, but I think it's the long call. And I think HIV is just one point. I think we have to flip the system for so many across the board. So, I'm hopeful and optimistic. I think, again, PrEP Clinic and UAF are those, obviously, agencies that I feel like it's going to be those agencies that do it. So very much, obviously, very biased, but having those agencies and the communities they serve coming to the front, I think, is what needs to happen. So dynamic shifts. 

PW: That's excellent. So, what I'd like to do is take what you've just described and transition to this idea of: What does community health look like in a conservative state?  

AA: Yeah. 

PW: And you could come up with some examples of ways in which that's a challenge, and I would love to get into condomgate, which I think is... [chuckle] 

RC: I may or may not have brought that up in our planning discussion. [chuckle] 

AA: Can I out you, RyLee, for being the proud owner of... 

RC: Yes, you can. 

[chuckle] 

PW: If somebody knows who made those condoms, and maybe you guys do, they have a legit sense of humor. They are, they're funny. I love going over them again and seeing it and reminding myself of that story. Do you want to focus on the challenges of community health here in Utah?  

AA: Yeah, so I think there's two parts. It's interesting, but I think those more academic settings need more of a community perspective, and the community side needs more of an academic perspective. And I think one can exist without the other. And so, as you're moving forward, I think that's really what we have to do, is taking and bringing those voices to the table, but also putting it within very formal structures of public health and medical systems that get the money and have been proven through decades of research to work. So, I think for me, those are the two big things. 

AA: And I think the other thing is losing the pretension, the pretentiousness of medicine and public health. And I think UAF is a very casual organization and it's very deliberately done that way. And I'm sure Adam can also speak to this as a lot of Adam's patients are also very casual with him and open with him and feel comfortable. And so, I think that when you're getting into community health, you have to know that it's also very much dictated by the community. And that's in everything. If that means the way you dress, the way you're doing intakes, the way you're talking to someone, the language you use, the staff that is hired to represent the community, it has to be a holistic partnership. 

RC: So, I found this idea interesting, this health in a conservative state. Why do you see success with things like needle exchanges? We're accepting of education and outreach for people who are substance users, which it could also potentially lead to HIV and AIDS, but we're lacking the systemic education of sex education. STIs are high in the state, HIV, we're not getting anywhere with our numbers. What do we have to do to make people move on this issue?  

AA: Yeah, I think the reality is that sex is taboo. I think even sitting in this room and having this conversation in a professional manner, saying "Sex" or "Sexual health" repeatedly; sometimes, I pause and think, "What am I saying? And is this the right audience?" And I think that just speaks to how ingrained that is in Utah. So, I think, particularly, with syringe exchange, when you look at that, I think substance abuse has been well-marketed. And I think when we look at substance abuse, the way it's intentionally been marketed, as you're looking at opioid use and you're looking at your next-door neighbor, and you're looking at more general things. But I think sex still is such a taboo topic no matter... I mean for the majority, wherever you are. 

AA: So, it is hard to have those conversations. It's hard to have those conversations with funders who will read grant application after grant application about what you're doing. And I think that's what we do at UAF, is every day, I'm looking at: How do we tweak this? Or is my mission or vision too edgy? But you know... And RyLee, you've been on this as... Is using the term "Sexual health" going to make it so I don't get any more money? And that's a very real fear and concern. And Adam has to deal with this, too. No matter where you're going, you have to think, "Is this going to get me what I need? Or is this going to inhibit that from happening?" And there's two kinds of things about that... But hard is getting money and giving the community what they want. And those don't line up a lot and oftentimes, people don't understand that. 

[music] 

PW: Interesting thoughts there. I just can't get my mind off condomgate, though, so let's... 

[chuckle] 

RC: Oh, very good timing. 

PW: Let's talk about that. Could you give us some context for that? And then Isaac, I don't know if you can give us a couple of examples. I think all our listeners know who Isaac is. He's here, he's really the brains behind all this stuff, helping to support all of us, but maybe you give a couple of good examples, too, for some good laughs. 

AA: Yeah, so when that intervention was coming to fruition, I was at the Department of Health. So, within those meetings, really, what it was is, "How can we get condoms to be more approachable, and to get a conversation started about them, and to get people to utilize them more, and to just generally make them more accessible?" Cause I think... Again, going back to growing up in Utah, not having any sex education, not having seen a condom until I was at Pride, my first year of college, I think that was really what we were trying to do, and it was coming from what we know, again, research has shown us, that how to make HIV prevention tools utilized and approachable. And so, this is not something that was just done on a whim. It wasn't something done just to be funny or edgy. It was based in science, and it was based in what we know works within the communities we are trying to serve. So, what came about was these Utah-specific condoms that had... 

PW: "Uintah to sex?" 

AA: Yeah, yes. 

PW: Yeah, for example. [chuckle] 

AA: Yeah. And I won't disclose which ones I came up with, but RyLee and I can have that conversation. RyLee is the proud owner of her very own set... 

RC: Full set. 

AA: Full set of condoms, one of the only ones in Utah. 

PW: Oh. Collector's item. 

AA: Yeah. 

RC: I paid a pretty penny for them, but they went to a good cause. [chuckle] 

AA: They did, they did, our lovely UAF Gala Fundraiser. So once these were released, which were, one, very... I would say this was probably 2% of a larger HIV campaign. And what ended up happening is the entire campaign being overshadowed by these condoms because individuals deemed them as inappropriate. What we saw was a lot of grasping to make connections to larger social movements. So, for example, within... For example, what we do from the community perspective is a lot of empowerment in terms of, "Let's own terms like," I'll be very casual, but, "Let's own terms such as 'slut' or 'whore'." There's a term, Truvada Whore, which is, in the early days of Truvada, people were being shamed for being promiscuous, for using Truvada. And so that was the quote that people used to normalize these things. And it worked, and it worked well. 

AA: What ended up happening is people took that and were not taking time to understand and pause what the purpose was of these condoms. And I think, again, in Utah, what you will see over and over again is not your target demographic for what you're trying to do, making the decisions of what happens. And so that's what happens non-stop. And I've worked in government settings, obviously, and you very quickly realize what flies and what doesn't fly. And so, I think this campaign, it highlights that. And it was squashed. And the good side of it is a lot of press happened for HIV, and I think if I have to think of a silver lining, that's what it is. We were able to talk about the PrEP Clinic in UAF. The HIVandMe website got a lot of traffic. But the flip side is it negatively impacted a lot of passionate people who were on the inside of this project. 

RC: I want to point out, too, didn't Wyoming also, another very conservative state, maybe more so than us even, and they had a successful condom campaign. 

AA: They did, yeah. They did. So, Wyoming shipped the condoms over so we could get a look of what they had done. 

AS: I think Alaska did, too, didn't they?  

AA: They did. 

AS: Yes, multiple conservative states had pulled this off without... 

AA: And I will say, one thing that kept coming up is that Utahns shouldn't be paying for this. This was Federal funds. So, individuals in Utah who don't put any money towards HIV prevention, I have to note that, no money in Utah, from a state legislature is given to HIV prevention. So now, they're pulling a campaign that is being funded by Federal funds. 

AS: I thought just one of the best encapsulations of this is a very petty and just infuriating political backlash to something that clearly has been shown to work and that, God forbid that we make some jokes and there's actually... There's sexual content, or whatever it was, out of the Governor's Office at the time because they were the ones that became very vocal and saw this, I think, as some red meat to throw to the base, was a statement along the lines that the condoms contained explicit sexual references on them. And I just thought... I remember seeing this young staffer delivering that line with a serious face and thinking about how sad it was that there is no sex ed here because I don't think that person knows what someone does with a condom. [chuckle] It has explicit language on the condom. 

PW: What do you think the condom is for?  

AS: Do you... Yeah, it was... And it was sort of the full shock and horror of this, that's like, "You know what people do?" Oh, God!  

AA: It was a show. I think that... 

AS: Dude, crazy! It was absolutely a show. 

AA: And that's what's hard, is when public health is interfered with for these needless reasons. 

PW: Right, and it's... That seems like the story for public health for our country, so I think... I like the condomgate story because I think it does, like you said, Adam, encapsulates or it serves as a microcosm for some of these larger themes. So, let me ask you guys this: How do we go about changing that culture? How do non-profits? How does the free PrEP clinic? Where is this all going?  

AA: I think it's just being true to your community. I think, really, it's been there. I think not being afraid to have those conversations, pushing boundaries as what that sounds, it sounds odd, but you do have to fight for your community and get people to come along for the journey. But I think if you're not afraid to have those conversations, that's the only way you're going to get anywhere. So, while I do acknowledge that sometimes, I can't have those conversations, I do selectively and strategically pick the time and place. So, for example, our social media at UAF is open and free. We have Sex Tips Fridays because that's what we know people will engage with the most. And so, I think it's not being afraid to have that. Non-profits, obviously, aren't in a very privileged position that we can do what we want. And you have to have some considerations, but you also can just really go for what you believe in. 

PW: Adam, thoughts about changing the culture here in Utah?  

AS: Oh, I don't... Yeah, I don't know if that's possible, but I appreciate everything Ahmer's saying. I just think... The way I'd approach this when I think about my part of my job, interacting with patients, is something I've had to learn as sort of a lifelong introvert and whatever, is how to get along with everybody. And better than that, how to develop a trusting relationship with someone you've just met. And it doesn't matter what walk of life they are from and how different or similar they are to me, I have to find common ground quickly or I'm going to be a bad physician for that person. And I wouldn't say that I'm an expert in that. I think that's something I'll spend my career and my life trying to get better at, but I think that translates to something that we can all do, and it's such an incredibly disheartening, hyper-polarized time, and I can't help but blame social media because I'm middle-aged and I didn't have that when I was growing up. And so, I'm not really on social media, so I'm a bit of a cave dweller. But it feels like everyone's shouting and no one is listening on every side. 

AS: And obviously, our politics have picked up on that, and we have a politics, whether it's here or nationally, that emphasizes to people how different we are and how we're unable to communicate with each other. And I think it's easy to point to examples of that, that there's just no way I could ever find common ground with, you name the group. And I'm sure people would feel the same way towards me about my views. And then I walk into an exam room, and I meet someone, and I will find common ground with them. And it may be awkward, and I may say something stupid or something incorrect. And if I'm taking a sexual history, I'm going to botch it a few times and we're going to laugh. But there's the benefit of the doubt, and there's this intentional good faith effort to find common ground. 

AS: And I will say that whether it was being in Baltimore or being here, two very different areas in the United States, demographically, you name it, people are more alike and they are different, and we are all capable of finding similarities and ways to interact with each other, and yet, we somehow, I think it's encouraged by our politics and by social media, find ways to disengage with each other. So, I don't know that we changed the culture, but again, why did Orrin Hatch pass the Ryan White Act? He doesn't march at Pride, and that's okay. I don't need Orrin Hatch at Pride. But you know where we needed Orrin Hatch. We needed him shaking hands with Ted Kennedy back in the day, and he did, he did. And so, I'll meet him halfway there. I don't agree with anything the guy did, except for that. But that's fine, it doesn't matter. 

AS: And if I ever got the chance to talk to Senator Romney or his staff, he's got big shoes to fill. And he should be doing it. He's the guy that should be stepping up and saying, "You know what, Ryan White should include HIV prevention, and we'll end this disease," period. Hatch started it; let's finish it. Utah started it; let's finish it. It could be done. But I think... And that is itself a cultural shift, and I don't... I'm shouting into the wind or whatever. 

PW: Well, I know, I love the words, and I love the idea of finding common ground. And in fact, that's a cultural shift, it is for us all to do that, and I think all of us can work on that. So, what I'd like to do now is just move in and transition to our last topic, which is the future. And then for both of you to speak to that. So Ahmer, do you want to start with where do you think UAF, Utah AIDS Foundation, is going? And I want to throw this out at you, too: If we're successful at eliminating HIV/AIDS, if that's a realistic possibility for the future, which I also feel like it really is, are you okay losing a job?  

AA: Absolutely. I think that's interesting. In public health, it's one of the only professions where you go in to work every day and your goal is to put yourself out of business. And so, I'm more than alright with that. I will be happy, and I will... My goal as Executive Director at UAF is to constantly adapt. So, whatever that adaptation is and is needed, that's where we'll go. And again, RyLee's very in-tune with this, looking at our strategic plan, but that's what we're looking at, is: What does the next five, 10, 15, 20 years look like for us? And so, what we're looking at is expanding clinical services. Again, speaking to the PrEP Clinic and the success that they've seen there is we've talked about: What does it look like to shift the culture in Utah?  

AA: And I think where we're at right now, for us, that it makes sense that it means having more specific, concentrated areas of very competent providers in these unique spaces to provide clients and patients what they need. So clinically, looking at HIV care, prevention care, and then looking at mental health, and then focusing on the holistic side of: What does it look like, again, to thrive with HIV? Looking at nutritional services, looking at just general... A lot of what we do at UAF is just making sure people have social connections. 

AA: For the past month or so, I've been down in the Food Bank cause we're hiring. So, I've had the opportunity to run the Food Bank and just being down there and seeing the people that just... They can get by without the food, but they're there for the social interaction and the comfort. It's an intense weight of feeling that that's their only interaction for the week or for the month. So, it's one of those things I would be happy to be out of business, but there will always be something. And so along with those, I think we really want to be a center of sexual health and HIV excellence. And so, if that means having technical assistance for providers, individually, being able to train medical students, having people call in to our physicians or whatever that looks like, really, that's my goal, is to have a one-stop shop for clients, for providers, for public health, for anyone. 

PW: Excellent. I love the mention of mental health. I think it's something that often gets overlooked. And integrating mental health services into the clinical care we do, I think, is key and it's something I just non-stop talk about. So, thank you for those thoughts. Adam, what are your thoughts about the future of the PrEP Clinic and your work?  

AS: Yeah, well, as I mentioned, we're hoping to grow. We've got a lot of directions to go in and just expanding, in general. But I'll tell you, just touching on a theme, you're talking about changing culture. And one cultural change that I would love to see happen that I think is maybe more realistic than a broad American or Utahn cultural shift is a shift in the way we provide healthcare. And we assume it's normal to ask patients to figure out this Byzantine system of insurance and copays and donut holes and Medicare and Medicaid and state bureaucracies and pharmacy benefits, and we don't teach it in medical school. It makes absolutely no sense. It's incredibly wasteful. It's an embarrassment worldwide. Our healthcare is an abomination, from a financial standpoint. 

AS: But the bottom line in this one little area around PrEP, we've found a way, sustainably, at least for the time being, to provide PrEP to people, whether they can pay for it or not. And if they can't, then our colleagues, UDOH, again, led by Ahmer, were able to step in and help us. And we don't ask the patients about our UDOH contract or what page it is on that they should be paid from, or whatever. They come in and they get PrEP, and then they leave, and then they come back three months later, and they're fine. And they don't have to hear about the money. I don't have to hear about the money. We figured that out on the backend. And God forbid they get a job, they get insurance. We've had that happen all the time with both directions. You know what? They come and see me, we'll bill their insurance, and we get paid, and they leave, and they don't have to worry about the money, and they get the drug that way. 

AS: And so why do we put this onus on patients that they have to figure out the system and navigate it? I'd rather just give out healthcare, and let's figure this out on the backend, because we, in healthcare, have this enormous machinery to figure it all out. You know this. We're sitting in a building where people do this every day and figure out how to navigate and get paid. And I know we have to get paid; we're not doing this for free. But there's... But why do we put the onus on patients? And what that's doing is not letting people in the door. So, as we expand, that's my goal, would be able to provide HIV prevention services to everyone and figure out how to pay for it on the backend, and not burden them. Let's get them in. 

RC: I'm going to mention, I would be remiss if I didn't, because I worked on Medicaid expansion here in the state before I took this role at the University. And we talked about HIV and AIDS being a chronic condition that we manage, we talk about mental health. There's so much more that these patients and these community members need. And so, one thing, another community partner that has integrated into PrEP is the Utah Health Policy Project, and they actually... We bring in healthcare navigators to the clinic on the days that the patients are coming in and we help them. We ask, "Do you have access to health insurance? Do you need help with your Medicaid application?" Because now that we are an expansion state, really, the only individuals that should not have access to health insurance are those who are undocumented. Everybody else should qualify through their employer, through Medicaid, through the marketplace. Ahmer mentioned this before, but the PrEP Clinic is just this amazing conglomerate of just integration of community and physicians and access. So, I just had to say that. [chuckle] 

AA: One, RyLee, an important thing also is... So, Ryan White doesn't look at citizenship status. So really, when you're looking at HIV, there's no reason why someone shouldn't be receiving care and medication. There are little issues with Federal poverty level and things like that, but from a very scratching the surface base, everyone is eligible in some way. It's just making sure they know that. But also, these are very complex systems. To Adam's point, we have to switch that narrative of "Healthcare is a privilege," where we expect the individual to access that using their privilege. And switching the mindset of healthcare is a right, and making sure people are empowered to help other people. 

AS: Awesome! That's such an important point, and I don't think people hear that enough. And it's added into the debate, but there's a lot of shouting on both sides. And I think one way I've tried to frame it, because I've thought about this the whole time I've been in medicine, is this idea of a privilege versus a right. But I think another frame that may be helpful, we monetize things and we're in late-stage capitalism, and medicine is a business, and sports are businesses. And we talk about people's personal brands, and that makes me want to throw up in my mouth. But that's where we are. That's where we're at. And so, let's talk about medicine as a business. Let's talk about it as a market, as a service that is provided for pay, fine. Who bought it? Who paid for it? It did not drop out of the sky, carved on tablets. Medicine came from somewhere. Our system came from somewhere and is built, and is continually built, by something. Who paid for my medical education? Who pays for resident's salaries? Where does residency... Every doctor that is trained and licensed in this country, who pays their salary while they're in training? It comes out of... Do you guys know? It's Medicare dollars. Where did Medicare come from?  

PW: Taxes. 

AS: Who bought the system? Every one of us paid and is paying for this system. So, we want to talk... And I'm talking right, left here. "Okay, this is a commercial system, and you have to have a job to pay... " No, no, no, no, no. Who built the system and who paid for it? I did, and you did. So why can't I get access to it? I have to have the right kind of job or the right kind of access, and then I got this copay and all that. That is a bunch of garbage. And you really want to go into it, and you look at the salaries of the CEOs and the C-suite of the insurance companies, and then you get angry. And we're paying for people's second and third and fourth homes and boats. That's what we're doing with this system, and that's what's being protected. But where did modern medicine come from? The training, the technologies, the research, the vast majority, well over half of it was paid for by the US taxpayer, and they're not getting the benefits, so we're getting ripped off, big time. 

PW: Hear, hear. Excellent words, Adam, Ahmer. Thank you very much. So, what I'd like to do is just... Let's finish with just last thoughts. And RyLee, I'm going to start with you, I'm going to put you on the spot. Do you have any final thoughts as we drift to the end here?  

RC: I just... I'm hopeful. I think talking about access, talking about equity, these are things that I think I hear more and more daily as I work at the hospital and I work with C-suite leaders, and I think that there's a real emphasis on focus. And then hearing Adam and Ahmer today talk about how we could get to zero, it's left me feeling inspired to continue to do this work and to support this work. So, thank you, both. 

PW: I'm hopeful, too. That's the feeling I'm left with, and I don't know if that's what listeners will feel like listening to a device, but that's how it feels in this room. I want to make a little button on my jacket that says "Zero," you know, "Get to zero," like the moonshot, and that would be, I think, an awesome goal. Ahmer, final thoughts?  

AA: Yeah, I think just having these conversations are what need to happen in Utah. And so, thank you for the opportunity. But I think, really, again, like RyLee said, fighting for those things that we know work and just continuing having those conversations. And I think we have some lofty, but achievable goals. 

PW: And Adam, over to you. 

AS: Yeah, I always, I think of one of my sports heroes LeBron James who likes to say that teamwork makes the dream work. It's one of my favorite quotes. Emily and I moved here 10 years ago, and we love living here, and this is a special place, and people really do come together. And I think we've talked about cultures and difficulties and whatnot, and there's a lot that we have to overcome, but I am also hopeful. And I think this is a place where we could do something special together. 

PW: I'm also hopeful, like I said, and I want to just thank both of our guests. It's really... It makes me happy to be able to have people like this here in our community that would take the time out of the day to spend with us, talking about this important topic. I'm honored to have both of you guys here in this room to spend some real quality time getting into some depth on this issue, so thank you very much. 

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PW: Thanks to Isaac Holyoak, who you have not heard from, but he is right here in front of us. He's got a pair of headphones on. And he is the one that's putting all this together behind-the-scenes. And he's also going to help us with editing. This podcast will be distributed by Accelerate, University of Utah Health's online learning community. Check out Accelerate's work at www.accelerate.uofuhealth.edu. And Communivation, which is the name of our podcast, is available wherever you get your podcasts. Thanks for listening and see you next time. We've already got some wonderful topics bubbling, so I would encourage you to keep checking it out. Take care. 

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