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Jessamy: Hello and welcome to The Lancet Voice. I'm Jessamy Bagnall. It's February 2022 and I'm here with my co host Gavin Cleaver. Today we speak with Samuel K. Roberts, Associate Professor of History and Social Medical Sciences at the Mailman School of Public Health. We discuss the racialization of public health in the U.
S. taking a long historical view. As ever, please find us on our Twitter handles at jessamibagunal and at gavincleaver.
Gavin: Thanks Jessamie. So here's Jessamie and I speaking with Professor Samuel K. Roberts. about racial inequity and the history of public health in the USA.
All right, so Professor Samuel Roberts, welcome to the Lancet Voice, we're so happy to have you. I wanted to, kicking off with like the big subject, obviously we can't do this podcast without asking at least a few questions about COVID, so let's get that out of the way up front. But particularly you published this book, Infectious Fear in 2009, which looks at infectious diseases.
What's the pandemic been like for you viewed through the lens of this book of like your prior work?
Samuel: Yeah, I'm still trying to wrestle with that to come to grips with that. That book has gotten a renewed interest. I think their interest has always been there. I think people are still teaching it.
It came out in 2009. But, it's got a new audience, I guess is what I should say, after the pandemic, because the book deals with primarily the historical origins of racial health inequities here in the United States, and it covers more or less this period in, it's really a foundational moment, an establishing moment in American public health in the 1870s, 1880s, and I carry it forward to roughly the 1940s.
Forties into the early fifties, and this is a period that it's actually two historical periods, which on the surface would seem unrelated, but I make an argument that they're actually very much related. The first period is that of bacteriology and bacteriological discovery. From the 1870s forward, there's this, amazing period of activity where we're discovering the path of the pathogenic causes of a number of diseases, one of which is tuberculosis, which is one of the primary foci of the book.
But then there's this other period, which is more or less overlapping with that one, which is the period of what we in the United States called Jim Crow. This is very much your listeners, if they're not familiar with the term Jim Crow, I imagine they're certainly familiar. with apartheid. So it's the if one knows South African apartheid is basically the American variants.
And in fact, I've heard arguments that the South African variant was modeled in part after the American one. And that also begins roughly in the 1880s and starts to officially end in the 1950s, which is to say by court cases, we start to see this dismantlement By the 1940s and 1950s of Jim Crow segregation, all is to say is that the renewed interest or this new audience wants to know how long have these inequities been with us.
And I think they've been here. Since the founding of the country, really, but certainly in modern public health and law has not done. a good job of really ameliorating them. I don't think we can argue that the law is completely irrelevant to health inequities, but it certainly has not done anything that we had hoped.
And so those are still there. And so when something like COVID comes around, which reminds us that infectious disease matters, that if you really want to see, and I guess we don't want to see, but if, if you did want to see health inequities really show up in stark relief, In a very quick period of time, meaning an epidemic time, then infectious disease is really what does that.
That's what it's been like, and just really still coming to grips with it. These were, some of these questions were ones which were still, I think researchers are still grappling with them, but there are some that, I think a lot of us, particularly in the mainstream public, thought we'd put to bed.
Because after all, infectious disease isn't something that looms large. Until now, for many people, right? HIV is the kind of one outlier for that, but many of the scourges of humankind a century ago are, diseases that I think most people like under the age of 20 probably couldn't even spell or hadn't even heard of, right?
So it's like a historical reminder for those of us who might have forgot it.
Jessamy: Super interesting. I just wanted to pick up on your point about the fact that law hadn't done very much to, to combat those inequities and what you feel the balance or the weight of responsibility, where does that lie in terms of the public health and scientific community and the legal and justice community?
Because, one, one can't work without the other and both have been fairly, I would say, willfully blind to these types of issues.
Samuel: Yeah, I think that's a great question. And I wish I had a great answer for it, to be honest with you. I think that in, you were saying I think the word used is blame, attribution, or responsibility, and I think it's in multiple sectors.
On one hand, I think, and maybe in the first instance, public policy here when it is called upon to address inequities is fairly anemic. We just don't have the legal structures in place. This goes to health inequities, And health care disparities. Um, there's really not much of a basis of legal argument to say that if a community is underserved, there is a right of the people in that community to have better quality health care.
We don't really have that as a structure. Our environmental justice. Regulation is open to wide interpretations, and unfortunately, it does depend quite often on who is in office, meaning the White House, but on the local on the state level means who's in the governor's office so that if you have a more progressive administration, you might have a more robust enforcement of environmental protection environmental justice oriented policies.
If you have a administration that's more shall we say more free market capitalists in this orientation, more socially, politically and economically conservative, then you won't have that enforcement. So those are two examples. It's really a characteristic of our. Of our, of our political structure overall.
Gavin: Over the last two years of the pandemic, we were talking about health inequities, obviously. Has anything that's happened in the pandemic surprised you particularly? Or, I guess not surprised you, but so much as, has it played out as you expected with your knowledge of these health inequities and how infectious diseases exposes them?
Samuel: I think if the last two years have taught us anything, it's that we can still be surprised. And unfortunately, in this case, it's been You know, surprised, appalled, disconcerted might be better adjectives. There's things which did not surprise me. And then there's things which did surprise me, but in hindsight, weren't all that surprising.
It's just they weren't anticipated. For example, the announcement here in the United States, it was around April or so of 2020. So it was about, six weeks, six, seven weeks into the pandemic. came findings that black and Latino communities in particular, but also in certain communities, South Asian immigrants and Asian immigrants as well, particularly like here in New York, in the, in Queens, in the borough of Queens and Elmhurst, for example, but there are these communities across the country who are bearing.
In an ordinate burden of disease, morbidity and mortality in COVID. And I think for those of us, it's a small cadre, granted, historians of medicine and public health who specialize in those topics. That was not surprising. If any, if there was a surprise for me, it was that everyone else was so surprised.
But, this is something that I've been studying for a number of years now. And I have that advantage. So that was not surprising. Something that I was surprised about in hindsight, I guess now it's I wish I hadn't been the politicization of the pandemic here in this country and not, and to be fair, not just here, we've seen this, where you are in the United Kingdom, it's happening in Canada now and elsewhere where things that I think we all assume to be basic assumptions about good public health and also one's responsibility to one's Fellow, to one's, neighbors and fellow citizens those went out the window really with a simple political decision in the Trump administration to Pretend like the pandemic was not real.
That's all it really took. If had that administration not done that, I'm not sure that this would have been two years later, so politicized as it's, as it remains still, that was surprising and very disconcerting. So I don't know where we're still dealing with that. And honestly, I'm not sure what happens the next time.
something happens, which will obviously be soon. Whether it's a different, more virulent variant of COVID or if it's something else entirely, but it's going to happen. Our political culture, I don't think is really prepared for that. So those are two of the things that were not surprising and also surprising.
Jessamy: Just on that point, do you hold much? People are desperate to move on now from COVID 19, here we're about to. stop isolating. There's a real desire to forget about it and move forward. Which obviously we feel is probably premature, but that's the, that's the movement. Do you feel that movement to forget about the pandemic, to move forward will also mean that we gloss over many of the things that we've learned that have been highlighted so clearly by the pandemic, which have, been discussed and discussed, but we haven't actually had any movement on them?
Samuel: Yeah, I think as much as anybody, I want to forget this pandemic. Two years later, I still haven't gotten used to wearing a mask. Like many people my age, I wear eyeglasses, and if nothing else, I'm tired of my eyeglasses fogging up all the time when I go in and out of buildings to say nothing of, it's difficult to breathe or to read other people's facial expressions.
I am sick of this as well. But to go to your question, I do worry that Not that we will forget. I think we actually might have already started to forget some of the lessons that this has taught us, particularly vis a vis ethnic health inequities here in this country. Keep in mind that, just to give you a little bit of deep history on this, If one were making a, an argument in 1920 for civil rights, it's a very good chance that included in your list of reasons why American apartheid is a bad thing.
One of them would have been the physical health effects, diseases like tuberculosis, pneumonia. Whooping cough, particularly in infant and maternal, the gradient there was dark and undeniable in terms of the burden of morbidity and mortality borne by black people and particularly and also, working class and poor communities with the 1940s and after where we have treatments and, cures for these diseases.
We'd forgotten that it. That these were indices of inequality and inequity in this country. HIV came in the 80s and by the 90s we started to see HIV in those terms as being structurally based. But that's still, that's one condition which I think a lot of people still don't understand. Most people think HIV is something where it's about individual responsibility.
You protect yourself. You inform your partners of your infection status. We don't really think about it structurally mediated. In the way that COVID. Has been. And I think, we knew that in 2020 and 2021. I'm not sure we're going to know that in 2022. I think once we move on, it'll be business as usual, paying no attention to, differentials in health care, health attention, health surveillance, like there's a lot of conditions in certain communities.
We just don't even know when they show up because the surveillance is so just weak, really. Yeah, I do. I don't want to be a pessimist and we're, only trying to be. A few minutes into this interview, but yeah, I do worry about that. Just to me, I do.
Gavin: It is, when this, when the pandemic started, I remember Jessamy and I had so many conversations, amazed that people were suddenly talking about these issues of like deep inequity and how that was affecting the health of people suffering from the pandemic, as we've gone on, we've moved further and further away from those conversations, there's been this kind of hardening, hasn't there?
And there's almost the sense of. Back to business as usual now, putting it in the past like you were talking about, I think it's, um, maybe I'm being a little bit pessimistic now as well, but I think it is it's quite disheartening, isn't it?
Jessamy: I also think there's this tension, there's a tension between the sort of power structures that we have in place at the moment that can see that the pandemic has Shone a light on all of these things and has the potential to catalyze change in a way that would remove power from those people.
So there's that tension. And then I also feel that there's the tension of, the health community of liberal progressive types who we almost assume that the pandemic will move us in that direction, that it will move us towards more equality, whereas actually that's, that's not The natural sort of arc of history doesn't necessarily take us towards that you have to fight for that.
You have to make that happen. And I, I don't feel that there's enough of a focus about that at the moment. I don't know how you feel, Samuel.
Samuel: Yeah that's a great observation. It's something I've worried about, as well. Yeah, there's nothing teleological about this at all that we are not on some kind of, ineluctable march of progress.
Where, walking hand in hand with a virus, we will realize some sort of, you know, egalitarian utopia. That's not at all for granted. In fact, I would say present circumstances might mitigate against that as a possible reality in the near future anyway. I think in terms of our political culture, we do have to be concerned or at least cautious about how material events dramatic ones like this, the emergence, almost out of nowhere or seemingly out of nowhere of a virus, can really change our political culture in negative ways.
As people, we don't do well with fear. We often don't do well with sacrifice. We don't do well with the unknowns and our reactions can often be violent. They could be unjust, unreflective, uncountable, without contemplation at all. And I think in some ways we're, we've seen that and we should be cautious about that.
I think as you, if I think I'm hearing your question correctly, the implication is that there is something that we should, about which we should be cautious and an assumption that because this has shown us something, we will now act upon that thing. And that's not at all to be taken for granted. Even amongst, I think, our current administration here in the United States is certainly more quote unquote progressive than the one that preceded it, but.
I'm not sure that it is, particularly disposed to act, decisively and boldly on this issue that's been around for decades, meaning health and equity. So I'm not sure that a coronavirus spurs it into action in that way.
Gavin: What led you, and you mentioned it was such a small cadre, what led you towards this interest and, career in kind of researching medicine and researching public health?
Samuel: Yeah. There's a couple of answers to that. And the first one is the broader one. I came of age in the 80s and 90s and, intellectual age in the 1990s, I would say, where I was really interested in these questions about space and its relation to capital, right? How the space around us reflects our economic, political, and social organization.
And these were questions A lot of them originated in the United Kingdom. The kind of cultural Marx, Marxist cultural geographers were an operation that from the late seventies into the nineties and beyond. And those are questions of scale, right? When you're thinking about the social. And so it's a matter of time before you're thinking about how registers, how or scale will register in different ways, on the level of the human body the, and the level of, It exchanges between the individual and society and institutions and structures.
If that is your course of inquiry, then it's a matter of time before, you land in public health. A critical I'm actually not trained in public health. I did my graduate work at Princeton University, which, I had a wonderful experience, their wonderful education, but they actually do not have many professional schools.
I was not exposed to. Public health as a practice, except in a historical sense. And now I, I teach in a public health school and also in the history department and in an African American studies department. I have, that's been very rewarding. But also say is that I came to public health and history of public health and medicine as thinking about issues of power and space and scale.
In terms of my work in, my earlier work in the history of tuberculosis, It's a similar answer in the sense that, I came of, adult age in the or, my late childhood and, early adulthood in the 80s and 90s. in the era of HIV. And I think, as I became a historian, I discovered this community of scholars who were wondering, when was the last time we saw something like, HIV in a lot of ways was, is completely different after world, is in the post World War II landscape, historical landscape, it's a condition of its own.
And so a number of these scholars looked at tuberculosis, which was the last time we had a disease that was so stigmatized. Fear inspiring in terms of the way that people, just wasted away. This is, HF now you can, HIV is like a chronic condition. You can manage it and treat it and live a long, happy life.
But that was not the case in the eighties and early nineties. And so there were a number of historians who influenced me who are thinking about the history of tuberculosis. None of them really were thinking about black communities at all, except for Randy Packard's work in South Africa. But and that's where I came in.
Someone who was trained in African American studies, trained in African American history, and then, realizing a certain type of training at Princeton in history of medicine, public health, and technology and science. Those were the two, two of the axes, two of the crossroads at which I was working.
So that's how I got there. And I've loved it. I'm at a point now in my career that I'm not sure. Sometimes I can imagine doing something different or imagine a world where I'd taken a different choice, but I'm, I've been doing this long enough that this is my home now and I've really enjoyed it.
The questions for every one you answer, three more pop up. And then of course, then a pandemic shows up and now there's dozens of questions to be asked and answered.
Gavin: So how important is this kind of understanding of the history of racialization in U. S. neighborhoods when we're thinking about the history of health in the U.
S., when we're thinking about how to conduct health research in the future in the U. S.? And I guess as well, following on from what you just said then, what was research into health in the U. S. kind of missing before by not having this understanding of segregated neighborhoods?
Samuel: I would say in a certain regard, in our terms of, again, going back to our political culture, we don't really have that much of an understanding of segregation and its effects.
In popular parlance certainly those of us who do research in that area are, acutely aware those of us who grew up in the business end of those circumstances are acutely aware, but in our public discussion, I'm not convinced of that. I think it is, however, all important because I'm trying to think of the short answer for this, but there are ways in United States history.
Where issues of class, you could perhaps arguably say more intense now than they've been since the 1920s for, nearly a century. I don't think that's really a controversial statement. Issues of class in this country historically have often been put off into issues of race, right? We have a long and storied, tradition in this country of, divisions between black and white working classes because of racism.
We have a long and storied history of playing one group off of the other. We have a long and storied history of not thinking, comfortably about how, race and class are actually mutually constitutive. Not just mutually influencing one another, but actually constitutive of one another.
Those are both of those topics or both of those terms are just abstracts. They're, platonic ideals. In reality. You can't really talk about class, quote unquote, in this country without thinking about race and vice versa, I would say, particularly like issues, as you said, Gavin, of racialization, how events, ideas, topics bodies are ascribed a sort of racial, I was going to say pigment, but I guess, yeah, there it is, yeah, racially colored and how we think about them.
So I think it's all important. Will we ever get there? Because it's not a comfortable discussion. in this country at all. But then again, neither is class either. So I'm not sure where we go with that.
Jessamy: I guess I'm interested, with your with the expertise, the background that you've had, whether you see a major sea change now that there is.
A greater presence in public health and medicine of people who are from a different background that the sort of drive for inclusivity and diversity is working and whether you see a change in the way that we're doing research or whether you think that process is too slow or are we making progress?
Samuel: I think we are. Yeah. And I'm glad, I am glad that you did ask me that question because I. I am. Yeah, because we, yeah, we were going to a pretty dark place and rather rapidly, yeah. And I appreciate that. And in all seriousness, I think fundamentally I consider myself an optimist. I could not do the work that I do if I just carried like the cloud of pessimism.
Wherever I went, it's cautious and qualified optimism, but optimism just the same or some of the reasons that give me cause for that are, as you said, the changing composition of our medical public health and medical personnel, the professional class that's most involved in this, even in my career, which is, I'm mid career now.
I'm not, yeah. I'm not brand new, but I'm not a senior retiring member of the profession either. So even in my career, I've seen changes. If I gave lectures at medical schools 15 years ago, there would be a couple of people of color in the student body or in the audience, most of the faculty were not and the questions were often dominated by, the faculty who tended to be older white people, sometimes they would either not get the point or even just be hostile to some of the observations that I was making.
That is increasingly less the case these days. I'm not saying it never happens, but It does happen. Now you get, there's a change in culture in medical schools, from what I can ascertain, where, the students aren't expected to just sit by and passively receive audience, and also Recognition that they're worthy to join this profession.
They're actually more assertive in what they believe about their mission, which I think is, you know, incredibly, I don't like to use the word incredibly unless I mean it literally not to be believed it. Sometimes I find it hard to even believe the change that I'm seeing 15 years later, even faculty, I think, are are changing their orientation.
This has been slow coming. When you think of the literature on social determinants of health in this country or fundamental causes. It's. Or what we used to call racial disparities, racial inequalities. And now he's talking about, racial and ethnic inequities and structural inequities.
That's the literature that goes back to the, those terms go back to the late eighties. It's the heritage or the genealogy that goes back to the, a century ago. So it's been a while in the making, but what we're seeing now, I think is impressive and it has, I believe, accelerated in the past two years.
And some of that's about coronavirus, but I think some of it is. It's George Floyd, and it's not like police weren't murdering black people before that, but something about that just galvanized the world and not just in criminal justice, not just policing. You see it really in public health in the last two years, the structure of who is the voice in the face of a public health department.
Has changed schools and public health departments that never thought about having, or barely thought about having, offices of health equity. If they did, they'd be like these, almost shells and I'm not speaking of anyone in particular, but this, you see this, you did see this a lot.
These are actually now offices and individuals who have a voice and have a say and have a bit of power. And that's, yeah, I am optimistic about that. And unlike, where we have the kind of intermittent and, often, perennial amnesia that we see in this country. We learn a lesson and then we quickly forget it.
Power is different. When people have a foothold in power, they try not to let it go. So when you start to see, a health department that had you know, 1 percent black and latino staffing. And all of a sudden it's, 45 or 6%. That's ideally it will stay at that level for at least some time and that may even grow or at least certainly what the scope of their activities may grow.
So I think, um, there is cause for optimism. Absolutely. And then just to add something to that, and I know I've promised to give the short answer, and I don't think I've adhered to that promise once in this entire interview, but there's something else to add to that, is that at the same time, while I focus on the professional composition, the composition of our social organ, of our protest movements for a political organization has changed dramatically.
I think Black Lives Matter started as a response to extrajudicial and legal murder on, from white Americans and also from police. But taken literally, it's the idea that all aspects of Black Lives Matter. And so it rippled out, not just, I've been thinking for a while, it's not just about the right to not die, but the right to live our own lives.
On the same terms as everyone else does, to pursue our own happiness, to be able to, walk the streets on harassed and eventually, and part of that is to be able to go to a physician's office and get good health care, to not have things dumped in our communities, environmental toxins, et cetera.
So I think what happens in the future, I don't know, but I think there is some cause for optimism. Yes.
Gavin: In terms of supporting this optimism, what kind of changes would you like to see in public health and institutions like that?
Samuel: I think when you're a historian like me, you take, you tend to think of, history as in blocks of, 25 or 50 years.
And as a result, you think of macro structures. I'm honestly very concerned about our political structure. I think if we had a system in which, perhaps there was greater democracy, democratic input. That would, I think, have ripple effects into our healthcare system. Right now, we're not going in that direction.
We're actually in a movement to suppress people's folks, to disenfranchise people. That is, for me, a bit of a cause of pessimism. I think in a world where you have more people with more say in how the government works, then I think it's, not surprising to imagine that, they will have greater say in how their health is attended to.
Gavin: Which isn't a controversial thing to say, is it? The more people having the more say, it generally tends to make things better. But you're right, there's a backsliding there. Yeah,
Samuel: When you think of like the groups in this country who have, the worst health outcome, they're also the groups who are most alienated from the political process.
Like health care in prisons is horrible and by, by the way, not for nothing by a Supreme Court decision of some 40 something years ago, you must have, it's a right that you have health care if you are in prison, the ways that the rest of us outside do not have that as a right, it is supposed to be a right there and it's a right.
That means absolutely nothing. Health care health in prison is nothing. And, I might make the arguments that if they voted, right. They would at least have more of a say, but we don't allow people in prisons to vote, to have any sort of, input in their government.
Just because you've done something that society has said is something for which you should pay a penalty, I'm not sure it means the ultimate penalty of complete political erasure. These are still people who have health concerns. These are people who have children in schools. They should be able to vote about school issues about, for, for, on behalf of their families who have the same issues, that we all have.
That's just one example. So I think if we were thinking in a kind of macro structural and a long term perspective, what's best for our health, our public health, is public participation.
Gavin: So actually, I just wanted to finish up by asking you about the book that you're currently writing, which is on drug policy in the US in the mid 20th century.
What are some of the kind of really important lessons that you've That you've taken from that because it sounds like such an interesting topic and kind of a time period to research that policy from
Samuel: Yeah, the quite yeah that the book is about Addiction recovery, you know what we used to call rehabilitation and addiction treatment from the 50s to the 80s Which is basically the kind of the heroin years heroin shows up in the united states in the late 40s I mean it had been there before since the late 19th century, but in terms of epidemic levels in the late 40s And then I go through the early years of HIV and, needle exchange, harm reduction, et cetera.
The central question is we know that so much of drug policy and addiction treatment policy in this country has been racialized. You are more likely to go to prison on a drug charge. If you are black in this country, you're more likely to be arrested, more likely to be sentenced, more likely to get even a harsher sentence than someone sentenced for the same crime.
In short, how this country thinks about addiction at all levels is always inflected with race, right? You're if you're black in this country, it's almost presumption that you are prone towards. Abuse of a substance and uncontrollable, you know, hedonism of a sort. And so then the question is what does that mean for recovery?
What are your chances? What does recovery look like? And the question is confounded by a couple of things. One that, so much of our treatment historically has not asked that question. It's a one size fits all. And then on the second hand. We haven't done a very good job of defining recovery or rehabilitation in this country, except abstinence, it's if I think in a lot of places, today, and certainly historically, if someone said, yeah, I used to have a really bad drug problem, but now I'm rehabilitated or I'm recovered, the assumption is oh, I guess you're just abstinent.
Like you're just not using drugs. We don't ask any other questions about what recovery means. What does it mean for your own mental health? What does it mean for, how you engage the world, your family, your colleagues, your friends. It's just a matter of can you stop using drugs? Both of those problems are, I think, hinder us moving forward as we rethink, we're rethinking criminal justice over here.
We're rethinking how we think about addiction. We're rethinking how we think About treatment and harm reduction. We really need to think about the deep history of race and all of those. So I think that's the contribution that this book will make. It's been a long journey because it took me quite some time to realize that was the question.
But now yeah, I think that is the course, yeah, and I think that'll be the contribution, the question anyway. I think I might have some answers, but certainly I think the question will be worth the trip.
Gavin: And what do you think that tells us about kind of modern U. S. drug policy? I often think to myself that the drug policy of the 70s was actually probably a lighter touch than what we have now.
Samuel: Oh, absolutely.
Gavin: I think today
Samuel: you have more people embracing the idea that, quote unquote addiction is a disease. There's some problems with that theory. I think it's, as criminalization, absolutely. Is it actually a medical disease in the way we think of other diseases? That's still up for debate.
But certainly thinking of Taking a policy stance that substance use or uncontrolled or detrimental substance use is a disease is better than the assumption that it's a moral failing and a brand of deviance whose proper response is incarceration. Absolutely. And we're moving away towards that response now in ways that we were starting to do in the fifties and sixties as well.
The war on drugs is fairly recent. It's 50 years old. But in terms of our. Are the history of our drug policy, which is a century old. It's the latter half of that period. So yeah, I think we're moving in that direction. But I think as we do so we need to be cognizant of how we got here.
What were the assumptions built into the war on drugs that got us here? And a lot of those were racial assumptions. I think it's former members of the President Nixon's administration have gone on record saying, Yeah, we knew it was about race when we proposed a war on drugs. So we need to know how we got there.
It's not just about thinking, Oh, we need to be more sympathetic to people who use drugs. That is absolutely true. But a kind of deracinated approach to our drug reform only leaves the door open for us to continue down the path that we've been walking for all of these decades.
Gavin: That's it for this episode of The Lancet Voice. If you'd like to join the conversation, you can find both Jessemy and I on Twitter, and our handles are at jessemybagunal and at GavinCleaver. Thanks so much for listening, and we'll see you again in two weeks time.