Plain English with Derek Thompson - Abortion Pills Are a Game Changer, Plus Our Next Big Culture War

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Why the next phase of the culture war will be over, abortion pills.


I want to start this episode with a reading.

This is from a recent piece, in the Atlantic, by my colleague David from quote, the culture War raged most hotly from the 70s to the next centuries 20s.

It polarized, American society.

Dividing men from women, rural from Urban religious from secular anglo-americans.


From more recent immigrant groups, after a Titanic, constitutional struggle, the rural and religious side of the culture.

Imposed its will on the urban and secular side.

A decisive Victory.

Had been won and quote, the culture where he’s talking about is not abortion, it’s alcohol prohibition.


The 70s or the 1870s.

The 20s are the 1920s.

I have been thinking about this.

Passage all week is I’ve mulled over the Dobbs decision that overturned row.

I’m not interested interested in the moral equivalence here.

I’m interested in the broader Dynamic.


What happens when broadly popular rights?

The right, to drink the right to obtain.

A first trimester abortion are overcome by a successful and motivated.

Minority, Oh, prohibition is famous today, not just for Banning alcohol, not just for ultimately failing.


But also in this is what interests me, the most the difficulty of enforcing, the law, the way that Americans got around the law, the Bootleggers, the speakeasies, these two are the long-term Legacy of prohibition.

So what does it have to do with Dobbs?


What does it have to do with row and dozens of States?

Moving to severely restrict or ban abortion right now?

Well, in the news media I’ve heard a lot of people talk about how we’re Back to a pre row era, that’s not entirely true.

Because unlike 1972, we have something today that is a game changer or at the very least, a game Scrambler abortion pills medication abortions.


They are popular.

They are common.

They are safe.

They are hard to track and they are legal in more than half of the country.

So today, dozens of states are moving to Outlaw, most abortions.

And they’re also moving to Outlaw these abortion pills.

But Adding pills is a very different proposition than shutting down a clinic, a clinic exists in a physical location, it doesn’t move, it’s got one address Banning uphill that you can order online.


Banning a pill that moves through the mail that you can’t see on an envelope.

That is a lot harder and the lengths to which states would have to go to surveil packages or to spy on women’s digital activities.

In order to track down pill buyer here in a pill buyer there.


Those are invasions of privacy that will make a Of Americans, very uncomfortable, even those that want to reduce legal abortions.

So the very same way that prohibition coincided with a surge of extra legal activity.

Abortion pills today provide an opportunity for thousands of women to obtain abortions in red States.


I cannot help but see this, as the next battleground of the abortion culture War, it’s going to be the war over the pills.

Today’s return guest is Margo singer.

Cats of the New York Times.

Margo explains the 101, basics of the abortion pills, what they are, how they work, who uses them, who prescribes them, how states are planning to band them, why they’re so hard to ban and how they’ll change?


The abortion debate forever.

I’m Derek Thompson.

This is plain English.


Margo, welcome back to the podcast.


So let’s start with the basics.

What is medication, abortion?

What are abortion pills and what do they do?

So you know for a long time if you wanted to have an abortion, it was basically like a surgical procedure.


You’d have to go into an office and someone would have to remove an embryo or fetal tissue from your uterus.

That is no longer the case.

There are these medicines that will end a pregnancy without a lot of other medical interventions.

So the FDA approved a to pill regimen in the year 2000.


There’s one pill that blocks a hormone that’s necessary to continue a pregnancy.

And then A second pal.

And the second pill basically induces a miscarriage so it expels that embryo from work fetus from your uterus and the FDA says that that is a safe method of abortion up to about 10 weeks of pregnancy.


And this is a very common method of abortion around the world and in the US during the covid pandemic.

It became the most common way that women got abortions here in the United States and Europe.

It’s something like 75 percent of abortions are used are done with pills instead of with A journal techniques and in some parts of the world where abortion is not legal at all.


Pills are just like very predominant because as we’ll talk about more, they’re easier to smuggle and to administer illegally than other methods of abortion, even in Finland and Sweden.

Scandinavia they seem to account for 90% 90-plus percent of all abortions in those countries.


Can you pronounce the names of these two pills?

We don’t need to say them over and over again but I just want to make sure we have that on the record.


Well then Sound very similar.

So it’s easy to just very crystal is called Niva pistone.

And the second pill is called misoprostol, and I think to know about that second pill is that in addition to causing this carriages, it also is an approved treatment for ulcers.


So that is one of the reasons why these pills are so often used illicitly around the world.

That is a medicine that is widely available in almost every country of the world to treat stomach ulcers.

The miscarriage is basically a side effect of that.


But obviously researchers and activists realize that it could be used for this purpose.


And so now it’s used for both purposes and we don’t want people to confuse emergency contraception like, Plan B with the abortion pills which are prescribed to terminate a pregnancy not to block fertilization.

They are not the same so when can these pills be used?


When does the FDA say that these pills can be used?

Are there other health organizations like the World Health Organization that has different guidelines.

So there are Islands are depending on where you live in the world, but in the United States, the FDA says, basically you can take these pills within the first 10 weeks of pregnancy.


So you have to actually be pregnant in order to get prescribed, these pills the later into pregnancy.

You get the greater the likelihood that there might be some kind of complication and so the FDA in their research felt that 10 weeks was a really safe and effective period where those pills would be the most appropriate.


And how do people get abortion pills prescribed?

So there’s of course the legal System for the provision of abortion pills.

And the first medicine, the one that stops the pregnancy from developing is kind of more tightly regulated than most drugs in the United States.


So, the FDA has like a special set of rules around that pill.

And so you have to get special training as a prescriber in order to prescribe that pill and so that means it like not every doctor in America can give you, abortion pills generally, these are providers who this is a kind of crucial part of the practice.


So it’s like a worth getting certified.

And getting this special training.

So generally speaking, you have to either see a doctor in person who has this training or you can get it by telemedicine.

So you could do you know video or phone consultation with such a doctor and then you could have those pills mailed to you.


We’re going to talk about this a little bit later but there are so many more pharmaceutical companies that have gone DTC direct-to-consumer.

How exactly does that work?

Do you have a Telehealth appointment with a doctor that is associated with that company?

And And then they will send you the pills in the mail.


That’s exactly right.

So it used to be the case until very recently that this first pill was not allowed to be prescribed using telemedicine, so you had to go to a physical appointment and I think that’s part of the reason why the use of pills is was lower in the United States than in some other parts of the world because we’re going all the way to an abortion clinic and you had to actually take the pill.


They are right in front of the doctor.

Maybe you would rather have a procedural abortion if you’re going to go to all that trouble, but the Biden Administration during The pandemic temporarily lifted, that rule, and then after seeing how it went, they decided the FDA decided to permanently lift that rule.


And so now these pills are available via telemedicine.

And so now, there are these startups that, like, just do this, they do telemedicine abortions, they have to operate, of course, in states where telemedicine abortion is legal.

So even though the FDA said it’s okay, some states. 19 states have banned this way of administering, these pills, But there are these startups that are basically just specializing just in doing this.


And I think they’re seeing a lot of growth lately.

So there are us companies that mail these pills legally and you need a live doctor’s appointment or a telemedicine appointment to get that regimen.

But then I’ve also read about European companies that basically do the same thing.

Like European pill providers is that legal, it’s in a weird category of thing that is sort of illegal and sort of legal so you know in general the Approves medicines and the state’s licensed, medical doctors and you know you’re supposed to get your medicines that are prescribed by us position that are dispensed by a us Pharmacy.


And you know, we see examples of people kind of getting around this all the time where they’re ordering, maybe from Canadian pharmacies or people, you know, just Googling like where to get viagra pills.

You know, when they get spam and who knows what they’re getting or where it’s coming from, I think this is a little bit in this category.

I spoke with Rebecca gompertz.


She’s the Dutch Doctor Who runs this organization called Aid access.

So that’s like the biggest of these online overseas.

Abortion pill providers and she says, you know, she’s talked to her lawyers in Europe.

And the Dutch lawyers say she’s not breaking her country’s laws and she’s providing the prescription and then she works with a pharmacist in India and he mails the pills to these women.


And he feels, he’s not running afoul of the laws in his country.

But again, you know, most of these laws Banning abortions Not punish women who try to end their own pregnancy.

So the taking of the pills we don’t think is really a crime in the United States and yet it is not really legal, it is not the same thing as getting a medicine that is prescribed by us doctor and dispensed by us Pharmacy.


And in fact the FDA wrote a very angry letter to Rebecca gompertz and told her that what she was doing was inappropriate and she should shut it down.

She basically ignored that letter and it’s just not really clear what the next level of enforcement look.

Looks like, but do you think she’s a pretty reputable actor in this space?


But there are lots of other pharmacies.

They’re just, you know, you’re just Googling abortion pills and it’s some Pharmacy in India and you’re ordering these pills and women don’t really know what they’re getting.

This is pretty complicated, but I think I got it.

The European pill providers are technically illegal everywhere in the US but they’re still rather popular and the u.s. abortion pill providers are now illegal.


In many of the red It’s but they are also still potentially popular.

I want to move on to the law itself.

These many red states with the trigger laws and these new laws on the books that are Banning abortions.

What are they doing regarding abortion pills?


So I think the most important thing that they’re doing is they’re basically saying all abortions are illegal in our state so that includes medication abortions.

But then separately a lot of states have had additional laws that they passed where they’ve said also no telemedicine.



So it’s a little bit of a belt-and-suspenders approach where they’re saying you cannot do this in our state and you cannot do it by contacting a provider out of the state and have the pills mailed to you in our state.

So in general, the states that are allowing procedural.

Abortion are also allowing telemedicine abortion and the states that are trying to ban abortions are really trying to ban all the forms of abortion.


So this is where I become very confused, I become very confused.

When it comes to the enforcement of The rules that ban getting pills in the mail.

Like I understand laws that shut down abortion clinics, you go to the spot where the abortion clinic exist, you say, you can no longer operate.


We will sue you out of existence but these states are Banning pills that are often legal a couple hundred miles to the North or the South they’re banning pills that can be sent by national pharmaceutical company by European direct-to-consumer pharmaceutical companies.


And more Pharma is moving direct to Consumer.

Like you know there’s ads are all over TV like you know hey guys losing hair, sign up now get your first pills, these kind of companies are growing and growing so with all of this happening, how are these states planning on policing?


The interstate transport of abortion pills?

Well, I think there are two answers to your question that are both important.

So one is in general, when you look at state laws, that are trying to ban abortion of All Sorts, they really are placing the Majority of the penalty on the person, providing the abortion, not to the woman who’s receiving the abortion.


So, in general, you know, if you live in one of these states where abortion is illegal, you as the person who obtains an illegal abortion are not going to be subject to prosecution.

But whoever gives you the abortion whether it’s a car, you know, license doctor or some unlicensed person that person would be subject to prosecution.


And so these bands on pills kind of operate in the same way where they’re basically saying, you know, if you’re a doctor in Edit and you want to provide abortion pills to a patient in Texas.

You would run afoul of this Texas law in Texas.

Might try to prosecute you.


So that’s that’s one.

And then the other is I think that you make a really good point which is that if you are a patient and you can figure out a way for someone to send you these pills, even if it is technically illegal for that person to give them to you.

It’s pretty hard for the state to regulate you receiving them and most of the state law, Make it very hard for them to prosecute you for using them and so I think that’s where we’re going to start to see a kind of illegal or sort of I sometimes called extra legal abortion that we, of course did not have before Roe versus Wade, you know, before Roe versus Wade, all abortions were Surgical.


And so we have this model of like, what is an illegal abortion and it’s always someone doing something to a woman or in some cases doing something to herself.

I think this is this is sort of a different kind of illegal abortion, which is like, can you just get up hill from someone?

Who is not a licensed medical provider.


And we already see around the world and in the United States, that people are ordering abortion pills online from overseas pharmacies, and they are ending their own pregnancies at home.

So I think what we’ll see in the future is, I think it’s unlikely that US based doctors for the most part are going to deliberately run afoul of these state laws.


I think, you know, we’re not going to see a lot of doctors in one state.

Telemedicine appointments for patients, in a state where telemedicine abortion is banned.

But I think what we will see a lot of is patients ordering pills from other countries where it would be much harder for the State of Texas.


For example to go after the person who is writing the prescription and sending the pill.

And I think we may also see kind of more informal networks of people helping each other.

You know, maybe a friend gets the pill and gives brings it across state lines to you.

You know, the second pill that I mentioned the one that Causes a miscarriage is available over the counter in Mexico and so we already see a lot of women living close to the Mexican border will sometimes cross the border and go buy those pills and then you know, bring them back and take them in the United States.


So there’s going to be a kind of illegal abortion using these pills.

I kind of smuggling that is really different from what illegal abortions looked like in the past, I totally agree that smoking is going to be an aspect of this that the extralegal reaction to the laws.

Going to be a huge aspect of this David from at the Atlantic wrote that there’s ways in which this is Innocent of prohibition that after the prohibition Amendment.


It’s not as if American stop drinking entirely, they often got around laws by forming, extralegal networks of or explicitly illegal networks of bootlegging alcohol into some places barely adhering to some laws.

I just got a cocktail at a place called in in Manhattan called rains law room and rains.


Law was the law in the 1920s.

I believe in New York, maybe just before that.

It said that you can’t serve alcohol in a hotel in less in any establishment on Sundays unless it’s a hotel and it’s also serving food.

And so all these little establishments would pretend to be hotels and they would serve this, absolutely terrible sandwich that they were only serving in order to serve the alcohol.


And you just see that the marketplace essentially, contorts itself to serve the consumer interest and that’s to a certain extent.

While you’re describing here to Quick, follow-up questions about the scenarios that you’re painting.

Number one, and this is a little bit Grizzly, but you mentioned The FDA has approved a to medication regime regimen, the first drug blocks, the hormone progesterone that’s necessary for the pregnancy to continue and the second drug brings on the contractions.


That’s the one that’s used for ulcers.

If the second drug is legal over the counter for ulcers, is it possible that will see women try to use just that for abortions?


And is there evidence that just the second drug has been successful for abortions, that that is essentially the way that some of these medication abortions are bootlegged around the world.

This is a very common way that women and their pregnancies, this second drug does succeed in During pregnancies at a very high rate used alone.


So, you know, there are various studies of this, but there are some researchers who say, you know, 90 95 percent Effectiveness with just the single pill, the studies that were done in the United States.

When the two pill regimen was first approved, sort of did a little bit of head-to-head comparison and what they found is in u.s. patients in the u.s. medical system.


The second pill loan only completed the abortion in like 80% of patients.

And so there was a pretty Substantial minority of patients who then would end up having to go back, go to the hospital, go back to an abortion clinic and get some kind of surgical procedure in order to complete the abortion.


And so the FDA didn’t feel like that was effective enough to approve on its own, but I think you do raise a really interesting question, which is, that is a drug that is FDA-approved for another reason, any doctor in the United States can prescribe it?

And currently the law is that if you are a doctor, you can prescribe FDA-approved medicine.


For what are known as off-label uses.

So you don’t have to just prescribe them for the thing that they were approved for.

So I do think theoretically, we could see these pills being prescribed to women for these reasons.

And I think we also could see again that pill is easier to smuggle across the border from Mexico and particular because it’s very easy to obtain there.


So, I am interested in this question.

Whether what we will see our women, the United States sort of sticking with what the FDA says doing the two pills or whether We will see more American women, serve choosing this one pill option, which is a little bit.

Less effective potentially a little bit less safe, but widely used throughout the world and perhaps a little bit easier to access.


I think you get exactly the vibe that I’m trying to raise here.

I’m definitely not suggesting that people do something.

That’s not FDA-approved.

I’m just trying to be realistic in an environment in a state where it is impossible to get an abortion in that state where it’s very difficult to maybe to travel outside of that state.


You know, it is made populi aware that you can tell your doctor that you have an ulcer and get access to this pill.

That has a certain likelihood, that’s, you know, 70, 80, 85, % of relatively safely inducing an abortion.

It just seems like this is the sort of thing that we’re likely going to see unless people start cracking down on this.


This also medication specifically Another layer here on enforcement is this sort of mildly dystopian Frontier of digital tracking?

Lots of Stories, the New York Times about digital surveillance and I want to quote from one that I read.


That was a really, really just shocking story.

Quote, latice Fisher, a Mississippi woman who was charged with second-degree murder after he still birth at home in 2017.

According to a local report investigators downloaded the contents of her phone including her internet search history, Three.


And she quote, admitted to conducting internet searches including for how to induce a miscarriage and how to buy pregnancy, terminating medicine online and quote after significant public attention, the case against Fisher was dropped.

That’s, that’s pretty harrowing what kind of digital surveillance is being talked about in a way that would enforce these laws.


That ban abortion pills.

Well I think there’s certainly a lot of fears about this kind of Digital tracking and you know digital investigation.

I will say right now most of the laws that ban abortions as I said are really focused on the provider of the abortion.


I think they are less focused on Prosecuting women and we have seen, I don’t want to downplay this truth that we have seen cases throughout the country.

In the last few years where women are prosecuted on murder, charges associated with these miscarriages, but that’s like a pretty novel legal theory.


That is not an abortion law.

That is a law against Marriage.

And I don’t think very many of them have succeeded, but I think that we have to imagine now that there is no constitutional right to abortion, whether women are going to be subject to criminal penalties, if they obtain abortions is really a political question now, so that’s not a legal question.


I think it’s safe to say that many of these state laws.

Do not punish women now but there’s really nothing other than political pressure that is stopping state.

Legislators that want to continue to restrict abortion from imposing.

Posing criminal sanctions on women in the future.


And I do think as you say, there are many tools that could be useful in mounting, those kinds of Investigations and prosecutions Because the Internet is something that didn’t exist before Roe and does exist.

Now and also I think is really a crucial tool in women learning about abortion, women finding abortion providers and if they are trying to obtain these pills outside the US Healthcare System where they’re ordering them online, And because it’s a political process, there will always be this tension people.


That are very fervently, pro-life will do everything they possibly can to Outlaw every possible abortion.

But when the most common way that people get abortions is by ordering pills that pushes the pro-life movement into various policies like digital tracking, and digital surveillance and monitoring the mail and bringing lawsuits.


Against people that live in other states and other countries, it moves them into extreme actions that I think are going to incur a kind of blowback.

And so this is the tents that I’m just really interested in looking out for for the next few years.

We know what politics is like over the last 50 years.


In a regime under row, we don’t know what Republican especially, very conservative Republican politics.

Looks like in an era after row were the state legislatures are going to move.

Right right, right.

And then National Republicans will have to comment on the most conservative anti-abortion policies and I think there is real division in the anti-abortion movement in America about how far to go.


I think there are some actors in that space who really their goal is the abolition of abortion.

They think abortion is a terrible moral wrong and that all abortions need to be stopped.

And that the law should go as far as is necessary to prevent all abortions.

And I think those people are much more comfortable.


Terrible with laws that potentially punish women who obtain abortions for doing so.

But I think there are also people in the pro-life movement and in Republican politics who are identified as very strongly anti-abortion who feel again that that is you say is not really a politically helpful place to be that Americans will not like that.


And so I think there are other anti-abortion activists who think that these laws that are just trying to focus on the providers of abortion.

Criminalizing, the provision of abortion will.

Do enough to end and stop abortions and that the law should not go further than that in try to predict the future.


I want to talk a little bit about Texas, the Texas recently, banned all but the earliest abortions in a law that passed last year and the number of legal abortions in that state fell by half.

But as you reported the number of abortions among Texas, women declined by much less, it declined by just 10%.


And I looked at the data, Acted by Texas policy evaluation project and Jama Network.

And it looks like about half that Gap was filled by legal abortions obtained, in other states and the other half was filled by abortion pills.

So, I wonder what you think the Texas case tells us about the future of abortion in America and how women who want abortions.


But live in red States, will try to access them.

I think the first thing it tells us and perhaps the most important thing, it tells us is that Men who want abortions are pretty motivated to obtain them.

So Texas passed this law that said that you could not have an abortion after fetal cardiac activity, could be detected that’s around six weeks and most pregnancies.


And, you know, that law by itself stopped about half of the abortions that had been previously happening in Texas, but those women who wanted abortions and no longer could get them in Texas, really worked hard to try to find an alternative route to abortion.

And I think the two methods that we measure that, we We saw they used are very likely to be the methods that American women in this kind of post Dobbs world are going to use as well.


They’re going to travel to states that where abortion is legal to obtain abortion, from license, medical providers in the US healthcare system, and then the other technique that they’re going to use is they’re going to order these kind of extra legal.

Abortion pills online from foreign countries where the enforcement of the laws are much more difficult for these states.


The It in Texas was about half and half.

There were slightly more women that were traveling than were ordering online, abortion pills.

I think it’s an empirical question, what is going to happen, going forward?

But I think there are reasons to think that the split May, ultimately skew more towards these overseas pills and less towards Interstate travel for two reasons.


One is that, you know, right now it’s not just one state that is restricting abortion but we have, I think there are nine states right now where abortion is already not available and There could be as many as 26 that are looking to ultimately be an abortion and so that means that women have to travel much.


Further, many women won’t have an abortion available in a neighboring state anymore so they would not just have to travel out of their own state but perhaps travel across several States and also the states that are continuing to offer.

Abortion are going to be very overwhelmed by these many women who want to travel in there.


May not be appointments that are available for a procedure.

That is very time-sensitive.

You have a limited amount of time in which to obtain An abortion.

So I think there’s going to be this problem of like mismatch of supply and demand for out-of-state clinics and also just the ordinary difficulty that women face traveling because it’s expensive and it’s time consuming.


And it’s inconvenient, it requires childcare and missing work and all of these other challenges.

And then the other reason that I think these overseas pills, may become more popular is because I really don’t think a lot of American women really know about them or no, I was just gonna say that.


Yeah, exactly.


That is just becoming more widespread.

There are more organizations that are trying to spread the word about this.

There is more discussion of them in the media and conversations like what we’re having right now and I think as more women obtain abortions in this way, they’re going to be more likely to tell their friends about it as well.


So I think that we’re going to see that poor unless there is a very effective means of shutting these overseas providers down if the state’s get very clever about how they’re going to enforce their laws, maybe that won’t happen.

But I think there’s a lot of common sense reasons to think that that is going to be Very substantial form of abortion in this post-ops world.


I have one last big question for you and I don’t know if this question is going to upset conservative listeners or liberal listeners more, but I’m just going to ask it and hope that people understand this Spirit of curiosity.

Here is it possible that we the news media the entire country is under rating.


Just what a game changer.

Abortion pills are like this technology is so hard to regulate as long as the pills.

Are legal that.

I just don’t understand what a conservative ruby red state would have to do in order to shut it down.


Entirely you have European providers.

You have National providers.

You have the possibility of people ordering the pills in a blue State and then sending it to a friend or cousin or acquaintances in a red State.

There are simply so many ways to move a legal pill into a state that I just don’t understand the enforcement mechanism that would be.


I didn’t order to shut this down.

I frankly can’t imagine anything.

It would be that successful short of a republican becoming the president and forcing the head of the FDA to basically shut down.

Both pills entirely mean what would a pro-life movement have to do realistically to stop abortion pills from making up the entire difference?


I do think that this is a very transformational technology for many reasons, but I think in large part because as you say, it’s just very hard to sort of hard to track and surveil and prevent in the same way that medical procedures happening in a medical office are.


But we will see, I mean, I, you know, if you speak with folks in Texas, you know, they have this law that provides legal liability for anyone who AIDS and events and abortion.

And so they’re trying to figure out could we go after the internet service?

Provider could we go after the, you know, the Google that’s providing search results for these websites?


I think they are Going to think pretty creatively about how they can shut down.

These marketplaces for online pills.

And again, I think they do depend on the internet.

So there is some possibility for enforcement or for making these Services more difficult to access, but I do think that it really does make the post real-world, quite different than the pre-roll world because it’s just the nature of a legal abortion is so different to go back to what I was saying earlier.


It just seems like the lengths to which If a republican legislature would have to go to.

For example, try to stop Google from publishing any results on its front page about abortion pills, you know, trying to sue doctors, you know, or bring felony cases against doctors from out-of-state, trying to find some way.


I suppose of going through, maybe individual women’s phones to look at internet search history, the lengths to, which you have to go in order.

To shut down something like getting pills in the mail.

Just seems to me so intention with electability that, like, you already are operating in a country where the majority of Americans support, the majority of abortions happening in the first trimester, but to also have to prevent abortions by not just shutting down clinics but by running this kind of enforcement Dragnet that forces you to be a digital spy in a Google sewer it It seems very very, very hard to stop this wave.


I mean, I think it’s a very interesting question and we’re going to see the nature of a politics at the state level is such that I would not be surprised if certain states, do pursue these kinds of strategies if they feel like it will help them prevent more abortions.

And I think the political cost of those kinds of aggressive measures May differ, depending on the political climate of the different states, very well put Margo.


Thank you so much.

Thanks for having me back.

Thank you very much for listening.

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