Got yeast? (Transcript)
Body Stuff with Dr. Jen Gunter
Wednesday, June 1, 2022
Dr. Jen Gunter:
So you’ve got an itch… and it’s not going away. You think you might have a yeast infection… a vaginal yeast infection. If you go to your local drugstore looking for a treatment, you’ll find all sorts of products…
There are wipes doused in aloe. Anesthetic sprays or creams. Even herbal suppositories that are marketed as “all natural.” And then there are the probiotics, those oral supplements that claim to protect against yeast infections by balancing your vaginal pH. You’ll also find a whole section of medications known as vaginal antifungals… Or you can call your health provider and maybe even ask for treatment over the phone…with so many options to choose from, it can be a little overwhelming!
So you’ve got an itch. What should you do?
I’m Dr. Jen Gunter. And from the TED Audio Collective, this is Body Stuff.
There can be so much confusion in diagnosing and treating yeast infections. People get the wrong information online, or even from their doctors. And then there’s a long list of supposed “yeast cures'' that seem pulled straight from the Journal of Old Wive’s Tales.
Listen, fungal infections - and a yeast infection is a fungal infection - are tricky! Particularly the ones that don’t respond well to medication.
So in this episode: What’s the deal with yeast and other fungi in the body?
[00:01:39] Dr. Jen Gunter:
We’re going to talk a lot about vaginal yeast infections today – because…DUH! I’m a gynecologist! But yeast and other fungi can cause infections in lots of places in the body… the mouth, esophagus, folds of the skin, toenails, and even the bloodstream. Fungi tend to get a bad rap when it comes to our health… So before we go deep on vaginal yeast infections, I want to start with a little Fungus 101. I talked to Dr. Johanna Rhodes, who’s a genomic epidemiologist at Imperial College London. She studies lots of fungal infections in humans.
[00:02:16] Dr. Johanna Rhodes:
Things like cryptococcus neoformans, Aspergers fumigatus and candida auris.
Dr. Jen Gunter:
So I have to say, I always think that, the names of yeast to always sound like magic spells.
Dr. Johanna Rhodes:
They do a little bit. Don't they? With fungus. It's a little bit like you still get people going out exploring and finding new fungus all over the place. And people, people who go off and find fungi , we're all pretty eccentric.
<MUSIC IN >
[00:02:44] Dr. Jen Gunter:
Fungi are pretty wild… they can be microscopically small, or form huge networks that sprawl for miles. Fungal cells are different from bacteria. They’re more complex… and much more closely related to humans. We've even borrowed some strategies from fungi to fight bacteria – Penicillin, for example, is a compound that the fungus Penicillium uses to defend itself from bacterial infection!
[00:03:13] Dr. Johanna Rhodes:
I think the coolest thing about fungus is that they have so many different life cycles. And they can just basically, whatever the circumstances they can make it work and they can reproduce. They can adapt extremely well, and without them, we wouldn't have life on this planet.
[00:03:32] Dr. Jen Gunter:
Right. I think that's something, a lot of people don't understand how essential fungus is.
It’s normal for fungi to live in and around our bodies; all healthy humans have them in their microbiome – that’s the system of microscopic organisms, like bacteria, that live in and on the human body.
Researchers are still figuring out all the roles and interactions of the organisms that make up our microbiomes, but we know that as a whole, the microbiome is important to our immune system and our digestive system… A healthy microbiome – including the fungi – helps us a lot!
With that in mind, let’s <MUSIC OUT> zoom in on the vaginal microbiome.
[00:04:18] Dr. Paul Nyirjesy:
The vagina is not a sterile environment. There are bacteria that are there normally, and yeast is part of the environment of, of different organisms that can be in the vagina.
[00:04:27] Dr. Jen Gunter:
Dr. Paul Nyirjesy is a professor of obstetrics and gynecology at Thomas Jefferson University. And he’s the co-director of the Jefferson Vulvo-vaginal Health Center.
One important point to get started with is yeast is often normally present in the vagina.In one study, researchers collected regular vaginal swabs from women for a year. These women had no symptoms of a yeast infection… but at any given time 20% of the swabs tested positive for yeast. And by the end of the year-long study…
[00:05:03] Dr. Paul Nyirjesy:
85% of those women ended up with at least one positive culture during that time period. so, so, and, and these were asymptomatic women, normal, healthy women. They had no idea it had happened most of the time, the yeast went away with no treatment whatsoever, but it was just there.
[00:05:18] Dr. Jen Gunter:
Yes, yeast is often in the vagina without any symptoms… just hanging out as part of the microbiome, not causing any problems. <MUSIC OUT (Coffeehouse)> Like me, Dr. Nyirjesy says he doesn’t worry much about it unless people are having symptoms.
[00:05:34] Dr. Paul Nyirjesy:
And so the most common symptoms associated with yeast are actually itching and irritation. and then the kind of the discharge that everybody hears about is actually relatively uncommon and not a helpful indicator as to whether or not a woman has a yeast infection.
<MUSIC IN >
[00:05:50] Dr. Jen Gunter:
I want to underscore this point, because it’s a common piece of misinformation: discharge is not a reliable indicator of a vaginal yeast infection. But burning and itching? They can be symptoms of an overgrowth of yeast.
You might have also heard yeast infections being called candidiasis. Which is in reference to the most common yeast found in the vagina, candida.
The populations of bacteria and yeast in your microbiome typically keep each other in check, with a little help from your immune system. This is a tightly controlled ecosystem, like a garden. And just like a drought or an invasive plant can change a garden, a change in the immune system or a new microorganism can throw the vaginal ecosystem out of order.
For instance, taking antibiotics may affect the ecosystem in some cases. The theory is that antibiotics kill off vaginal bacteria and this disturbs the microbiome.
And estrogen levels may play a role too — estrogen-containing birth control pills can increase the risk... and yeast infections typically decrease when people reach menopause. Pregnant people seem to get slightly more vaginal yeast infections. Maybe because of an increase in estrogen levels…or maybe because parts of their immune systems are suppressed.
The truth is we don't really know WHY these factors could change the ecosystem. Remember, the microbiome is still a bit of a mystery.
Another big mystery is recurrent yeast infections … when symptoms go away during treatment, but the infection comes back after the treatment is complete… Going back to our garden analogy, it’s a bit like a weed that you can never quite get rid of.
<MUSIC OUT )>
[00:07:40] Dr. Paul Nyirjesy:
This is a problem that happens primarily in normal healthy women. And the way that I explain it to them is that the, the thinking is that there is something very subtle about the local immune system of the vagina that makes it easier for the yeast is there to keep causing infection.
And so she's going through cycles of getting better with treatment, but not quite clearing the yeast. Over time, the yeast starts up again, starts causing another infection and it becomes a pattern of infection getting better with treatment, relapsed to the infection, getting better with treatment, and that the underlying reasons why this is happening are not well understood.
[00:08:24] Dr. Jen Gunter:
The good news is even though we don’t quite understand why this happens, we do have great therapy.
Currently the standard is to treat people with an oral yeast medication called fluconazole… they stay on it for 6 months or even longer. Most experts, like Dr. Nyirjesy and I, treat our patients for up to a year. They take a pill once or twice a week. At the end of a year we stop the medication to see if the imbalance that allowed these recurrent infections to happen has resolved. Just under 50% of people will be yeast-infection free with a year of treatment. For those who have a recurrence, this therapy can be continued for longer periods of time.
Because the vaginal microbiome is still a bit mysterious… and because we don’t quite understand everything that can trigger a yeast infection… and because there are plenty of non-scientific theories …. there’s no shortage of “advice” for how to prevent a yeast infection.
A LOT of it focuses on changing your diet like avoiding foods made with yeast, such as beer…or bread… Another popular one is avoiding sugar!
But none of these diets are based in science…and the vagina is actually full of sugar. It feeds the good bacteria! All this bad diet advice doesn’t help people… and it often hurts them.
[00:09:48] Dr. Paul Nyirjesy:
I, I can't tell you how many women I've seen over the years with recurrent yeast infections who have talked actually with a fair amount of bitterness about how tough it is to go on these, uh, anti-yeast diets.
And, and actually I've had more than one, um, sob tears of relief when I tell them that they can eat what they want and do what they want, because it doesn't seem to make a really big difference.
[00:10:12] Dr. Jen Gunter:
Yeah. I had one very poignant interaction like that, where I told someone that she could just have a slice of chocolate cake and she just started sobbing. And I just felt so badly for her.
[00:10:25] Dr. Paul Nyirjesy:
Yeah. And so imagine the frustration, first of all, that these diets are really tough to follow. And then secondly, it's not helping anyway. And then some patients kick themselves cause they say, oh, well, you know, it must be because I'm cheating a little bit on the diet and this is my fault. Um, and so then it starts generating all this guilt that she's doing the wrong thing, but she was given the wrong advice in the first place.
[00:10:46] Dr. Jen Gunter:
There’s even a study where researchers measured glucose levels in the vagina after people ate a bunch of sugar. And surprise surprise, there wasn’t a change in the glucose in the vagina at all.
Then, there’s probiotics.
A lot of conversations about probiotics are for gut health, but other people take them to try and cultivate a healthy vaginal microbiome. The problem is, we’re still figuring out exactly how the microbiome works… and if the vaginal microbiome is even affected by diet and probiotics.
Because there’s no good science behind taking a probiotic pill for vaginal health, it’s pretty likely that you’re flushing your expensive probiotics right down the toilet.
[00:11:32] Dr. Paul Nyirjesy:
So if you look at the guidelines from both the CDC and also from the American college of OB GYN, they specifically say not to recommend probiotics for vaginal yeast infections. And I agree with you that they're a huge waste of money.
[00:11:48] Dr. Jen Gunter:
That goes for probiotics in vaginal suppositories too.
Sometimes in desperation, because of old wive’s tales or misinformation online, people start complex cleaning rituals for their vaginas and vulvas.
[00:12:02] Dr. Paul Nyirjesy:
The data on all these cleanses and, feminine hygiene products, women who use those products seem to have a higher rate of yeast infections. So I think it actually may cause trouble.
[00:12:14] Dr. Jen Gunter:
So one of the myths that I feel I'm dispelling a lot online and in the office is the myth about balancing the pH of the vagina. And if there could just be this holy grail of a product to do that um, we could fix things. And so, what have you heard about that? And can you tell me what you might respond, how you might respond?
[00:12:35] Dr. Paul Nyirjesy:
In a typical day, I'll see about 18 patients. Probably five of those patients will talk to me about how the problem is that the balance of their pH in their vagina is just off and they need to fix it.
[00:12:52] Dr. Jen Gunter:
A healthy vagina is acidic… acidic…the pH is controlled by the microbiome. This is an inside job. And we know that attempts to change the vaginal pH don’t work and sometimes they can even damage the ecosystem.
In our garden metaphor, it’s kind of like spraying pesticides all over the plants that you don’t want to kill. We have really robust studies here. So all of those products that profess to balance the vaginal pH? They are garbage. They’re garbage, garbage, garbage. And marketing lies.
[00:13:28] Dr. Paul Nyirjesy:
The greatest myth out there right now is that you need to use boric acid as a vaginal health supplement to control the pH of the vagina. There's been this explosion of boric acid supplements for vaginal health. And, um, up until two, three years ago, I'd rarely have a patient come in using it.
[00:13:49] Dr. Jen Gunter:
There are two very specific circumstances where both Dr. Nyirjesy and I suggest vaginal boric acid: resistant vaginal yeast infections and recurrent bacterial vaginosis… and they both require a visit to a healthcare provider to diagnose correctly. Boric acid is not something to experiment with or to use now and then to “touch things up.” And it won’t “balance” the pH in the vagina.
The best advice here is to leave the vagina and vulva alone!
Let's say you’ve got an itch… and you think it's a vaginal yeast infection…so you decide to head to the pharmacy.
It’s important to know that most people aren’t great at self-diagnosing vaginal yeast infections. Dr. Nyirjesy and some colleagues studied this… they offered a free medical evaluation to anyone buying an over-the-counter treatment. People who thought they might have vaginal yeast infections came in, and….
[00:14:48] Dr. Paul Nyirjesy:
Two thirds didn't have a yeast infection at all. They were sure that they had a yeast infection, but they didn't.
[00:14:54] Dr. Jen Gunter:
There are skin conditions and bacterial infections that cause very similar symptoms… so it can be challenging to diagnose vaginal yeast infections based on symptoms alone.
Someone might listen to this and think, “Look, I know my body, are you telling me I don’t have an infection?” And what I would say is: absolutely you are having symptoms and we can find out why, but the cause isn’t always yeast, even if you’re itching and burning. I want you to have the right diagnosis so you can get the right treatment.
Even if they take the time to look at a sample under a microscope, they might still get the diagnosis wrong.
[00:15:49] Dr. Paul Nyirjesy:
I use my own example. I was already the regional expert in, in, um, the Northeastern United States. And I'd been taught wrong, what yeast look like. And I really couldn't understand why I was seeing all these women with yeast infections and all my cultures were coming back negative. And I realized I'd been taught wrong how to recognize yeast under the microscope.
[00:16:10] Dr. Jen Gunter:
The best way to accurately diagnose a vaginal yeast infection is using a fungal culture test. That’s what I use, and it’s something you can ask your doctor about directly.
I tell my patients, if they have itching and burning inside the vagina they can try one over-the-counter treatment. Only ONE! These over the counter medications are as effective as the oral prescriptions. So if they don’t see results, they either doesn’t have vaginal yeast infection or they have a resistant infection… and either way, they need to come into the office for a diagnosis.
The reason I tell my patients not to try to over-the-counter treatments over and over again, is: if you use them when you don’t have an infection it can actually lead to a bigger problem: antifungal resistance.
The yeast can evolve to withstand the -azoles… the drugs we have for treating a fungal infection.
Thinking about it like a garden again….it’s as if a weed has developed a defense to all the common weedkillers, and the gardener can no longer keep it at bay. And that stronger weed – it’s spreading, fast.
Antifungal resistance is a growing problem – both Dr. Nyirjesy and I are seeing more and more cases.
[00:17:29] Dr. Paul Nyirjesy:
Probably the first case was maybe a decade ago, but now what we're seeing almost every week or so in our program is women with candida albicans infections that are very resistant to antifungals. In the past, the standard azole medications were very effective at at least controlling the infection. And, and now some of these infections, they don't do.
[00:17:51] Dr. Jen Gunter:
Yeah. I have the exact same timeline about 10 years ago, like maybe one resistant candida albicans infection a year, like maybe two. And I see now at least one a week. Um, possibly more.
[00:18:05] Dr. Paul Nyirjesy:
Yeah. And I'm not competing with you. I saw two this week, so yeah.
[00:18:10] Dr. Jen Gunter:
These antifungal resistant vaginal yeast infections are part of a much bigger problem. Remember: fungal infections can happen in other parts of the body too. For example, one species of fungi causes a serious lung infection.
Over time, something strange happened…, patients started coming in with lung infections that were drug resistant – from the beginning.
That means the fungi were already resistant to treatment before they even infected a person.
To try to understand why… we’re going to take a little trip to the Netherlands.
[00:18:57] Dr. Jen Gunter:
It’s late April, in Holland. The tulips are in full bloom – brilliant reds and oranges and yellows fill the fields–tourists abound taking pictures.
The tulips and the soil they’re in are full of fungus – just like us. Sometimes yeast, but other kinds of fungus too.
And like us, they rely on fungi – without fungi, there’s no way to break down old vegetation into nutrient-rich soil, which is necessary for growth. But, here too, the fungi can overgrow, and instead of a beautiful array of colorful flowers, you grow a field full of brown leaves.
The tulip farmers, of course, want to prevent that!
[00:19:40] Dr. Johanna Rhodes:
The Dutch are massive tulip exporters for at least sort of Europe. They spend millions and millions of euros on, antifungals, to, to treat their tulip bulbs. And they literally have these massive vats that they just dunk the, the tulip bulbs into.
[00:20:01] Dr. Jen Gunter:
Dr. Johanna Rhodes is the fungi enthusiast we talked to earlier.
We don’t just reach for antifungal medications to treat yeast infections in the body. We also use a massive amount of antifungals in agriculture.…often, the same -azoles that we use in humans.
[00:20:20] Dr. Johanna Rhodes:
They're called the triazoles and they are used heavily in the fungicides, but also they're administered to cattle, to chickens.
[00:20:27] Dr. Jen Gunter:
We’re relying on just a few drugs for all of these cases because antifungal drugs are tricky to develop. It’s very difficult to create a drug that targets fungal cells but doesn’t also kill host cells in the process.
[00:20:44] Dr. Johanna Rhodes:
It's kind of like if you imagine chemotherapy, chemotherapy is really horrible because it doesn't distinguish between cancer and the rest of the cells in the body, necessarily.
It just basically targets everything, which is why it's so horrible to experience.
[00:20:59] Dr. Jen Gunter:
Dr. Rhodes worked with researchers in the Netherlands and Ireland to try to pinpoint why drug-resistant fungi are emerging.
One of the first fungi they studied was Aspergillus fumigatus, which the Dutch tulip breeders are trying to keep at bay.
Aspergillus is very common – if you’ve ever noticed a fluffy mold growing on your strawberries, it might have been aspergillus. Dr. Rhodes wanted to know: Where did aspergillus develop resistance to antifungal drugs?
[00:21:30] Dr. Johanna Rhodes:
So we kind of decided to work together to try and figure out where it came from and the, the group in Ireland, they just basically bought a load of tulips from the Netherlands. They bought other things as well.
So like onions, things like that and just basically to see how much drug resistant aspergillus they could recover and they're recovering way more than you should recover really from these bulbs.
[00:21:57] Dr. Jen Gunter:
So issue number 1 is: Way more drug resistance than expected. Dr. Rhodes then analyzed the fungi samples and determined that they were all genetically similar, which made it hard to trace the drug resistant strain to one particular location…
The similarities also suggested issue number 2: drug resistant aspergillus is spreading.
[00:22:22] Dr. Johanna Rhodes:
Aspergillus spores are able to go up into the air and they follow the air currents of the world. So they'll go from Europe, they'll go down southeast Asia, Australia, and then they'll loop back around and we're starting to pick them up in America now. So they've basically done the whole globe. So those rates are just going to increase now is drug resistant, fungal infections, going to find that foothold in new environments and they'll just out compete whatever's there.
[00:22:44] Dr. Jen Gunter:
So, you may be thinking – what’s the big deal? A few dead tulips? Maybe a few sacks of potatoes lost to a fungal infection?
Aspergillus may seem harmless when it’s on your strawberries. But it can cause serious lung infections in humans.
[00:23:01] Dr. Johanna Rhodes:
It causes lung infections in cystic fibrosis patients, but also lung transplant patients as well. Um, and those who are, who, whose immune systems don't really work that well, so immuno-suppressed or immunocompromised people. Um, and it's, it's, it's a big deal.
It's huge. And it's not just the morbidity and the mortality. If you want to put it in terms of like in monetary values, you know, how much does a lung transplant operation costs in in terms of the operation, the aftercare, the immunosuppressive drugs afterwards, if a cystic fibrosis patient has a lung transplant and thinks I've extended my, my life expectancy, then they get a drug resistant infection.
So it's not just a loss of life. It's not just a loss of quality of life. It's a lot. So there's a monetary cost associated with that as well.
[00:23:50] Dr. Jen Gunter:
Dr. Rhodes and her collaborators are also worried about the impact of COVID-19. Especially people whose lungs were damaged or who had long COVID who might be dealing with chest pain or breathing issues.
[00:24:04] Dr. Johanna Rhodes:
We think that COVID, in some cases, sufficiently changes the lung architecture to such an amount that it makes it more susceptible to getting fungal infections.
[00:24:16] Dr. Jen Gunter:
Aspergillus is everywhere – some research estimates that most humans breathe in a few hundred spores every day... which makes the growing proportion of drug-resistant fungi – and the growing number of people with lung issues – very alarming.
Experts have even recommended that hospitals avoid planting flower bulbs on their gardens. One researcher identified drug resistant aspergillus in a flower bed just outside the hospital where he worked.
And that being said…if you think aspergillus is bad…let me introduce you to a species of yeast called Candida auris.
<MUSIC IN >
In post-production, there needs to be some very ominous music after that.
[00:25:05] Dr. Johanna Rhodes:
I know. Right. Completely.
[00:25:15] Dr. Jen Gunter:
What makes it different from other species of fungus and why should we be so worried?
[00:25:15] Dr. Johanna Rhodes:
It's--it's, it's insane. It can evolve drug resistance really quickly. We see within patient evolution of resistance in a matter of weeks. And also the way that it emerged globally, all of a sudden you've got it popping up in South Korea and Japan, India, south America, South Africa as well, but they've all got different drug resistance mutations. It's evolved resistance independently. At least three times. And to do it so quickly is it's mind blowing,
[00:25:55] Dr. Jen Gunter:
Candida auris is mostly found in hospitals – not just in the humans there, but also living on surfaces like tables or windowsills. And it’s somehow capable of evading many of the disinfectants used to sterilize hospital environments.
[00:26:10] Dr. Johanna Rhodes:
It can form biofilm. So this is something that some bacteria do as well. And, you know, I've spoken to other people and they say, what is a biofilm?
And you have to imagine it's like this, this, this yeast has kind of like gone: "I want to survive, this potentially adverse environment that I'm in" and it essentially puts on a, on an iron man suit and kind of goes a little bit dormant. It kind of protects itself.
[00:26:36] Dr. Jen Gunter:
And if someone gets infected, Candida auris doesn’t respond to most antifungal drugs. So we might try to treat it with a combination of drugs or therapies…
[00:26:49] Dr. Johanna Rhodes:
Because all these different auris that are kind of getting into your kidneys, they're getting into your urine stream. They're getting into your bloodstream, they're sitting on your skin, will all have different drug resistance profiles. Some will be susceptible and some won't be, so you, you have to be really clever when treating an auris infection. it's just unlike any other fungus.
[00:27:10] Dr. Jen Gunter:
Almost as if someone decided to design a super yeast that could evade…
[00:27:18] Dr. Johanna Rhodes:
Dr. Jen Gunter:
Like somebody who knew how medicine worked, like how doctors prescribe things or like, okay, I'm going to go to the lab [evil laugh] and come up with this.
Dr. Johanna Rhodes:
Dr. Jen Gunter:
So how do you begin to solve this massive problem of antifungal resistance, when new antifungals are notoriously hard to develop?
[00:27:38] Dr. Johanna Rhodes:
So what we really needed was a new drug class, which is going to be really hard to develop. Um, but since COVID a lot of companies have, you know, understandably shifted their focus to COVID drugs, to COVID vaccines, things like that. So the development of new antifungals has kind of slowed down and obviously the development of a new, of a completely new, drug class, would require…10 years to get through clinical trials. Um, which is a long time. It's a lot of money as well.
[00:28:06] Dr. Jen Gunter:
Dr. Rhodes says it would also help to quit using so many antifungals in agriculture.
<MUSIC IN >
Researchers are still working to fully understand OUR microbiomes let alone plant or soil microbiomes – and yet we’re killing off whole swaths of fungi when we apply fungicides to crops.
[00:28:27] Dr. Johanna Rhodes:
We have no idea what is in our ecosystems. And therefore, if we don't know what's in our ecosystems and we're all interconnected, we have no idea, really the influence that we are having on those ecosystems. And it's potentially just a recipe for disaster for us to basically be cultivating, um, new drug resistant bugs, whether they're bacteria or fungi, um, that are capable of infecting us, but not just us, our food as well. Um, so it's, it's just a recipe for disaster .
[00:29:08] Dr. Jen Gunter:
You might be noticing some similarities here…
Remember that study that found many women who planned on using over the counter medications for a vaginal yeast infection didn’t actually have yeast?
When antifungals are used, especially over and over again, they can lead to resistance in the yeast that is normally happy and not causing any harm. If that resistant yeast overgrows, you really have a problem.
Dr. Rhodes’s recommendation for agricultural antifungals, and my recommendation for how to handle a vaginal yeast infection – well, they follow the same logic! And it’s probably the same logic you’ve heard when you take antibiotics: Get a diagnosis. Only take them if you really have to. And follow the directions!
So we all have to consider how our choices could impact people with different health risks… as well as ourselves.
We’re still figuring out what most of the fungi in our lives really do for us…when they help keep us healthy and how they become dangerous invaders. But one thing’s for sure: we gotta respect the fungi.
Next time, on Body Stuff…is it an intolerance? A sensitivity? AN ALLERGY???
Your immune system is saying, okay, we got an invader and we got to get it out.
[00:30:21]Dr. Jen Gunter:
We explore the mysterious world of food allergies…
Body Stuff is brought to you by the TED Audio Collective. It’s hosted and developed by me, Dr. Jen Gunter. The show is produced by TED with Transmitter Media. Our team includes Mitchell Johnson, Camille Petersen, Gretta Cohn, Michelle Quint, Banban Cheng, Sammy Case and Roxanne Hai Lash. Phoebe Wang is our sound designer and mix engineer. This episode was written and produced by Poncie Rutsch and edited by Sara Nics.
Fact checking by the TED fact checking team.
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