Wednesday June 14, 2017

June 14, 2017 Full Episode Transcript

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The Current Transcript for June 14, 2017

Host: Anna Maria Tremonti

STORIES FROM THIS EPISODE

Listen to the full episode

Prologue

[Music: Theme]

SOUNDCLIP

We shouldn't be encouraging women to be stereotyped as having problems once a month and that would lead people to treating them as incompetent in the workforce.

ANNA MARIA TREMONTI: It's called menstrual leave or period leave and it is available to women in the workforce in Japan, South Korea, Taiwan, parts of China, Indonesia. Italy is moving toward legislation, Nike has done it. And while it's applauded by proponents as positively progressive others are aghast seeing it is a step backward toward stereotypes. Is this a nod toward new feminism or simply setting an old trap? We've got the debate in an hour. Also today.

SOUNDCLIP

If Hollywood were making a blockbuster pitting China on the path to war with the U.S. central casting could not have fell a better lead for team America than Donald Trump.

AMT: But who needs Hollywood when you've got history. Graham Allison sees the outline of a troublesome pattern taking shape and ascendant power, that would be China, threatening to displace a ruling power that would be the United States. History calls that our run up to war and add in some hubris, a sense of honor and pride on both sides, and this is one movie you don't want to be in. Avoiding a scenario destined for war in half an hour. But we begin with the price of getting your life back.

SOUNDCLIP

VOICE 1: This drug is too expensive but still I hope many more people can use it.

VOICE 2: This drug has a potential to save my life.

VOICE 3: If it helps me that's all that matters.

AMT: No one argues that Soliris is a bad drug but a year's worth of prescriptions rivals the cost of a house in a major Canadian city. The financial fight over one lifesaving drug. I'm Anna Maria Tremonti. This is The Current.

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'It's been a roller-coaster': Patient questions $750K price tag for life-changing drug

Guests: Marie-Eve Chainey, Sachdev Sidhu, John Haslam

AMT: Four years Marie-Eve Chainey has been on dialysis six days a week. She also takes a drug called Soliris made by a company called Alexion. Soliris is approved to treat two extremely rare blood related diseases that affect the immune system for Marie-Eve’s dosage the cost is immense. More than $700,000 per year, every year. At that price even governments have trouble covering it and not everyone who needs it meets the government criteria to be covered. Marie-Eve Chainey does qualify. She has been using Soliris since January. It has helped stabilize her illness so she can be eligible for a transplant. Right now the Ontario government has agreed to pay for six more months of Soliris. Then she has to reapply. Marie-Eve Chainey is in our Ottawa studio. Hello.

MARIE-EVE CHAINEY: Good morning.

AMT: You have something called a typical hemolytic uremic syndrome. What does that do to you?

MARIE-EVE CHAINEY: Basically the illness is creating clot throughout the body. And in 2002 that's when it coagulated both my kidneys. So it will continue doing damages across the body. Usually the kidney is the first organ to go.

AMT: And so how long have you been on dialysis?

MARIE-EVE CHAINEY: So it's been over 15 and a half years now.

AMT: And tell me about this drug series. How does that help you?

MARIE-EVE CHAINEY: The drug itself is not a cure but it does control the illness enough to not continue doing damages. So for 15 years I've been on dialysis and it continues to do some damages and in the fall I was attacking my ankle. So I had an ulcer as well as kidney pain and the drug itself as soon as I started it. Basically it got better right away.

ATM: And so the drug will allow you to get a transplant because it stabilizes? Is that how it works?

MARIE-EVE CHAINEY: Exactly. So the medication itself is an infusion. And it's once every two weeks and lasts about two to three hours. And this infusion just makes sure that it doesn't continue doing damages, doesn't start creating clots again which, would a kidney transplant [unintelligible] a lot of studies show that it would cause a relapse right away. And I would lose a transplant as well as have damages to other organs.

AMT: Hmm. And so how did you find out about this drug?

MARIE-EVE CHAINEY: It's been a few years now so I [unintelligible] this 15 years and I've had this illness all this time but we've only discovered that it was HOS and not HUS or TTP about half that time. So it's fairly new. It's been approved by Health Canada for a few years already but it's just not covered.

AMT: And so what does your your actual dosage cost?

MARIE-EVE CHAINEY: So the dosage in a year's worth is $750000 a year, every year. And this is a medication I'm supposed to take for life.

AMT: OK so clearly you need help so you had to qualify for it.

MARIE-EVE CHAINEY: Exactly and that's why I haven't had a kidney transplant. People generally especially my age doesn't.. They don't stay on dialysis for 15 years that's really extreme. But with this medication I can finally have a kidney transplant. I'm doing dialysis six days a week.

AMT: Are you scheduled for that transplant now?

MARIE-EVE CHAINEY: Yeah. It is actually next Thursday it's on June 22nd.

AMT: Oh. Should I say congratulations I guess?

MARIE-EVE CHAINEY: Yes, absolutely. I mean is a positive news for sure. There's always that stress of knowing if the medication will be approved six months down the road.

AMT: Because you'll have to keep taking this forever, this drug?

MARIE-EVE CHAINEY: Yes. Depending on which genetic mutation you have, which one is causing this. It does change if you have to get for life or not. But from my particular case because of a factor H this does prove to be a very long time, like a lifelong illness.

AMT: How hard was it to qualify for the drug then for you?

MARIE-EVE CHAINEY: It's been years. It's been years to try to qualify as been very it's been a roller coaster emotionally and just physically as well. It's been difficult because you get told that you can have a transplant now that you're healthy enough and then you're being told that you are healthy enough and you could have a transplant but you don't have this medication to control your illness. And then you go through processes and with Soliris in particular hires a third party company that helps you through this through the hoops of getting approval and what not. And as has been very difficult at one point they told me I was covered no matter what. Like I would have the transplant. I would have the medication and a few hours later they call me to say actually you're not going to be covered.

AMT: Who told you that? The company?

MARIE-EVE CHAINEY: It was yeah, it was a third party company it's called One Source. And just in my situation it was just devastating. For a few hours, I had hopes and dreams and I was going to travel and you think about all that. And then a few hours later I got a call saying actually you're not going to be covered and you have to stay on dialysis.

AMT: It's a lot, uh?

MARIE-EVE CHAINEY: It's a lot. That's why I like even for now like I'm having trouble accepting them getting a transplant because so far I've always been told yes and then been told no. So it's a very difficult emotionally to accept the situation.

AMT: So who do you hold responsible for your struggles to get access to this drug?

MARIE-EVE CHAINEY: It's on both parties I think and the government plays a role and the company obviously the pharmaceutical company. It is very hard for me to see how they can justify seven hundred fifty thousand a year for this medication. And on the government side I think there's also this procedure to get the medication covered, should have a special procedure to have rare disease medication covered. The requirements are the same whether it's a rare disease and a disease that's very known. And unfortunately there's just not enough. Well not unfortunately, fortunately there's not many people with the disease so it's very hard to prove a research in how effective it is.

AMT: But you're telling me that the pharmaceutical company actually hired a third party company to work with you to convince the government to pay for this drug.

MARIE-EVE CHAINEY: So this third party company actually helps patients just go through their hoops and hurdles so they'll call in and see how things are going, where things are at, they'll work with your insurance if you have insurance. And they are also the one I will coordinate for treatments once you do have the treatment. So the problem is most Canadians wouldn't have a private insurance that would be covering for this type of medication. If you do it they'll help you through it. But they are the company that is, kind of in-between company with the patients and the insurance and pharmaceutical company.

AMT: It's very complicated. Well I wish you all the best for that transplant next week.

MARIE-EVE CHAINEY: Thank you.

AMT: Marie-Eve, thank you for talking to me today.

MARIE-EVE CHAINEY: You're welcome.

AMT: Marie-Eve Chainey, she has a rare blood disease that requires her to take the drugs Soliris that drug costs, as you heard her say, upwards of $700000 a year. She joined us from our Ottawa studio. Well it seems extreme that the cost of one drug for one year would be about ten times the median family income in Canada. Soliris is considered an orphan drug and to learn more about how such drugs are developed and priced. I'm joined by Sachdev Sidhu. He is a professor of molecular genetics and director of the recombinant Antibody Center at the University of Toronto. He is in our Toronto studio. Hello.

SACHDEV SIDHU: Hello.

AMT: So an orphan drug, a rare drug for a rare disease few people write. How does that affect pricing?

SACHDEV SIDHU: Yeah that's obviously an interesting question as we're learning. An orphan drug by definition treats a limited number of patients and it's given a special status so that there's less competition and more flexibility in pricing. That's my understanding. And I think the unfortunate thing is the short answer to your question is nobody knows. A major problem in this field has been preferential pricing which actually does make sense if it's a small market but critically without corresponding transparency. I mean normally when you grant special rights you should be granting special responsibilities and I think in this case that's not happening.

AMT: So the government grants preferential pricing through the federal government some body that does that, and then the provinces have to pay for that, right? But what you're saying about what are you saying about transparency? What do you want to know that you can't find out?

SACHDEV SIDHU: Well why it costs this much. I'll give you an example of the absurd situation. If you ask me how much this drug costs to make; cost of goods it's a few hundred dollars. If pricing is $700000, obviously there are other steps in there that raise something from you know say a thousand dollars to 700000. And to my understanding we have limited if no understanding of what are those other steps that the company uses that raise that price. So it's a very, let's just use the word silly situation that something is costing not much more. And even experts have no idea why it costs that much.

AMT: OK and so you're saying cost of goods a few hundred dollars. How do you know that?

SACHDEV SIDHU: Well we and others make antibodies all the time. So these are become very common in drug class now. It's like the iPhone of drugs. There's many of them around many different models. So we know very precisely what it costs to make it. But of course that leaves out everything to do with research marketing et cetera. But we do know what it costs to make it. That's not a black box.

AMT: Because this drug uses monoclonal antibodies?

SACHDEV SIDHU: Yes.

AMT: And that this took 15 years of research. Has the technology changed over time?

SACHDEV SIDHU: Yes the technology advance tremendously. And our current laws I think have kept up with the pace of the technology. Things are more rapid, cheaper and easier to make. In most industries costs would go down, and I should say it's not just orphan drugs that have this issue. I mean cost of all major biologics keep going up even on ones where the research is all done. So it's clearly not driven by production or even research at this point.

AMT: How much do universities and other public institutions fund the development of orphan drugs?

SACHDEV SIDHU: Well if you look at research they do a large share of it, or a significant share depending on the drug. I think it's safe to say no drug is produced without the input of some public research. And again I will criticize universities because I'm a professor. I don't think the universities do a good job of valuing that and putting that as part of the public good that's gone into these drugs. And again drug companies job is to make as much money off a drug as possible let's never forget that. And I don't think that's a good or a bad thing that's how business works. But I think both government and public institutions should play a much more active role in defining their own contributions in the drug. And currently we don't do that at all.

AMT: So what are you saying, that essentially Most pharmaceutical companies get the benefit of that research without, and then they can charge for it as opposed to the publicly funded institutions?

SACHDEV SIDHU: Yes. And again I don't blame the companies something gives you something for free, say thank you. You don't say how much. But we the public institutions should do a better job of raising awareness and actually changing the laws that account for that. So if a drug costs a billion dollars to make but five 500 million came from the public that can actually be counted these are black box processes. You don't make a drug with any undefined process that just wouldn't work. So everything can be accounted. It is just, do we want to do it? And will the government put in laws that allow it to be done?

AMT: And speaking of accounting then we get back to transparency, do you think drug companies are ethically obliged to disclose their costs then to be more transparent?

SACHDEV SIDHU: I don't think it should be a matter of ethics they should be legally obliged. I mean again you don't force a company to do something based on ethics. You make laws to make it do so and I think that's a fundamental point here. The government should not sidestep their responsibility and put in laws that make this work.

AMT: What if a company said well if you put in that law we won't selling your country?

SACHDEV SIDHU: Well that would be a very serious step but it might need to be taken. People forget in the 90s or was it the 80s Brazil and other countries took on HIV drug manufacturers and got drugs reduced in price. And guess what? The companies made a lot of money. So you have to take that step but that is obviously one of the reasons the government is hesitant but that doesn't mean you don't need to do it especially as more and more drugs get approved. You can't dodge the question forever.

AMT: OK. Thank you for coming in.

SACHDEV SIDHU: Sure.

AMT: That is Sachdev Sidhu. He's professor of molecular genetics at the University of Toronto. He joined us in our Toronto studio. Well over this past winter and spring the PMPRB the patented medicine prices review board held a public review of Alexion pricing of Soliris in Canada. The review board is an independent quasi-judicial body with a mandate to protect the interests of Canadian consumers by ensuring the prices of patented medicines are not excessive. The Board believes that Alexion is charging too much for Soliris and wants the company to drop the price and pay back access revenue earned over the past few years. Joining me now is John Haslam He's the general manager of the pharmaceutical company Alexion Canada. He joins us from Vaughan, Ontario just north of Toronto. Hello.

JOHN HASLAM: Good morning Anna Maria. How are you?

AMT: I'm well. I'm curious to know how you justify the price of Soliris?

JOHN HASLAM: Well the price of Soliris and the price established in Canada was based upon those exact rules provided by the PMPRB Soliris back in 2009 when it was first introduced in Canada, about two years after it was introduced in other countries. It was designated a breakthrough product and the price was set according to those regulatory requirements and guidelines. It was approved and accepted and the price has never changed over the last eight years.

AMT: But can you tell us why it's so expensive?

JOHN HASLAM: Sure. When we look at the price of… How we price our therapies it's based on a number of factors. First the extreme rarity of the disease, and you heard that from Marie-Eve and how HUS or a typical HUS and the other disease PNH are what are called ultra-rare diseases. And the population in Canada of those patients is literally dozens of patients so it's less than four per million of population. So that plays a role in terms of how you price a product. But also we look at the devastating effects of the disease, without Solaris more than half the children and adults with HUS will die, require dialysis,or have permanent renal damage within two months of diagnosis. And then above all we look at the transformative value of our therapies for patients and their families. With Soliris 80 percent of children and adults on dialysis are able to eliminate dialysis and get back to normal life.

AMT: OK so no one's arguing that it's not a great drug for this group of people but you know, you charge more in this country then in comparable Western countries why is that?

JOHN HASLAM: Actually that's not correct. We charge a similar price across all comparative countries that are looked at through the PMPRB regulations. It's part of the reason why we defended ourselves versus the PMPRB because we set the price according to their rules and how the guidelines were set out. And we have stuck to that price. The price has never increased in Canada in over eight years. And when we look at the price of drugs for rare diseases what Canadians have to understand is that there are so few of these patients and so few of these therapies that the actual cost and impact to provincial drug budgets or insurance company budgets is less than 3 percent and the actual cost in relation to that total health care spend is only about 0.04 percent. So these drugs as a whole, when you look at the benefits they provide are affordable and reasonable in the Canadian health care setting.

AMT: At the same time what does it cost for you to make that drug? We just heard our last guest say the cost of goods is a few hundred dollars.

JOHN HASLAM: You know I was listening to that and I really wish it was that easy to produce drugs for these rare and devastating diseases, and if it were we'd have a lot more of these therapies to treat patients in Canada and around the world. The reality is that with over 5000 rare diseases the number of these innovative therapies that have been produced over the last 35 years is still very small.

AMT: But let's talk about the costs of this one drug though. Why can you not be transparent in and give the breakdown of what it actually costs to make that drug? And what it did cost in the R&D of that drug?

JOHN HASLAM: Oh well I can be. It’s cost over a billion dollars and 15 years of work byAlexion to bring Solaris to market.

AMT: Right but what's the breakdown? What's the breakdown in the actual cost of the drug like the monoclonal antibodies that you use what do they cost you per drug?

JOHN HASLAM: Well it's not what the previous guest has said. I can tell you.

AMT: What is it then?

JOHN HASLAM: What I can tell you is that in producing an antibody in a lab it's a lot different from scaling up by our manufacturing to produce the product and use it commercially across the globe. It takes a lot of people and a lot of investment to meet the strict requirements of regulatory agencies. Now we've invested hundreds of millions of dollars in basically bio manufacturing facilities around the world to produce this product. So the cost is significant. It's not a one to one ratio of the cost versus the price that is paid. But there are many other factors that go into setting the price of the drug and you know when we look at a product like Soliris, Soliris success and Mr. said you know this, is one product. But there are probably thousands of products out there and hundreds of early stage companies.

AMT: Okay but we're not talking about that Mr. Haslam, we are almost out of time but this is the only drug you make right now is it not?

JOHN HASLAM: No that's not correct at all. We'll make another drug called Strenzic which was actually a drug that was early development was done in Canada.

AMT: Okay. We're going to have to leave it there because we're not talking about the second drug.

JOHN HASLAM: Sure.

AMT: But I'm sorry we're out of time. Thank you.

JOHN HASLAM: Oh well. Okay. Thank you.

AMT: John Haslam general manager of Alexion Canada he joined us from Vaughan Ontario. Stay with us. The news is next and then we're talking about China - U.S. tensions. This is The Current.

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Are U.S. and China headed for war?

Guest: Graham Allison

AMT: Hello. I'm Anna Maria Tremonti and you're listening to The Current.

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AMT: Still to come Italy considers a new law that would entitle female employees up to three days of paid leave if they're in pain during their monthly menstrual cycle. Some say it's about time others say it opens the door to gender bias at work. We've got that debate in half an hour. But first it is called Thucydides Trap, and it means America and China could be destined for war.

SOUNDCLIP

I just want to say it is great a honor to have The President of China and his incredibly talented wife. A great great celebrity in China, a great singer. It is an honor to have you in the United States. We've had a long discussion already and so far I have gotten nothing. Absolutely, nothing. [Laughter] But we have developed a friendship I can see that. And I think [unintelligible] we're going to have a very very great relationship. I look very much forward to it.

AMT: While against the clatter of camera shutters, that was U.S. president Donald Trump and the Chinese president Xi Jinping at the presidential retreat in Florida in April. During the U.S. election campaign Mr. Trump threatened to label China a currency manipulator and he raised concerns in Beijing by taking a call from the president of Taiwan. Just after the election. Now he says he and the Chinese president have really great great chemistry. But despite that new bromance dark clouds may be on the horizon between the two nuclear nations. Graham Allison has been thinking a lot about the prospects of conflict between China and the U.S.. He is the director of the Harvard Kennedy School Belfer Center for Science and International Affairs. He's a former U.S. assistant secretary of defense for policy and plans and he's written a new book entitled Destined for War: Can America and China Escape through Thucydides Trap. Graham Allison joins me from Harvard University in Boston. Hello.

GRAHAM ALLISON: Good morning Anna Maria. Glad to join you.

AMT: What is Thucydides Trap?

GRAHAM ALLISON: Well it's a big idea by a big thinker named Thucydides who was actually the founder of history. And the idea is that when a rising power threatens to displace a ruling power in general bad things happen. Alarm bells should sound extreme danger ahead. So Thucydides wrote about the competition between the two great cities states of classical Greece 2500 years ago, and he said in a famous line it was the rise of Athens and the fear that this instilled in Sparta that made the war inevitable. So Thucydides Trap is the deep structural stress that occurs when a rising power like China threatens to displace a ruling power like the US.

AMT: And what does your research show you about where facilities trap has led to conflict between what happened between Athens and Sparta and now?

GRAHAM ALLISON: In the book I look only at the last 500 years, the most recent 500 years. In the last 500 years I find 16 cases when the rising power threatened to displace the ruling power. Think of the rise of Germany at the end of the 19th and beginning of the 20th century and World War 1, and 12 of the 16 cases in the war. Four of the cases it did not work. So Thucydides line about inevitable is an exaggeration. It just means likely. But as I argue in the book business as usual in the case of US and China will most likely produce history as usual. And in this case it would be catastrophic.

AMT: Okay well let's talk about this a bit because China is obviously the rising power.

GRAHAM ALLISON: Yes.

AMT: And the ruling power is vulnerable right now.

GRAHAM ALLISON: Yes. Correct. If you've not been following China it's just unbelievable what's occurred. In our lifetime, just to the last generation, a country that did not appear on any of the international league tables for anything has grown to be a competitor or a rival indeed even to surpass the U.S. in many many different dimensions. So for example if you go back to 1980 China's GDP was less than 10 percent the GDP of the U.S. in 2014, the big headline from the IMF World Bank meeting was China is now the number one economy. The largest economy in the world, measured by the best yardstick which is purchasing power parity. And today China's economy is to the 15 percent larger than the U.S. and the current trend line by 2024. It’ll be half again larger. So you look and you say [unintelligible] a chart in the book that this is the previous version of what I give to my students at Harvard and it says when could China number one. And I have in my full chart 26 indicators but this is just 10 of our biggest automobile manufacturer, biggest smartphone manufacturer, biggest robot manufacturer biggest number of billionaires, biggest the fastest supercomputers, largest economy whatever. I asked students when could China become number one. They say 2040, 2050, not in my lifetime. You know it have to answer each one. Then I give them chart two. Chart Two says, the headline of it says “already” and I tell him what year this is already happened. Vaclav Havel the former president of Czech had this great line that I quoted in the book. He says, “Things have happened so fast we haven't yet had time to be astonished”.

AMT: Well let's talk a little bit more about China through the prism of how it sees the world. How does its own history with foreign governments and armies play into how China sees the world versus how the West sees the world?

GRAHAM ALLISON: China is almost the poster child case of a rising power from Thucydides point of view within many ways it resembles Athens in that respect, not as a democracy. Leave that aside. But in terms of just exploding in terms of its wealth. And in the Chinese case they think of their rise not as a rise but simply as a restoration, because in Chinese history and every any Chinese you talk to will explain this to you. For 5000 years China was the center of the universe the largest the most powerful country in the world, the most advanced country in the world. That was then this 200 year interruption, when Westerners came and interfered in China and imperialized China and exploited China and took Chinese territory. So that’s the last 200 years. But now what is happening as China has emerged to be itself again to be big and to be strong, is pushing back and pushing out these Westerners who were taking advantage of it to become itself again the biggest power in the world as it sees it. And in the first instance, the biggest power in Asia. So the Chinese story is one what they call it the century of humiliation in which a great China which was supposed to be at the top with the pyramid was somehow knocked off the pyramid by these Westerners who had taken advantage of technology and other, plus bad leadership in China. But in any case that was then they've gotten over it. They've emerged to be big and strong and they now want to be to return to the place that they had in fact long before Donald Trump picked up his tagline about make America great again. When Xi Jinping the current president of China became president in 2012, colloquially, his tagline was make China great again. It is literally the great rejuvenation of the great Chinese people.

AMT: So you say that when President Xi has nightmares the apparition he sees is Mikhail Gorbachev. Why is that?

GRAHAM ALLISON: The Chinese sense of order. So the Chinese have, in terms of the Chinese values order is the highest value and chaos is the greatest fear. So in the case of Gorbachev, Gorbachev took a communist authoritarian system and was trying to bring it into the real world and he tried to both do economic reform and political reform at the same time. So one of them if you remember was called Perestroika which was the restructuring of the economy, basically to move towards a market economy. And the other one was called Glassnost which is basically we're going to become more democratic and people are going to be able to have free speech and say what they think. Because he loosed all these forces at one time, the whole house came tumbling down. And actually the Soviet Union fell apart and disappeared. So instead of the Soviet Union on their maps now we have Russia and 14 other newly independent states. So for Xi Jinping that was where he thought that China was tumbling down that same road that China had adapted significantly and much more effectively than the Soviet Union to a market economy. So under Deng Xiaoping they began moving towards the basics of a market economy. But similarly the political leadership was by a combination of democratizing and allowing corruption to grow rapidly was going to see the whole society collapse. He said he's trying to prevent that by this very ambitious agenda that he's undertaking now.

AMT: So he doesn't want the Chinese Communist Party to go in the way of the Soviet Politburo.

GRAHAM ALLISON: Absolutely. This is complicated for him because communism is dead. I think I can find more Communists in Cambridge Massachusetts than I can find in China. So nobody believes in communism but he wants to resuscitate the party as a vanguard leadership. He wants four or five percent of the population and really less than 1 percent of the so-called mandarins to be able to rule the whole society. Now how do you justify that? Well that's a complicated thing because in this day and time most people think, “Well, wait a minute mean why should you rule me rather than I should have a chance to say something about my own condition”. So he's trying to resuscitate and relegitimise the party. And now they just call it the Party. They haven't got rid of the name communism but they don't talk about communism very much and the Party is supposed to be people who are more virtuous. That's why the [unintelligible] corruption drive and more competent. And they're going to steer the ship for everybody else. And as long as they deliver great results and they've been delivering three times the growth rate of any other economy like ours like the U.S. or like Canada, and as long as they can make China great again so Chinese are we're proud because China's pushing back and taking its place in the world. So if they deliver the goods other people will say well you the guys that can run things and that's fine.

AMT: So before we go any further because I do want to hear where you think there's real potential to a war between China and the U.S. Let's just stop for a minute and look at President Xi, because his own life informs where he's coming from on this.

GRAHAM ALLISON: He was born a princeling. So his father was one of those buddies in the civil war. And so he thought he was going to live in Beijing and everything was going to be nice. He'd just be rich and fooling around. But lo and behold came the Cultural Revolution when Mao has had ahead this madness. And basically they took everybody that had any position and they threw them into the ground. And basically he went to the countryside where as he says he had to basically struggle to eat anything he could find and shovel dung all day long. And his sister was so distressed by this that she committed suicide and he thought about what am what am I going to do. He's just nine years old. And basically he ultimately decided well I'm going to become redder than red. And he called his way back up the system, determined that he was going to get to the top at some point. And when he got to the top he was going to make a difference in the society. So this is a person of substantial capability.

AMT: Okay, so this is a very wise wily determined man and his sparring partner is Donald Trump.

GRAHAM ALLISON: Yes. Well this book was five years in the making. So this was not written for Donald Trump. It's not a book about Donald Trump.

AMT: But that's the reality the U.S. has right now apparently. Didn't Mr. Obama and Mr. Xi actually discuss Thucydides Trap?

GRAHAM ALLISON: Thucydides Trap, yes. Absolutely. Xi Jinping talks about a lot because Chinese Unlike Western leaders study history and they're very interested in trying to learn from history so Xi Jinping talks about this often to foreign leaders including President Obama, but others who come to visit. And President Obama talked about this because he was at least interested in the idea. I mean you can't deny Thucydides’s historic pattern that when a rising power threatens to displace the ruling power there very typical behaviors that occur in both parties. And there's no question China's a rising power and that the U.S. is the ruling power. For Donald Trump, who knows? I would say I think if Hollywood were making a blockbuster pitting China on the path of war with the U.S. Central Casting could not have found a better lead for Team America than Donald Trump would be.

AMT: And you outline a number of nightmare scenarios that could lead to war between China and the United States. Before we talk about some of those just give us the shorthand, what's the Chinese military capability right now?

GRAHAM ALLISON: Ever since 1996 when China had tried to intimidate Taiwan and the U.S. had said a couple of carriers into the area and China had to back down. They regarded that as a great humiliation. They've been building up their capabilities so that that could never happen again. And they've already had a big impact on the U.S. Navy's operation, so that the U.S. Naval carriers now operate beyond the first island chain which is the chain that goes from Taiwan to Japan. Because if they get inside that zone they can be hit by missiles that China has deployed on the mainland. So the Chinese D21 and D26 missiles were very good carrier killers. So the local balance has changed in a way that makes China more confident as it looks at potential conflicts in the regional area. If you go to the global area, China can't fight a war in the Middle East the way the U.S. can. But if you go to the nuclear arena, China and deliver nuclear warheads against American cities. And if you go to the cyber area, China can impact you know could close down electrical grids in the Northeast as effectively as the U.S. could do something equivalent in China.

AMT: Okay, so let's talk about some of the scenarios that you outlined. The first involves an accidental collision in the South China Sea. What happens?

GRAHAM ALLISON: Well it's hard to tell. And again this is just you know war-game it, and in both Beijing and Washington what happens how often and I remember this often at the Defense Department, you get one group of people to play the Chinese hand and one group to play the American hand. So you're playing the American hand and your ship by accident crashes into my ship and it sinks. And so I'm the captain on the ship, and I think you do this deliberately and so I sink an equivalent ship in your navy. And you then respond by, perhaps if I've done this by air or going after you think, “Well wait a minute he may be attacked by other ships in my in my fleet here.” So you attack the air base from which my aircraft occurred. And now you're attacking my air base or one of these islands so I respond then against your supply point which may be on a base in the Philippines, or it might be a base in Japan, or it might be a base in Guam. And so we get on an escalatory ladder in which case one of us may be playing tit for tat and one of us may be playing tip plus for tat. So at some point, particularly if there is a launch of something from the mainland and China, the person playing the American hand may think: “Well okay we can't tolerate that”. So you could imagine a cyber-action against that facility trying to prevent it launching additional missiles against the American ships. Then one thing leads to the other and pretty soon you find you see yourself in a place where you didn't want to go. And in these games which have been played over and over, even though people know they don't want to get to the end of the game in which Americans and Chinese are killing each other the process turns out to be a lot easier than you would suspect.

AMT: And then there's North Korea. How could a collapse of the North Korean regime become a conflict between China and the U.S.?

GRAHAM ALLISON: Well that I would say the most likely path to war if a war between China and the U.S. were to occur in the next year or two, it starts in North Korea. And let me just do it very briefly. So basically because of the Thucydidian dynamic, so you have a rising power threatening to displace a ruling power. Under those conditions, each of the parties knows that the primary problem is the other guy. So would you really want rising China, is for me to be out of there out of the whole area. And that's true. That's what they want. They would like the U.S. to just exit Asia. And the ruling powers thinking: “Wait a minute why did I belong here. As I've often felt Chinese.” The U.S. is an Asian power we're not leaving Hawaii for sure, we're not leaving our alliance with Japan. And actually we've been in the South China Sea in the East China Sea all these 70 years since midway, providing an international order about a security order and an economic order that provided the environment in which China has been able to grow to this area of strength so we're not leaving. In the Korean case we came to the rescue of South Korea. South Korea survived. South Korea has grown to be a great successful democracy the 13th largest economy in the world. South Korea is a poster child for the American led international order. We're very proud of the South Korean democracy. So the idea that we should just be out of there, I mean no. That's the inherent situation. Under those conditions nothing… There's no trust zero trust. Everything one party does is misperceived by the other. So you're trying to be helpful to me and I am suspicious that you have something else up your sleeve. And I take an action that I think is purely defensive. And you see it: “Oh he has some ulterior motive and he's doing something else.” No under these conditions an external party or an extraneous event that would otherwise be easily managed or even would be inconsequential can become the trigger for a set of actions and reactions by the two of us that lend lead us to a place where we don't want to be. So to the North Korean case specifically, North Korea is in the next year going to test an ICBM that could deliver a nuclear warhead against San Francisco or Los Angeles or indeed Vancouver. So that's going to happen unless North Korea is prevented from doing so. That's on the one hand. On the other hand Donald Trump has said that it's not going to happen. I'm not going to allow this to happen. I don't know what Obama did and I don't know what Bush did and I don't know what Clinton did but I'm telling you what Trump is not going to do. They're not going to do that. And if they have to do that, I am going to go attack them. And if the MiraLago summit that you lead with which was just perfect, basically that's what he told she should pay. He said you can solve this problem. And if you solve it you know we will have a good relationship. But if you don't solve it I can solve this problem and you're not going to like the way I do it. And then he served them chocolate cake. This was at the dinner. He excused himself and he went out and he announced that the U.S. had just launched 50 cruise missiles against Syria. Just to kind of underline the point about how the U.S. can solve it. So if we end up attacking North Korea we may end up triggering a second Korean War. And in the first Korean War Americans and Chinese of thousands of each other killed kill each other.

AMT: So what you're outlining is national pride in the populations on both sides. Suspicion and bluster by leaders or one leader that the other one feels has to be addressed. How can the United States and China avoid falling into this trap?

GRAHAM ALLISON: It's a great summary national pride suspicion and blunder. Thucydides had this great line. He said: “What causes war?” He said interests, fear, and honor by which he meant you know pride or demand for respect. So the answer is you have all the dynamics in this case now. But it's also the case and I think if we look back historically only those who fail to study history are condemned to repeat it. So there's nothing that requires us to make the same mistakes people made that led to World War One. There's nothing that requires us to make the mistakes that may lead to other wars.

AMT: We're almost out of time but I but I want to pick up on what you're saying because no one wanted the Iraq war either and a whole bunch of people tried to stop the people who could create the war. Now you have a president who has already in his short history in the Oval Office, is not willing to listen to his own advisers. And you have a rising power like China. How likely is it do you think that we could get really close?

GRAHAM ALLISON: Oh. I mean I would say Thucydides he's sitting on the edge of his chair watching and thinkin: “ I see a train wreck coming and I think I would like to tell them guys get real. We also have in the White House somebody who's historically impulsive. So when something comes into his mind or comes into his gut you know outcomes a tweet or outcomes a choice or outcomes.. so that, out could come an order.

AMT: But what you're telling us as well is at a time when everyone's focused on the U.S. and Russia we need to actually shift our gaze to the U.S. and China right now.

GRAHAM ALLISON: We need to be able to walk and chew gum at the same time. Yes that is.

AMT: [Laughs] Graham Allison, it's important to hear what you're thinking. Thank you so much.

GRAHAM ALLISON: Thank you so much for having me and I enjoyed the conversation.

AMT: Graham Allison director of the Harvard Kennedy School's Belfer Center for Science and International Affairs. He's a former U.S. assistant secretary of defense for policy and plans. His new book is called Destined for War can America and China Escape Thucydides Trap. And he joined us from Boston. Let us know what you think of what he had to say. You can tweet us we're at the current CBC find us on Facebook. Go to the website cbc.ca/thecurrent and click on contact. Coming up in our next half hour Indonesia South Korea Japan all offer parrot paid period leave to women. Italy could be next. The idea of granting time off for menstrual discomfort and pain is gaining traction across Europe and in North America.Supporters call it progressive. Critics say it's reverse sexism. We've got both sides covered. We'll have a debate when we return. I'm Anna Maria Tremonti. This is The Current on CBC Radio 1 Sirius XM Online on cbc.ca/thecurrent and on your radio app.

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Should women get paid menstrual leave?

Guests: Chella Quint, Chris Bobel, Elissa Stein

AMT: Hello I'm Anna Maria Tremonti and you're listening to The Current.

SOUNDCLIP

I manage this place. All day I'm juggling about a million things and the way I make it through is to really keep my mind on the job. The fewer distractions the better. That's why I like the dryer kind of protection I get from Always Maxi's so dry. I know it's working and that's the kind of protection I want.

AMT: Well that's a maxipad ad from the 80s. A confident working woman who won't let her period get in the way of her career. At least that's the message. But the reality for some women is different periods can bring painful debilitating cramps that can lead to missing work, and often missing pay, so much so that Italy has tabled legislation for paid menstrual leave. If it passes that law it will be the first European country to do so but not the first in the world. Japan South Korea and Indonesia currently offer some form of period leave. Now some women want countries, more countries including Canada to follow suit. But not everyone is a fan of the idea. Last week tape was released of the Russian president Vladimir Putin saying he does not have bad days because he “is not a woman”. It's exactly that kind of stereotype that critics say Period leave would reinforce. So we wanted to debate the merits of menstrual leave and to do that I'm joined by two people waiting to do just that. Chella Quint is a researcher, educator and the founder of #periodpositive. That's a campaign for better menstrual education and shame free menstruation talk. She joins us from Sheffield, England. Chris Bobel is the president of the Society for menstrual cycle research and an associate professor of women's gender and sexuality studies at the University of Massachusetts, Boston. She is in Boston. Hello to you both.

GUESTS: Hello. Morning. Thanks for having us.

AMT: Well Chella Quint Let's start with you should women have the right to paid period leave?

CHELLA QUINT: Yeah I think that companies that list this in their company values are showing that not only can people take period leave if they want to but they can talk about menstruation generally in that workplace. And I think that's the most important message.

AMT: Why wouldn't current sick leave policies suffice?

CHELLA QUINT: Well menstruation isn't an illness and to medicalize it every case seems to me to uphold a lot of old stereotypes that people have in trying to break down for a really long time. But you know it's true that sometimes periods can be painful and a few painful period might be something you want to investigate if you've got an underlying medical condition. But really taboo and stigma are the main issues around menstruation and not being able to talk about it with other people can make you feel isolated and you might not even be able to share why you want sickly if you know your employer happens to ask. So talking about menstrual leave sort of separate s that out.

AMT: Okay, but it's not an illness but it can it can create pain that makes you feel ill, right? And you're taking the leave because you feel ill, are you not?

CHELLA QUINT: Sure. I mean the nature of the way the uterus works is that it causes cramping to slough off uterine linings is breakfast radio, right. But it's not it's not inherently an injury it's that's how it's designed to work. But it can be painful.

AMT: Right. So what you're saying that sick leave policies aren't enough for that, because you have to be able to talk about it.

CHELLA QUINT: I think not that they're not enough. I think that it would be great if anyone felt that in a sick leave policy they could take off if their menstrual pain was bad. But because of the sort of the sort of converse stereotypes of menstruation, that either it makes you weak and ill and irrational, or that you know you should have a happy period and be strong and powerful. Like you know, some people are feeling some way sometimes and the other way other times and sometimes they have just kind of neutral periods. But menstruation is a vital sign and a reliable menstrual cycle shows that you are in generally good health. And it might be if it's not sort of underlined, people might feel that they can't take months to leave if it's not explicitly stated. But I would, if I worked in a workplace where they made a point of saying you can take months or leave, I would know that I could talk about what's in there and that like me make me feel like it was a more open workplace so a lot of ways where I could talk about a lot of stuff that might be considered taboo.

AMT: Chris Bobel. What do you think? Should companies, government institutions be obligated to provide paid menstrual leap?

CHRIS BOBEL: I'm ambivalent, honestly. I think on the one hand often menstrual leave does put menstruation on the map. It challenges the taboo simply by writing menstruation into a company or in some cases national policy. And as Chella says, it in the sense authorizes people to take leave that they might otherwise not feel comfortable taking. But I'm concerned about some potential unintended consequences, and reverse sexism by the way is not one of them. I worry that menstruators might hit and forgive the cheesiness, but a sort of red ceiling will be used as a sort of quiet basis for bias. You know for instance in the Italy context, women are already under-represented in the workforce. So will this fortify sort of assumptions that women are unreliable workers that they should be passed over for promotions or raises or given those choice projects because gee we know Susie Q for instance has tough periods and she may not show up. You know one to three days out of the month. My other concern is that Chella tapped into this is that menstrual leave might fortify the notion that menstruation is an illness even though that's not the intent that it all sort of support assumptions that menstruation makes women weak or unreliable or unproductive. And that real disorders of the menstrual cycle for instance endometriosis might go untreated because rather than women taking menstrual pain and discomfort very seriously then go home and suffer in silence. So it may in some ways ironically push menstruation further into the closet. These are my concerns. We don't have data to know if this is actually that will happen if when these policies are enacted.

AMT: Right but again, can I just point out we do have history we do know that historically, not that long ago. You know women that were really frowned upon in the workplace because they had a menstrual cycle and they couldn't be as on their game as men. And you heard in the intro there that Russian President Putin just said he doesn't have bad days because he's not a woman. We heard Donald Trump talk about an interviewer of having blood coming out of her. I mean there are stereotypes already are there not?

CHRIS BOBEL: Yes exactly and that's why I'm concerned that the policies might fortify them rather than challenge, reframe the menstrual cycle as the vital sign, as a normal biological process, as something not to be stigmatized, shame, silence and so on. So in some ways I worry that the menstrual leave is sort of policy ahead of its time that we have a lot more deep tissue work to do to challenge stigma before menstrual leave could really be appropriately applied and not experienced backlash or produce backlash against menstruators.

AMT: What do you think Chella?

CHELLA QUINT: I feel that Putin and Trump clearly did not have menstruation education at school. And I think if a lot of the legislators who don't menstruate hadn't learned about menstruation quite early on in life, comprehensively you know not with sort of you know, from a tampon company with leaflets like all the girls got when they were at school, they'd be in a position to understand everything that we've just said and it would sort of be taken as red. I guess that's another pun, but it was you know it's really interesting the Trump example because that was really one of the first times where mainstream media really turned on somebody for making fun of someone for menstruating on the scale that that happened. So it was just the Red State gathering and everybody you know in loads of different sort of journalistic sources you know right wing, left wing, pretty neutral like we're all saying stuff like he can't say that that's outrageous you don't make fun of a woman like that. And I couldn't tell that first of it was how much people dislike Donald Trump or how much people were starting to understand. But you don't tease someone for getting their period. And a lot of the work I do with young people in the UK for the period positive projects is around looking at how menstrual taboos are transmitted. And it is most often through the media, through advertising and through school where a lot of companies send they're sort of advertised resources as teaching resources and you know the boys and girls are separated. This all happens in a lot of schools. What a lot of people are not aware of is that those kids are pretty brand loyal to those brands and those brands are sharing those messages. What I worry about is while sort of maybe educators themselves don't have control of that process, the messages that are getting through are commodified and are holding all of these taboos. So one thing we could do is make sure that anybody that's going to grow up to be a head of state, which could be anyone whatever their gender, knows a lot about menstruation and that their teachers know that their parents feel comfortable talking about it.

AMT: Okay.

CHELLA QUINT: Because, you know, we have problems that are around…Yes.

AMT: One could argue [laughs] that if you're going to be grow up to be head of state there are lots of things you should know and we've got examples of what people don't know about.

CHELLA QUINT: [Laughs]

CHRIS BOBEL: [Laughs]

AMT: But let's not go that's not our conversation today.

CHELLA QUINT: Sure. Like we get have another about that soon.

AMT: I want you to take a listen to a clip from Elisabeth Ballermann. She's with the National Union of Public and General Employees. She's concerned about what a menstrual leave policy could mean for employee rights.

SOUNDCLIP

One of the things that we've been fighting for in the labor movement for a long time is the privacy of my medical information. This is private information. No one is disputing that there may be legitimate reasons related to menstruation why a woman might need to have time off and that should be treated as a sick absence. I should not have to tell my employer that I'm having my period. Period.

AMT: Chella Quint, is there a privacy issue here?

CHELLA QUINT: I think that there is so much information that employers hold on us that the issue that I would fight for through my uinion in the teacher is what's done with that information. I think that periods should not be secret but they can be private if you choose them to be and that it is up to each employee's choice. But in terms of worker's rights it's sort of at our discretion. And I think there are more offers made by the opportunity to have this leave on a company by company basis. I think Chris is right it's not we're not ready for nationally embedded period leave because many companies might not uphold correctly policies or just sort of hearts and minds as we go on. But no I don't think it is in Congress with my views on worker's rights.

AMT: Chris Boel, when menstrual leave was granted in South Korea in 2001 men's rights activists called it a form of reverse discrimination. What do you think of that?

CHRIS BOBEL: Well I think claims of reverse discrimination is simply the sound of people losing privilege. I think that's not a very just or rational response. I mean the [unintelligible] for menstrual leave as I understand it is, that people she meant strangers feel that they shouldn't have to use their sick time to care for their menstruating bodies particularly if they had very heavy cycles or they have severe cramping or they have other within the range of normal but still discomfort, as you said Anna Maria symptoms as with the cycle, that it's not a sickness and so they shouldn't have to take sick days. And that basically the menstruating body has certain needs, a need for accommodation that an administrative body does not. Right? So is that reverse discrimination that that certain bodies are accommodated?I think not. I mean it's a recognition of a biological reality. But again it is the application or the implementation of that lead that concerns me. So I don't really want to give a lot of attention to the reverse discrimination claim because I think it's really missing the point.

AMT: And you know there are proponents Chris who argue this is simply a corollary to mat leave and in quality promoting accommodation of women's needs.

CHRIS BOBELS: Yeah I mean I can see the validity of that argument. I think however mat leave has been reconceptualised in many places to be to be parental leave, so that it's not tied to bodies but it's tied to the role of parenting. So that adoptive parents, fathers, you know anyone caring for new children in their lives is afforded the appropriate leave. Of course we see that that for instance in the US fathers don't take parental leave even though it's provided them and that's because of gender roles, right? Certain assumptions about what it needs to be a parent's tie to gender roles. So in some ways menstrual leave is like maternity leave. But in many ways it's not because it is it is tied to a particular kind of embodiment, female embodiment, right? Whereas parental leave is not. And I think progressive leaves are indeed considering that anyone can be a parent.

AMT: Chella? Your thoughts on that?

CHELLA QUINT: I agree about most of what Chris said. I feel like maternity leave is a positive. And menstrual leave is not a sickness. So it's you know it's more on the neutral, the positive side of things for me. And also I mean it's important to point out that not all men's traders identify as women. Some are non-binary trans men and some women don't menstruate for a physiological reasons or for illness reasons and might you know feel alienated by assuming that all women do. However there are a lot of options for different types of leave that may reveal some things about your personal life according to sort of you know unions but accommodate different realities of the workforce. I don't I don't think that capitalism is sort of slowly thinking isn't it. And there are things that happen around workers’ rights that have implications for that. You know people always talk about well what if people take advantage of this or what have people kind of pull a sickie. I mean I think it's about you know people deserve to be recognized for their contributions to the workforce and the working environment needs to acknowledge that productivity and well-being will increase when individual needs are accommodated. There should be no options for mental health leave or for discussion around particular leaves…

AMT: Well, there are but you don't have to… But that again comes under… Mental health is is under issues related to illness.

CHELLA QUINT: Oh. Sure.

AMT: But again then why a separate leave? Because again doesn't that perpetuate the…

CHELLA QUINT: The mental health does not have to be [unintelligible] it could be related to well-being.

AMT: Well yes. So what are you saying though about people showing up to work? Like mental health is one thing and well-being is another.

CHELLA QUINT: I think different… Well mental health it doesn't always mean in mental health. Mental health is just that you know, the general topic, if you have poor mental health…

AMT: Oh, no. We actually know mental health is an actual real health illness in every western country.

CHELLA QUINT: Sure.

AMR: So it's not just it's not just whatever. It's actually an illness that has to be addressed.

CHELLA QUINT: Right but I'm talking about the state of mental health I'm not talking about mental illness, which is an illness, I am talking about when one is looking after one's mental health that comes under workplace well-being. So just like your physical health just like your work life balance and childcare and other issues around you know absenteeism. I think it's important to look at all of the ways workplace can better accommodate its workers. And one of those might be highlighting people wanting to take time off for counseling for example you know if they can only find therapy appointments in the daytime rather than the evening. Or, menstrual leave, havinga regular time to do that and parental leave, that being something that comes up.

AMT: So is this generational I'm going to admit to you that, you know I'm a former war correspondant. The first time I was in a newsroom there were no other women. Women worked really hard to not have their menstrual cycles judged in order to even get jobs because the view of Mr. Putin that we said there was, when I started my career in the early 80s that was the view of a lot of bosses. So are you actually are you putting women into a position where the stereotype that still exists will actually perpetuate again. How do you how do you speak to those women who actually fought really hard to get jobs that only men had at one point? And one of the reasons that we had them that was that issue; “well you know honey, you know you're going to have a different attitude at a certain time of the month”.

CHELLA QUINT: I think everything happens in stages. I my mother gave me a copy of our bodies ourselves when I was 12 years old and I was highly influenced by that. The way that the second way feminism challenged a lot of the tropes and stereotypes put upon women from like the 60s, 70s, 80s set into the kind of feminism I was doing in the 90s and early 2000s and I see younger women in me taking things from an intersectional perspective that I've come to get used to and be a part of rather than having initiated it. And I think everything happens in stages. What you guys were doing was necessary at the time, and what I was doing felt necessary at the time. And what's happening now is we need non menstruators to catch up to where we are. It's almost like it feels like it's coming full circle, where everybody has the right to ask for or demand what they need and what we need from society right now is an end to menstrual taboos. And one of the ways to get it may be to talk about it more but pretending everything's great and that we don't have periods. It's taking us even further back to the 50s where they literally hid menstrual products in unmarked boxes and advertised everything by promising you will nevere , ever…

AMT: Point well made. Point well made. we have to leave it there. Thank you both for your thoughts on this.

CHRIS BOBEL: Thanks for having us.

CHELLA QUNT: Thank you very much.

AMT: Okay, well, thank you very much. That's Chella Quint. She is a researcher educator and founder of #periodpositive. That is a campaign for better menstruation education. She's in Sheffield, England. Chris Bobel is an associate professor of women's gender and sexuality studies at the University of Massachusetts in Boston. And that's where we reached her. Well we got someone else listening in. Elissa Stein she coauthored a book called Flow the Cultural History of Menstruation. And she says the stigma surrounding period statement dates back to the beginning of recorded history even before they were hiding the tampon boxes in the grocery stores. And Elissa Stein is here with us from New York. Hello.

ELISSA STEIN: Good morning. Thanks so much for having me on.

AMT: Well what are you thinking as you've been listening in?

ELISSA STEIN: It's a really fascinating conversation. And I see the points that both Chris and Chella are making about this. I've done a lot of thinking about it and I think that Chella right on the one hand. Anytime that there's an opportunity in society and in public to be talking about menstruation, big step forward because for thousands of years it was such a shameful secret. No one was talking about it. On the other hand though, throughout history there's been such a stigmatization of menstruation that giving an opportunity for employers or for coworkers to use it as an excuse to blame women or say that they're not capable if they're taking menstrual days off, seems like a way to open a door into maintaining more of the same mindset that we've been battling for thousands of years.

AMT: So what are the beginnings of some of the negative attitudes toward menstruation that continue today?

ELISSA STEIN: When I was researching flow and this was all kind of new to me I discovered that the Bible and the Qur'an and Hindu texts speak specifically about menstruation and claim that women are dirty and incapable when they had their period. So going back thousands of years in what was taught and accepted in religious texts as a long time. That's a lot of people who were exposed and I believe that through centuries and centuries of this doctrinatio,n we've all been sort of coerced into believing these things as a truth a fundamental truth. What it may not be what we personally believe but culturally and society has sort of home these messages for such a long time. There are a baseline way of all of us assuming is how we think and feel.

AMT: And what about in politics How did women winning the vote, the right to vote change things?

ELISSA STEIN: The right to vote was really hard to come by. Women started to fight for the rights of those around the time when African-Americans were fighting in the United States to vote, and it was denied back then. It wasn't until the 9900 that they got the right to vote and there was a heated discussion in politics in the United States about it. The New York Times came out several years before the right was given saying that women were emotionally unstable because of menstruation and they shouldn't be trusted with the vote. So politics has often taken the same stance as religion, in that women were rendered incapable they were too emotional they were too unstable to have the responsibility of voting. And that mindset carries through it today. There are so many laws still on the books certainly in the United States that aren't fair towards women. And there's a huge movement right now to repeal tampon taxes and to make products available in prisons and in schools to sort of equal the playing field for women in a world that's been run by men for too long.

AMT: It's only in the last century that women have had things such as sanitary pads and tampons. And now of course there are drugs that have been developed that can halt the cycle. What impact has all of that had?

ELISSA STEIN: It's an interesting concept because on the one hand yes things are more available and I always say that for every step forward when it comes to menstruation and society there are steps back. So yes there are so many more products available. But with those products comes the message of shame and secrecy so that while for the past 100 years since PAD's first went on sale we've also been trained to use this alternative language of shame talking about feminine protection talking about sanitary hygiene pads with walls. It's very rare that a package will actually say period or menstruation on it. So we've all been trained to use a different language to talk about this. And if not it's helping keep the secrecy and shame of menstruation alive.

AMT: And so the idea of period leave forces a conversation that would otherwise happen.

ELISSA STEIN: Yes. And on the one hand that's great. I think that conversation about menstruation is imperative and I wrote flow to start that happening, because too often women weren't talking about it. On the other hand it couldn't be used against women for example on PMDD which is premenstrual dysphoric disorder which is like PMS but more, stronger symptoms, more dramatic for the women who suffer from it. That's a diagnosis that can be used against women in the workforce if they are diagnosed with PMDD that can be used in terminating a job or in maintaining custody of children in a court battle. So that's a way that coming forward about periods and about period symptoms and how women suffer but they can be used against women.

AMT: Hmm. There are a few things that have happened in the last little while that got a lot of attention in the news in the sort of coverage of… There was a tennis player Heather Watson who attributed her Australian Open loss to being on her period. There was a yoga instructor who posted a video on Instagram that was filmed during her period in which the blood soaked through her pants. What's the result of that kind of stuff going public for people to look at and talk about?

ELISSA STEIN: It's been twofold. There are people that are horrified and disgusted. And there are also people who recognize that as this is moving the conversation forward. What I would hope for the world going forward is that if menstruation could be more of a conversation, as a conversation about anything else regarding health, regarding well-being, regarding disability because menstruation has all those different components to it. The more it's just a conversation in real words and terms the more the stigma can be taken away. So kudos to those women for being honest. You know having your period isn't all strolling in a field and flowers. It is also not so debilitating that you can't function. Some days though it can be harder, like that tennis player. Sometimes a marathoner will run with her period and will do absolutely fine. It depends on the woman. It depends on the month, it depends on the situation. But being able to acknowledge that it exists, it's a part of us, it's real and it can affect how we are and who we are and then sometimes also not. That's an important part of the conversation that too often gets glossed over, for bigger arguments or for sales sake.

AMT: Okay, so before I let you go what needs to change to break the stigma?

ELISSA STEIN: Talking. Straight up honest talking about periods as they exist in the world, not as people think that they should.

AMT: Okay. Elissa Stein thanks for your thoughts.

ELISSA STEIN: Thanks so much.

AMT: Elissa Stein co-author of Flow: the Cultural Story of Menstruation. She joined us from New York. Now over to you. Do you think it's time for paid menstrual leave? Is it a step forward, as you heard our guests argue or is it back in addressing workplace inequality? Tweet us @thecurrentCBC find us on Facebook. E-mail us from our website cbc.ca/thecurrent and click on the Contact link. That's our program for today stay with Radio 1 for q. Nickelback releases a new album this week. The band tells Tom Power about defying the naysayers and then plugs in for a loud live performance.

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AMT: I just want to remind you again if you can listen to The Current on a CBC Radio app it is free from the App Store or Google Play. And we'll leave it at that. I'm Anna Maria Tremonti thank you for listening to The Current.

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