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A recent article by conservative watchdog Campus Reform targeted my collaborative research talk on racial justice work in and as Buddhist practice. The talk traced the multiple ways whiteness has operated in American Buddhism including the erasure of Asian American heritage communities and detailed some of the strategies by which Buddhists of Color and their white allies have been confronting structural racism in their communities for over three decades.

While opponents have dismissed such initiatives as the intrusion of identity politics into the tradition, Joy Brennan, my collaborator, showed how the Yogacara school of Buddhist philosophy provides a framework for recognizing and being liberated from whiteness. Jessica Zu, our respondent, provided historical continuity by linking anti-racist Buddhist work to neglected Asian Buddhist figures such as Lu Cheng, the Chinese Buddhist modernist who forged socially progressive visions of the tradition in the early twentieth century.

Rather than engage with the actual content of the talk, the reporter opted for a website quote from White Awake, one of the anti-racist organizations working with Buddhist communities, and solicited a comment from anti-woke crusader and mathematician James Lindsay in which he linked whiteness to communism and the abolition of private property.

As he put it, Whiteness is the racial repacking of Marxs concept of bourgeois private property. Reposted by Legal Insurrection, another conservative organization, one reader added Critical race theory is more than a delusion, its a disease; another suggested our karmic punishment should be reincarnation as vultures.

The attack on racial justice scholarship by Campus Reform is unsurprising. The conservative organization has an established history of targeting scholars who work on racial justice, with many of my colleagues in religious studies coming under fire.

Research has shown that Campus Reforms so-called attempts to reduce liberal bias have led to professors facing harassment and even being dismissed by their institutions. Such attacks have now become state-sponsored with anti-critical race theory laws being passed for K-12 schools in a number of Republican states and further bills aimed at higher education proposed.

What many will perhaps find more surprising is that the rhetoric being used by Campus Reform and their ilk is far from new to me or fellow researchers working on racial justice in American Buddhism. Rather it echoes some of the white Buddhist backlash to racial justice work. A number of white Buddhists* have adopted the language of invasion and infection in an attempt to discredit long overdue racial justice initiatives in their communities.

Popular Zen teacher Brad Warner, for instance, has declared that racial justice work has nothing to do with Buddhism but is merely a tool of identity politics designed to shame white men. Secular mindfulness teacher Shinzen Young, meanwhile, delivered an explosive rant in which he claimed critical race theory was being used as a hammer to beat half of America to death with and blamed it for the election of a jerk.

Brenna Grace Artinger and I have charted the emergence of a broad spectrum of anti-woke white Buddhists who have attempted to delegitimate and derail racial justice work. We organize these anti-social justice Buddhists into three distinct but overlapping categories: Reactionary Centrists, the Buddhist Right, and alt-Right Buddhists.

We borrow the term reactionary centrist from political theorist Aaron Huertas who defines it as someone who says they are politically neutral but who usually punches left while sympathizing with the right. Reactionary centrism, in other words, is a conservative ideological stance that sees and presents itself as transcendent of ideology.

Such an approach is clearly at work among white Buddhists who claim to be apolitical while mobilizing conservative assumptions and strategies to delegitimate anti-racist work in Buddhism as ideological. A good example here comes from the transnational Buddhist Triratna community.

Given their strong links to the Ambedkar Buddhist Dalit community, an engaged Buddhist lineage that has combatted caste violence and discrimination in India, one might expect to find a similar commitment to justice for other marginalized populations. Indeed, some Triratna practitioners have confronted the legacy of racism within and beyond their communities by consciousness-raising, compiling anti-racist resources, and starting PoC affinity groups and white awareness groups.

In reaction to racial justice efforts, however, seven white male members, an affinity group of its own sort, produced a website called Apramada: Buddhist Perspectives on Society and Culture, whose mission statement declares: The aim of Apramda is to bring Buddhist perspectives to bear on questions facing the world todaya task of urgent importance in an era when public discourse is often clouded by divisive ideologies and partisan animosity. One article title suggests that Buddhists should leave their politics at the temple door. On further reading, however, its clear that its not politics per se but rather a certain type of politics that arent welcome. To give a hint: as the author explains, diversity, like social justice, is one of those words that sounds innocent and good, but is informed by a political ideology that is not so innocent and good.

One wonders why the author sees the call for racial justice in his community as ideological rather than as reflecting the lived experiences of his PoC sangha members. Why did he not include any of the first-person reports by Triratna members of color who have experienced racism within and beyond white dominant Triratna spaces? In fact, in a commonly employed reactionary reverse victim strategy, the only identity group he does name as vulnerable in Triratna are conservatives.

One also wonders how he squares his apolitical call with some of the articles written by his co-editors. Reproducing familiar conservative rhetoric, one of these denounces the postmodern anti-racism of Black Lives Matter and Critical Race Theory but adds a unique twist by comparing the current police racism panic to the ritual panic abuses of the 1980s. Another compares responses to structural racism, climate change, and Covid-19 to mental illness that are wreaking havoc in Western society. Just like Campus Reform, he turns to James Lindsays anti-woke polemics for support.

While Buddhist reactionary centrists seek to naturalize their own conservative political positions as transcendent of ideologies, what we identify as the Buddhist Right explicitly embrace their right-wing positions. In response to a Statement Against Anti-Asian Violence by the Buddhist Churches of America, the oldest Buddhist organization in the U.S., published in the wake of the shootings in Atlanta that left eight people dead, including six women of Asian descent, Jason Manu Rheaume released an article titled Critical Race Theory is Corrupting Buddhism, which claims that critical race theory has not only infiltrated colleges but also Buddhism in America.

Rheaume and two other white Americans, David Reynolds, a former Theravada monk, and Mark Vetanen, a Zen practitioner, have started a new podcast called The Spiritual Right, which reproduces much of Christian conservative anti-woke rhetoric: The West has become a spiritual wasteland of progressive and materialistic forces. Wokeness masquerades as authentic spiritual tradition, gutting and commodifying ancient teachings to fit its values.

Writing under the signifier politically incorrect Dharma, Reynolds had earlier called for an Alt-Buddhism, namely a relatively conservative, non-feminist (in the emasculating, man-hating socialist sense of the word) spiritual system directed mainly by men. One response came in the form of the self-proclaimed alt-right Buddhist group Right-Wing Dharma Squads.

Hiding behind pseudonyms, these four white men have produced a series of podcasts that mock liberal Buddhism and interweave reflections on Buddhist texts with misogyny, antisemitism, and the celebration of Asian Buddhist monastic extremists such as U Wirathu who have incited violence against Muslims.

For those readers who associate Buddhism with progressive liberal values, or hold an ahistorical reading of the tradition as apolitical, the white backlash to racial justice will be a surprise. As within all religious traditions, however, Buddhist doctrine has been used to both support and resist power regimes.

Rather than argue for a real interpretation of the tradition, scholars can illuminate the ways in which reactionary Buddhists attempt to naturalize their own positions while simultaneously claiming progressive positions as distorted by ideology. They can also point out that such a strategy itself performs the operations of whiteness: as African American philosopher George Yancy notes, others have racialized identities but white people are the transcendental norm.

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*Correction: The word teachers was removed in order to clarify that the subsequently mentioned teachers were not the ones who had in fact used the terms invasion and infection.

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This article was made possible in part with support fromSacred Writes, a Henry Luce Foundation-funded project hosted by Northeastern University that promotes public scholarship on religion.

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Reactionary White Buddhists Have Joined The Fight Against Critical Race Theory - Religion Dispatches

There are as many reasons to unfollow someone on TikTok as there are to follow someone. For instance, you might not like the experience of being spammed by their all-too-frequent uploads, or you have outgrown the kind of content they create. What if some you follow turned out to be very politically incorrect, but you are not one to tolerate a grain of sand in the eye. Unfollow, of course!

The reason could even be more personal, I mean, is it wrong to unfollow someone who doesnt follow you back or suddenly unfollowed you out of the blue? Absolutely not!

Whatever the reason may be, now that you are here, your requirement is to learn all about all the ways to unfollow someone on TikTok. Without any further ado, lets jump right into the heart of the topic.

Related: How to repost on TikTok

It could be a good thing, or it could be a bad thing, regardless, the unfollowed user is not notified of the event if you unfollow them. So, you can unfollow anyone without alerting them, especially so if you unfollow the user without visiting their profile. Well, it works both ways, because, if someone unfollows you, apart from the change in followers figure, youd receive no indicator as to who unfollowed you.

So, unless a user unfollows someone by visiting their profile, the unfollowed party might not be able to immediately pinpoint who unfollowed them.

There are three ways to unfollow others on TikTok. The first method is to access your following list from your TikTok profile and manually unfollow each and any account. The second method is to look them up on TikTok Discover and unfollow them from their profile. Finally, there are a few popular third-party apps that undertake it in your stead.

Unfollowing from your following list is the most recommended method, as it avoids the need to alert someone of your profile visit to unfollow them. It also doesnt involve the looming threat of being shadow-banned that comes along if you employ bots or third-party apps to take care of the job. However, unfollowing from your profile could end up feeling onerous if you follow a large number of accounts, and you want to mass unfollow all or some of the accounts you follow.

Related: How to Turn Off Restricted Mode on TikTok Without Password

Launch TikTok on your device. Hit the profile icon to go to your profile.

On your profile page,beneath your username, you will see the shortcut to your Following list. Tap to view the list.

You will see the list of all accounts you follow. Tap the Friends button against the username of the account you wish to unfollow.

There, with a single tap, you have unfollowed them. You may repeat the same steps to unfollow anyone on the list. When you unfollow an account, itd show Follow back, if you were mutual follows, or, Follow if you werent moots, to begin with. Their names will disappear altogether from the list after a simple refresh.

The more the number of accounts you follow, the more time-consuming itd be if you have a long to-unfollow list in your hand.

Related: How to Turn On Profile Views on TikTok

Launch TikTok. Tap Discover to go to the TikTok Discover page.

In the search box at the top of the page, enter the username of the account you wish to unfollow.

Tap their profile picture to go to their profile.

Hit the following/mutual following icon to unfollow them.

The screenshot below shows an account you unfollowed (which still follows you).

Both these methods discussed are suitable to unfollow specific accounts that you can pinpoint, like those accounts you frequently interact with. So, what about mass unfollowing on TikTok? Is it possible?

Related: How to Turn Off Restricted Mode on TikTok Without Password

It is a popular behavior among the hottest of TikTokers to keep the number of people they follow to a bare minimum, all to create an aloof and in-demand identity. Mass unfollowing is also a deceptive game played by some users to gain more followers by initiating the following process and then stealthily unfollowing them later.

If your intention is only to cleanse your for you page feed and restart on TikTok, then mass unfollowing could help you in the process of reeducating the TikTok algorithm of your preferences. That said, there is no select all or unfollow all button on TikTok that offers this facility.

What users generally do is resort to bots and software from third-party sources. But, we have all used third-party apps to get something or the other done for us on our device, so what is wrong with that?

There is nothing really wrong with the method, apart from the aftermath. The TikTok algorithm is steadfast in rejecting interference from third-party apps and bots. If you are caught cheating the system to engage in the restricted behavior using bots, consider yourself immediately sentenced to being shadow-banned for who knows how long. The intensity of the penalty varies from account to account.

But wait, how does the TikTok algorithm even detect it if you unfollow some well a lot of people from your profile. TikTok detects it based on your behavior on the app the sudden drop in the count of your users in your following list within a short span raises red flags without fail, and the penalty is inescapable when you are tracked down.

To continue what we discussed above, the only legitimate way is to unfollow manually from your profile.

That means, if you follow 500 users on TikTok, to unfollow them, you have no choice but to un-Friend each one on the list one by one. But, things arent as simple. To discourage users from allowing bots to disrupt its system, the algorithm has established a very particular rule that you must abide by on the platform the maximum number of people you can unfollow per day is 200. It is recommended to keep the number below 150 to avoid the risks of getting an account ban or lock.

Even if you use legitimate means to unfollow each account manually, there is still the risk of getting banned on TikTok, and this depends on the time duration taken to unfollow accounts. If you unfollow too many accounts at once, the algorithm might misunderstand the activity as a bot-interference and lock your account. It is better not to risk your account and maintain a good gap between a group of unfollows, preferably 3-4 hours.

We have already discussed the risk of shadow-banning involved if you use third-party apps for bulk unfollowing. However, the greatest risk is getting scammed or hacked. Many of the third-party apps which recommend themselves as the best tool to unfollow others automatically on TikTok have been indicted with privacy invasion according to user reviews.

That is not to say that there arent any dependable tools out there. For instance, the fueltok TikTok bot has been receiving a good amount of word-of-the-mouth recommendations as quite a handy tool for its specialization in automating following and unfollowing activities on TikTok.

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How to Unfollow on TikTok: Unfollow Someone, Everyone, and More - NerdsChalk

The level of violence across Mexico involving drug traffickers and the armed forces has become the subject of considerable controversy and much debate. The right-wing opposition and the government are both weighing in, as are analysts and independent investigative journalists. Every week, it seems there is a new event highlighting just how serious the situation has become in several states that are the weakest links in a panorama that extends to most of the national territory. Its reminiscent of what Mexico experienced during the presidency of Felipe Caldern from 2006 to 2012.

While it is difficult to cull from official statistics which violence is linked directly to drug trafficking, an estimate is possible if we consider, for example, that of the more than 2,000 murders that occurred in Mexico in January 2022, Guanajuato, Michoacn, and Zacatecas three of the states with the greatest cartel activity are also among the states with the highest number of violent deaths.

Journalists in particular face a dramatic situation. So far this year, six journalists have been murdered. Journalists in Mexico face conditions of danger and defenselessness that are similar to those in a war zone something the international media has already pointed out, and that the European Parliament has opportunistically tried to take advantage of as it approves censure motions against the press in its own countries.

As we have written in other articles, it is journalists and women with an increase of femicides to more than 10 a day who suffer the most from the consequences of Mexicos political and social decomposition.

The government of Andrs Manuel Lpez Obrador (AMLO) campaigned in 2012 and 2018 on a pledge that he would return the army to their barracks. This stance won him a lot of approval after the tremendous social protests of the preceding decade, especially against militarization, by democratic movements such as the Movement for Peace with Justice and Dignity and the movement for Ayotzinapa.

After AMLO won the election, though, his promises gave way to an opposite policy. The National Peace and Security Plan, released in November 2018, made it clear that AMLOs aim was to put security and the fight against drug trafficking under the direct responsibility of the military. For this purpose, he created the National Guard, with members from the Navy and the Army, through a process that went through several iterations including a debate on whether it would be under military or civilian command. It culminated in the new body being assigned to Mexicos Secretariat of National Defense (SEDENA) and an ironclad centralization of internal security within the armed forces. The government also began to include the armed forces in civilian tasks and aspects of its political agenda, including having the armed forces participate in the administration of ports and customs as well as various social programs, including building up the Banco de Bienestar and helping construct a new airport. All of this has meant deepening Mexicos militarization by giving the armed forces a greater role in security and in various areas of society.

As one researcher has written,

During the transition period, Lpez Obrador and his team maintained their commitment to a new pacification strategy. In addition to including a package of social policies focused on youth in particular, this strategy contemplated changes in drug regulation policies, as well as a battery of alternative penalties and amnesties. Although many of these proposals were well received by public opinion, it was not easy to know whether they would be compatible with Washingtons security priorities, let alone to anticipate their viability in the context of the insecurity and violence engulfing the country.

Indeed, since AMLO became president, his orientation with respect to security and drug policy has always been largely in accordance with whatever is dictated by the White House first from Republican Donald Trump and then from Democrat Joe Biden, without much change from one to the other. Although AMLO has on numerous occasions used the phrase hugs, not bullets to summarize his policy in these areas, and claims to be attacking the social causes of violence, the truth is that the National Guard has 170,000 troops (more than ever were deployed by Caldern) and is doing nothing to attack the root causes of poverty, inequality, and social marginalization.

Following in the footsteps of previous neoliberal governments, AMLO justifies militarization to the Mexican people as the necessary response to drug trafficking. The primary work of the National Guard, though, has been to repress migrant caravans and social movements as its territorial presence and its image and strength as part of the state apparatus grows in the eyes of working people. The proof of this can be seen it its repeated operations against migrants beginning in 2020, the Ayotzinapa students, and the teachers of Michoacn in the first months of this year. The actions it has taken against organized crime and the drug cartels are a matter of much controversy and debate.

A number of journalists and researchers have argued that the strategy of hugs, not bullets, rather than using social policy to undermine the drug cartels, actually protects a policy aimed at avoiding any direct confrontation with the cartels a kind of unsigned agreement so as not to repeat what was experienced in previous presidencies. El Pais columnist Jorge Zepeda Paterson, for example, has written, The president concluded that given the real impossibility of facing the problem, it was better to buy some time a strategy that could not be admitted to publicly, and that was politically incorrect, but was, in his opinion, realistic. Thus, the actions of the National Guard, in addition to guaranteeing militarization, would be aimed at recovering territorial control in the 248 districts into which Mexico was divided for security purposes, without looking for direct confrontations with the cartels, but rather to show more of a presence. This has been accompanied with greater financial intelligence to interfere, if necessary with the economic operations of some of the cartels.

This approach has not achieved its objectives, and now we face this spiraling violence thanks to the expansion of some cartels and more confrontations between them which has played out over the last two years in the form of thousands of violent, barbaric episodes. One of the most notorious occurred in Culiacn in October 2019. There was a violent response to the government operation to arrest Ovidio Guzmn Lpez, son of Joaqun Chapo Guzmn and a known member of the Sinaloa Cartel. The cartel shut down access to the state capital a demonstration of its armed power that compelled the government to agree to release the drug lord. Another example is the attack against Omar Garcia Harfuch, Mexico Citys Secretary of Public Security, in June 2020. It took place in broad daylight in a well-off area of the city. Members of the Jalisco Cartel New Generation used high-powered weapons and showed logistical capabilities.

AMLOs detractors many of whom belong to or identify with the right-wing opposition parties criticize the president, saying that behind the hugs, not bullets line is a decision not to act against the cartels, showing the state to be weak. Sectors of imperialism itself such as former U.S. prosecutor Barry Carr argue that the government has lost sovereignty over the cartels and that its strategy is now to coexist with the cartels.

All of them demand a head-on fight against drug trafficking; that is, a return to the policy carried out by the governments of Caldern and Enrique Pea Nieto, the president who preceded AMLO. They want the National Guard in addition to the militarization and repression against social movements that the AMLO government has fostered to go on the offensive against the cartels instead of being limited to some sort of containment of drug trafficking. The Biden administration seems to be calling for the same thing.

Part of the increase in generalized violence must be attributed to this deepening of militarization through the actions of the National Guard, which constitutes the genuine realpolitik of what AMLO has called the Fourth Transformation of Mexico his 2018 campaign promise to end the privileged abuses of high government officials in the country. Human rights violations are widely documented, and the presence of the different armed bodies in the streets (whether the police, the Armed Forces themselves, or the militarized National Guard) has had dire consequences for the population, from intimidation to repression.

In addition, the dynamics of the drug trafficking business in Mexico in recent years must certainly be considered as fundamental to the increase in violence. Today, there are at least 16 cartels in Mexico spread unevenly throughout the 32 states. This expansion has been consolidated during AMLOs administration. Two cartels, present in 25 of the states, are at the forefront. One is the historic Sinaloa Cartel. The capture and extradition of Chapo Guzmn to the United States did nothing to eliminate the cartel; instead, its different factions are led today by a number of his relatives and by Ismael El Mayo Zambada, who has miraculously evaded capture for more than 30 years. Its base of operations is concentrated in the so-called Golden Triangle and the northern states of the country, strategically located near the U.S. border. But it has a presence, either directly or through shaky alliances, in most of the republic.

The other is the Jalisco Cartel New Generation (CJNG), which rose meteorically in recent years under the leadership of Nemesio El Mencho Oseguera. It has employed a very aggressive expansion strategy, with alliances and clashes with other cartels and organized crime groups. The CJNG is now present in more states than all of its competitors. Some analysts compare it to the Los Zetas cartel, particularly for its paramilitary style and propaganda, with its forces dressing and parading as if they were a regular military force as they openly defy state control.

With so many large organizations, smaller groups, and cells, as well as the alliances that quickly give way to confrontations for the control of the plazas, the struggle between cartels plays out in a complex and intricate manner. Wars break out between them and government forces, as weve seen in most states, including Guanajuato, Michoacn, Zacatecas, and a long list of others. One of the most recent chapters in this saga was the collective executions in San Jose de Gracia.

It is important to keep in mind that the different cartels, in pursuing their economic interests and quest for profit through illegal means, are not limited to drug trafficking. Increasingly, they have been getting into other lines of business, including kidnapping, extortion, fuel theft from pipelines, collecting protection payments, and human trafficking. As is well known, many migrants have been the victims of cartel kidnappings and murders. The cartels have also been intimidating lemon and avocado farmers and loggers in Michoacn and Guerrero for protection payments; this also facilitates subsequent efforts by narcotics cops and transnational mining companies to carry out their megaprojects.

Drug trafficking activities particularly by the two leading cartels have become increasingly internationalized, extending their links to countries in Europe, Asia, and Africa, while they have become the main suppliers of cocaine, methamphetamine, and fentanyl consumed in the United States. The production and trafficking of synthetic drugs such as fentanyl, with much higher profit margins than other drugs, really stands out; fentanyl is made from ingredients that come from China. Thus, the cartels are fighting for control of the routes to Mexico and from Mexico to the United States, which is why the airports have become so strategically important, along with the countrys main ports in the states of Michoacn, Colima, and Veracruz.

A recent investigation by Contralnea magazine highlights the criminal enterprise networks shared by the two main cartels in Mexico, which combines a federated network with a highly hierarchical structure that has branched out into an array of criminal activities and to various countries and continents. The character of this business is explained by its ultimate goal: commercial dominance in one or several criminal economies. In all cases, the source of power is the accumulation of economic capital around these markets, which is used to exert increasing amounts of social and political power over their areas of influence.

Again, it is important to consider the actions of the drug cartels in light of their search for profits through activities that are not simply illegal, but are the greatest expression of the decomposition and social degradation of Mexican capitalism. These include human trafficking and extortion, to mention only two.

There are various aspects to the relationship between the state and drug trafficking. Many speak in terms of infiltration, but the reality is one of genuine collusion and criminal association between different levels of the state and institutions and the different cartels. One of the most scandalous expressions of this was the relationship between Genaro Garca Luna, Mexicos Secretary of Public Security from 2006 to 2012, and the Sinaloa Cartel. Only someone looking at this navely (or with self-interest) could pretend that it all ended in 2018 or that such corruption is found only at the lowest levels of the police forces and local authorities. That is far from reality; as history shows, it has reached the highest levels of the capitalist state, and drug trafficking has a direct influence on the appointment of political and police officials.

Similarly, corruption and criminality are not exclusive to this or that political party. All the political forces that represent Mexican business interests are, to a greater or lesser extent, involved. Investigative journalist Ricardo Ravelo, in his most recent book Los narcopolticos (Narco-politicians) shows the evidence of corruption belonging to all the parties in the highest spheres of government. Of course, he was threatened with legal action by the current governor of Jalisco, Enrique Alfaro, whose party is the Movimiento Ciudadano (Citizens Movement). Along with the huge number of officials from the PAN and PRI, quite a few governors and mayors belonging to MORENA have also been singled out in different states of the country governed by the ruling party.

The actions and expansion of the cartels cannot be explained without their close relationship with the so-called political class and the different levels of the state and the armed forces. This worked particularly well for the political parties involved when there was a hegemonic cartel as in the 1980s, with the so-called Federacon (Federation) created by godfather Miguel Angel Felix Gallardo, which enjoyed a privileged relationship with various U.S. agencies that became public with the IranContra scandal. The relationships were also used to tip the balance toward one of the contending cartels, as with Luna and his association with the Sinaloa Cartel. At the same time, when there was a lot of fragmentation or competition became especially tough, the states choice whether at the level of the central or regional government, or even locally to protect this or that cartel and guarantee its position led to reactions and confrontations that were quite violent, as was seen under previous presidential administrations and is currently happening in many Mexican states. It is the local populations that always suffer the consequences of these confrontations between cartels and with the armed forces.

Today, some point out that the states efforts are concentrated primarily against the Jalisco Cartel New Generation, which thus favors its main competitor. Others defend the official strategy, arguing that it is simply a reflection of the CJNGs greater aggressiveness.

The links between drug trafficking and the institutions and political parties at the service of big business and military forces signal that we are confronting a fundamental characteristic of Mexican capitalism. In light of oppression at the hands of imperialism and its acceptance of Washingtons prohibitionist drug policies, Mexico has rolled out a profound degradation and decomposition of every aspect of so-called public life.

This is the context for the U.S. administrations call for more decisive action against drug cartels by the Mexican government. The U.S. State Department, in its recent International Narcotics Control Strategy Report (INCSR) 2022, argues that Mexico has little capacity to prosecute money laundering, that the chemicals used in narcotics production are not regulated, and that Mexican cartels are playing an increasingly transnationalized role as a production and transit point to the United States and in relation to Chinese chemical ingredients.

The Biden administration made the decision to point out openly the influence drug trafficking organizations wield over high-level Mexican government officials. This undoubtedly aggressive gesture was combined with a call to continue to work together to intensify efforts to dismantle transnational criminal organizations and their networks, increase prosecutions of criminal leaders and facilitators, and strengthen efforts to seize illicit assets. It is important to keep in mind that these remarks were preceded by the indictment of Genaro Garca Luna and the detention of General Cienfuegos, who was finally released following the diplomatic protest of AMLOs government.

Now it appears that the White House is particularly concerned about the boom in production and trafficking of synthetic drugs such as fentanyl to the United States. Washington is expecting more intense activity by the AMLO administration against the cartels operating in the United States, and greater collaboration which can only mean greater involvement by the U.S. Drug Enforcement Administration. U.S. pressure, although presented in a diplomatic manner as part of its U.S. interventionist policies is evident, and will only lead to even greater militarization of Mexico and the northern border.

It remains to be seen whether AMLO will accede to U.S. expectations meaning a stronger confrontation with the cartels, which would create greater instability and comes with political costs for the government, considering the societal sensitivity to violence in the country. He may keep on his current course, focused on maintaining state presence in the hottest areas by means of the National Guard, which again is most effective against social protest.

In recent weeks, we have seen the arrest of several leaders, such as the apprehension and deportation to the United States of El Huevo Trevio, capo of the Northwest Cartel and nephew of the fearsome Z-40, as well as the regional leader of the CJNG in Colima. These could be interpreted as gestures aimed at calming U.S. anxieties and demands. And it comes in the context of new actions by organized crime, such as the murder of the mayor of Aguililla, a town in Michoacn where the armed forces had taken back the municipality from the cartels. That had been touted as a positive expression of the governments policy of greater territorial presence.

The current situation is creating tremendous instability. And it can be dangerous for a government that seeks, precisely, to preserve a certain political stability so that it can make it to the 2024 presidential elections with its current level of popularity and keep the right-wing opposition from capitalizing on the situation through calls for greater security.

AMLOs security policy, part of his Fourth Transformation, is fully aligned with the subordination of Mexico that Washington demands. It is based on the prohibitionist drug policy and the deployment of the armed forces throughout Mexico.

In past years, the so-called war against drug trafficking and the militarization that supported it brought disastrous consequences for Mexicos workers and impoverished people: a shocking toll of hundreds of thousands of deaths and tens of thousands disappeared and displaced. This was the most abhorrent expression of the consequences of economic, political, and security subordination to the United States, as well as of the decomposition and degradation that has resulted from the historical oppression of Mexico by imperialism which shares a 3,000-kilometer border with the colossus to the north and the most recent policies imposed by the White House.

It is clear that the only way out of the current trap, crisscrossed by the actions of the cartels and the Mexican states security strategy, necessarily involves breaking with imperialism and its dictates. Demilitarizing the country, legalizing drugs, and expropriating drug capital are fundamental measures that must be taken. This is far from what the political parties that represent the interests of the capitalists can do or even wish to do. Even the most progressive among them have no intention of antagonizing the United States and opposing its policies, which in Mexico and throughout the region, have had such dire consequences.

The perspective we must promote is an anti-capitalist and socialist one that begins with these measures just outlined. That is the only perspective that serves the interests of the masses, and that can put a stop to the spiral of violence and social degradation that is a direct result of capitalism and imperialist oppression.

First published in Spanish on March 20 in Ideas de Izquierda, the Sunday supplement of La Izquierda Diario Mexico.

Translation by Scott Cooper

See original here:
The Mexican Government and the Cartels: Colluding in Service of US Imperialism - Left Voice

In this episode, PitchBook PE and healthcare senior analyst Rebecca Springer welcomes Avi Jayaraman and Dexter Braff for a discussion about the rapidly evolving behavioral health industry and how private equity is helping to drive innovation in the space. Jayaraman co-founded Sonara, which provides a remote solution for medication-assisted opioid addiction treatment. Braff is president of The Braff Group, an M&A advisory firm specializing in healthcare. They share their thoughts on growth and greenfield opportunities in behavioral health, the advantages and challenges that PE firms face when operating in healthcare, how technology can bridge staffing shortages and more. Plus, PitchBook senior manager of publishing joins discuss the 2021 Annual Interactive PE Lending League Tables and PitchBook's exclusive coverage of venture debt deal terms.

In the Upwork segment of "Innovations in Private Equity," Tim Sanders is joined by Dave Stangis, chief sustainability officer and partner at Apollo Global Management. Dave discusses how private equity firms can bring strong sustainability practices to life internally as well as across the portfolio companies they're invested in.

Listen to all of Season 5, presented by Upwork, and subscribe to get future episodes of "In Visible Capital" on Apple Podcasts, Spotify, Google Podcasts or wherever you listen. For inquiries, please contact us at podcast@pitchbook.com.

Avi Jayaraman: Thanks Rebecca.

Dexter Braff: Thanks for having me.

Rebecca: I want to give both of you a chance to introduce yourselves a bit and talk about your perspective on the behavioral health space and where that comes from. Avi, maybe you can go first. Why don't you give us the elevator pitch for Sonara?

Avi: Oh, fun stuff. Yes. I'm Avi. [I] founded Sonara in my fourth year of medical school. The reason we founded the company is because right now we live in a pretty remarkable world. You can get anything delivered on Amazon that you want within 48 hours. You can send Jeff Bezos to space, but for some of the most vulnerable in the addiction communityspecifically those addicted to very severe opioidsto get quality treatment, they need to get methadone and they have to go into the clinic every single day to get this treatment for the first few months that they initiate treatment. Then they stay on the drug for quite a while after that, still having to come to the clinic very regularly.

In this world where everyone else can get stuff delivered to their door in 48 hours, we thought there should be a way to get this drug delivered to their doors, or at least taken home in a safe and dignified manner. We came up with a technology platform to help these patients do that, to help clinics keep better track of their patients when they're at home and to just optimize things for everyone involved in this workflow specifically, which is just so highly unique in medicine.

Rebecca: Avi, you're an M.D. What made you want to found a company rather than practicing medicine?

Avi: Oh man, that was totally by accident. ... I met my co-founder just taking an elective course in psychiatry actually. I [had] just finished applying for plastic surgery residencies and I want[ed] to learn more about other types of medicine just before I went and shipped off to the operating room, ostensibly for 90 hours a week for forever. I met Michael, he had this cool idea, and we just rolled with it.

We picked up a bunch of momentum as the year went on. Then once we started getting some serious investor attention, validating things in the market and getting some customer attention, I saw the writing on the wall. I'd had a lot more fun doing this than I had wanting to train to be a doctor. I thought I could make a bigger impact in propagating healthcare technology out to the world, rather than the individual patient-to-patient perspective that you get just when you're in the operating room [and] you're physically limited by what you can do with your hands. I decided to make the jump.

I wouldn't recommend it for most people, but I think we had a pretty cool idea at hand and the ability to help a lot of people quickly. I wanted to strike fast and I suppose I can always go back to medicine if this doesn't work out. It's been a great ride ever since.

Rebecca: Yes. Love it. Dexter, why don't you introduce yourself and introduce us to The Braff Group?

Dexter: Thanks Rebecca. The Braff Group is a boutique M&A advisory company that focus exclusively in healthcare services. One of our primary verticals these days is behavioral healthcare, which has just exploded over the past five years and then exploded even further in the most recent two as it relates to what's happened with COVID.

As we all know, COVID has been very, very difficult on the collective mental health of our country and other countries as well. As a result of that, investors are rightly identifying that whatever streak behavioral health had been on prior to COVID, it's now even greater because of the expectations of increased utilization predominantly in mental health services.

Unfortunately in the servicesnot unfortunately because of Avi's company, unfortunately because of the need for interventions for substance use disorderI think it was well-documented last year that there were 100,000 deaths from opioid addiction, which was absurdly high and the need for intervention on addictions and substance abuse disorder is astonishing.

Within the behavioral health area, we look at five different primary segments within that. That's mental health, substance use disorder, which is what Avi's company is involved with predominantly, intellectual and developmental disabilities, programs that target at-risk youth and then autism services, which has also exploded in the last four or five years.

Rebecca: That's great. With that higher-level view, can you just set the scene for our listeners in terms of what kind of private equity activity we're seeing across behavioral health and some of the economic dynamics that we're seeing in the space?

Dexter: Well, let's just say it's good to be a sell-side intermediary right now in behavioral health. I'm looking at our data over the last 10 years. In 2021 we were able to identify 251 aggregate behavioral health transactions. In the previous year, which was a new record in 2020, was 189. [That's a] 33% increase in the number of transactions done in the behavioral health space from 2021 versus 2020.

The other thing that we note is that within behavioral health, if we look at the percentage of deals being done by private equity versus the percentage of deals being done by strategic players in particular in behavioral health, there's a substantially higher percentage of deals being done by private equity sponsors than there are by strategic players. That includes both platform transactions and follow-on transactions.

Rebecca: Yes, pretty remarkable. I want to bring in this regulatory and policy context as well, because this has been in the news lately, the last State of the Union address included an emphasis on behavioral health. We're seeing some movement at a really bipartisan basis at the state level around this space. I'll start with you on this Dexter, but Avi, feel free to jump in. How's the political landscape shaping the investment dynamics that we're seeing right now?

Dexter: Sometimes it's unfortunate when you're talking about something like behavioral healthcare, where people are really struggling. Then you talk about it from an investor standpoint. The reality of it is that the regulatory environment could not be any better than it is for behavioral health. Now, when I say that [it] doesn't mean that there can't be improvements.

What I mean by that is that the openness with which Congress and federal state and local governments are looking at providing services to people suffering from mental health and behavioral health issues has just never been better. There's a real emphasis on trying to find new and creative ways, both for people to access behavioral health services and to have them funded.

It's really politically incorrect at this point to be voting against things that are going to improve access to behavioral healthcare. From that perspective the acceptance is just so favorable. It had been getting better under the Affordable Care Act where President Obama expanded the regulations that required that private insurance reimburse behavioral healthcare services on par with what they were reimbursing on medical services, but even greater as needs have become more important.

The openness with which we're seeing all payer sources looking at behavioral healthcare has never been better with the exception that the private insurance companies are still, they're being dragged, kicking and screaming into the amount of money they're having to spend because the amount of utilization has gone up and their spend has gone up tremendously in behavioral healthcare.

Avi: Well, that's capitalism for you, right? They've got to learn to play the game. I would agree with a lot of what you've just said especially being on the other side of the investment market, trying to raise myself, there is money floating everywhere in the behavioral health space. And fortunately that means that, it's unfortunate that the need is there, but the fact that the money's starting to float around to everyone who needs it, really means that people are starting to pay attention and that the need for important solutions is really staggering.

I think Dexter, you had mentioned the 100,000 opioid addiction deaths that had happened last year. I think that was actually the highest cause of deaths from people age 20 to 50 from 2020 through the end of 2021, higher than COVID even. Then need is certainly there and it goes beyond just the market reaction to the problem. Biden in his last State of the Union speech had mentioned that we need to increase access to care, even named opioid addiction by the specific disease, but they're backing that up hard.

The NIH is investing billions and billions and billions of dollars into technologically enabled solutions for behavioral health. Fortunately for us, that means addiction too, but everyone really wants to solve all of these problems in behavioral health and I think it's an amazing time for people to be looking for solutions and looking to invest in solutions.

Dexter: Yes, and one of the things that we sawI was writing something about tech-enabled pay for healthcare, and the space that you're in Avi is so attractive because you're not only marrying the behavioral health needs, but you're marrying a technology solution or assistance into that and so your matching digital health on one side, behavioral health on the other, and people just love that combination. But I believe I read somewhere, and Avi you might have seen a different number, but I think I read somewhere there were approximately 20,000 different apps that have been developed that in some way, shape or form are trying to address the various different aspects of behavioral health.

We're talking about these various different [apps], like Calm is one of those apps that you see advertised on television. But there are literally thousands and thousands of applications that people are trying to develop to engage people from that smartphone interface, as people are trying to find easier ways, frictionless ways, to engage people, to get more in touch with their mental health needs. One of the things that we see as a result of that, is we see that, and I think the investment community sees it right, is that any of these access points are ways, not necessarily to cannibalize services that might be used by more traditional mental health providers, but bring people in as people who would otherwise never seek treatment.

Now we're seeing an easy way to do it and to say, "Hey, I'd like this, I'm getting benefit out of this, I'd like to expand that into other areas, and maybe tap into telehealth, telemedicine, face-to-face type of services." And then the money is there to support it. You've really got this tremendous [support] from various different directions, this groundswell of access into behavioral health services, it's really a fascinating time.

Avi: Absolutely. It's almost like you've seen our company. I should just have you do our pitch for us. You certainly know what to do.

Dexter: By the way, Avi, I'd like to do that, anytime you're ready I'm all with you, but it's a great thing that you're doing in there. There are other folks that are working on that tech adjacency to these services and there are some people who are doing really, really innovative creative work that are generating real, measurable returns. Not only do we get to see the financial benefits that investors and sellers have, but it's really making a difference and it's always a nice bonus.

Rebecca: I want to jump in and put a kind of a fine point on that and then I'm going to hand it back to you, Avi, because I think we've seen such a broad interest in telehealth through the COVID pandemic, a lot of investor interest in anything that can be considered remote or enabling healthcare to happen outside of a clinic or a hospital, and we're starting to see in public markets, certainly, and maybe, to a lesser extent private markets, kind of a winnowing down of solutions that do clearly add value to the patient care experience and maybe those that were sort of jumping on a trend, but haven't really proven that value that they can add.

I want to turn it back to you, Avi, and talk to you a little bit about where are the data points in terms of telehealth utilization by patients within behavioral health? I think behavioral health is one area where we're able to see really clear positive results from telehealth solutions. Maybe talk a little bit about that.

Avi: Yes, totally. I can speak more specifically to patients with opioid addiction. I think I'll leave the kind of broader telehealthI mean, I imagine the numbers are, I don't think you have to be a genius to figure out that the numbers are probably higher now than they've ever been and that access is greater than it's ever been. But even saying that, I don't really think it brings to light how ubiquitous this type of thing is now and I think discussing a little bit about the most vulnerable opioid addiction patients can really bring to light how technologically enabled kind of everyone is.

So one of our early customers/partners is a clinic in rural Oregon right now. I think about like a good two-hour drive from Portland, another hour-and-a-half drive from Eugene, if you were to fly in there. Relatively low literacy rates in a very, very rural community. Exactly the type of place where you wouldn't expect people to have smartphones or internet or LTE, 5G, or whatever it is. And when we were doing some of our early market research last year, we realized that like 84% of them had a smartphone with a data plan.

These are folks ... I'd say maybe not half of them are homeless, but probably a good quarter of them don't have stable housing. A number of them are under the poverty line. But the one thing that really seems to be connecting everyone is that they do have access to technology now. Again maybe the most, most, most vulnerable folks don't, but we're really reaching a point where everyone's able to access tech and get themselves plugged into exactly the type of help they need.

With opioid addiction specifically, I think Sonara it's just one solution. That's specifically for the folks who need methadone, but there are tons of other applications, really high-growth startup companies that are there helping folks with addiction who don't need methadone, and it's amazing to see.

Dexter: Yes, the broad telehealth utilization obviously has gone up with COVID. There has been a contraction, by the way, in the last five or six months, because what happened is that the payers and the government pretty much opened the floodgates and said, "We are not going to subject these types of visits to the type of scrutiny that we would normally apply in terms of whether or not it's a reimbursable service or not." There was this acknowledgement across, by the way, many healthcare sectors, where their guidelines for getting paid were loosened.

Look, we're not going to require you to do all this pre-authorization. We're not going to require this. We're not going to require that. We need to push out services, and we'll worry about that later. So you saw this big explosion. [Now] we're seeing a little bit of contraction. But the thing about [it] that's inescapable, is that if you think about telemedicine, and you think about applications for telemedicine, what could be more intuitively understandable than talk therapy? I don't have to have somebody look in my ears, to see if I have an earache, it is already a visual and a verbal medium.

Now, there'll be people, and Avi you probably know about this, that will say that there is something lost in the actual in-person, body language type things that you can't quite get. But if you think about the greatest, easiest application of telemedicine within all of healthcare services, you look at mental health and talk therapy. It's about as intuitively likely to be successful without loss of clinical efficacy, as virtually anything else.

I've used, for example, telemedicine for some physical ailments and I'm like, "I hope that the doctor can see everything." But I'm not 100% sure it's efficacious, but talk therapy, I would imagine it's probably very, very efficacious.

Rebecca: Well, there's also an element of access to care for folks who may live a distance from a clinic to Avi's point about rural communities. I don't know if either of you have a perspective on how that's perhaps changed some of the provision of behavioral health.

Dexter: Well, you can't see a therapist now. I mean, right nowand I know this from personal experience from some family membersto try and get an appointment, to be a new patient for a mental health provider, is very difficult. People [are saying], "I have no room." And the shortage of healthcare professionals across the board is acute. It was acute prior to COVID. It's much worse now with COVID.

But even within the healthcare professionals, SAMHSA, which is a government body that kind of looks over addictions, put out a report that suggested that the number of behavioral health professionals broadly speaking, that would be necessary within the next three to five years is something on the order of five million5.2 million, 5.3 million. And they say that the number of people that are currently in those positions are about 800,000.

They're suggesting is about an 80% shortfall in the amount of professionals that are needed. And in clinical nursing there's a shortfall, but it's not 80%. And so it is so difficult. Telepsychiatry and telemental health is designed to at least provide some access to people who can't otherwise get it because some places you might have some capacity built in, but it's hard. One of the best value propositions, if we were to represent a telepsychiatry company, one of the biggest value propositions is just simply having the psychiatrists and the practitioners that are able to actually do the service, because it's just not there.

Rebecca: This staffing issue is something that is on the mines of everyone in healthcare, but as you say, Dexter, it's just been such a key issue for behavioral health. Avi, how have you thought about your own product in the context of addressing the shortfall and providers?

Avi: Yes, I would love to say that we can totally fix that problem. I don't think we can, but I really do think we can help with that one, at least specifically in the context of the pandemic and a highly contagious disease, which fortunately isn't that terrible, but gets in the way of people's lives now. A number of these clinics that we go to are in very rural communities. It's not just a matter of people having burnout now that the staffing problem is there. It's because physically for people ... [in clinics that] are fully staffed, the staff can't come in because a bunch of them end up having COVID or whatever it is.

And obviously, that boils down to the root problem of maybe that full staffing wasn't actually full, but what we would hope for technology to do is be able to either increase access to care for patients or make life easier for clinicians, right? Right now, in methadone clinics and opioid treatment programs, patients have to come and be seen taking their medicine every single day when maybe they could be doing that on video instead, maybe for patients who know that they come in and they take their meds like they're supposed to.

You don't have to watch every video with the normal speed. Maybe you could speed those videos up for some patients, maybe you don't necessarily have to have them come in every single day, or maybe you can communicate with them in some other way. Instead of having clinic staff who are reviewing videos necessarily be at the clinic every day maybe they could do some of this work from home. In terms of what our technology does, I think reducing foot traffic to the clinic, of course makes itI guess COVID [is] hopefully going through one of its valleys now and not at one of the peaksbut I think that would help reduce foot traffic to the clinic, prevent risk of staff getting sick from their patients and then staff getting sick from one another too.

Anything that allows the work to be done from home, it's not really a medical specific thing, would probably help a lot in the medical world where the disease is more likely maybe to be spread around.

Dexter: There is also another factor and that is that the specific area that Avi is in, which is medication-assisted treatment, is ... , from a human resource perspective, [far] less costly than other treatment mechanisms. Now you can get instances and theoretical issues that people get a little anxious about, and some people believe in abstinence-only programs and they're not real big fans of medication-assisted treatment. But the reality of it is, it has been proven time and time again, from an effectiveness standpoint, in terms of people staying on medication, staying employed, staying with their families, not resorting to any criminal activities.

Medication-assisted treatment is not only the most effective, but it also requires the least amount of external resources. So as you move, not only toward a technology-enabled solution, but you move toward a technology-enabled solution that is a medication-assisted treatment solution, that in and of itself is a less human resource-intensive approach, which is why the government agencies really like that as an intervention strategy.

The residential programs obviously have a different approach and it's not that one necessarily is instead of the other, they could be a continuum, but the fact of them matter is that MAT, medication-assisted treatment, can extend the resources that are available without having to necessarily have to add tons and tons of staff. Now again, we're only talking about addictions [and] substance-use disorder. We're not talking about mental health, autism services, individuals with developmental disabilities, that's a whole another area of behavioral health.

Avi: Of course, and I think one important thing to hit on specifically in substance abuse and specifically with opioids, the term medication-assisted treatment, it sounds obvious to a lot of people, right? You take medication, it assists with your treatment. But if those people need medicine for the disease that they're afflicted with right now, by a disease called addiction, they're going to get that medicine wherever they go. So whatever technological solutions come around, they need to make it more appealing to seek to specialized treatment than it is to just go and get the drugs on the street or to go get the drugs from whoever you're going to get the drugs from.

That's such a big part about making any of these solutions succeeding, right? The ones that succeed are the ones that make it easier to seek treatment rather than the ones that add hurdles, even if they reduce costs or help in some other way.

Rebecca: I want to bring it back a little bit to the investor perspective, not to dehumanize the conversation, but because it's really important to get these clinics and these treatments funded and because we are a private equity podcast, so here we go. [I] wonder, Dexter, if you can talk a little bit about how you are seeing behavioral health providers position themselves in terms of this staffing shortage that we're looking at, in terms of the technologies that can be adopted to mitigate it. What are some of the selling points that a provider might have when they're approaching a private equity buyer that might make them stand out?

Obviously you can't just snap your fingers and have plenty of providers running around everywhere, but you can make some of these dynamics a little bit more attractive for a specific group, so maybe talk about that.

Dexter: Yes, as you mention, there are a variety of issues. Right now, a lot of private equity, it's not that they don't want companies that have technology part of them, they do, but that's one of the value adds that they bring, often. What they're predominantly looking for, what they really want to do is, they want to see programs that are where there's strong census, where the number of patients that they are treating is regular and or increasing. They want to see good clinical protocols to make sure that what's being done are good and accurate services [that] are being billed properly.

One of the things that they are very, very concerned about is the difference between what a company is billing and what they actually get paid. Because when you're dealing with private insurance, very often there's a bill rate and then there's a pay rate. And those numbers can be very, very different and if you're not managing that revenue cycle well, you can think that you have a $20 million company when you really have a $18 million company and an $18 million company may look really great. But if $2 million isn't really there and your EBITDA is $5 million, it means your EBITDA is actually now $3 million and all of a sudden the numbers become very different. They're very concerned about in-network versus out-of-network providers.

For those of you who don't know, when services are being provided out-of-network, so a beneficiary is accessing care that is not part of their network of services, the bill rates tend to be much, much higher. And in behavioral healthcare, there's a lot more out-of-network coverage because I can't access a lot of my behavioral healthcare services in my catchment area where I have insurance. So if I want to go to a residential treatment center, there may not be one in the area where I'm currently covered by my insurance. So the utilization of out-of-network services is substantial in behavioral health, much more than we see in other areas. So understanding the reimbursement dynamics between in-network and out-of-network is very, very critical.

Buyers also like when services are being provided in a tight footprint. So there's one thing about having a clinic in Seattle, and a clinic in Boston, and a clinic in Dallas, and a clinic in Chicago ... But it would be much better if I had one in Seattle and Olympia and Portland, and so I could say I serve the Pacific Northwest. Because there's commonality of reinsurance. There's a greater opportunity to leverage infrastructure. We don't have to manage by going across the entire country from West Coast to East Coast. Those are some practical issues which contribute to value. As you can imagine, there are a host of other things, but those are some of the big ones.

Compliance, though. I will say that if compliance is not there at pretty much the gold standard, it's not like buyers go, "Well, I would have paid $20 million for your company, but your compliance is so-so, I'm going to pay you $18 million." It's, "I would have paid you $20 million and now I'm not going to buy it."

Rebecca: Interesting and [I] want to pick up on one thing that you said there. Often a private equity firm is going to make an investment in a provider group. One of the things that they're going to look to do in addition to growing revenue expanding, improving some operations is to add technology-enabled elements. Avi, I want to turn this over to you. What should provider groups and their private equity sponsors look for in evaluating a technology partner?

Avi: Yes, that's a good one.

Rebecca: Other than going with Sonara, clearly.

Avi: Yes, it keeps on coming back to everyone should just buy us. But I guess if everyone doesn't want to buy us, other things that they should look for should be things that I think we excel at. The first thing I think that's really important, just from a fundamental level, is alignment of all your stakeholders. Everyone knows that in healthcare, behavioral health, ... honestly just any technology that's going to be helping people's lives, the patient, whoever's the end user, needs to be able to use it well. The provider needs to use it well, have clear benefit, and it has to benefit the payers eventually, too. Without those fundamental three layers of alignment, I think any solution is going to fail.

I'm sure there are some that are falling through the cracks, but at an early-stage company, I don't think you really want to take a risk on investing in a technology or taking up a technology that doesn't do all those three things. From that point onward, I think scalability is something that's important. I remember early on one of our original ideas was not very cost effective, but it still aligned the payers, the providers and the patients. It made everyone's lives easier, but it cost too much money.

Even though it saved payers a little bit of money, in the end, it wasn't really worth the upfront investment to go and propagate everything. Cost effectiveness is huge. I think not just from a pragmatic perspective, but just from an uptake perspective, any technology that you want to go propagate in the healthcare world shouldn't be a technology that's made just for the Kaiser Permanente's or the UC San Francisco's or the Harvard's and the Yale's of the world.

Going back to Sonara, we tried to make our software something that I can go into a rural clinic in the middle of nowhere in any rural state that's two, three hours from the nearest airport [and] I can get them up and running in three hours. Every solution does not have to be that simpleif it is, that's probably not a good thingbut they need to be able to scale quickly at a low cost and in a variety of different environments. [That's] I think the second layer.

The third is probably just likability of the team which I think is just normal VC stuff. From both a provider and an investor standpoint, you want to listen to people who are coachable. In the end if you're a provider, that customer that you're buying technologies from, they're working for you. They should listen to you, they should be willing to customize things to what you want or to address the needs that you have. And if you're an investor, you now you'veDexter, it's clear from the way you talk that you've been around the block. You know what you're doing, right? If I were to come here and start not listening to you if you were to give me advice on something, that'd be pretty silly, you wouldn't want to partner with me. I think just from a person-to-person level they need to be likable. It doesn't need to be that they're amazing, great people, but you should at least get along with them.

Dexter: Yes, and Rebecca there's also something really unique that's happening right now with private equity groups and what's happening particularly in behavioral health. That's that they have a real challenge because the typical model that we would see in healthcare services, where there is so much fragmentation out there, is that I buy at a small company multiple, and I get really, really big, and then I sell for a large-company premium plus other improvements to profitability I may have been able to add along the way with technology and revenue cycle management and things of that nature.

One of the challenges private equity has, of course it's to the benefit of the sell-side folks, which is what we work on, is the valuations that buyers are having to pay right now for companies that they previously would not have to put these kinds of multiples in. They're now buying companies at size premium levels. So we have clientsand this is literal and it is surprising to mewe will have clients that have well below $5 million of EBITDA, that are getting multiples of 12x and 13x.

Now, that used to be the exit multiple after I had gotten to size. If I'm buying at 13x, there's not a lot of multiple expansion I can get with size. There may be some, but it's not nearly as much as it was before. The pressure to me as a buyer is I have to look at it two different ways. I have to first really focus a lot on what I can do to increase profitability in terms of real organizational improvements. I have to be a better private equity group than I had to be before, because before I could just rely on getting big.

Now some people did it better than others and also added the other things, but you could do really well buying companies at 6x and selling at 12x. That's a model that works. That opportunity is substantially less. I have to be able to really add real value in terms of technology, marketing, revenue cycle management, and all the other nice things that a good private equity can do, can hook up companies with human resources and things of that nature.

The other thing that we're seeing which is very interesting is the buyers, the ones that are really smart, the PE guys that really understand the market dynamics, after they make their platform deal, they are immediately looking towards startups as opposed to doing secondary acquisitions. Because the ROI on a startup is going to be much higher. But they have to do it early in their investment cycle. They can't wait to year six because that's too late.

One thing about behavioral healthcare is that because it's, generally speaking, not referral-source driven, I actually can have much better opportunity to grab revenue through a startup than I can otherwise have in other businesses that are referral-source driven and I can't grab that referral source from somebody else. It's hard in behavioral health because I'm paying a lot more, but I have greater opportunity to layer on startups. You've got to be good at it, you've got to be conscious of it and you've got to make that a prime directive as opposed to a secondary directive.

Rebecca: Yes, I completely agree. It underlines the importance, I think, for investors in behavioral health right now to be looking into the future and trying to see where this industry is going in terms of patient care improvements and technology improvements to deliver that. I want to put a bow on what has been a fantastic conversation. Thank you both. I wonder if each of you can give me one prediction for the future of behavioral health that is either contrarian or just a little bit under appreciated by folks who might be listening to this.

Dexter: Well, my first prediction is that Avi's company is going to be very valuable. No, I think the one prediction is this is not a flash in the pan. This is not something that's ramping up fast and it's going to fall off as quickly. There is a long runway of opportunity, and the other thing is that the model of delivery is going to change. We're already beginning to see the carters between autism services, individuals with developmental disabilities, at-risk youth. Those are all handling people of youth.

We're beginning to see that the big boundaries between those begin to drop as we're trying to be able to service the whole human. A lot of Avi's services, there's co-existing conditions, co-occurring conditions. Treatment of addiction services is not separate necessarily from treatment of mental health services. People who are beginning to look at treating the mental health services of a population, as opposed to defining my population as someone with addictions, defining my population as anybody who needs to access behavioral and mental healthcare services, is where all of healthcare is going and the opportunities to be able to provide a lifetime suite of services to people at all levels of their treatment program.

Because people in behavioral health don't necessarily have a beginning and a defined end. The opportunity to create new models that have longer and more comprehensive bases of services, I think are absolutely there. They're real. There's benefits to them both financially and clinically, and I think we're going to see that evolve over time.

Avi: Yes, I agree with all of that. I think two specific areas that I think are going to be really interesting to hit on and I think a lot more information and data will come to light in the coming years ... Eventually whatever mental health companies or behavioral health companies start to prop up, they're going to start to going back to helping the most vulnerable people in society. I guess specifically homelessness, low socioeconomic status at birth, those things are intrinsically associated with worse medical outcomes, worse mental health outcomes, worse behavioral health outcomes, and hopefully we don't want technology to leave those folks behind.

I think as a society, we really improve and we become better when all these technologies that we're developing are able to help the most vulnerable and bring the most vulnerable up. ... Right now it's great that most people have smartphones, most people can probably download some app and get access to care, but how many of them have insurance? How many of them can afford to pay for the services once they actually download the app? I think there's going to be a huge, huge, huge explosion.

Whoever figures out that problem, that real access problem, that getting the money to the people who need it problem and seeing if they're able to fix their lives or better themselves however that way. I think that's going to lead to a huge boon in the general mental health of the nation. Part of that's going to come from behavioral health and increasing access to care, but I'm curious to see what, there's a deeper layer in all of this. I'm fascinated to see what folks can come up with when it comes to helping the whole person and how that's going to affect mental health and behavioral health.

I'll close with one last thought here, I think we probably don't even know what's going to come in the future. We started treating depression by having people snort ketamine five years ago. We eat mushrooms now that like our folks used to eat in the '70s for Grateful Dead concerts and it's like a real medical treatment right now. We can change behaviors with a smartphone and, and we're at the infancy of all of it. Crazy stuff is going to happen.

We just need to make sure it helps the most vulnerable because I think people who are richer, they're happy, they're doing their thing, but society really evolves when it's not just the rich that are benefiting.

Dexter: Avi, you actually said something and I think it's really, really meaningful. Treating the person as a whole. I mean, it's interesting that we separate behavioral health from physical health, because we all know that they're connected. So this is where population health, movements toward population health, are innately going to merge behavioral health services and medical services together. So we are beginning to see combinations of primary care and mental health care and that they're not separate and that we need to blend them from the onset and what opportunities are there to create a more healthy society that down the line is not going to be accessing more expensive care further down.

We have a dichotomous system right now, but arguably it shouldn't be. But everything springs from reimbursement. With models becoming more population-based that changes everything. I've been in a lot of conferences where people talk about the next new thing and it's like, "Yes, maybe." An no. This is happening, this population-based approach towards treating people more of a whole person is definitely happening and I think it's both great clinically and it's good financially from a cost-saving standpoint.

I actually think that we've actually made progress as a nation and as a society in terms of being able to provide services better. It's kind of cool to see some of these forward thinkers when they're talking about stuff, and then they are actually showing that's actually working and it's not really theoretical. That's always pretty exciting.

Avi: Yes, we're already helping patients and we track when you drink your medicine. There's so much more in the world, there's so much more to be connected and to be built on. We live in a pretty beautiful time.

Rebecca: That's a great note to end it on, so I'm going to thank both of you Avi and Dexter for a fantastic conversation. Thanks so much for your time.

Avi: Cool, thanks.

Dexter: Thanks for having us. It was fun.

In this episode

Avinash JayaramanChief Growth Officer and Co-Founder, Sonara

Avinash Jayaraman, M.D., is a co-founder and chief growth officer at Sonara, a healthtech company providing telehealth options for methadone patients. Avi and his co-founder (Michael Giles, M.D.) started Sonara while they were in medical training. Michael wanted to use simple technology to increase access to methadone, a segment of opioid addiction treatment that had been neglected. Since earning his M.D., Avi has been building Sonara full-time.

In his pre-Sonara life, Avi was a prolific researcher across many disciplines including plastic surgery, transplant surgery, psychiatry and genetics. He has been published numerous times and gave over 50 poster and podium presentations at research conferences. Before medical school, he spent time as a project manager at Epic, a transplant surgery researcher at Northwestern, an MCAT tutor with BluePrint prep and also served as a nationally renowned high school debate coach.

Avi holds an M.D. from the University of Texas Southwestern Medical Center in Dallas and a B.A. in mathematics from Northwestern University.

Dexter BraffPresident, The Braff Group

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On the podcast: The new PE behavioral health play - PitchBook News & Analysis