Introducing: Assembly Required with Stacey Abrams

Hey guys, it's Tommy. We're taking a break for the holiday season, but we've got something special for you today. Instead of our usual episode, we're dropping a new one from assembly required hosted by the one and only Stacey Abrams. In this episode, she talks with Celine Gouder, an infectious disease specialist and epidemiologist about the threats to public health with the incoming Trump administration. They dig into what's at stake with appointees like RFK Jr., how to bring science back into policymaking and the path forward to driving real change.

If 2024 is leaving with a lot of questions about the future or if you've also found yourself shouting at the TV more than usual, stay tuned for this great episode because if anyone knows something about not giving up, it's Stacey Abrams. Don't forget to subscribe to Assembly Required wherever you get your podcasts and on YouTube.

Welcome to Assembly Required with Stacey Abrams from Cricut Media. I'm your host, Stacey Abrams. Since the election, we've been unpacking how the incoming administration and Project 2025 will actually work. What's possible and how can we respond? As a reminder, Project 2025 is the 900-page-long Policy Blueprint published by the Conservative Think Tank, the Heritage Foundation.

with a complicit Congress and a compromised Supreme Court, their to-do list could undermine everything we rely on for a just society, from civil rights protections and environmental defenses to public education, free speech, and today's topic, healthcare. When we think about human rights, when we think about the core of what makes us who we are, there is nothing more relevant and more fundamental than healthcare.

The ability to participate in society begins with good health. I grew up in a family without health insurance. I grew up knowing that if I got hurt, if it wasn't major, it was going to be treated as minor, not because my parents didn't care, but because they simply didn't have the resources to get access to health care.

And in fact, since I grew up and got access to healthcare, since my parents finally have health insurance, I can see a night and day difference in the way our lives are lived. And I also feel an incredible degree of privilege because I know what it means to not have healthcare and to have it now.

I am also deeply annoyed and sometimes outraged because the fight over healthcare is a fight that the people stopping it don't have to have. Every elected official in Washington DC has healthcare and it's the height of hypocrisy to deny it to others. And in the wake of COVID-19, now more than ever we should understand how vital and essential healthcare as a human right is.

So while fighting to protect and improve health care in this country is not new, here are some of the ways that health care may be impacted by the next administration. One, there is an intent to dismantle or gut the Department of Health and Human Services, which is one of our nation's core agencies.

And let's be clear, HHS, as it's called, has a very broad mandate. It's in charge of Medicare, Medicaid, the healthcare marketplace, the Children's Health Insurance Program, the Food and Drug Administration, the National Institutes of Health, the Centers for Disease Control and Prevention. They also cover the human services side. So, TANF, the temporary assistance for needy families, Head Start, childcare and child support, and that's not an exhaustive list.

HHS is under attack. Number two, they want to split the CDC into two agencies, one for data collection and one for public policy recommendations. And this effectively takes away the already limited authority of the CDC to provide public health guidance. It slows emergency response and it could hurt state and local governments that rely on the CDC for public health guidance, for example, in the case of another pandemic.

Number three, they want to tinker with the food and drug administration's drug approval process. For example, take away the approval for mythopresto. And number four, at the state level, the goal is to turn Medicaid, the vital national healthcare program that covers the poor, the elderly,

the disabled and some children to turn that program into block grants, which means that states would have further permission to deny access to healthcare to the most vulnerable in our society, because states would have less money and limited federal accountability. Okay, so I've just done a very long list of what's at stake.

And it's not just about what's in the proposed policy papers from Project 2025. It's about who Trump wants to put in charge of that vast agency.

In the words of 77 Nobel laureates in medicine, chemistry, physics and economics, RFK Junior at the helm of the Department of Health and Human Services would put the public's health in jeopardy and undermine America's global leadership in the health sciences. This in a letter addressed to members of the United States Senate, listing off the health secretary nominee's most sensationalist conspiracy theories on public health.

The incoming president's decision to nominate Robert F. Kennedy Jr. to be the Secretary of Health and Human Services is indeed a source of much anxiety in the medical and scientific communities. So much so that Nobel laureates, a group that usually tries to stay out of politics, felt compelled to speak up.

But there are other nominees, as I mentioned, HHS is huge. So, among the list of people whose names are being put forward include Maymed Oz to lead the Centers for Medicare and Medicaid Services and Marty McCarrie as the head of the FDA, both of whom have been controversial to say the least and their respective medical practices.

I've just given you a lot of information. And right now, like almost every day, listening to what's to come can feel like daily doom scrolling. And unlike 2016, when people talked about resistance, this time, people have responded by saying they need to protect themselves first. I totally get that. The rule is, put your own mask on first. But we're not on this trip alone. So eventually, we'll need to help our fellow travelers.

I'm here to help us prepare for when and how we engage and insist. That begins by understanding what's really at risk versus what's just hateful, wishful thinking. What impact can these proposals have and what's not being said? And as always, how do we fight back? So let's get straight into it with our interview today.

Dr. Celine Gounder is an infectious disease specialist, epidemiologist, and a science communicator. She is the editor at large for public health at KFF Health News. She produces podcasts and other content to help us understand what's going on in public health, and she was a regular guest on news shows during COVID-19.

bringing us grounded, reasonable, and actionable information when misinformation and disinformation met a wave of panic and worry. Does that sound familiar to anyone? So here to keep us all informed and sane is Dr. Gounder. Thank you so much for being here. It's great to be here. Thanks, Stacy. Dr. Gounder, I have a public health crisis question for you. Are American politicians and policymakers allergic to science?

I think this is something that is very much on the mind of those of us working in science and medicine and public health and related fields right now. What we saw during the pandemic was really an attack on science and public health.

Because many of the conclusions of the science were politically inconvenient, did not reflect well on certain politicians and leaders, I do think there is room for discussion. If we start from a place of shared

understanding, facts, science, and then to weigh what are some of the trade-offs, how do you weigh different values, whether it's value of human life, value of an elderly person's life, value of a young student's schooling, etc. But I think we have gotten to the point in some of these conversations where instead of having a conversation about values,

We are attacking the science or some of us are attacking the science because they don't want to have that honest conversation about what they actually value. It's more convenient. It's easier to say the science is wrong.

That language is perfect, that it's when science is politically inconvenient. And it's actually a perfect encapsulation of one of the reasons I started with that question. There was the letter from the over six dozen Nobel laureates about RFK Junior's appointment.

to lead the Department of Health and Human Services, and then there's just the incoming Trump administration's overall approach to public health, which seems to be laser focused on finding those who reject science as a foundation for policymaking and giving them the highest appointments possible.

These Nobel laureates, though, these chemists and medical professionals and economists are very deliberate about pointing out that RFK Jr. has no credentials or relevant experience, quote unquote, in science, public health or medicine or administration. And as you pointed out, this is a question of value. So how important is it to not only have values-driven decision-making and science-driven decision-making, how important is it to have science?

and scientific knowledge and experience to be the Secretary of Health and Human Services? I do think, could you be a Secretary of Health and Human Services without being a scientist? I mean, we have one right now, Javier Becerra, you know, but he has other skills he brings to the table, being able to manage large administration, understanding sort of institutional norms and practices. So he does bring a certain skill set. And this is where

your career civil servants are really important, which is to say the scientists, the technical experts who work under numerous different administrations who are not political appointees, who are not partisan, you can rely on those people to help inform your decision-making, take the science, the expertise that they are using to advise you, and then make decisions that may be partisan decisions, but at least informed by that science. Now, what we're seeing

are conversations coming from the incoming president and his team about eliminating some of those civil service protections to make it easier to fire, hire, whomever they want in those scientific technical expert roles. And the problem is if those roles are filled by people who do not have the qualifications, the scientific, medical, public health expertise, then the person at the top is not going to be appropriately counseled.

So you don't necessarily yourself as the leader of HHS need to have that expertise, but you do need to have people who have that expertise to advise you. And if we don't have either, then we're in real trouble.

Well, that brings us to the other nominees. So while a lot of tension has focused on RFK junior heading, HHS, the two of the top jobs are also under consideration. And one of the pending nominees is May met Oz. The other is Matt McCarry, both of whom are physicians, but who each have had controversial

behaviors and there have been questions about their fealty to scientific principles and their work or the implications of their policy proposals. So what did their nominations tell you about the incoming administration's thinking about this? So to your point about combining the need for science and for policy making, what happens when you have a scientist who doesn't seem to believe or at least live those beliefs?

You can have differences of opinion as to whether you should mandate masking or vaccination or whether schools should be closed in the context of a pandemic. But you should start, at least with a common understanding of what the science is, what we saw, Jay Bhattacharya, who's nominated to head the NIH,

and some of his colleagues, Marty Macquarie, who's now nominated to run the FDA, they came up with estimates of what they thought the infection and death rates for COVID. Their estimates were really flawed and very small compared to very low compared to what actually played out. And so we do need to start with people who understand how to make these estimates, who understand how to advise us and say, you know, these are the trade-offs.

you with your values, your politics, your partisanship may make different choices, but at least start with that basic level of understanding. And I think that's also what's scary because we may have another pandemic on our hands before too long. Unfortunately, we in this country have not been managing the H5N1 bird flu situation as well as we could, and that is putting us at risk for a pandemic sooner than later. So these questions are really quite pressing and imminent.

And you just pointed out that we are already on shaky ground and this administration is not only rejecting expertise or bringing in people who have demonstrated a flawed use of their expertise, but there's also, as you said at the top of the conversation, this intent to replace civil servants who have that expertise with hires who are based on loyalty and not capacity.

You mentioned H5N1 as one of the possible outcomes. Can you talk a little bit more about the implications of this lack of capacity when it comes to public health, not just in terms of pandemics, but just the larger public health universe?

Well, one of the things that I think was made very clear during the COVID pandemic is we've very much under-invested in public health. Some of the areas of real need are our data systems. When we were dealing with public health departments faxing their data into the CDC, to Debbie Burke's team at the White House, that is not something where you can get real-time data, quality data.

Part of the challenge here is, and this is something a lot of people don't understand still, is that public health powers reside at the state level. There's only so much the government, federal government can do. Yes, the federal government provides funding, technical expertise, advice, guidelines,

they're not the ones, actually, that institute mandates, requirements, or do the boots on the ground work. And so this creates issues in terms of how well health departments are funded at the state level. Do they have the capacity and funding from their state legislatures to do what's needed, including the data modernization issues? And then do they report that to the CDC? So they can choose not to report.

they can choose to report only certain things. The CDC has some levers it can use tying some of that reporting to funding but in general they're not usually too aggressive with that because of the potential harms of withholding funding. Can you talk a little bit more about state and local public health preparedness because that's one of the issues we try to focus on here on assembly required. We have a lot of attention

that necessarily needs to be turned towards the federal government. But often the real levers of power and particularly the accessible levers of power for our listeners happens to state and local level. So can you talk a little bit more about how state and local public health works and how public health preparedness works at that level?

Yeah, so the Constitution does not provide public health powers to the federal government again. The federal government has the right to tax and spend to regulate interstate commerce. But that's really the limits on federal powers and all of the other federal powers really derive from those two. So if you're somebody who's concerned about public health,

Yes, you should pay attention to national politics, but it really is at the state level and to some degree the local level that you can have the most impact. So that's where I would say pay attention to what's happening in the state legislature, what your local health department is doing. At the state level, we've seen increasingly public health powers eroded.

We've seen some of the recommendations around vaccination being eroded, where you have increasing non medical exemptions around vaccination. So what vaccines kids need to get to go to school?

Another area that you should be paying attention to is public health versus the economy, public health versus industry. It will always be a theme. And so it's sort of balancing those different trade-offs values. But you do see this play out very concretely, as it is right now with H5N1.

There's a reason certain states have reported a lot more cases of humans infected. It is very much related to how much testing is happening, also how much testing of the herds, of the milk. This is all related to how aggressive the states have chosen to be. So you have states like Michigan, Colorado, California. Yeah, they're reporting a lot of cases, but it's because they're testing so much.

And so we don't have a clear view into what's happening in other states. And why does it play out differently? Well, this is a question of values, to some degree. And wanting to maybe protect industry from what some of the economic impacts might be of realizing they have a bigger problem on their hands than they want to know.

And this is also about the impact of influence of industry in certain states on what happens, right? So if you have a very powerful dairy industry lobby in that state, that's going to be very different from a state where your political interests might be a lot more diverse and varied. Can you think of an example or a time when

citizens or local citizens sort of raised the alarm and had an effect at the local or state level. Because sometimes it can feel like industry is too big and the problem is too big. We can't do anything about it. You've spent a lot of time advising local and national policymakers. When have you seen citizens actually take what you use and have an effect?

We did see a very real impact of citizens in communities on COVID mitigation measures. And this played out differently in different communities. There were communities where people wanted to reopen businesses. They wanted their kids back in school as quickly as possible.

There are places where parents had good reason to be very concerned. For example, here in New York City, you had a lot of parents and families of color, lower income neighborhoods, multi-generational households, where they were concerned not just for their kids, but for other family members in the household, what it would mean if their kids were back in school before

a lot of people had been vaccinated, what that would mean for elderly relatives living at home. And so what we saw this sort of patchwork reopening reflected a lot of those local values. And

Some of that was the parents, some of that was teachers who were concerned for themselves. Whether you agree or disagree with those particular decisions different communities took, regardless of that, aside from that, that was the local communities that were dictating those decisions.

Well, let's stay there for a second because, you know, I talked about the allergy to science among policymakers, but there's a second strain that seems to have affected segments of the general public and, you know, Project 2025 and its acolytes, they tend to harp on the uncertainty of COVID and the changes we adapted to. And as you described,

the uneven and sort of patchwork response, which seemed to prove that nothing was true, therefore nothing would ever be true. First, we all wiped down every surface, and then we realized wiping down every surface so it wasn't necessary.

And opponents of science hold this up as proof that the public should turn against the scientist. How do you respond to people who might be convinced that no one is right without invalidating how difficult that time was?

I think there's a real understanding of what science is and the scientific processes. I think there are people who think scientists are a bunch of liberals who already have an opinion and they just use science to back up that opinion. That is not science. Science is you start with saying, I don't know. Here are some hypotheses. I'm gonna try to disprove that hypothesis. And then based on what I learned from that, I'm gonna create another experiment and repeat and repeat and repeat.

And that means you are going to build your understanding knowledge over time in an incremental way. That's just how science works. You're not going to be able to jump from, this is what I think, and here's the thing that proves it. It just doesn't work that way. I think most people find that approach to be very counterintuitive. It's not the way we normally think. Normally, we think in what I would call a more lawyerly way, which is to say, we already start with, this is the conclusion that we want to back up, and then we try to find things to support that.

And that really does also lead to things like cherry picking and confirmation bias and looking for things that will back up what you already believe. So basically, I'm going to translate this into television. We need to be more like Dr. House than we are like law and order. I think that's a great way to put it. Yeah.

So as a practical matter, as a practical translation, if I'm having a conversation over the holidays with someone who tells me, well, we didn't get it right in COVID and that's why I'm not paying attention to H5N1. That's why it doesn't matter who's in charge. What's the pity response that we want listeners to be able to give? Or at least how do they start a conversation in a way that reminds us all of our high school bio classes?

Well, I think also to be aware of what your pre-existing biases and opinions might be. So to ask them, well, what matters to you? Let's say another pandemic breaks out tomorrow. What would be your number one, two, and three concerns, and why?

what was your experience of the COVID pandemic? And I think starting with that kind of understanding and being aware of why you might already have certain opinions. And then also just explaining, you know, what is the scientific process? I think are two different ways to go about this.

So part of the genius of Project 2025 and the effectiveness of the Trump administration approach is that by targeting everything, our attention has nowhere to focus and it's nearly impossible to concentrate. And that is especially true in this assault on health.

because HHS is such a mammoth agency with so many responsibilities. I gave a little bit of a primer at the top of the episode, but I want to spend a few minutes with you really making sure we understand what the Department of Health and Human Services is and why these attacks matter. So number one, can you break down what we need to understand about the agencies within HHS and what are you most closely paying attention to?

There are many agencies within HHS, but I'll focus just on three. The three big ones are NIH, which does biomedical research. The CDC, which is the nation's public health, well, main public health agency. And then you have the FDA, which is in charge of food and drug safety, most food. You have certain things that fall under the USDA.

So why does the NIH matter? NIH is the world's biomedical institution and funder. And a lot of that research actually happens outside of NIH. Some 80 plus percent of the research is actually outside of NIH itself. It's awarded to researchers at academic medical institutions and other institutions to do that research. And it's a way of really getting a diversity in the kinds of questions being asked, the places where they're being studied.

But we have created a system of funding for research where government funds the earlier research, the basic research.

And then we leave it to industry to take that research and to turn it into drugs and vaccines and diagnostics and other products. And I think what's unfortunately happened is we as taxpayers fund what the NIH is doing. But if you don't have the pharmaceutical companies, device makers, et cetera, who use that science and then translate that into affordable, accessible products for the population,

the general public may not benefit from those investments. And so I think what part of what we're seeing is a real frustration with this money being spent on research and people not necessarily feeling the tangible benefits. Now, I would say the COVID vaccines are a great example of a very tangible benefit

of 20 plus years of research on mRNA vaccines, we had no idea that COVID was going to come along, but we were very lucky to have had that research already in the can where we could then pivot to using those for COVID and we were able to develop vaccines very quickly for COVID. And it's a platform that's really ideal for pandemics because you can so quickly tailor those for the next pathogen.

So you have NIH. Then you have the CDC. The role of the CDC is partly as a funnel, frankly, as a funding to state and local health departments. So a lot of the funding does not stay at CDC. It goes down to the ground. But then also to collect data from the state and local health departments, to analyze that, to feed that back to the states. We've already talked about some of the data issues there.

to also help develop guidelines, and it's not just for vaccination, but for any number of public health issues to provide guidance and technical support to the states. CDC cannot mandate or enforce any of that. That is, again, at the state and local level. And then you have the FDA, and where people will be most familiar is the FDA's role in approving drugs. This is also something that I think people don't understand, is the FDA

Take generics, for example, RFK Junior has expressed frustration that the FDA is somehow blocking people's access to generic medications for additional indications, so in using existing medications for additional uses, those sorts of things. And it's not the FDA, it's

Essentially, a market failure where pharmaceutical companies, again, are the ones that pay for the clinical trials, the studies, that determine whether something is safe and effective. They then take that data, they send it to the FDA in application, and they say, will you approve

this medication for this purpose. If there's not a profit incentive for these companies to do so, the FDA is never going to be able to approve that medication. Now, the FDA is partially funded by fees on these companies when they submit an application. That's a decision we've made. We could decide we're going to use more taxpayer money for betting these applications. We've decided to partially fund it with these fees.

And we've decided that this kind of approach to funding R&D for drugs, diagnostics, vaccines, et cetera, we want that in the private sector. And that is going to have certain implications for what becomes available to people, how excessively and how affordably. So let's go back to the CDC for one second. When we hear about dividing the CDC, what does that mean and why should we be worried?

So this is very much focused on some of the conversations we've had around COVID and vaccines. That's really where this is coming from. So there's a desire by some to divide the CDC into a

scientific data gathering institution, and then an institution that makes the recommendations and policies. The idea being recommendations and policies may be more political because you are talking about values at that point. How do you value life at what cost financially? What implications it has on society?

And so there's a desire to create a firewall, so to speak, between who publishes the data, gathers the data, and who is making the policy recommendations.

When I think about all of these agencies and how they intertwine, one of the conversations then is how easy is it to do this? And I know you focus on public health and not necessarily the ins and outs of congressional action, but how easy would it be to divide the CDC or to allow the FDA to rescind the polio vaccination authorization?

Are those things that take a lot of time? Are those things that are imminent? Is it something that happens by executive order? Can you talk a little bit about how public health actually gets changed in this country?

Yeah, so some of this would need to be congressional action. Some of it could be done by the Secretary of HHS and by executive order by the president. This is a very heavy lift to do something like this. You've had a number of CDC directors who've tried to reform the agency numerous times. And it is a very time consuming, very challenging thing to take on.

In terms of congressional action, you would need that in order to split off certain functions from the CDC and to fund these things independently. In terms of the FDA rescinding authorization for polio vaccines,

It really depends on to what degree the incoming president and HHS secretary and FDA commissioner follow would have been institutional norms. Now, do they have the power to single-handedly do some of these things? Yes, but that would be really extraordinary to see an FDA commissioner or an HHS secretary taking that kind of action and that there are

processes for withdrawing an approval, you would definitely see lawsuits from the pharmaceutical companies that produce these products if there was threat of rescinding of an approval. And they would have standing in terms of is there actually science to support whether these actions are evidence-based and warranted?

And I would also throw out there that there are budgetary implications. And that means Congress gets involved. And when someone, let's say Mitch McConnell, flags that he is very unhappy about the threat to the polio vaccine, his lever of power is whether or not something moves through, even though he's not going to be the majority leader, he has a vote in the Senate and a little bit of influence. So I want folks to understand that the straightforward

demand for action does not necessarily translate into immediacy of that action being taken. Would you agree? No, I do agree, because right now you have budgetary lines for the CDC. You do not have budgetary lines for these separate agencies that they're proposing. So you really do need to have congressional action to implement that kind of split. Fantastic.

So health is not simply the ability to know what diseases and threats are out there. You know, it's also about the ability to get help. And that means we also have to pay attention to the healthcare access side of things.

So, for example, Project 2025 proposes to roll back the progress that the Biden administration has made in reducing drug prices. It also wants to accelerate the privatization of Medicare, which older and disabled Americans rely on. And they want to break up Medicaid and two block grants, which will set fixed amounts that go to states, regardless of the actual cost of healthcare or the size or needs of the population.

What are you concerned about when it comes to this administration's impact on health care access? And how would you process this information as a layperson? Well, if you read Project 2025, they literally spell out that the cost of Medicare and Medicaid combined since 1967, which is when these programs were started, is about $17.8 trillion. And the US deficits

for that same time period are 17.9 trillion dollars. So in other words, they are pretty clear in that they think that Medicare and Medicaid are the principal drivers of our national debt. And if we want to eliminate our national debt, we need to dramatically scale back if not eliminate Medicare and Medicaid. That's essentially what's implied in what's written in Project 2025.

There are several strategies to try to scale back spending, one of which is, as you mentioned, privatization of Medicare. A lot of people who have Medicare Advantage plans may think they're getting a very good deal. They get dental vision benefits, maybe other perks thrown in, and it's great until they need to see a doctor, they get hospitalized, and then realize that their coverage is actually really a barrier to what they might have had if they had traditional Medicare.

You mentioned the Medicare's Authority to negotiate drug prices under the Inflation Reduction Act. This is an area where the incoming administration is under pressure to roll back that authority.

Then this has very tangible impacts for people. One of the drugs that was likely going to be in the next round of drug negotiations is semagluetide, also known as ozempic or wigovii. A lot of people are desperate to get access to that medication.

currently is very expensive. The Biden administration has proposed new guidance that Medicare can cover these medications, also known as GLP1 weight loss drugs, for people even if they don't

have diabetes or cardiovascular disease, but simply because they have obesity. And it will be up to the incoming administration to finalize that rule, whether they will or not we don't know. But then if they do, and they don't make use of that lever to negotiate down drug prices for including the GLP1 drugs, that would have huge cost implications for Medicare.

So it's a little hard to know how each of these pieces will play out. With respect to Medicaid, you mentioned block grants to the states. That's a great way if you're looking to cut your Medicaid costs federal spending on Medicaid to do so.

What we're also seeing are conversations about reducing the federal amount that's being provided for that. So both states and the federal government put money in for Medicaid. But if we see a reduction in the federal contribution, some states that have expanded Medicaid may reverse that decision. We've seen more and more red states expand Medicaid, North Carolina, for example.

And that's because there was an understanding that this actually was good for their bottom line. And it had an impact not only on patients, but also on rural communities, where prior to expansion of Medicaid, many rural hospitals were really in financial trouble, so many still are. But we've seen many of these facilities close, and Medicaid was a lifeline, expansion of Medicaid was a lifeline to many of these facilities.

to keep them open and also to keep many of those jobs at those health facilities still available. So those are some of the things that we could anticipate with respect to Medicare and Medicaid. So you know a lot and you have been all over the world, all over the U.S.

You've decided to take your experience in epidemiology, but you've really channeled it into sharing information in a way that is extraordinarily accessible. You and I met actually in the midst of the COVID pandemic, and you invited me to be on a podcast, but it was such an important conversation because you're just a really fantastic communicator on really complicated issues.

was there an inciting incident for you that made you decide, I not only have to know what I know, I need other people to understand what I know.

Yeah, so it was a process of years, really, to come to this point. But I think some of it was what I experienced working in Southern Africa. I started my career working in global health and tuberculosis and HIV was often asked to moderate town hall meetings, meetings with patient advocates, informing policymakers, both overseas as well as on the Hill in the US.

So that sort of planted the seed, but then I had pivoted from global health to domestic health around 2012 was an assistant commissioner of health at the New York City Department of Health. And we were dealing with massive cuts to public health funding in the aftermath of the 0809 recession.

And in year one on that job, I was tasked with having to cut essentially 20% of my Bureau of 250 people, so 50 people out of 250. That's huge. And what I realized coming out of that was we will not fund public health if people don't even understand what it is.

People at least need to understand what it is. And then you can decide, is this something valuable or not? But I would argue that coming out of the pandemic, people still don't understand what public health is. They often confuse public health and health care. And so that's really what motivated me was I wanted people to be armed with the facts, to be informed citizens, and then to make decisions, however they want to based on that information. OK, so here's your platform. Tell people the difference between public health and health care

and how they should describe it when they're sitting around the dinner table. Yeah. So healthcare is what people are more familiar with, right? It's what happens in the clinic, in the hospital. It is very individual, patient-focused. Public health is largely funded by the government, which is in contrast to healthcare. Much of healthcare is in the private sector in this country. Not all of it. You know, Medicare is a great example. Medicare, by the way, is socialized medicine, which people don't wanna hear, but it is.

So you have largely taxpayer money, some philanthropic foundation money, maybe some public-private partnership, but most of public health is taxpayer dollars. It is looking at health from a population public

hence public health perspective. And so it's not decision making for an individual patient. And I think this is one area where people got frustrated during the pandemic because you had these blanket recommendations for how do we reduce disease and death at the population level. And some people would say, yeah, but that's not me. And so

They would not see themselves at being at risk, for example, and are not necessarily thinking about not just what, say, COVID infection means for them, but what it might mean for the people around them. And so those are just different ways of how do you weigh risk and benefit of certain different things.

Another way to think about public health is it's all the stuff that does not happen in a clinic or hospital. It's all the stuff like what's your air quality, your water quality, what is the safety of your neighborhood? Is it so violent you can't go out for a walk and exercise in your neighborhood? What is your access to healthy food?

Those are the kinds of things we think about in public health, and that's not something you address with a prescription pad or a surgery. A lot of our levers in public health are really about policy, and how do you shift the needle through policy?

which brings us to the doing section of this conversation. You have been such a thoughtful partner to powerful people, but as you pointed out, you've also been doing that work with local organizations, with town hall meetings, helping citizens understand their power.

How do we as individuals push back and meet this moment? We know there has been a recent tragedy where vigilante justice seemed like a solution to someone.

But we know that that's not the answer. So how do we think about what else we can do? We know we talk about voting and for some that didn't seem to work this time. It does work. It just doesn't work all the time in the ways we want it to work. But how do we talk about starting at the local level, using public health as the point of entry? Give us our marching orders. What do we do?

You know, with respect to the UnitedHealthcare CEO's assassination murder, I found that profoundly disturbing because it speaks to how disempowered even this highly educated, privileged young man, how disempowered he felt in fighting the issues with our healthcare system. And yes, our healthcare system is horrible.

We spend more than any other country in the world. We have the worst outcomes of any high-income country. And by the way, health care itself only predicts about 10 to 20 percent of life expectancy of people's health outcomes. And so a lot of what needs to be done to improve people's health is not in health care. Again, it's in public health. It's about 80, 90 percent of the game is in public health.

What really upset me about that incident was people are so disempowered that they feel like they have no choice but vigilante justice but political violence. And that's a very scary place to be when people don't believe in voting and government institutions, in meeting with their local officials. Yes, all of that takes time. It does take time to get informed, to understand the issues, to reach out to those people and to talk to them.

But I think that is where we really need to be encouraging people to get involved is do those things.

DC might seem very far away. And again, a lot of the action is not in DC for these issues. It is in your state. It's in your city. Get involved at that level. In New York City, for example, we have these community health boards. And I've met with a bunch of them over the last several years during the pandemic to educate them. These are concerned citizens who are really trying to do what they can to make their communities healthier.

And yes, that, again, takes time. It takes lots of people. But that's where you can have a very tangible impact. So that's really the level at which I would encourage people. The powers are there. These are really kitchen table concerns people have. Like, it's what's happening, I don't know, with pollution near the school where your kids goes to school.

It's what's happening with gun violence in your neighborhood. It's the opioid overdoses, you know, your neighbors, you're talking about so-and-so lost their son. These are things that are very tangible to people where you can get involved, and it doesn't have to be a partisan thing. Dr. Celine Gounder, thank you so much for joining us here and informing us here at Assembly Required.

At Assembly Required, we encourage the audience to be curious, solve problems, and do good through a segment we call our toolkit.

Now, we're going to fight the allergy to science and information by being curious. During my time in the Georgia State Legislature, I relied heavily on KFF News, and it's still my go-to. KFF News is an independent source with news and health policy research, so sign up for their newsletters at kff.org slash email. For regular listeners, you're going to notice that today I'm doing things a little differently.

You see, we've gotten quite a few listener questions that have a running theme. First, Ed Boag wrote an email titled, How to be an Activist with Social Anxiety.

He writes, since the election, I have felt energized to help defend human rights, but severe social anxiety has been a major barrier for me. Even when it's just low-stakes small talk, my throat gets so dry that I can barely speak, and years of customer service work hasn't helped me overcome this. How do I get involved and make a difference when so much of the work is about connecting people? Number two.

Muyan Chen wrote about wanting to be politically engaged even though she just has a green card. I came to the US from China more than 10 years ago and now work as a researcher in a national lab. Being a foreign national with a green card now, it's been quite stressful to watch the events unfolding, but it seems difficult to do anything about it legally. I'm wondering if there are anything such as volunteer opportunities that I can contribute to.

And number three, a caller whose name I didn't quite catch called in and left a voicemail responding to the Heather Cox Richardson episode.

She writes, I've been getting myself and my small online community to call our representative every day and leave messages with them, as well as in email. Just kind of letting them know, you know, what we think and what we need from them. And so I'm just wondering, are there specific folks we can be calling and writing? I like the idea of a bunch of us doing this kind of small thing together. We've been calling individual members that we can, also writing and calling our senators about Trump's nominations to his cabinet.

but just looking for any other ideas for folks to call. Now, normally, this is where I'd either answer your questions or give you resources on what to do about what we just discussed, like public health. But today, we're going to begin a capsule course. In grassroots organizing, Ed's social anxiety means we just find a different way for him to contribute to the cause, like setting up agendas or coordinating resources.

From Muoyan, her expertise can be a major asset in finding information and developing communication systems. And for our phone warrior, you're in the midst of convening advocates to push our agenda for good. Because here at Assembly Required, we know we can start solving problems by showing up and taking action.

Over the next several episodes, we're going to use this segment to talk about concrete steps that we can take towards insisting that political leaders do their jobs. Federal action will obviously matter, and absolutely it's important. But what I hope you've heard over these many episodes is that we're here to win.

However, winning won't be fast, and it will require many of us across the country to take on different parts of the problem and combine our successes. And that means often working at the local level so we can one day have federal impact.

This is not in lieu of federal action. It's an addition to. Let's get started. Our first step is identifying the issue that matters to you most. Is it your state's refusal to expand Medicaid, book bands in your local school district, a food desert that seems to be growing? Do you need to launch a tenants union? Pick one as your tester pancake, the issue that you want to start with.

So over the holidays, your task is to decide on the issue you want to tackle. Be as specific as possible about the problem. And also, be as local as you can with the solution. If the City Council can solve it, start there. If it's the County Commission, know it. Does the state have jurisdiction? If so, that's your target.

Take the time to know who's in charge and who can make the change you want to see. This is called power mapping. So find out as much as you can about the issue, who's responsible, and who else is already working on it. Check social media and Google to see if anyone else is talking about this issue. Write it all down and let's get ready to go to work.

As we close, I want to share one last listener comment, and this is from Emily Drake. She writes, I wanted to thank you, first of all, for answering my question a few weeks ago.

After hearing your answer and listening to this week's episode about the education system, I have decided to go back to teaching public school and to get involved as much as possible. I taught public school for seven years and I've had a few years off staying home with my kids, but I think it's a good time to go back and use my skills for good. So thank you. I appreciate all you do.

Well, thank you, Emily, for sharing and for telling me how you're getting to work. And if any of you want to tell us what you've learned, how you've solved a problem, or how you've rejoined the fight, send us an email at assemblyrequired at cricket.com or leave us a voicemail. Your questions and comments might be featured on the pod. Our number is 213-293-9509.

I wanted to say thank you. Thank you for listening, thank you for engaging, thank you for letting us know that we're coming together and we're getting to work. That wraps up this episode of Assembly Required with Stacey Abrams. I'll meet you here next week. Assembly Required with Stacey Abrams is a crooked media production.

Our lead show producer is Alona Mankofsky, and our associate producer is Paulina Velasco. Kiro Paloviv is our video producer. This episode was recorded and mixed by Evan Sutton. Our theme song is by Basileus Watakalas. Thank you to Matt DeGroat, Kyle Seglin, Tyler Booser, and Samantha Slausberg for production support. Our executive producers are Katie Long, Madeline Harringer, and me, Stacey Abrams.