Tommy (8:30)

It's great to be here. Thanks, Stacy.

Stacey Abrams (8:32)

Dr. Gounder, I have a public health crisis question for you. Are American politicians and policymakers allergic to science?

Tommy (8:42)

I think this is something that is very much on the mind of those of us working in science, in medicine, in 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, schooling, et cetera. 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.

Stacey Abrams (9:48)

The science is wrong, that language is perfect, that 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 Jr. 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?

Tommy (10:58)

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 a 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.

Stacey Abrams (12:28)

Well, that brings us to the other nominee. So while a lot of tension has focused on RFK Jr heading HHS, the two of the top jobs are also under consideration. And one of the pending nominees is Mehmet Oz. The other is Matt Makari, both of whom are physicians, but who each have had controversial behaviors, and there have been questions about their fealty to scientific principles in their work or the implications of their policy proposals. So what do their nominations tell you about the incoming administration's thinking about this? So to your point about combining the need for science and for policymaking, what happens when you have a scientist who doesn't seem to believe or at least live those beliefs?

Tommy (13:23)

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 Macri, 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 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.

Stacey Abrams (14:40)

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?

Tommy (15:21)

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 Birx'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 same state level. There's only so much the federal government can do. Yes, the federal government provides funding, technical expertise, advice, guidelines, but 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.

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Stacey Abrams (18:14)

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 happen at the 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?

Tommy (18:45)

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 intrastate 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 clue, clear view into what's happening in other states. 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.

Stacey Abrams (21:07)

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's 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?

Tommy (21:33)

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 you know, some of that was the parents, some of that was teachers who were concerned for themselves. And you know, whether you agree or disagree with those particular decisions, different communities took. You know, regardless of that, aside from that, that was the Local community. That was the local communities that were dictating those decisions.

Stacey Abrams (22:47)

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 describe, the uneven and sort of patchwork response which seemed to prove that nothing was true, therefore nothing would ever be true. There was the first. We all wipe down every surface. And then we realize wiping down every surface isn'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?

Tommy (23:39)

I think there's a real understanding of what science. Science is and the scientific process is. 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.

Stacey Abrams (24:46)

So basically, I'm gonna translate this into television. We need to be more like Dr. House than we are like Law and Order, I think.

Tommy (24:53)

Yeah, I think that's a great way to put it. Yeah.

Stacey Abrams (24:56)

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 pithy 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?

Tommy (25:24)

Well, I think also to be aware of what your pre existing biases and opinions might be. So to ask them, well, you know, 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.

Stacey Abrams (26:01)

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?

Tommy (26:48)

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 gonna 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, of funding to state and local health departments. So that's 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 state. 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 Jr has expressed frustration that the FDA is somehow blocking people's access to generic medications for additional indications. So 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, an application, and they say, will you approve this medication for this purpose? And so 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. So we could decide we're going to use more taxpayer money for vetting these applications. We've decided to partially fund it with these fees. And we've decided that this kind of approach to funding R and 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 accessibly and how affordably.

Stacey Abrams (31:20)

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?

Tommy (31:30)

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 is 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.

Stacey Abrams (32:24)

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?

Tommy (33:00)

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 what 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? Yeah.

Stacey Abrams (34:35)

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?

Tommy (35:11)

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.

Stacey Abrams (35:26)

Fantastic. Health is not simply the ability to know what diseases and threats are out there. It's also about the ability to get help. That means we also have to pay attention to the healthcare access side of things. 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 into block grants, which will set fixed amounts that go to states regardless of the actual cost of health care or the size or needs of the population. What are you concerned about when it comes to this administration's impact on healthcare access and how would you process this information as a layperson?

Tommy (36:16)

Well, if you read Project 2025, they literally speak that the cost of Medicare and Medicaid combined since 1967, which is when these programs were started, is about $17.8 trillion. And the U.S. deficits for that same time period are $17.9 trillion. 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. And 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 inferior 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 gonna be in the next round of drug negotiations is Semaglutide, also known as Ozempic or WeGovy. A lot of people are desperate to get access to that medication. Currently is very expensive. The Biden administration has recommended or 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, you know, 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. 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.

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Tommy (41:57)

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 that 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. We were dealing with massive cuts to public health funding in the aftermath of the 0809 recession. 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 inform citizens, and then to make decisions however they want to based on that information.

Stacey Abrams (43:22)

Okay, so here's your platform. Tell people the difference between public health and healthcare and how they should describe it when they're sitting around the dinner table.

Tommy (43:31)

Yeah, so health care is what people are more familiar with.

Stacey Abrams (43:35)

Right.

Tommy (43:35)

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 health care. Much of health care is in the private sector in this country, not all of it. Medicare is a great example. Medicare, by the way, is socialized medicine, which people don't want to 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?

Stacey Abrams (45:27)

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?

Tommy (46:27)

You know, with respect to the United Healthcare 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% 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% 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, in 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 D.C. 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 your 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.

Stacey Abrams (48:52)

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@kff.org 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 Bogue wrote an email titled how to Be an Activist with Social Anxiety. He writes, since the election, I 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 an email just kind of letting them 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. Eds Social anxiety means we just find a different way for him to contribute to the cause, like setting up agendas or coordinating resources. For Moyan, 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 in 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 bans 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@assemblyrequiredricket. 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 Ilona Minkowski and our associate producer is Paulina Velasco. Kirill Palaviv is our video producer. This episode was recorded and mixed by Evan Sutton. Our theme song is by Vasilius Fotopoulos. Thank you to Matt De Groat, Kyle Seglin, Tyler Boone and Samantha Slosberg for production support. Our executive producers are Katie Long, Madeline Herringer and me, Stacey Abrams.

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