Dr. Céline Gounder
Appearances
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
And so it's sort of balancing those different tradeoffs, 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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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?
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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?
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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 going to try to disprove that hypothesis.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
And then based on what I learned from that, I'm going to 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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
I think, yeah, I think that's a great way to put it. Yeah.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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?
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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?
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
And so I think 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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
The role of the CDC is partly as a funnel, frankly, of 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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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...
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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? this medication for this purpose.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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 accessibly and how affordably.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
You know, 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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
And they would have standing in terms of, is there actually science to support whether these actions are evidence-based and warranted?
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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. So in other words, they are pretty clear in that they think that Medicare and Medicaid are the principal drivers of our national debt.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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. And 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 semaglutide, also known as Ozempic or Wigovi.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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 GLP-1 weight loss drugs, for people even if they don't have diabetes or cardiovascular disease, but simply because they have obesity.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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, including the GLP-1 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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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 U.S.,
Pod Save America
Introducing: Assembly Required with Stacey Abrams
So that sort of planted the seed. But then I had pivoted from global health to domestic health around 2012. I 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 08-09 recession.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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?
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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, you know, however they want to based on that information.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
So health care 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 health care. Much of health care is in the private sector in this country. Not all of it. Medicare is a great example.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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 perspective. hence public health perspective.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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. You know, and so...
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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?
Pod Save America
Introducing: Assembly Required with Stacey Abrams
You know, 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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
It's great to be here. Thanks, Stacey.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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, et cetera. But I think we have gotten to the point in some of these conversations where instead of having a conversation about values,
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
And if we don't have either, then we're in real trouble.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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,
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
Well, one of the things that I think was made very clear during the COVID pandemic is we've very much underinvested 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,
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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 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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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.
Pod Save America
Introducing: Assembly Required with Stacey Abrams
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, too. So if you're somebody who's concerned about public health,