Ready or Not with John Auerbach | Crooked Media
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April 06, 2021
America Dissected
Ready or Not with John Auerbach

In This Episode

Abdul breaks down why we were so ill-prepared for COVID-19. Then he talks to John Auerbach, former Associate Director of the CDC and President and CEO of the Trust for America’s Health about their new report on the state of public health emergency preparedness—and what we need to do to fix it.




[sponsor note]


Dr. Abdul El-Sayed: CDC director Rochelle Walensky warned of yet another COVID surge as hospitalizations spike among young people, including children, in several states. Meanwhile, several states announced that COVID vaccines are available for all adults. And promising new data from Pfizer suggests they could be available for kids as young as 12 soon. The WHO last week released a report detailing its investigation into the emergence of SARS-CoV-2, but it leaves more questions than it answers. This is America Dissected. I’m your host. Dr. Abdul El-Sayed.


Dr. Abdul El-Sayed: Sometimes I don’t think we should call this the coronavirus or COVID-19 pandemic. That gives way too much credit to the virus. This virus was serious, don’t get me wrong. But it didn’t have to take 550,000 lives in America. Even Dr. Deborah Birx, White House COVID-19 Coordinator under former President Trump, said so. This was her in an interview with CNN’s Sanjay Gupta:


[clip of Dr. Deborah Birx] Well, I look at it this way. The first time we have an excuse, there were about 100,000 deaths that came from that original surge. All of the rest of them, in my mind, could have been mitigated or decreased substantially.


Dr. Abdul El-Sayed: Dr. Birx is talking about our fundamental failure to bring this pandemic to heel. Having a reality TV star for president, well, that didn’t help, of course. But to put this all at Donald Trump’s feet is a bit of a copout. That Trump blame game, it buys us out of having to do the real soul searching about the decades of disinvestment and disregard for our basic public health in this country. This week, a new research article in the journal Health Affairs documented the shocking state of disinvestment in public health. The study looked at state-level public health spending between 2008 and 2018. They found over the course of the decade, public health investment stayed exactly the same. We got 10 new iPhones in those 10 years and public health stayed exactly the same. Worse those baseline numbers in 2008 weren’t particularly strong to begin with. They’re what was left after funding was cut during the Great Recession. But public health is more about preparation than response. If you’re scrambling to get all the resources you need only after an emergency arises, well, you get something that looks like America’s broken COVID-19 response. Simply put, we were just unprepared for COVID-19. Our public health spending had been lacking for a while. And perhaps worse, the social safety net that so many people needed as they lost jobs and health care and hope, was in tatters. The federal minimum wage has stagnated. Housing is becoming more and more expensive. Even kids were left hungry as schools closed and with them the cafeterias offering free school meals. Think about this. Income inequality is higher now in the midst of a pandemic than it’s been in the last century. Last week, President Biden announced his sweeping new infrastructure plan.


[clip of President Biden] It’s not a plan that tinkers around the edges. It’s a once-in-a-generation investment, unlike anything we’ve seen or done since we built the interstate highway system and the space race decades ago.


Dr. Abdul El-Sayed: Though, I think there’s a lot more that it could include, this is a great start. That’s because there’s a piece of genius at the core of this bill that I want to take a second to dissect here. When we think about infrastructure, we think about things like roads and bridges, airports and train tracks, even schools and rec centers. But infrastructure is a lot bigger than that. It’s not just physical infrastructure, it’s the human infrastructure that matters, too. That’s what I think is the genius underneath President Biden’s new infrastructure bill. It recognizes that our infrastructure goes way beyond the beams and concrete that hold up our physical environment, to the people and institutions that hold up our social and socio-economic environment too. His plan would spend two trillion dollars over eight years. It would fix 20,000 miles of road and 10,000 bridges, as well as take the lead pipes that line to many cities and poison too many kids, out of the ground. All of the construction would be green, including things like electrifying 20% of the country school busses, and 174 billion dollars to incentivize vehicle electrification overall. It also embraces the 21st century, including major investments in broadband. But here’s what the plan really takes off: it includes 400 billion dollars for in-home care—a major investment in women of color who usually do this work. It includes 100 billion for public schools, 25 billion for child care facilities, and 213 billion for affordable housing. And it includes fundamental investment in our public health infrastructure that was so sorely lacking ahead of this pandemic: 30 billion dollars, to be specific, in support for pandemic preparedness.  30 billion we should have invested well before this ever happened. But if we can’t go back in time, at least we can learn from our experiences to prepare for the future.


Dr. Abdul El-Sayed: Today, we speak with John Auerbach. He’s been the Health Commissioner for Boston and the state of Massachusetts. He served as Associate Director for the CDC, and now he’s the President and CEO for the Trust for America’s Health. They recently published a report showing that the majority of US states and territories remain ill-prepared for the next public health emergency. We speak with him about what we need to do to shore up our public health infrastructure, after the break.


[ad break]


Dr. Abdul El-Sayed: Our guest today is a repeat offender of sorts. He was our first guest on the second season, John Auerbach. He previously was the Commissioner of Health for both the state of Massachusetts and the city of Boston. He was the Associate Director of the CDC, and now he is the CEO and President of the Trust for America’s Health. They’ve just released a really critical report called “Ready or Not: Looking at Public Health Preparedness Across Our States.” John, thank you so much for joining us once again on the pod.


John Auerbach: And it’s a complete pleasure. Thank you.


Dr. Abdul El-Sayed: I want to jump right in. You know, I’ve been saying this a lot, and I think you can be a lot more clarifying for our listeners, but public health isn’t about a response. It’s about how you prepared to respond? And can you speak to folks about what we mean when we talk about public health preparedness, and why it matters so much?


John Auerbach: Certainly, public health preparedness and prevention, it is critical for the health and safety of the public. It represents the policies and practices that you need to have in place to reduce the likelihood of a public health emergency. And when one does occur, to reduce the likelihood of serious illnesses or injuries, and/or deaths. And two clarifications: when we talk about a public health emergency, we’re talking about something larger and more significant to the health of the public than the sort of day-to-day emergencies that are serious, like a fire or car accidents. Those are serious emergencies—they’re not public health emergencies because the scope doesn’t affect a large segment of the population. And the other thing I’d say is that we talk about them, we think about all hazard emergency. So right now we’re thinking of COVID but when we think of a public health emergency, it could be weather related, related to climate change, as well as infectious disease, it could be a man-made attack like occurred in 9/11.


Dr. Abdul El-Sayed: You make really two really important points there that I want to pick up on, which is in public health, we sort of bake in the notion that bad things happen and we just want to limit and reduce the consequences of those things happening. So, you know, when we talk about a car accident, we sort of know that the nature of having cars on highways is that there are going to be accidents that happen. And we look broadly at how often they happen, how deadly they are when they happen, and what we can do to reduce them from happening. But it’s not like we’re aiming for a full zero, it’s that we’re aiming for consistent reduction. And then a public health emergent moment, right, the kind of public health outcomes that we’re trying to solve for, are the kinds of things that would cause many, many accidents in a short period of time. The things that we don’t see coming, you know as a function of the normal functioning in the world. And so there’s sort of two pieces to this. Right? Which is the slow work of constantly trying to bring a number lower, to try and get to that zero even if you’re not going to get there. And then there is the preparedness for a moment where that number could, could go off the charts for some reason that you didn’t see coming. The question that that often comes to mind when we think about public health preparedness and the kinds of health-related catastrophes that we’re trying to prevent, are how do you see them coming? And how can you handle or deal with the fact that you just really can’t see what’s coming around the corner? And we’ve all got COVID on the brain, as you mentioned, but that’s not always the one that we’re looking at. Obviously, it’s the sort of obvious one, an epidemic, a pandemic of infectious diseases, but there are so many other things. Can you explain sort of how public health looks around the corner and tries to optimize our preparedness to any of these situations?


John Auerbach: Certainly. You know, and I would say there’s real danger in thinking that the most recent emergency is the only one you need to prepare for, or they’re all going to look like that. When we started doing serious emergency preparedness, it was after 9/11. And so the first year or so, people were thinking: oh, it’s really going to look like a 9/11-type emergency. And in fact, emergencies can be a very different types. We do know that there are certain emergencies that are likely. We’ve seen over the last 20 years a number of novel viruses: H1N1, Ebola, Zika, now COVID. So we can probably assume they’re going to be some infectious disease outbreaks. We’ve got to prepare for infectious disease. We’ve also seen lots of weather-related emergencies. Some of those are just seasonal: bad winters, flooding. But now we’re seeing more and more of them, likely related to global climate change. And so we have to get ready for those types of emergencies. But there are also other kinds of we can’t know whether they’re going. I think a year and a half ago it is now, we had the vaping emergency, as you may recall, where nobody knew what was happening with vaping, but people were either dying or developing very serious pulmonary conditions. You need to have a certain core of activities that can respond to any type of emergency at all. And there’s some similarities, but you have to be ready for whatever it is, and you have to be continually paying attention to whether there’s certain kind of emergencies that are likely to happen. So you have specialized preparedness for those ones that are likely to be the ones that you’re going to encounter in the next year or two.


Dr. Abdul El-Sayed: Only about 20 of the 50 states—as well as the territories that you also analyzed—only about 20 of them were quote unquote “higher tier.” What does this tell us about the state of those fundamental functions that public health has to be able to do, and how does that map to what we saw with COVID-19?


John Auerbach: Well, I should start for you and your listeners just to explain, what we measure in our annual report is 10 indicators that measure a variety of different action steps that should be taken based upon past emergencies in order to be prepared. But they’re not, it’s not a comprehensive report card. It’s not a comprehensive analysis. It’s really looking at a snapshot of 10 types of policies that that would be wise to put in place. And so, unfortunately, even for those 10, as you say, only 20 states come out in the higher tier, 15 states were in a middle tier, and 15 states we’re in the bottom tier. What that suggests is we’ve got room for improvement across the country. And that was true even for the ones in the higher tier, but certainly for the ones in the lower and the middle tier we’re pointing out some best buy’s, sure things: if you do these, it can be helpful in your all-hazards preparedness. Of course, that said to your second question, these don’t necessarily correlate exactly with what was necessary and is necessary for COVID.


Dr. Abdul El-Sayed: As we think about this, it’s worth sort of going back and reviewing some some recent history. We’re coming out of a moment of real investment in austerity—or disinvestment, we’ll say—through austerity, and one of the places where we saw austerity measures take from has been public health. I think about my state where the health department I worked at had been shut down in the poorest and largest majority Black city in the country. And that happened with a governor who tried to combine multiple departments and got some of the important infrastructure inside of the state’s health department. Ultimately, we saw this disinvestment in local and state public health of about 45% over the past 15 years. How much of what we’re seeing right now in terms of the lack of preparedness is a function of that basic disinvestment?


John Auerbach: A fair amount. We have lost an estimated 50,000 jobs since 2008 in public health across the country. 50,000! In the recession of 2008, 2009, everybody was tightening their belts. All sectors were seeing reductions in their budget. But when the recession ended, a lot of those budgets got restored. They didn’t get restored with public health. And so public health is still operating in many places at that recession level that was below what would be normal, or considered normal. And so there are some essential functions that every community needs if it’s going to be prepared for an emergency, avoid some emergencies, but respond in a way that protects the public when they occur. We know what those are, and they’re just missing in many of the departments across the country.


Dr. Abdul El-Sayed: We’ll be back with more of my conversation with John Auerbach after this break.


[ad break]


Dr. Abdul El-Sayed: We’re back with more with John Auerbach.


Dr. Abdul El-Sayed: You know, we’ve all heard the story in the midst of this pandemic that Bush read a book about a great pandemic, “The Great Influenza” by John Barry, who was a previous guest of our—and recognized the need to beef up. And then post recession as you said, there was this great belt-tightening that never really got on tightened. One of the hard parts with COVID is that it has occurred in this moment of deep polarization and deep politicization, and therefore was also politicized, and politicized with it was, frankly, all the public health. How do we go about depoliticizing public health again? What does it mean to engage with policymakers on both sides of the aisle, and speak to the need to reinvest in government? Because, of course, traditionally it is a more progressive approach to government where you invest in government. We’ve seen it done by folks on the other side of the aisle. What will it take for us to make that argument beyond the political polarization lines that we have today?


John Auerbach: I think one thing we should do is spend some time reflecting on what worked and what didn’t work with COVID. There are lessons here. One of the key lessons is: expertise matters. People specialize in their field. If you want to hear an excellent performance of a musical composition, you don’t just pull someone who likes music off the street or someone who has a strong opinion about music. You really turn to someone who has the skill, studied, knows what they’re doing. But with responses to emergencies, in particular COVID, what we had was a marginalization of the people who have expertise, who know what you need to do in order to protect the public. They in some cases weren’t allowed to speak, and in some cases they were threatened if they tried to speak. And the policies were often not science-based. I don’t think that has anything to do with being on one side of the aisle or another. I think it simply has to do with recognizing that there’s value and expertise, is there a value on people who know how to save lives. You know, again, think about it in the fire department. If you want to put the fire put out in your house, you want skilled firemen, you don’t want people to have opinions about what firemen should be doing. You need the people with the skill. The core way to avoid politicization is simply to say: let’s look to the experts and let’s rely upon them. And hopefully, you know, if that’s done, we will see a greater investment in the tools that the experts need. We’ll hire some additional experts in areas where we don’t have enough, we’ll invest in the equipment that they need: laboratories, that sort of equipment. And hopefully that will move us away from the situation which has led to so many unnecessary deaths in the last 12 months.


Dr. Abdul El-Sayed: I want that to be true. But I’m going to push you here a little bit just because I think part of our frustration, right, is that when the subtext of organizing for one of the parties is fundamentally against institutions that you consider to be elite, and therefore against the expertise that those institutions tend to be able to acquire and [encorner], at some point, the notion that we are against elites and/or expertise is going to undercut that goal. And I worry because some of what we saw with the last administration was bounded up in this idea of opposing any source or any form of knowledge or truth that did not comport with what the leadership said was true. And that’s the hard part with public health, is that politics oriented to public health puts the science first and then orients the rest of the bureaucracy to capture both what the science says and what we think we want to optimize with respect to that. Right? And so if we want to save lives and the science says that X, Y and Z are how we do it, then we’re going to reorient our bureaucracy around X, Y and Z to save lives. The hard part becomes when you don’t actually agree that science is a means of arbitrating truth, or that saving lives is something that we want to do. And that’s sort of what we have. I wonder, you know, and part of that is written in the changing character of partisanship and public policy—and there are problems on both sides of the aisle, don’t get me wrong, and I think sometimes we perpetrate what we see on one side of the aisle in the other by positioning fundamentally to tweak the other side. But I’m wondering, what will it take for us to sort of, to make knowledge, expertise and the goal of saving lives, something that is bipartisan? How do we talk to, is there a way that we can talk to the base of the Republican Party, the leadership of the Republican Party, to say: you know, actually this science thing is worth investing in and folks who have expertise matter? Because in the end, the people that we’re trying to save, it doesn’t matter if they wear red or blue, it doesn’t matter who they voted—we saw people die of COVID across the board. I’m wondering if in your insights as a public health practitioner or communicator, there’s something that we’re not doing right, to bring back the ideals of science and of collective benefit that are so critical to public health.


John Auerbach: Well, I’d start by saying: not going to be easy. But I think you’re right, it is an important goal for us to strive to to reach. And a couple of thoughts on that. One is: I think that we need in public health to do a better job of establishing connections with a range of different individuals and organizations and sectors that do have the trust in different communities. So we may need to work more closely with people in the faith community, so that they have some of the tools to talk to their parishioners. We may need to work better with businesses, so that they have some of the tools to be able to make the case and to explain public health decision making. I participated maybe two or three weeks ago in a focus group that was organized with people who define themselves as conservative and said that they weren’t going to get a COVID vaccine and over the course of two hours, several different people got onto the focus group and pitched an idea. And they, they all of them, for the most part, were people who politically were aligned with the thinking of the focus group participants. At the end of it, it was clear that some of those messages resonated and some didn’t. The fascinating thing was the messages that resonated the most were from a doctor who was thought of as not political, but just explaining the facts as if someone was sitting in the doctor’s office and having a discussion about the person’s health and what the risks were, what the benefits were, a particular kind of intervention. The people listening said, well: you know, I didn’t think that doctor had a political agenda so I was willing to listen to him and he made good points that kind of convinced me. Even when they were hearing the messages from elected officials that they would have voted for and liked, they suspected that the messages were politicized and so they didn’t resonate. So it may be that working with doctors, working with others in the sector, in those other sectors, as I mentioned, is an important way to begin to build that kind of trust.


Dr. Abdul El-Sayed: Mm hmm. So it’s like we have to decontextualized a lot of the conversation and just get right back to the fact. You know a hard part about this is that so much of what we communicate is sieved through media. And in poll after poll, we find that people are more likely to trust information coming from who they see to be as objective arbiters of truth. But it almost always has to get sieved through some system, some platform, and that platform is almost always carries an implicit political identity to it. And so maybe just the way that we communicate, the platforms that exist today we’ve allowed to get captured by some semblance of a political discussion in ways that problematize them. And I say this as someone who both works for CNN and has a podcast on Crooked Media, where we don’t hesitate to talk about the ways that politics shapes our public discourse on this. You know, when we think about what we as the majority of our listeners here are going to see the world in a particular way, and as we think about what we do armed with the knowledge that you’ve given us, John, about the state of our public health preparedness, how would you like people to take this information and turn it into facts on the ground in their communities? Who should they be talking to about correcting the lack of preparedness that exists so that we’re not in another situation where a year down the line, we’re talking about another pandemic, or another serious likely climate event, for example, that knocks our lives fully off balance? What do we do from here?


John Auerbach: Well, I would say even when you’re thinking as a local person, it’s important to talk to your federal elected officials. And that’s because the vast majority of the emergency preparedness funding is federal. And if we’re going to get more money at the local and the state level, in all likelihood, it’s coming from the federal government. So I would say talk to your elected officials and say you need a robust public health system well-funded for the day-to-day activities as well as the big emergencies. I mentioned a specific thing that that if people are interested in they could support, and that is there’s an effort now to pass in Congress as part of an annual budget, an increase in funding for local and state public health departments at a national level that would be $4.5 billion. That sounds like a lot of money, but it’s spread across 50 states and thousands of local communities. And it would be paying for core activities in every community that are necessary to protect the public: the laboratories, the epidemiologists who are following up on a case, the communicators who can make sure that the public is getting the right information, the policy people who understand what the evidence shows is necessary in order to protect the public. So that’s infrastructure. 4.5 billion is now getting some support, members of Congress are now saying to us: that seemed like a lot before, now doesn’t seem like so much after we spent trillions in a single emergency. So there’s some momentum to get that passed. People calling up and saying we need strong public health departments, that’s one way to do it. I’d also say: tell them you need a strong CDC at the national level. It needs updated laboratories, communication and an updated workforce as well. So CDC needs our support. So those are two key things at your local and state level. Support your public health department. They have been beaten up in the last year. People have been fired in record numbers. They’ve had demonstrations on their front yards. They’ve had threats because they’re simply saying: here’s what we know will protect you, wear a mask, keep socially distanced. They need to know that members of the public have their back, and recognize that they’re working to protect the public. So I’d say those are few good things that would really make a difference.


Dr. Abdul El-Sayed: We appreciate that, John. And listeners to our podcast are very active and they don’t they don’t want to see something like this happen again so I know that there’s going to be a lot of energy put in to seeing this through. John, we really appreciate you and your leadership in public health at the state, federal and local levels, and coming on to share this important report with us. The last thing I’ll ask is, I’ve already asked sort of how the pandemic was for you—that was a year ago. Can you tell us a little bit about how your year has been since the last time we chatted?


John Auerbach: Well, you know, I certainly, like everybody else in America has [laugh], have had a different kind of a life. You know whatever work we planned on doing, it shifted over to COVID. And our organization went completely into telework mode. And so we have put a lot of things aside. That worries me, I would say, from the perspective of someone who thinks about the broader public health issues like: obesity still rising to record levels and chronic diseases coming from that, like diabetes, suicides and overdoses. Drug overdoses went up 20% last year. We didn’t even notice that because we were focused on COVID. We’re seeing incredible problems with climate change that we’re not paying enough attention to. The final thing I would say that this year is really reinforced again and again, is we cannot separate the issues of promoting equity, particularly racial equity and social justice, and paying attention to poverty and the other social and economic conditions that shape someone’s life. We can’t separate those from public health. So we’ve just again and again have really just seen this year, if we think we can ignore discrimination, if we think we can ignore poverty and focus on health, we’re kidding ourselves. Those issues are front and center in dealing with the health of the nation. So those are some of the some of the ways I’ve spent my time this year.


Dr. Abdul El-Sayed: Well, we’re grateful for it and we’re grateful that you gave us a little bit of it both today and this time last year when we were kicking off. That was John Auerbach. He is the President and CEO of the Trust for America’s Health, and they’ve released a really critical new publication looking at public health preparedness called “Ready or Not.” Thank you so much for joining us today.


John Auerbach: Thank you, Abdul. Always great talking to you.


Dr. Abdul El-Sayed: As usual, here’s what I’m watching right now: the World Health Organization released a report on the origins of SARS-CoV-2, a.k.a. the coronavirus. The 123-page report assesses the various hypotheses about this [report’s] origins: the bat theory, the lab experiment theory, the frozen food theory, and rates their probability of having been the origin of the virus. The report concludes that the virus’s most likely origin is that it made a leap from a wild animal host—a bat, or a scaly anteater—either directly or through a farmed domestic animal. But the report draws more questions than it answers, highlighting the problematic role that the Chinese government had in influencing the entire investigation, from choreographing the investigators trip to China, to vetoing potential investigators. To be sure, this isn’t about blaming the Chinese government, but it’s about understanding what happened, so we can prevent it from happening again. For more on this, check out my piece in The Incision at


Dr. Abdul El-Sayed: Cases are skyrocketing in a number of states, including Florida, New York, and my home state of Michigan, where over the weekend there were 8,400 new cases in one day. Here, the B117 variant is spreading rapidly and though seniors are largely vaccinated, young people are still not. That’s why hospitalizations were up 633% among people in their 30s, and 800% among people in their 40s. It’s a combination of the variants, aggressive reopening, and the fact that those vaccines are on their way, they’re still not here yet. Importantly, this same toxic brew, we’re seeing in states all over the country, reminding us that COVID isn’t over. So mask-up, wash-up, back-up and vax-up. We’ll be doing an episode on the experience of getting vaccinated. If you’d like to be featured, send us an email with a voice memo of your vaccine experience to And don’t forget to visit the Crooked Media store for our Science Always Wins America Dissected merch. We’ve got T-shirts for kids and adults. Sweatshirts and dad hats


Dr. Abdul El-Sayed: America Dissected is a product of Crooked Media. Our producer is Austin Fisher. Veronica Simonetti mixes and masters the show. Production support from Tara Terpstra, Lyra Smith and Alison Falzetta. The theme song is by Taka Yasuzawa and Alex Sugiura. Our executive producers are Sarah Geismer, Sandy Girard and Me: Dr. Abdul El-Sayed, your host. Thanks for listening.