S1E46: Vote Like Your Health Depends on It / Alister Martin, Betsy Hoover, Ralph Noyes

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Healthcare is political. There’s a difference between politics and partisanship. Thinking about healthcare as not being political I think is where many doctors and unfortunately our healthcare system stand to lose the most.” —Dr. Alister Martin

COVID has made voting a public health issue this year. In this episode, we’ll hear how nursing-home workers, doctors, and entrepreneurs are working to get out the vote in the middle of a pandemic. This podcast was created by Just Human Productions. We’re powered and distributed by Simplecast. We’re supported, in part, by listeners like you.

Alister Martin: Healthcare is political. There’s a difference between politics and partisanship, to think about healthcare as not being political, I think is where many doctors and unfortunately our healthcare system and the folks who make it up, stand to lose the most.

Celine Gounder: You’re listening to EPIDEMIC, the podcast about the social and public health impacts of the coronavirus pandemic. I’m your host, Dr. Celine Gounder.

Celine Gounder: Ralph Noyes was a speech pathologist working in a nursing home just outside St. Louis, Missouri. In March, he started to see some early signs of the arrival of the coronavirus where he worked.

Ralph Noyes: We started to see a couple of strange employee absences. So we had a week where we had 3 or 4 people stop showing up to work.

Celine Gounder: COVID hit the nursing home hard in April.

Ralph Noyes: We had our first, I call him our, our ground zero patient. He was, um, one of my patients that I was working with five days a week.

Celine Gounder: Ralph’s patient was in his 70s. He had had a series of strokes and other health issues that got in the way of him speaking normally. As a speech pathologist, Ralph had to be close to him. He was basically in this guy’s mouth a lot.

Ralph Noyes: So I was in very close contact with this person and, you know, I got a call Sunday night late that he had been admitted to the hospital and he had tested positive for COVID. And, by that by that night, um, I was burning up with chills and fever.

Celine Gounder: Ralph, and then his wife, both got COVID. He had a fever, a tightness in his chest, and a lot of fatigue. His symptoms lasted about three weeks. But he says it took another two months to really get over it. COVID brain — a kind of mental fog that just never lifted — was the symptom he suffered with the longest. Meanwhile, Ralph was dealing with his job.

Ralph Noyes: Fighting my bosses, who were trying to pressure me to go back to work, fighting the worker’s comp people to try and prove that it was a workplace injury. Obviously, here was no paid time off. It was a disaster.

Celine Gounder: When Ralph did finally get back to work… the nursing home was a very different place than the one he remembered.

Ralph Noyse: Yeah, it was bad. I mean, I remember pulling up in the parking lot and the parking lot was empty and I remember going inside and it was just strange. I was walking past room after room and they were all just empty with these made-up beds and all these people that I used to know and used to work with are just walk by every day we’re gone.

Celine Gounder: Half the residents had either been taken to the hospital or died because of COVID. And his coworkers didn’t fare much better.

Ralph Noyse: 42-year-old nurse who ended up on a ventilator for three weeks and will never be the same. We had someone in our kitchen staff who was in the hospital for like two weeks and came back 80 pounds lighter, looking like death and me and everybody I know suffered and, and that just really really raised the stakes for me and made it real.

Celine Gounder: With all the failures of leadership at his work, he got increasingly disillusioned with the state and federal response to the pandemic. And that’s when he made up his mind.

Ralph Noyse: I was sick of, um, feeling at times scared, hopeless, angry, argumentative. And I just decided, that’s, that’s all a waste. I want to do something positive.

Celine Gounder: So he started registering people to vote. When Missouri’s legislature passed a requirement that mail-in ballots had to be notarized, Ralph became a notary. And he started where he worked, with the same patient who likely gave him COVID.

Ralph Noyse: He was my ground zero guy, and he was also the first person who I started, you know, getting him registered to vote, updating his address, figuring out how to request the ballot.

Celine Gounder: COVID has upended American political life this year. From voter registration to rallies  and fundraising…even plexiglass dividers during the vice presidential debate. Social distancing measures have changed how political campaigns can safely reach and mobilize their supporters. In this episode, we’re going to hear how individuals like Ralph, ER doctors, and tech startups are trying to reach voters this fall and encourage them to vote like their health depends on it.

Alister Martin: COVID-19 has turned voting into a public health issue.

This is Dr. Alister Martin.

Alister Martin: I’m an emergency medicine physician and a faculty member at the Center for Social Justice and Health Equity in Harvard Medical School.

Celine Gounder: He’s also the founder of VotER, the program designed to get some of the most vulnerable in society registered to vote. So, what’s the first thing that comes to mind when you think of an emergency room?

Celine Gounder: On TV, emergency rooms are made out to be adrenaline roller coasters. Life and death decisions every minute. In the middle of all this chaos, why would this be a good place to register voters?

Alister Martin: What many people don’t know about the ER is that many, many patients who come in actually have no real medical issue. There’s no, there’s no, um, acute or emergent medical problem. These are folks who are coming in asking for a prescription to be refilled like I had a couple of weeks ago, a patient who had a rash for about seven years who needed the rash to be checked out tonight. And so these are folks who are looking quite frankly for primary care and often are waiting.

Celine Gounder: Not exactly great TV, but a great place to register voters.

Alister Martin: And it’s in that downtime where there’s an opportunity to vote for folks — if they want to — to do voter registration and VotER helps them do that.

Celine Gounder: VotER is in 200 hospitals across the United States. In these participating hospitals, there’s lots of ways voter registration information reaches people. There could be a poster on the wall with a QR code or a number to text. There might be information about voter registration on a patient’s discharge paperwork. And some physicians have a badge around their neck that says, “VOTE” to help start the conversation.

Alister Martin: One patient I had, uh, about a week and a half ago now who was in his seventies. He had metastatic cancer, he was on chemotherapy, and he was immunosuppressed. And I remember, as I was leaving the room, I remember thinking, oh my God, I didn’t ask him, you know, what he’s planning to do on election day. So I come back and I say, you know, “what are you doing on November 3rd?”

Celine Gounder: He planned to vote in person. This had Alister concerned. The man had cancer, was immunosuppressed, and he was in his 70s — three big risk factors for COVID. Alister asked the man if he wanted to get a mail-in ballot instead.

Alister Martin: And he said, “wait a minute, you can do that?” And I said, “of course,” and I showed him my badge, and I said, “okay well, you know, do you want to get one while you’re here?” And the look, that he, that he had, the look of surprise and, like, delight that we could help him get his mail-in-ballot while he waited in the emergency room was just incredibly gratifying. And that look, and that sort of, uh, feeling of connection that this doctor cares enough about me to care about my physical health but also my civic health. It’s happening all across the country and it’s been a really sweet phenomenon that we’ve been a part of.

Celine Gounder: The VotER program has helped more than 27,000 people get registered or request a mail-in ballot since it launched in September 2019. The original plan for VotER was to have kiosks and other materials available in hospitals. But the extreme demands of the pandemic — especially during its early days — meant that a lot of hospitals that were interested before suddenly weren’t prioritizing voter registration.

Alister Martin: But we had to figure out, do we stop or is this the very reason for us to be doing this. Is COVID-19 not, making it obvious for everyone that the way that we have set up our public health systems is, uh, hurting those who are most disenfranchised. Those who are most vulnerable. When you look at who bore the brunt of mortality, morbidity, it’s the same exact patient populations that we take care of in our ERs, or in our community health centers, or in our free care clinics when they need primary care. It’s the same exact populations that are not registered to vote.

Celine Gounder: And many doctors still wanted to get involved… even if the kiosks, posters, and other materials weren’t available. So Alister and the team he was working with came up with something called a Healthy Democracy Kit. It’s a lanyard that doctors wear around their necks that says VOTE in big bright letters. It has a QR code and number people can text, just like the one Alister used to get that patient who had cancer, his mail-in ballot. But Alister has gotten some pushback. Some people say doctors need to “stay in their lane,” and not be doing things like registering people to vote. But Alister also says ER doctors, nurses, and EMTs are the ones who see the failures in our healthcare system every day.

Alister Martin: I’ll tell you a story. had a patient who had come in because of what seemed to be DKA.

Celine Gounder: DKA stands for diabetic ketoacidosis. It’s a serious complication of diabetes. This patient had come into the ER twice in the same week with these DKA symptoms. Alister found out that she had not been taking her insulin.

Alister Martin: She was 19 years old. Um, and I remember asking her, “I see that you were just here a couple of days ago. What’s going on? Why aren’t you taking your insulin? She said, “doctor, I recently lost my insurance and over the course of the last month, I’ve had to make decisions around do I eat, or do I pay for this medication. And I’ve been thinking over the course of the last couple of weeks if I just ration it and take smaller and smaller and smaller doses that’ll last.” And I remember hearing that and thinking to myself, Oh my God. I can’t solve her problem with the surgery. She can solve her problem by voting, we can solve her problem by voting. If we want a fair, more just healthcare system, we have to vote like our health depends on it and I think that’s what we’re missing in healthcare.

Celine Gounder: This is what doctors call the social determinants of health. There’s a lot that happens outside the hospital that doctors can’t control. Uninsured patients, pollution, violence, food, and housing insecurity — these are all things that impact someone’s health that pills can’t fix.

Alister Martin: And COVID-19, I think really sort of shone a spotlight on that and exposed a lot of our sort of harsh realities about how deep the divide is in this country. In order for us to create a truly inclusive healthcare system that does that, we’ve got to start by creating a truly inclusive democracy. And the first step to do that is voter registration.

Celine Gounder: It’s hard enough to register voters in a typical year, and the pandemic has made this even more difficult.

Alister Martin: You know, when you look at, uh, voter registration rates across the country, and some places are down up to 70%, when you look at where people normally register, the DMVs, these voter registration tabling events, a lot of that stuff has been curtailed.

Celine Gounder: After the break, we’ll hear how some organizations are looking to entrepreneurs to develop pandemic solutions for things like voter registration and political organizing.

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Celine Gounder: A lot of industries have been upended by the pandemic. Campaign organizing is just the latest.

Betsy Hoover: Over the past 10 years, we’ve seen a slow adoption of technology in campaigns and political organizations. And then in the past six months, we’ve like jumped forward the next 10 years.

This is Betsy Hoover. She’s one of the founders of the investment fund and startup accelerator, Higher Ground Labs. Their goal is to help build digital tools for progressive organizations and Democratic candidates.

Betsy Hoover: I think we’re in a really fluid time in our society where the role of technology, the role of digital communication is increasing on a, you know, daily basis. And we’ve got to understand how that forces candidates, and campaign strategy to change and adapt, um, in order to really meet voters where they are.

Celine Gounder: Betsy was President Barack Obama’s online organizing director in 2012. Since the early 2000s, Democrats had been early adopters and investors in digital campaign and organizing tools. Way more than the GOP.

Betsy Hoover: Trump’s campaign and Trump’s organization flipped that. They ran a brilliant Facebook strategy in 2016 and they operated much more like a consumer brand does, um, in terms of really meeting voters, where they are with messages that they cared about. They targeted very, very deeply through Cambridge Analytica and, and other means at, at just a whole new level. And a lot of that was because they threw the traditional political approach out the window.

Celine Gounder: One of the strengths of that strategy was leveraging people’s personal social networks through platforms like Facebook. In the campaign business, this is called relational organizing.

Shola Farber: So it starts with talking to friends and family, talking to the people who you know about the things that you care about, and then inspiring them to care about those things also. That’s good organizing.  And that’s the potential that exists with technology more than any other way.

Celine Gounder: This is Shola Farber. She’s the co-founder of the Tuesday Company, one of the groups that got funding from Higher Ground Labs. In an increasingly digital world — and one where coronavirus makes it unsafe to talk in person — there’s an urgent need to move those tools online, for both sides of the aisle.

Shola Farber: So if you get a message from a friend, if you see a friend’s post on social media, that’s up to 25 times as impactful as seeing a paid ad or getting a cold phone call or a door knock from a stranger.

Celine Gounder: Shola says the fundamentals of political organizing haven’t changed even in the digital age. Traditionally, this meant knocking on doors. But even before the pandemic, there were limits to this kind of politicking.

Shola Farber: And so it’s a really great way to reach often white, suburban voters. It is not a great way to reach almost anyone in the city or in really rural places where families live very far apart.

Celine Gounder: Maybe you’ve gotten text messages this fall from someone you know asking you to support a candidate or some issue on the ballot. There’s a chance that message was sent using a program Shola’s company created. It’s called Team. Team lets groups leverage their supporters’ contacts to reach people through direct messages. One group that used the Team platform successfully during the pandemic was Equality Florida. The organization wanted to get the Jacksonville City Council to approve a bill to protect LGBT people from workplace discrimination.

Shola Farber: They started using Team in late May and over the course of Memorial Day weekend, they had 27 supporters send 354 emails to lawmakers and 537 relational messages, both to lawmakers and to individuals in the community. That advocacy put enough pressure on Jacksonville’s Republican mayor, that he agreed to sign into law any projections that the city council passed and the city council agreed to have a meeting and they pass the protections, um, basically supporting about 50,000 Floridians from facing gender or sex based discrimination at work. It’s not like we just swooped in and did everything, but they were really smart about how they use technology to make their strategy, come to life and closeout strong and exactly the moment that they needed it.

Celine Gounder: The pandemic has created a situation that forced many groups to adopt these new tools. So, if they work so well… do we even need in-person campaigning anymore?

Betsy Hoover: Um, I think that that’s a false choice.

Celine Gounder: Betsy Hoover again.

Betsy Hoover: This year we’ve seen Americans spend more time somewhat isolated from people physically and focused on their screens and that lends itself to technology and, and digital communication. But that isn’t only true in this  moment and that won’t stop being true when life goes back to something a little bit more resembling normal.

Celine Gounder: And that’s what Ralph Noyes has been doing. He went online to get the resources he needed to register voters. He volunteered to send text messages in support of Nicole Galloway, who’s running for governor of Missouri.He says the work feels empowering, but he worries he’s not reaching enough people.

Ralph Noyse: You know, I still have doubts about the ultimate impact of what I’m doing. I still… will spend three hours sitting at a coffee shop on the corner, trying to engage with people and just wonder if any of this matters.

Celine Gounder: Ralph says sometimes when he does connect with someone, he feels like he’s preaching to the choir. But he says he thinks he’s making a real difference at the nursing home. He doesn’t work there anymore, but he’s still using his relationships to help register residents and staff. Remember the nursing home resident in his 70s who couldn’t speak? The one who was hospitalized with COVID? He survived his stay in the hospital.

Ralph Noyse: I saw him today. I literally, I rushed to get back home to do this interview, um, after spending six hours at the nursing home today. And, you know, following up with everyone, making sure that they got their ballot, making sure I demonstrated to our activities coordinator to help how to help them fill out their ballot. And he was one of the people that I saw today. He’s still there.

Celine Gounder: The nursing home is in Florissant, Missouri, just a few minutes’ drive from Ferguson.

Ralph Noyse: Honestly, it’s a lot of dismantling these, you know doubts and skepticism that they have about voting in general. Some of them have never voted before or rarely vote and they have a lot of motivation and that’s motivating to me.

Celine Gounder: The safest way to vote this fall is by mail or by a ballot drop box if your state allows them. But many voters may have concerns about the postal service or other doubts about the rules around mail-in or absentee voting. If you decide to cast your ballot in person this November, please remember… wear a mask… and if you want to be extra safe, wear glasses, a face shield, or goggles. Stand 6 feet apart from other people. Go alone—don’t bring others with you who’ll add to the crowd at polling sites. Consider going at off-peak times, like the middle of the morning or the middle of the afternoon,  when the lines will be shorter. However you choose to vote, make a plan and do it!

Alister Martin: Because If we’re not at the table, we’re on the menu.

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Today’s episode was produced by Zach Dyer and me. Our music is by the Blue Dot Sessions. Our interns are Tabata Gordillo, Annabel Chen, and Bryan Chen.

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I’m Dr. Celine Gounder. Thanks for listening to “Epidemic.”

Alister Martin Alister Martin
Betsy Hoover Betsy Hoover
Ralph Noyes Ralph Noyes
Dr. Celine Gounder Dr. Celine Gounder