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

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.

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. Ralph Noyes was a speech pathologist 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.

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

COVID hit the nursing home hard in April.

We had our first— I call him our ground zero patient. He was one of my patients that I was working with 5 days a week.

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.

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 night, I was burning up with chills and fever.

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 3 weeks, but he says it took another 2 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.

Fighting my bosses who were trying to pressure me to go back to work, fighting the workers' comp people to try and prove that it was a workplace injury. Obviously, there was no paid time off. It was a disaster.

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

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 or just walk by every day were gone.

Half the residents had either been taken to the hospital or died because of COVID and his coworkers didn't fare much better.

42-year-old nurse who ended up on a ventilator for 3 weeks and will never be the same. We had someone in our kitchen staff who was in the hospital for like 2 weeks and came back 80 pounds lighter, looking like death. And me and everybody I know suffered, and that just really, really raised the stakes for me and made it real.

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.

I was sick of feeling at times scared, hopeless, angry. Argumentative, and I just decided to say, that's all a waste. I want to do something positive.

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.

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.

COVID has upended American political life this year. From voter registration to rallies and fundraising, even plexiglass dividers during the vice presidential debates, 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.

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

This is Dr. Alistair Martin.

I'm an emergency medicine physician and a faculty member at the Center for Social Justice and Health Equity at Harvard Medical School.

He's also the founder of Vote ER, a 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?

No spontaneous breaths.

She's cyanotic.

Faint pulse at 200.

We scoop and run.

What happened? Just stopped breathing. Has she been sick?

No.

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?

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 acute or emergent medical problem. These are folks who are coming in asking for a prescription to be refilled. Or like I had a couple weeks ago, a patient who had a rash for about 7 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.

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

And it's in that downtime where there's an opportunity to vote for folks if they want to. To do voter registration, and Vote-ER helps them do that.

Vote-ER 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.

One patient I had about a week and a half ago now who was in his 70s, 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 go back and I say, you know, what are you doing on November 3rd?

He planned to vote in person. This had Alistair concerned. The man had cancer, was immunosuppressed, and he was in his 70s. 3 big risk factors for COVID. Alistair asked the man if he wanted to get a mail-in ballot instead.

He said, "Wait a minute, you can do that?" 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 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 feeling of connection that this doctor cares enough about me to care about my physical health, but also my civic health, is happening all across the country. And it's been a really sweet phenomenon that we've been a part of.

The Vote ER 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 Vote-ER 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.

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 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.

And many doctors still wanted to get involved, even if the kiosks, posters, and other materials weren't available. So Alistair 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, a number people can text, just like the one Alistair used to get that patient who had cancer his mail-in ballot. But Alistair 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 Alistair also says ER doctors, nurses, and EMTs are the ones who see the failures in our healthcare system every day.

I'll tell you a story. I had a patient who had come in because of what seemed to be DKA.

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. Alistair found out that she had not been taking her insulin.

She was 19 years old, and I remember asking her, I see that you were just here a couple days ago. What's going on? Why aren't you taking your insulin? He 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 weeks, if I just ration it and take smaller and smaller and smaller doses, it'll last. And I remember hearing that and thinking to myself, "Oh my God." I can't solve her problem with a surgery or a prescription. 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.

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.

And COVID-19, I think, really shined 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 got to start by creating a truly inclusive democracy, and the first step to do that is voter registration.

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

You know, when you look at voter registration rates across the country, in 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.

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

Over the past 10 years, we've seen a slow adoption of technology in campaigns and political organizations. And then in the past 6 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.

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. In order to really meet voters where they are.

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.

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 in terms of really meeting voters where they are with messages that they cared about. They tested, they targeted very, very deeply through Cambridge Analytica and other means at just a whole new level. And a lot of that was because they threw the traditional political approach out the window.

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.

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.

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.

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.

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.

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.

Maybe you've gotten text messages this fall from someone you know asking you to support a candidate or maybe 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.

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 protections that the city council passed, and the city council agreed to have a meeting, and they passed the protections. 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 used technology to make their strategy come to life and close out strong in exactly the moment that they needed it.

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?

I think that that's a false choice.

Betsy Hoover again.

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 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.

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.

You know, I still have doubts about the ultimate impact of what I'm doing. I still will spend 3 hours sitting at a coffee shop on the corner trying to engage with people and just wonder if any of this matters.

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.

I saw him today. I literally, I rushed to get back home to do this interview after spending 6 hours at the nursing home today and, you know, following up with everyone, making sure 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.

The nursing home is in Florissant, Missouri, just a few minutes' drive from Ferguson.

Honestly, it's a lot of dismantling these, you know, doubt 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.

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 in 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 will 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.

Because if we're not at the The table were on the menu.

Epidemic is brought to you by Just Human Productions. We're funded in part by listeners like you. We're powered and distributed by Simplecast. Today's episode was produced by Zach Dyer and me. Our music is by The Blue Dot Sessions. Our interns are Tabitha Gordillo, Annabel Chen, and Brian Chen. If you enjoy the show, please tell a friend about it today. And if you haven't already done so, leave us a review on Apple Podcasts. It helps more people find out about the show. You can learn more about this podcast, how to engage with us on social media, and how to support the podcast at epidemic.fm. That's epidemic.fm. Just Human Productions is a 501(c)(3) nonprofit organization, so your donations to support our podcasts are tax deductible. Go to epidemic.fm to make a donation. We release Epidemic every Friday, but producing a podcast costs money. We've got to pay our staff, so please make a donation to help us keep this going. And check out our sister podcast, American Diagnosis. You can find it wherever you listen to podcasts or at americandiagnosis.fm. On American Diagnosis, we cover some of the biggest public health challenges affecting the nation today. In season 1, we covered youth and mental health. In Season 2, the opioid overdose crisis. And in Season 3, gun violence in America. I'm Dr. Celine Gounder. Thanks for listening to Epidemic.