D.C. Is Cutting Health Funding — Who Keeps Us Healthy Now?

Judson Howe Becky, what happened in your childhood that showed you that health is lived, not delivered?

Becky Payne That's a really good question. I think it goes back to how I was raised. So I was raised by two public servants, a social worker and police officer. And my entire upbringing was being in the community. For community events, my parents were always volunteering and giving back. So I don't know that I came into this really intending to go into health per se, as much as I was raised to believe you had to give back. Not that you had to, but you should give back. That's part of being a person going through the world. And I was also raised on dining room conversations about what was happening in our community, the experiences people were having, and my parents in healthy professions. And I say that knowing that policing is very different now than it was when my father was doing it. And it's very different than how he approached policing. He would be just devastated with what has happened in the relationship between police and community in this time. So I was raised hearing conversations about people who were struggling, people who were being harmed by systems, who weren't heard in systems, and watching my parents literally negotiate between themselves and their organizations how they could help connect people to resources and help give people another chance. So for me, it was not so much health as much as we all deserve the opportunity to go through life with fewer barriers. And those of us who are in positions to help remove barriers or connect you to resources have a responsibility to do that. And that is what I took into college and took into graduate school. I had no idea what public health was. I thought I would go into social work and then I learned about public health in the very early days of that. as schools were starting to come online and just decided to jump in and be really curious about it, and found that studying community systems, studying community health, organizing, really spoke to me and it gave me an outlet for what I had been raised to think I was meant to do.

Judson Howe You talk about structures that are unjust. Have we seen an increase in injustice in the structures, or maybe just a perpetuation of historical structures. Maybe just expound for the listeners on what structures we're talking about here. And just put words to them and define what we meant.

Becky Payne Yeah. I think it's hard. If we're honest, the injustices and unfair systems have been around since we arrived on this land. And I make no judgment about, you know, the intent. But we all know intent is one thing and the impact you have is where it really counts. And so if we're honest, you go back to the founding of this country, and we have displaced and brutally erased entire populations and people. And some of us, a lot of people who look like you and me, have benefited from that. And I don't think anybody, if they're honest, is saying that you, Judson, and you, Becky, are ultimately the ones who are responsible for that. I think that's where we get off in the conversation. But you can't talk about our system of wealth, our system of health, our systems for education, without talking about how uneven the table has been set in terms of having opportunity to take advantage of those things. We live in a country where your health is completely — and I'm going to go beyond health if it's okay — if we can talk about well-being in its broadest sense. Our well-being is completely dependent on our ability to not only attain wealth for ourselves, but to be able to pass that down generation to generation to generation. And you don't have to go too far to scratch the surface and understand that our wealth is built on home ownership. Our wealth is built on education, being able to attain work that will pay not just a living wage, but a meaningful wage that allows me to attain the higher things in life, which include homeownership. If I can't buy a home, if I am stuck renting — hopefully renting — I never get ahead to create that equity that then allows me to buy the next home or to leverage that equity to send my children to college or to send them to a private school if my public school is failing. And we all have heard the history of redlining. The value of my home in one neighborhood across the street is very different than the value of a home that is on the other side, literally and figuratively, of the tracks that somebody arbitrarily decided needed to be drawn. Doesn't matter how much money I put into my home. If someone living over there puts the same amount of money into their home, they're valued differently just because of zip code, just because of who the neighbors are, just because of the historical investments or lack of investments. And the systems that make those investments include the roads, the transportation systems, the access to safe green space and parks for children to play in, if it's walkable, if there's an absence of crime. You can go on and on and on. If you just think about the way in which you move through your day and the way in which someone who is from a different neighborhood who maybe didn't have access to the same education, who doesn't have access to the same job opportunities, who might be living in a very different way. What their community looks like when they move through their day, it doesn't take a big leap of imagination to conjure two very different images in this country. And you have to question how can that possibly be, in a country such as the United States, based on our Constitution, based on the intent of our founding, until you start going through the history books and you go through the trajectory of the country and you go through what we have done to indigenous people, indigenous lands, to slavery, to forced labor, to how we have structured our laws and sentencing rules. I mean, you can go on and on and on and look at difference just based on data. So when you talk about systems and injustice, it is really, I believe, impossible to offer that there's no inequity in our systems, that there is today justice, and that everything is fair. And if you accept that, then you have to question why and what should we be doing about it.

Judson Howe You took the time to delineate between health and well-being just there. Why did you do that? Why was that important to you?

Becky Payne Well, I took the time to do that, because I think health conjures up the clinical experience or an experience between me and my doctor, me and my health team. Well-being is much broader and you know um we tend to talk about Vital Conditions for health and well-being. There are seven. And well-being is much more holistic, and it takes responsibility and I think opportunity out of one system — in that case, the healthcare system — and looks at the broader construct of community systems and how they interplay with each other to reflect on how do we attain well-being? How do I as an individual think about well-being and how do the community systems that — my taxes, my philanthropy, my volunteer hours, all of the different ways in which we pour assets into a place — how do those show up in a person's life? If you narrowly define it just as health, then I'm beholden to hospital systems, to physicians, to nurses, to doctors, to a system that is actually there to be responsive to fix something when a problem arises. But it is not currently today set up to keep me in a state of well-being. That's not its purpose. We would like for it to be. Many of us would offer that that should be a core central part of its purpose. But the incentives of health care are much more about treating illness and sickness and fixing a problem once it shows up on someone's door. Well-being then broadens the table of both responsibility and opportunity. And if we talk about Vital Conditions — I'll just give you there are seven. Humane housing, reliable transportation, thriving natural world, basic needs for health and safety, which include access to good quality health care and mental health care, meaningful work and wealth. So not just a job, but a job that has meaning as you define it and gives you an opportunity to build wealth. So if I go back to that cycle of how important our economic, the way our economic system is. And then the most important for me — the data would show this and we call it the heart space — is belonging and civic muscle. When we talk about these seven, we show them in a circle with belonging and civic muscle in the middle by design. And that is the one where we demonstrate our care for each other, that I see you, fellow community member, that you matter. Your opinions matter. Your talents and skills matter. The assets you bring to conversations, your experience matters. And so the muscle is then, do we have meaningful outlets to capture all of that talent and trapped assets in our community? It's not just voting. It's not just showing up, you know, every two to four years. It's volunteering. It is mutual aid. It is saying, you know, we're coming into a period where resources are going to be even more strapped. You know, federal dollars are going to be waning for some period of time and that trickles down into communities. We have to figure out how to fill that gap. If you understand the assets in your community, you can draw upon the talents and skills and knowledge of people in the community and use civic outlets for engagement. And guess what happens when you do that? It's really hard to hate up close. So I'm interacting with you, neighbor, who I haven't talked to in a few years because we went through this pandemic. We all got stuck behind our keyboards and our computers for school, for work. It became scary to interact with each other. We were told not to interact with each other. And I think, yeah, we're emerging from that, but we're emerging from that with real trauma responses. We're emerging from that with less time and inclination and lost muscle in how to be neighborly. So getting back to that takes effort. We can't take it for granted. And belonging and civic muscle is a construct of value in a way in which we can start to pull people back together. I really think if we invest in that, first and foremost, even above any of the other six — they're all really important — but investing in belonging, in civic muscle, is the antidote to the division and the hatred that we see today.

Judson Howe What's the history on Vital Conditions that Ripple is so well known for? Where did this language come from?

Becky Payne I love the history. And I will say I came to Ripple partially because of my exposure to the Vital Conditions.

Judson Howe. So you had already been exposed to Vital Conditions?

Becky Payne I had already been exposed to Vital Conditions and we can talk more about —

Judson Howe So it is correct that it came out of Ripple?

Becky Payne I want to be really clear. The Ripple Foundation is a huge champion and proponent of them. We support the uptake of them as much as possible. We are not the sole creators or users of it. So if I can step back just a little bit and orient everybody. We really see a rising movement to thrive together. We see it happening in the country. We have an interest in seeing it happen in the country. At the foundation, our north star is a future where all people and places can thrive with no exceptions. And we believe deeply, not just that that is needed, but that it is possible. Now, that is a multi-generational proposition. It probably won't happen in my lifetime. And that is what we are calling people into, which is stop thinking just about what is the next move that you personally will benefit from and start having real conversations about what are the investments and the commitments that you can make that are going to create a better world and a better future and a better country for not just your grandchildren, but your grandchildren's grandchildren. This is not new. You know, our indigenous ancestors have been talking about seven generations for a long time. But it is a seriously new proposition and a serious commitment that we are trying to call people into to stop thinking in terms of budget cycles and election cycles and earnings reports. To really think about what is the kind of investment that gets us to thriving together. That is long arc work. So if you step back from how do you get to thriving together with no exceptions, well, then you have to say, what do we have to do differently? Because we've never had that kind of experience. And there is data behind this. Gallup has been tracking this idea of who's thriving, who's struggling, who's suffering for decades. And as a country, we have never gone above 58%. That's failing. We all came through some version of an education system where that is a failing grade.

Judson Howe How do we compare against our new G7 countries or other countries?

Becky Payne That data is out there. We are way below. I don't have the data at the top of my head, but we are nowhere near but nobody is doing great. I mean, some of the countries that score better on the happiness index and things like that, but we don't score that low on the happiness index, and recently all countries took dips. So how do you get there? You say well that sounds great all people and places thriving with no exceptions. That is starry-eyed and ambitious and intangible. It's not. We have a theory of change that we created with hundreds of other collaborators who also believe in that north star of thriving together. So there are a couple of stops on the road to get there. The first is really meaningful shifts in investments in those seven Vital Conditions. We have adversity loops in our systems, and we have prosperity loops in our systems. Adversity loops are what we're stuck in. Never-ending crises, investments in what we call urgent services because we're in a crisis, we're in another crisis, and we're in another crisis loop. And so people are hurting. And so we need to go in and save that. We need to give them emergency housing. We need to give them access to vouchers for transportation. Well, you know, those things are needed. There's no amount of paying for that that gets you to thriving.

Judson Howe So I'm hearing you say that these adversity loops, we almost exist in like a reactionary cycle, reactionary state to these adversities that people are experiencing as opposed to —

Becky Payne Absolutely. The only way to get up into a prosperity loop is to recognize first — it's a little bit like recovery, you've got to name the problem, you've got to see the problem, you have to recognize that well-intentioned investments in those things in times of crisis are needed in times of crisis. But we get stuck in a loop thinking that that is the only way to invest because there is need, instead of also at the same time making courageous investments in the kinds of things that will help people not need that as much when a crisis hits, and those are those seven Vital Conditions. Now how do you get the courage to invest in the Vital Conditions at a scale that will change that loop? That is through — I'm going to throw another term at you — but that is through a set of skills and capacities that we have studied and named shared stewardship.

Judson Howe Okay. Which are what?

Becky Payne So stewards can be people. Stewards can be organizations. I would argue when you were in your role, you were acting as a steward. Stewards are people who recognize that we have to take actions that are beyond ourselves, that are investments in what the greater good needs, and that we can't do that alone. There's no room for saviors in shared stewardship, that stewards work and join with other stewards in order to solve and tackle the problems of our time. And you don't do it for the benefit of yourself. You do it for the benefit of the commons, or the greater community. And that happens at scales. It happens within neighborhoods. It happens then within broader communities. It happens within regions, within states, and at the national level. We all sit in positions to make choices every day that have an impact on somebody else in our environment. And if you can capture the pause point in each of those choices and say, wait a minute, is what I'm about to do going to make it better for other people? Or am I just on autopilot? That's an opportunity for everybody to step into shared stewardship. So there are 15 skill sets that we talk about. We've studied them. We've been able to analyze them. We have data on them. And they fall into three categories. So people who show up as stewards —

Judson Howe That's one? People who show up?

Becky Payne Showing up is the first step. But people who show up as stewards tend to actively reach out and bridge across differences. They are not holding an ideological hard position. There's deep curiosity, and there's an interest in learning what matters to you. And the reason that's important is that north star of thriving together, we find that is a universal value. Most people far and away would agree that that is a future we want to see. Where we get off track is we start talking about tactics. So stewards suspend that. They're like, let's talk about our shared values. Let's suspend a discussion about policy or who you voted for or what neighborhood you live on that I have built up perceptions about what that means about you. Let’s recognize that we're complex people with multiple identities. And we actually share much more in common when we talk about values than not. So stewards start by being able to bridge across those differences. They're also very adaptive and they're constantly learning, which is part of what helps them bridge across differences. And they are constantly helping to create opportunities for transformation. And a lot of that is weaving vested interests across people, helping people think about long-term solutions versus short-term investments. There's a whole kind of way of showing up that is different if you are trying to act as a steward with other people than if you're going through day-to-day, through very transactional decisions and interventions. And when you think about society, so if we lay that together, the how people act in a different way to transform systems is through shared stewardship. They bring that to the table to help lots of different institutions and individuals recognize how they can invest in Vital Conditions. That puts us on a path toward thriving together.

Judson Howe We're in a time right now in our country's history that doesn't feel like this conversation is in vogue right now. And it could be wrong. It could be the time more important than ever. And I have space for that. But we have massive cuts coming to HHS, to research across the country. Not to opine or interject too much of myself, but I'm seeing a certain personalization of political power as away from systems. And I mean, maybe what I want to ask you, Becky, is, even if it's a few years ago, whether it's with Ripple or you were with CDC for 20 years. Give me a story of where this mentality actually made a difference in someone's life or a community's situation. Make this real for me.

Becky Payne I can give you a couple. I'll give you my personal story for why I mentioned I came to Ripple because of the vital issues. So as you said, I was at CDC for 20 years, worked in almost all of the centers at CDC in my time there. And my last kind of assignment, as I refer to it, is during the pandemic, I was leading the task force that was responsible for coordinating development of the many recommendations that were coming out. And so this would have been late March, early April of 2020. I'm in D.C. because the emergency had been declared. We were standing up to the Joint Command out of FEMA headquarters. And in one of the late night debriefs, we were asked to address the impending crisis of behavioral health and substance use that was unfolding. This was early days, it was March. Given my background in community health and community systems, our task force was asked to take the lead on it. And I recognized that in the data, we were seeing long food lines and we were seeing the inability to pay rent. And we were just we were seeing all of this immediate unwinding of things that we all take for granted and had nothing to do with virus because there were not yet cases in those communities. So the anticipatory unwinding of our systems, right? We all saw how fragile it all was. And several of us said, this is as much about our failure to invest for decades in the things that would have created health and resilience in communities and in individuals as it is about a virus. So fast forward, I called colleagues who were expert in community health, healthy communities, and said, I am being tasked to come up with a plan to address this. This is bigger than government alone. Can you please help coalesce some thought leadership and also draft what civil society's role should be to heal and move forward? They did that. And in the course of me doing my due diligence to look at social determinants of health, to look at resiliency frameworks, to look at all of the many things that Homeland Security had in terror zone preparedness response — which I had also come out of that in Louisiana many, many years before — there were no frameworks that could handle the complexity of what we were experiencing and could reflect the interdependence of those systems. So just in those lines that we were seeing, you've got housing, you've got food insecurity, you've got economic insecurity from jobs. And you can go on and on and on. You've got fear of the healthcare system. You've got no access to schools because our schools had closed. So then suddenly you're recognizing, oh my goodness, we don't have telecom infrastructure in huge slots of the country. Children can't attend virtual school, can't attend virtual healthcare visits, right? So suddenly the things that many of us had been, you know, a small voice in the big void of what really matters to produce health and well-being were laid bare for all of us. And whether you had the schooling to understand what you were witnessing, you knew what you were experiencing. And you knew the fear and the lack of personal control. There was no amount of individual control or individual wealth — certainly wealth bought some privilege, but it couldn't protect you from all of the things that were simultaneously up-ending. That feels pretty similar to right now. So I want to come back to your question about the fit for this moment. But to continue that story, in all my searching and turning over stones of what could possibly hold this complexity with civil society partners were on their path and they surfaced the Vital Conditions. And as soon as I saw it, I thought, this is it. This is the first thing I've seen that could start to hold this space. And so I started to socialize it. And in the end, Judson, we had 47 agencies come to the table across all of the federal government because they saw themselves. We had historically talked about social determinants of health and failed to make progress on them.

Judson Howe Why?

Becky Payne This goes back to your question, and I didn't ask about what is the origin of Vital Conditions. Decades of investment in trying to address social determinants of health, if we are honest, have failed to produce the kind of result that we should expect from the scale of investment. I was in that. That is not throwing shade on anybody involved. We did a good job of sounding the alarm. We did a good job of raising the gaze and helping people understand — back to why did I differentiate health and well-being — that health is far more than health care. We did a good job on starting to try to innovate in I would suggest small ways around the edges of social determinants of health, but we did not get the result that we should expect and demand from the kinds of investments of time, of talent, and money. And so Ripple, with all of those hundreds of other colleagues, came together and said, well, shouldn't we ask why? Shouldn't we be deeply curious and honest? One, that we failed, and two, why? So the Vital Conditions grew up out of that curiosity of saying, how can we do a better job? Because we are failing to meet the moment. Pandemic hits, that was about 2018, 2019. Pandemic hits, and suddenly you have a framework that was created, not yet really deployed, because it was just emerging, and it's fit for the moment. So we applied it. They applied it. We had 47 agencies, which takes you way beyond health and social services. So we had the Federal Reserve. We had EPA, of course. We had all the Vital Conditions plus small business administration, all of the resiliency agencies. So FEMA, Homeland Security, and subcategories within all of those agencies, looking at this and saying, I see myself. I see my agency. And guess what? We realized many agencies touched more than one vital condition. I couldn't just peel off humane housing and hand that to HUD and say, here, tell me what you would do differently. Because other agencies also had an interest in the success of what HUD was doing. And they were also trying to take care of the whole part of the people they were touching. And so they had some programs that ran through housing, or some ideas about what could help make what they were trying to do in transportation, or what we were trying to do in health, better if we could just crack this nut in housing. So suddenly there's a framework that is simple and elegant, but also very carefully constructed that has real definitions behind it that can handle the complexity of how we move through the world. And it forces the silos to be erased. You can't turf each other when you're sitting with how you each touch each of those Vital Conditions. And we had conversations then about how does each agency intersect? Where are the points where you are bumping up against each other in a given vital condition? And how would you do things differently? We had two rules. Anything you recommend for how we should do things differently cannot require another penny. And it can't require a different authority from Congress. So this was about those courageous acts of stewardship, which I didn't have that language at the time. But to ask a different question, to not say, well, this is the way we've always done it. These are my limitations because that's how I was trained. But instead to say, well, if I could do it differently, knowing what I know, knowing what we're trying to accomplish, we should be behaving this way with the resources entrusted to us. And there's actually, when I step back and really look at it, there's nothing holding us back except asking a different question about what it should be, not what are we trying to perpetuate.

Judson Howe You're talking to a healthcare administrator who's experiencing significant pressure both by state and local policymakers as well as communities to improve health outcomes in communities. There's a lot of negativity around financialization of healthcare, overrun costs. I think healthcare now it’s 18% of GDP, plus or minus. You have an administration in office right now that is looking at massive cuts to the Medicaid programs. How do we take this work around Vital Conditions, and if you were a hospital administrator, what would you be doing with that work right now?

Becky Payne Well, we are working with some hospital administrators right now. And I can tell you they're doing a few different things. All different because each community is different. Each setting and context is different. And I think that's the other beauty of the framework is that it is not values neutral, but it is meant to be applied and implemented in ways that make sense for your context. And that can be frustrating. People say, well, give me the checklist and give me the recipe and tell me what I'm supposed to do. And I would say to you, that tells me that you don't value your community. That's being, to be blunt, that's being lazy. Because you need to do the work. You need to do the work to understand what the experience of your community members are, not just when they're in the walls of your hospital, but when they go out. And I don't more data on a spreadsheet. I mean, go to the church supper. I mean, go to the community fair. I mean, walk the streets of your community and talk to people and understand what their life experience is, and the brilliant ways they have been innovative to survive in their life in spite of systems. And see what creativity and assets you untrap in that. Then come back in and say, well, if I understand this framework correctly, our total community needs to be providing these conditions in this way so that our population, so that my neighbor, so that your mother, your child, has opportunity to thrive. And then as a hospital administrator, I also need to step back and realize it is not my job to be the savior, and the expectation is not that you solve for all of those Vital Conditions. But the expectation is to say, Judson, you are a pillar of this community. Maybe this is where my childhood comes back. You are a pillar of this community. You have been given the privilege, the respect, and the trust to hold a leadership position. And while all of this isn't the sole responsibility of the hospital, guess what? You play golf, you go to dinner, you glad-hand with all of the other leaders in this community. And they listen to you.

Judson Howe Define glad-hand.

Becky Payne You know, the handshake with the pat on the back. The spaces that not everybody is invited to, frankly. You get to do those things and the conversation ought to be about not just the beautiful vacation that you're planning with your family — you get to do those things — it should also be about you know what's keeping me up at night? The fact that I have patients that have real issues that my hospital can't be responsible for, but you sit on the Housing Authority Board. Can we have a conversation? Can we call our peers together to understand the total community condition that each of us is responsible for leading pieces of? And let's talk about how well we are or are not working together cohesively.

Judson Howe Why is this burden falling on hospital leaders, healthcare system leaders? Where is community public health leaders? What do you see?

Becky Payne I'm not suggesting, I don't think it should be falling on hospital leaders to solve the problems. I am suggesting that you hold a unique space to call other people together. And that could be with your public health leaders. I also think coming out of public health, part of where we have failed is public health tends to center themselves as the center of all solutions and the center of all of the things that address health and well-being. And I don't think that's right either. I am simply saying you hold a position of leadership and trust to call people into a conversation and then for collective ownership of that. Now, if you sit in a community where your chamber is exerting that leadership, great. Then show up at the meeting and show up with a mindset that this is not just about the financial health of my hospital, but this is about the collective well-being of my community. And you hold one piece of it that not all of it.

Judson Howe Yeah, I guess something I'm processing as we're talking is in this series, we spoke with a health leader in Sweden. Who, if I heard him correctly, mentioned that they invest differently in their chains of health, their workflows of health. And I think he said they invest in the horizontals across, you know, almost the community members experience through whatever health care is defined as. And they invest very differently. And it got me thinking that I'm just wondering if we need to be shifting our investments differently in the United States. And if we're over-biasing our investments towards that reactionary system you're talking about. And this obviously is novel for me, which is, there's a lot of things that are novel for me. But in your 20 years at CDC and your time now at Ripple, am I resonating in the right direction? Or can you mature that thought a little bit for me?

Becky Payne Well, calling for shifts in investments is exactly what we do. I want to go back. You asked me to get concrete about the impact on people. So to close the loop on that federal plan. It's not about the federal plan because the federal system was changing before. So that plan is out of date. The recommendations that it called for, the agencies are fundamentally different. That federal plan used all of those Vital Conditions. So coming out of the pandemic, we wrote the plan, 47 agencies signed on. There were, I think, 68 recommendations.

Judson Howe But CDC took the lead on that?

Becky Payne So CDC did not take the lead. I was on loan to HHS. I was on loan to the unified command, which was sitting out of... it's complicated bureaucrats.

Judson Howe Hold on. So we're a half hour into this conversation. You were on the unified command for the COVID response.

Becky Payne Many of us were. It was all... it was all the unified command. Well, if you have listeners who are in public health being prepared in response, they will understand. It's not as grandiose as you just made that sound. When a public health emergency is declared — this is actually important. People need to understand what they lived through. Public health emergency is declared. Any single agency is no longer the lead. Everything shifts by law to Homeland Security because they are set up in a command-and-control structure.

Judson Howe Which is a relatively young agency, right?

Becky Payne It's a young agency, but FEMA runs disaster response. They have assets. I have a lot of feelings about the over-militarization of our public health system during times of crisis that are a different conversation. But it is the system we have. So that is what happened. We all got swooped up into this unified command structure. And during times of crisis, it has its value, right? So I was no longer acting on behalf of CDC. CDC had the lead responsibility for that particular task force. But I was beholden to and answering to the demands of the unified command structure, which in this case, as you'll recall, the vice president was leading the federal response. Through delegated authority to the Secretary of Homeland Security and on and on and on. So that was like the structure behind it. And that plan, when they came in and said, somebody please do something about the behavioral health and substance use crisis that is about to unfold in March of 2020. We then crafted that plan and ended up getting 47 agencies on board to contribute ideas and recommendations to say, how should we fundamentally change what each of our agencies are doing in light of these Vital Conditions for well-being? So that plan exists. It was not just drafted but it was vetted and what we call cleared which means reviewed, edited, and approved by all 47 of those agencies. Anybody who works in a bureaucracy knows that's actually a really big deal. That doesn't happen. It's important because one, I want to tell you, Judson, we can do this. We can coalesce seemingly disparate and diffuse assets, interests, perspectives, and missions. You can bring them together. And this framework just happens to be really good at making that happen. It's not a magic thing. It just happens to work. So we ran that plan through, we do modeling analysis at Ripple through our Rethink Health initiative. We have sophisticated models that scientists from MIT have helped us grow and evolve over the years. And we decided, you know, we are working toward driving together. We want people to shift investments in Vital Conditions. And we happen to now have a comprehensive example of that being done. We ought to look at ourselves and say, aren't we curious about what the potential impact of that might be? It's not enough to just talk about the fact that it could be done or that a plan exists. What is the impact of that plan? So we ran those recommendations and that plan through this model, holding true to our premise that this is long-arc work. We didn't model the impacts for two years or five years. We modeled out the impacts over 25 years. And what you see is when you take a plan that comprehensively shifts investments in all of those Vital Conditions simultaneously, you can realize a 20 point jump in thriving. So remember I said, it's stubborn. We have never broken that 50%. 20 point jump in thriving. I, having read a lot of science over the years at CDC, sent it back to my co-authors and said, this is wrong. This can't possibly, something is not right. Rerun it. They re-ran it. They pressure tested that model more than is standard practice. It is the most rigorous testing we've ever done on a model that we produced. The results came out the same. There are a couple other features that are really important, I think, for people coming from a healthcare system too. How do we get a 20 point jump in thriving? We got 2.6 years of increased life expectancy.

Judson Howe How do you measure that concurrently?

Becky Payne It's all in the modeling, in the systems model. And we have the paper. It was published in PLOS One a few weeks ago. All of the analysis, again, because we are a philanthropy, we make all of that freely available. We want that out in the world. So we use national data because it was a national plan, but we have also tailored that to specific locations and geographies. We did a similar thing. We created a Delaware model because the state of Delaware has been working with us to use the Vital Conditions and apply the Vital Conditions statewide through the Healthy Communities Delaware contract. They had some limitations to their plan. They only were relying on their state health improvement plan. So limited to one agency, the purview of one agency. And they had six kind of priorities that they wanted to focus on. So a much narrower set of recommendations. And I would say, and they didn't hit all seven Vital Conditions because of the limitations of the plan, the inputs of the plan. They saw a four-point jump in thriving if they would just implement their state health improvement plan. And so they are. And they're actively having conversations about how to pull other parts of the state and community into that work. So it is not so much about the specifics of any one of these plans. It is about me sitting here telling you it isn't just Pollyanna, nice words, pretty wheels and frameworks. It is about demonstrating that it is possible, first of all, to bring all of those seemingly disparate interests and parties together around one table and have a fundamentally different conversation. Whether it's the hospital executive who does that or the chamber of commerce or the public health entity or the transportation department, it doesn't matter. I don't actually care who takes the lead and neither should anybody else. They should all be clamoring to come to the table and understand how we are touching all the same people in our community, and do a better job. we should want to do a better job of that.

Judson Howe Go back. You mentioned you agreed that healthcare leaders, clinic leaders, shouldn't necessarily be the center of the solution. Maybe public health shouldn't either. How do we avoid that? What should we be doing? Just go deeper on that for me. How do we avoid that personal centricity to the solution? What have you seen work?

Becky Payne It does depend on a leader, so you have to have someone showing up who is making it about the community and not about themselves. So far I don't know how to avoid that trap. And I call it a trap because we all lament that you can have a single leader in a place that makes a lot happen. And then that leader leaves and those gains are lost, or those initiatives are lost. In this case, when someone shows up and they start by bringing that coalition and those networks together and focusing first on building trust-based relationships, so building belonging, not jumping to solutions. And I know that's going to feel like your heart rate's probably rising a little bit because I've got earnings reports and I've got metrics and I've got all of that. So this cannot be trapped in your day-to-day work. It has to be carved off, at least as a starting point in something else. Unless you can be a governor, Wes Moore, who isn't using our framework per se, but I would say pay attention to what he's doing in his Enough initiative. He is showing up and saying government is going to respond to the needs of our community in Maryland fundamentally differently. The way to start is to make it about the community and centers of community, not any one institution. But we do have hospital systems who are doing this in other ways. We have hospital systems who have, through discovery and learning, through their own learning, they have now committed to use the Vital Conditions to organize their community health needs assessments system-wide. And what is that going to show? Well, they've just made these commitments, so I can't predict the outcome, but what I'm pretty sure will happen is they're asking questions differently. So if you ask in your community health needs assessment and benchmark your community against each of those Vital Conditions, you're going to discover where you have gaps and you're going to discover where you have assets. When it comes time to then do your improvement plan, which IRS says you have to do, and think about your community benefit and how you invest differently, if your starting point is to ask from the perspective of those conditions, then your solutions should, in theory, be tied back to creating those community conditions. So that's one way. We have a group of hospital executives from very different parts of the country, very different settings, some rural, some urban, some nationwide, very large systems, some regional systems, some in competition with each other, if I'm honest, coming together in a very vulnerable way to say, how could I be investing in belonging in my system? So thinking about their workforce, thinking about the burnout that their doctors, their nurses, all of their staff are experiencing, they have decided, and our data would validate, that first they're going to start with belonging. And an investment in belonging goes a long way. If you can do nothing else, thinking about who feels like they belong and who feels like they're on the outside and that they don't matter and designing interventions specifically to bring them in goes a long way to changing what's possible in an environment. We've got hospital systems doing that. And then we have hospital systems who are in the position of calling all of their community partners together, teaching them about the Vital Conditions, teaching them about shared stewardship, and then sitting in conversation as slow as it may feel about what do we collectively want to prioritize for our communities. Then who's in the best position to make investments in making those changes?

Judson Howe I imagine the pandemic was, this is probably the closest I'm going to get to someone that worked deep in the CDC and close to the pandemic response. And, you know, at the time I was an executive of six hospitals in resource constrained communities in northern California. I dealt with quite a few challenging things that I won’t go into here, but it has shaped me a lot. I want to ask, how did the pandemic response shape you in the way that you approach your work today? Like, well, give me a story about something that either almost broke you or really challenged and maybe where you questioned why you're doing this work.

Becky Payne Shaped everything. My husband was at CDC, too. So I think there are, and not you certainly, but there are a lot of folks in this country who came through the pandemic and had clean closets and learned to bake sourdough. And I mean, that's, what else could you do? That was not our experience. And it wasn't the experience of so many of my colleagues and so many of your colleagues.

Judson Howe Maybe connect the listeners to what was going on inside the CDC.

Becky Payne So, I think history will tell the full story, I hope. It was a time of a lot of confusion about what our role was as an agency. We were used to being able to communicate directly with the public, and that was taken away from us.

Judson Howe Was that abnormal?

Becky Payne Extremely abnormal. To not have daily interaction with the media, to not have the ability to routinely communicate what we know, what we don't know, and what the best available information tells us to tell you about staying safe was completely abnormal. It was frightening because we were all living through the pandemic too. This was probably in my career, in my lifetime, the first time that we were at once responders and people experiencing this thing we were responding to. So, you know, when it's a far-flung thing, like when we were, I was very involved in the Ebola response or when Zika was flaring up. And even, you know, the Flint water crisis or Hantavirus, you know, we will have small flare ups in a place confined to a geography. But this was at scale across the country. It was happening in our communities. We had people deploying, and we didn't know enough about what we were experiencing to have certainty that we were keeping our own people safe. So this was shoe leather epidemiology in the moment that you hear about, but we don't get to experience at this scale. So there was, it was not normal times. It was not normal times for anybody. And we were living in an environment where we were not trusted from the inside. And we were living through an environment where a health crisis was in real time, letting us all see how intertwined the economic system is with health. And by that, I mean we were getting a lot of pressure to offer recommendations that would not have a negative impact on the economy. We were being asked to be thoughtful about the business impact in the recommendations we were making about health. And you can debate if that should or shouldn't be the case. The reality is that had not been our history and that had not been our role. And so we were making recommendations based on the best available science and not knowing what of those recommendations, how that would come out in the public forum until the next day when it was being released. Because we were not in control. There were other stakeholders involved in chewing through the implications of those recommendations and making decisions about —

Judson Howe This was two different administrations, right?

Becky Payne Yes. So, you know, and I will say that that federal plan that used the Vital Conditions, I think this is really important to know. That was initiated and completed during the first Trump administration. So we have experience with this current administration in valuing putting out an approach that looks at the whole experience of how do you return government to be responsive to the needs of communities? What I would say is different is that that was done by people who understood how government worked and they understood how their agencies worked. That is not where we are today. So inside, I mean, it was. It was chaos. And I don't lay that at the feet of an administration. I think responses generally are chaos. And suddenly we are at home. We aren't in the office. Normally when there's a response, there's a response room and everybody is together and you're constantly collaborating. And this was very strange because you were cut off from all of those resources and cut off from that collaboration. And it was no longer being run by CDC or even HHS. It was being run … and again, I hold a lot of space for everybody was figuring out the best. We had supply chain issues. We had challenges, unprecedented challenges that needed to be tackled, and we needed to call on all of the assets of the federal government in ways that CDC was not necessarily set up to do. So I don't question, it's not my place to question those choices. All of us have to be capable of recognizing that the game and the rules have changed, and we have to pivot. You're in these roles, you have to be capable of pivoting and moving forward. And I think that is the same that we have to say right now. I can be very frustrated in my personal view, what's happening to our democracy, to the unfairness, the hatred, the way in which things are going to have an impact on people I care very deeply about. And I do, I do sit here and no joke say we are not as safe today as we were six months ago, because I know what has been taken down inside of those agencies. And I am no longer in a position to do anything about that in a role that is formal. So I have to look at what is happening in this context and say, I have an organization that has something to contribute and a group of people that are counting on me to lead us through this. So we have to pivot. And pivoting can look like being real about the harm that is being caused and the changes we want to see, but I can't wait for those changes. And we are having more and more and more communities call us and say, this Vital Conditions framework, this hopeful, unifying view of a future where all people thrive resonates. And it resonates with me now more than ever because I have to figure out how to bring my community together. We can't wait for national systems to save us when they're failing us. And I'm tired of being divided in my community. So we are getting constant requests for help because they recognize that these are tools that help them come together and solve problems locally without relying on the resources that should be flowing from outside. But the reality is, Judson, today we know they aren't. And they aren't going to for a while. So we have to help people where they are.

Judson Howe But how does language like civic muscle and belonging — it's not quite equity and diversity and inclusion. But those words have almost been vilified right now, that language. Do you find yourself needing to modify the language of the Vital Conditions or do you find it being resonated across the board?

Becky Payne We don't. And I think that to me is one of the elegant things of the framework. And it's something we've taken critique over the years, I will say. We have taken criticism because it was not forward-leaning enough on equity and justice and racism and things like that. There are some people who are in a space where that is what they need to see, and that's what their community is ready to talk about. There are a lot of communities where that isn't the first front-of-mind issue or language. And whether you want to say, well, every community has those issues, sure, there is inequity in every community. There are haves and have-nots. There are people who've been trapped on the outside of our systems and people who have been on the inside who hold power and for various reasons have not engaged or brought in people on the outside of those systems. I choose to live myself in a way that doesn't believe that that is always intentional and that people mean harm. I have to sleep at night believing that if you see it, you want to do better. But every community isn't ready to have those conversations. And so our job is not to force them into that. I cannot as an outsider, as a white privileged outsider, come in and tell you, you know what's wrong with your community? These 20 things. And do you know what you, healthcare leader, how evil you are and how bad you've been? How is that? That doesn't call anybody in to solve the problem. And I don't think it's, it doesn't align with my personal values and it doesn't align with the values that thriving together and the Vital Conditions are anchored in, which is that there is a role for all of us to play. And we can figure out that role by building trust and building relationships with each other, not demonizing each other, not telling you all the ways in which you have screwed people over the years. There needs to be healing. There needs to be naming and recognition of the experience that people have lived through and the harm that they have gone through. That can take many forms. And healing conversations can be trust-building conversations. They don't they don't have to simply tear each other apart, and I think part of what we've lived through and I believe part of why we were we are living through what we're living through now is we have lived in our heads so much about the wonky policy solutions and the data and the ways in which, well you don't know, I'm in this role, you aren't smart enough, I'm going to tell you how we're going to fix this because it's complicated and the economics of it. And people are out here going, no I really just want to put food on the table for my family and I want to be able to take them to Little League the way that you do, but I can't afford that and I don't have time because I'm working three jobs. And there has been an oversized, outsized impact on Black and Brown communities. And they are not alone in that. Every community has a constituency of people who is living an experience where they feel unheard and uncared for. So when you start with, when I tell you to start with belonging. It is to suspend your assumptions about who feels like they belong in your community and start to ask.

Judson Howe What do we do about, you know, I just saw a stat recently in the book, Crisis of Democratic Capitalism, and the graph in there, this hits you. Imagine there's a trend line of men of different ethnic groups. Black, different Hispanic groups, and then there's all white. And then there's white non-high school educated. And the graph, all the other lines go from bad to better when it comes to mortality. And then there's this line that stands out. And it's white non-high school educated that goes from, I think it was 700 deaths per 100,000 to 900 deaths per 100,000. And there are other graphs like that. But that one hit me so much. So what do we tell white, non-high school educated men when they hear a conversation like this, that we still see them and that they belong? How do we have that conversation?

Becky Payne I don't tell them anything. I ask them what their experience is. I ask them, what is your day-to-day like? Where are you getting what you need? Where are you not getting what you need? What do you want for your future and how can we come together to imagine rebuilding that. That is actually a race-agnostic conversation, and I think that's part of the problem. Once you start to understand the true history of this country and what different populations have experienced over time, I have a hard term understanding how anybody can truly know that and think that there hasn't been structural racism in the history of this country. I just find that hard to believe. So I think a lot of times that conversation has felt very blaming and very charged, and then you get a shutdown, so people can't hear it or won’t embrace it. I think that's very different than saying, in our community, I am not going to start with an assumption that casts all of any one group into an experience. So I'm not going to label that all white non-high school men are living the same experience or all black people in the community or all of our tribal elders in their community are living the same experience. To lean into belonging means I'm curious and I genuinely want to know what I arguably should have known. For whatever reason I didn't, but I am here genuinely sitting with you wanting to understand your experience. And I want to understand what you think the solutions are. What do you need? What would you do? So it's not about extracting an experience and then still going back to my institution and crafting a solution that is for you. It is about being curious about the experience you've had because that will uncover where has there been harm that we're going to need to heal through. And you've been living this life. What would you do differently? What are you asking for? I think sometimes we get in these policy circles, and we make assumptions about enormous grand things that people are asking for that are going to cost too much money and politically are not popular. In reality, people just want a fair shot living the same life that you and I have. And I don't think that's too much to ask. And I don't think that I can bring my solution and just give it to your experience. I need to be deeply curious about them as experts in their own lives, in their own communities, where they see opportunity for things to be treating them better.

Judson Howe There does seem to be some intentional silencing that's happening. And at a higher form of myself, I probably would say, what responsibility do we have in acting for the future? If we're there again, how do we prevent the same outcome?

Becky Payne And I think we should all be asking that question and making space that you only know the little bit that you know about how people are showing up and doing what they're doing. I've been thinking a lot about this, actually, because for the first time in my professional life, I am not sitting in an organization that is in a position to … I don't have a formal role of responding to a crisis. You know, a crisis is unfolding around us. Now you could say, well, Becky, gee you sit as a president of a foundation. Now we happen to be a foundation that operates quite differently in our operating foundation. And all that means is we realized that the little bit of grant-making, because of the size of our endowment, a little bit that we can do, even if we were dipping in and giving more, the systems that we were set up to address around cancer and heart disease and women's health and the health of the elderly and preserving the nation's hospitals, it's our literal established mission, the little bit of money that we can put in now that we understand the systems that are at play and causing those harms, it's meaningless and so that's why we operate in this way to try to catalyze and push and influence others who hold much bigger curse strings, who hold much bigger decision levers to operate in different ways that can change those systems, way beyond any little amount of funding. So I sit with this question quite a bit, which is, what is our role? how can I use my voice? how can we use our assets, including our money? And I have studied it and turned the rock over every which way and had lots of conversations and doing a lot of reading, but I am reading very intentionally authors who are not like me. I am reading a lot from indigenous wisdom, black authors, artists, people who are not trained to come at health and well-being with the same set of tools that I have. But people who bring a different perspective to the conditions of our world. And every which way I go, whether it's a podcast I'm listening to or a book I'm reading or even leaders in health and democracy and economy, if you listen carefully, there is a group that is saying, this is not a time to be confused about only responding to the crisis. We have to do that. And we all have a responsibility to say the words out loud when justice is not being served and when we are actively harming entire populations of people, which is happening right now. There are decisions that are being made that have no basis in sound policy, in sound health or economic or other outcomes. It is only about causing harm and holding people back. And it is causing harm and holding back the least of us. But actually, they're doing it at scale. There is nobody who is going to escape feeling the impacts of the policy decisions that are happening right now. So I'm with you on that. But I do believe some of us also have to be thinking about, okay, so what's next? If you have read Caste, Wilkerson wrote very elegantly about a house, thinking of our systems as a house. And I'm probably going to not do this justice. I'm very sorry for that. And renovating a house. If you renovate a house, there are certain walls that are load-bearing. There's plumbing. There's wiring. There are certain things that are fixed, but if you take it down to the studs, you still get to make choices. And I've argued that they've taken the wrecking ball to our house that is this country. Collectively, they've hit all the rooms. There is no system that is being left untouched right now. So we are where we are. This isn't about convincing people that systems need to change. We need to wake up to the fact that the systems are changing, and they are changing in ways that even the legal system and our elections and our voice can't keep up with. We are emerging day to day into a reality that is already fundamentally changed. And I am very worried that part of the tactic is to keep us all very busy and very distracted, being very angry and casting blame and tearing apart each other. And even tearing apart — I mean there there's nothing that feeds them more likes and retweets and memes than a lot of angry people pointing out things that they actually think are good to do as being destructive. So we are playing into it, and by the way, it's an opportunity cost. I can spend my days doing that and I cannot spend my days doing the redesign, the reconstruction, the sitting in-conversation to say, you know what? They took it down for us. Not the way I would have done it. Definitely not the way I would have done it. But here we are. We've got their walls and their studs. And how do we want this to look? And there are a lot of groups that are thinking about that. And we choose to put our time and energy in helping to think about that while also holding accountable the harms that are happening. It is undeniable that people will no longer have access to health care. They will no longer be able to put food on their table. There are benefits that are just erased from the very people who have the least wiggle room to lose those benefits. Those are facts given what we know about agencies that have been wiped off, people including close friends and colleagues of my own who no longer have jobs. The reason they no longer have a job is because their part of the agency no longer exists. These are people who had 15, 16, 17, 18 years. Those things are fact. And there is no amount of me calling my Congress people that is going to change that in time to be helpful today. It's not to say don't keep sounding that alarm. We have to keep the pressure on. We cannot be complacent. And how do you free up the mental energy and the capacity to start to come together and actually re-imagine what we want it to be. I honestly, I don't understand. And I don't think it's intentional. I think it is accidental. We were all saying the systems were broken. And now suddenly the systems are being taken down. Again, it's a takedown that we don't agree with. But we were all saying these systems aren't working for everybody in the way that they should. So how do we capitalize on that?

Judson Howe Making the best of the situation. I really value that. And I want to understand — there's still a large number of people that think this is okay. And they're going to continue to advocate for an anti-democratic solution to what's happening in this country. It's not like we're going to get to this next election cycle. I mean, they're going to say, okay, let's reset and rebuild this thing. There's going to be our neighborhoods that are saying, we don't trust formal governmental institutions, we don't trust our neighbors, we identify tribally with ourselves, and you know we have unlocked a significant amount of white supremacy in this country, that's always there. We just allowed it to come to the top which is allowing other people to think this is validated and appropriate behavior. It's not just white supremacy, it's really whatever the term would be for wealthy elites taking care of wealthy elites. So I'll go into my question now. I think it was something to the effect of, I travel the country and I hear a lot of voices that are continuing to express frustration with the way that the federal government handled the pandemic, the COVID-19 pandemic. They're not articulate enough, neither could I be to know if the CDC or HHS or what Fauci is was a part of it. But I hear a lot of deep frustration that that was not handled correctly. I would love your perspective on how that was handled and how do we restore trust with governmental entities after what we went through in 2020. And I will lead you a little bit this way and that is, how do we start to have a conversation of healing as a nation around topics that break down trust like the COVID-19 pandemic?

Becky Payne I don't think there is anybody who is honest who would say it was handled in the best way it possibly could have. There may be reasons why people are incapable of giving that answer, but if anybody is honest you can point to lots of things.

Judson Howe Give me an example of how things weren’t handled well.

Becky Payne I don't really want to relive that history very much because I'm focused on other things now. But I think, the testing was not handled well. Right? We were slow. Mistakes were made. We didn't do the community engagement in the way that we should have early on to understand concerns and fears and needs so that when a vaccine was available, there would be trust. I think the silence from CDC that was forced, that was not choiceful from that particular agency's perspective. But the American people don't know and shouldn't know why or how those decisions are being made. Their experience was just, we stopped getting updates. Things have gone silent. My questions are not being answered. I don't know who the trusted source is, because actually the agency that is normally in charge is suddenly not in charge, and I don't know why. So we're all natural born storytellers. And what you learn from crisis communication when you're trained in that, when you're going through a crisis, there is inherently unknown. The first briefings you get after a hurricane, first briefings you get after a mass shooting, there's a lot of information that is not known, and it comes out in the following hours and days and weeks. And when leaders handle that well, when they are honest about what I know, what I don't know, what I am doing to get to the bottom of what I don't know, and what I can tell you right now in this moment is the best information about how to make sure you and your family are safe, you can suspend and give a lot of grace for the unknown. But when communication stops or when communication is partial or when other voices are suddenly allowed to pop up and say, well, I'm an expert because I wear a white coat and these are the things that I'm telling you that you should do. And when that isn't tamped down and myth-busted effectively right away, that festers. There will always be conspiracies. And I would say to you, I have never made it my priority to go first at the biggest skeptics. That's not who I'm trying to convert. They will always be there. The issue is to arm the people who are genuinely just wanting to know and wanting to contribute and want to do the right thing. That is a far bigger majority in this country. There are far more people who are tired of the division, who want a different path forward, and they are not being given an outlet or an opportunity to feel like the people talking to them also value that, let alone to contribute to that path forward. So when I think about the price we're still paying for the eroded trust from the pandemic, and then I see leaders who are appointed by current elected officials to hold some of those positions of trust, saying things and advocating for things that we know are counter to science, counter to the law, that is only going to perpetuate the erosion of trust. So this is not a moment in my feeling to put a lot of stock in this being the time to rebuild trust in our federal governmental institutions. And if I have finite time and resources, then I say, OK, I have to sadly sit with that for a while. But where can I go? My state institutions and my local community institutions. Those can still be opportunities of trust-based information. My hospitals, my healthcare leaders who are actually working in places, not perpetuating their reputation online, but actually seeing patients and credentialed and holding positions that are credentialed and respected, those become the places we have to look to. And I do think, you know, our state and local governments are going to feel, are already, and will continue to feel the next wave of all of these cuts. But recognizing that it is a whole community, government has a role, but so do all of the other institutions in that community. This is the time to come together. That is why I'm telling you, this is the moment for shared stewardship, for all of us coming together to creatively say, you know what? I can't be on autopilot anymore. I can't just expect that the things that were taking care of my family are going to be working the way that they should. So at a hyperlocal level, you know what? I actually can count on my neighbors. And maybe I need to rebuild that muscle to find out. And that's where local leaders do have a role to play. And I don't mean leaders just from traditional seats of power. I mean, our elders, our aunties, our faith-based leaders, our childcare groups, our book clubs. You know, we show up, inform community in lots of different ways. And there are many people who are trusted and respected who are not necessarily holding a title. And I think you're, I know we are seeing communities come together and coalesce in community. We are seeing community foundations play a really interesting role in this moment in doing just that. Because they are a trusted source of resources. And they are also a trusted place for me to put my resources. So people who've had wealth have been fortunate in a community, trust their community foundations as a place to give. And community members know that community foundations show up for the community and try to provide the resources that the community needs. And they can't do that effectively if they are not building relationships. So they have trusted relationships already built and are starting to play interesting roles as that convener across multiple sectors.

Judson Howe If you were Secretary of Health for the next year —

Becky Payne That won't happen. I'm not qualified.

Judson Howe What would you be focusing on right now?

Becky Payne What would I be focusing on? Given what I'm inheriting, so I'm inheriting the system today as it is, so the agencies that have been shuttered, the workforce that is enduring psychological trauma every day waiting. And I talked to my colleagues, like they are waiting every day to find an email in their inbox if they are still employed. We're going through budget negotiations right now as we're recording this. So they're also waiting to see, well, the shoe didn't drop for me in the first reorganization, but what is the shoe that's going to drop for me in the budget? So my first priority is the workforce. My second priority is calling in outside-of-government, trusted leaders who truly represent community. I don't mean, and I'm sorry, but I don't mean the people who have historically received money from the federal government to be an extension of government. There is a very important role and a place for them, but they are not neutral in their stance on how government should work. I mean actual frontline community members. So my workforce is my first priority. My community members and the constituents of all of the agencies that are under my purview are my second priority. My third priority is understanding where are the studs, and how I am going to call us into an opportunity to say, we get to rebuild. I would actually, I would dust off the long-term recovery resilience plan not because of my personal role in creating it but because there was asset bounding that told us how each of the agencies touched each of the Vital Conditions. And there were recommendations. And I would say, what of these recommendations still matter? What of these are actually easier to do now? Because all bets are off. We can do anything. And then I would understandably have to be paying attention to Congress. And I think we've lost … Love it or hate it, the system of government we have is the system of government we have. And we have lost civility and respect for the roles that the executive branch and the congressional branch and the judicial whole. And there needs to be some understanding of what is Congress concerned about from both sides of the aisle? What are they hearing from their constituents? And what am I responsible to as a federal agency in the intent of how those dollars were allocated? And I would immediately reinstate anything that was taken down that should have been in place based on the purse strings of Congress.

Judson Howe We've done a couple of times this little exercise where we've asked our guests for some homework assignments. So if you're envisioning a healthcare leader, a burned-out physician, maybe even with your beautiful extended definition of health and to community leaders, give me, let's put you on the spot. Give me like two homework assignments for people to empower themselves with knowledge and activation to see the world the way Ripple Foundation and Becky sees the world, to run alongside you guys in the work that you’re trying to do.

Becky Payne If you haven't started, I would start your own personal practice, whether that's journaling, meditating, listening to podcasts. Do something to get still. Pay attention to what the current environment is doing to you, and ask yourself is this how I want to show up. I think that's the most important work any of us can be doing right now. For me personally, be still and check how I'm showing up against my values. So that's the first thing. Go to our website, read about the Vital Conditions. Call me, you know, call us. We want to talk about this. There are hundreds of communities across this country that are starting to apply the Vital Conditions and work toward thriving together. So I want my second task is for you to take hope that this is happening. And then I think my third piece is actually a book recommendation. And that is The Four Pivots by Shawn Ginwright. It's called Reimagining Justice, Reimagining Ourselves. There are no shortage of good books that I can point you to, but I am finding that one particularly helpful because this question of tribalism and somebody always being able to say, well but I'm suffering, well but I'm suffering. It lays out a way for us to do justice work that starts with getting right with yourself first and going into it with a vision of what we're trying to build, not just what we're trying to tear down. And I think we have become victims of the only offer on the table is all the things I'm going to tear down, who I’m going to give it to. And his premise is, if you spend all of your time doing justice work with the thing that you're going to tear down — and this is fair criticism for all sides — then be careful because when you arrive and when you succeed, if you have given no thought to what you want to build, your only option is to then become the next oppressor, because you will be locking down and securing your position rather than having called in people to a vision of what you were trying to build. Pay careful attention to the actual words and solutions that are being offered right now. And if the only offering is a grievance-based approach to tearing something down, run away. Run the other direction. That is not a political statement. I think that is a problem on all sides. Find a way to be part of thinking about the future you want to create that is co-created genuinely with lots of people. It is not about persuading people to your idea. It is about genuinely being still enough to sit and listen and hear a difference that is actually softening for you, not something you thought of before. And if you're open to that, then you can do creative problem solving together in a way that is very different than simply, okay, I'm listening. Oh, I've got a counter-argument for that. Okay. Keeping track in my head. That's not co-creation. That's not genuine listening. That's not co-crafting a different picture. That's getting ready to persuade you that my idea is better with stronger and different language. We've been doing that. And I think the biggest thing we all have to say is, we have been doing these things for generations and look where we are. We need fundamentally different approaches.

Judson Howe So it's 2035. You're looking back to 2025. What are you most proud of that you've accomplished with your work?

Becky Payne I am most proud that we have hundreds, if not thousands of communities where I can see real evidence that those seven Vital Conditions are not just present by chance, but they have been actively invested in by those community leaders. So I see evidence of all of those Vital Conditions. I've got hospital systems that have genuinely, especially the nonprofit hospital systems, have genuinely thought about how to use their community benefit dollars to invest in the things that produce health, even if that means they've got an empty bed. So I'm looking back and I am seeing evidence that we are less tribal, that there is much more diversity in leadership. That we are crafting communities that reflect the needs and hopes and desires. And that those communities are trapping their town. Their youth are staying. They've got broad, vibrant economic bases that are local. And that allow people to stay. And we get back to multi-generational living in a way that is choiceful, not because we can't afford something else.

Judson Howe How do we all run alongside? What do you need from us to get that done? That's a broad us, undefined intentionally.

Becky Payne I need you to suspend certainty. I just wanted that to sink in. What I need from everybody is to be less certain that you know what's right. That's not ***, but that the solution in your mind, that too many of us sat by ourselves, or just with a couple of people, and crafted. We're so certain that we have the answers. And yet we are so bad at asking other people what they think. So my ask is that we all get a lot more comfortable talking to other people, genuinely asking, what do you need? What is your experience? What ideas do you have? Do you do that? The solutions that we can come up with, creativity that we can unleash, the excitement of contributing, that outlet, there is pent-up demand to be a part of giving back. We know that. The data shows that. Polling data shows that. It's across all generations. It's across all political spectrums. We know that people want to be connected and that they want an outlet for that, but they report not having an outlet for that. And that comes from feeling like there is nothing that is speaking to them that they want to contribute to. Part of that is because a small group of people believe they have the answers. Well, if you've already got the answer, what do you need me for? You just want me. I don't know. You don't need me. So then I'm going to sit over here and I'm lonely and I don't feel connected. I don't feel valued. So I think if all of us were a little less certain and a lot more curious, that is the first step. And starting to realize, oh, I just had a whole conversation with you. Who you voted for never entered my consciousness, I never thought of it. I recognized you for the many identities that you hold. And I found like half of them we share in common. Well, now I can't go home and complain about you.

Judson Howe What question, we asked you a lot of questions today. What question have we not asked that we should be asking?

Becky Payne I feel like it's more of a question for your listeners. You asked me what I need from everybody, and I think the question I'm sitting with is what would it take for you to feel like you could contribute to realizing a future where all people can thrive with no exceptions? What would it take for you to genuinely believe that that is something you could contribute to and wanted to devote your time to?

Judson Howe Becky, thank you for all the work that you and Rippel are doing. We definitely want to run alongside you. Thank you so much for your time today.