99% Invisible - Constitution Breakdown #5: Dr. Tom Frieden

Episode Date: December 26, 2025

This is the fifth episode of our ongoing series breaking down the U.S. Constitution.This month, Roman and Elizabeth turn to the rest of Article Two with former CDC director Dr. Tom Frieden, talking about the experience of being a highly trained expert in an inherently political institution within the executive branch. Dr. Frieden was also the New York City Public Health Commissioner under Mayor Bloomberg from 2002 to 2009, and he discusses the difference between running a city and a federal health agency.Elizabeth also explains the constitutional powers and limitations of the presidency, including hiring and firing, impeachment, pardons, and presidential duties—and how President Trump and the current Supreme Court are upending those powers. Subscribe to SiriusXM Podcasts+ to listen to new episodes of 99% Invisible ad-free and a whole week early. Start a free trial now on Apple Podcasts or by visiting siriusxm.com/podcastsplus.  Hosted by Simplecast, an AdsWizz company. See pcm.adswizz.com for information about our collection and use of personal data for advertising.

This is the 99% invisible breakdown of the Constitution. I'm Roman Mars. And I'm Elizabeth Joe. Today we are finishing up our discussion of Article 2, which establishes the executive branch of the federal government. Our special guest for this episode is Dr. Tom Frieden, who served as director of the Center for Disease Control and Prevention under President Obama from 2009 to 2017. We brought him on to talk about the experience of being a highly trained expert in an inherently political institution. that was once considered to be about as apolitical as you can get, but not so much anymore. Dr. Frieden was also the New York City Public Health Commissioner under Mayor Bloomberg from 2002 to 2009,

and he talks about the difference between running a city health agency and a federal health agency. Which one had the most power might surprise you. But first, Elizabeth is going to take us through Article 2, section by section. We covered Article 1 before that was addressing Congress, its powers and limitations. Now let's take a brief tour of Article 2. Okay. All right. So Article 2 can be seen as doing a couple of things, specifying the selection of the

president and the function of the executive branch, listing the specific powers of the president, listing the duties of the president, and what to do with a constitutionally inadequate president. Okay. So there are some, just like with Article 1, some very important aspects of the executive branch that are in Article 2, but some things that are not in Article 2. at all, but nevertheless important. So we'll get to those. But I think the big thing, unlike our discussion about Congress, is that with Article 2, a huge force affecting Article 2 is Trump and the

Supreme Court's treatment of Trump. Trump has had a very significant impact on how we think about the powers of the presidency. So let's start with Section 1. Section 1 contains the vesting clause, which says, the executive power shall be vested in a president of the United States of America. Now, we saw a vesting clause in Article 1 as well, but Article 1 and Article 2 have a notable difference. Article 1 says, all legislative powers herein granted shall be vested in a Congress. Article 2 doesn't refer to just powers here in granted. Now, you could say, well, maybe that was just a lapse on the part of the drafters, but maybe not because that suggests there are some ambiguity as to whether the powers in Article 2 are just examples, or are they the only powers

the president has? Wow. Now, the spoiler, of course, is that every president has said, no, we have more. We have more than what's in Article 2, right? Yeah. And practically speaking, we've treated presidents as having some more power than what's specifically laid out in Article 2, but of course, the contested part is always how much power. So that's the opener.

Section 1 also describes our system of using electors and the Electoral College. Each state appoints electors equal to the number of senators and electors. And Article 2 is a compromise, right, between directly electing the president by popular vote or having the president selected by Congress directly. There is, of course, a popular vote, but when we all vote, we are actually voting for a slate of electors appointed by our state's political parties. And that means the important number is not 50. 1% of everyone voting, but 270 of the 538 electoral votes up for grabs.

Because of Article 2, a presidential candidate can win the popular vote, but lose the electoral college and not become president, like Hillary Clinton did in 2016, and Al Gore did in 2000. This system is so central that, of course, we did have a fake electors plot during the 2020 presidential election, and that was when Republican officials and several battleground states came up with a scheme to submit fake certificates, claiming that Trump actually won in states like Arizona and Georgia. And these were acts designed to overturn the legitimate election of Joe Biden. And dozens.

It just was so many scandals ago that I forgot this fundamental one that is truly mind-blowing just in and of itself. If that was the only scandal a president had, that would be enough to disqualify them in my mind. Right, but it was also both dastardly and completely inept. No one really thought it was going to work. I guess so. So dozens of people have been indicted on these state criminal charges for participating in these fake elector schemes. In fact, the fake elector scheme was part of the criminal conspiracy alleged by special counsel Jack Smith and discussed in the criminal indictment of Trump in 2023. And of course, the Supreme Court put an end to that in 2024 with its decision on.

presidential immunity. And the re-election of Trump ensured that the Justice Department would drop the remainder of the case, which it did. Now, Article 2 then addresses the question of succession. If something happens to the president, let's say the president dies or somehow is unable to be president anymore. And while Article 2 is actually superseded by the 25th Amendment in 1967, after that amendment, there is no question that the vice president becomes the president when the president dies or resigns or does something similar. There was some ambiguity before the 25th Amendment. But now we know for certain that there is vice presidential succession

after the president can no longer be president. Oh, cool. The 25th Amendment also gives power to Congress to establish the line of succession. What if the vice president dies or can't serve in some other way? And so just as a little piece of information, the Presidential Succession Act today would mean, in order.

You ready? Oh, yeah, please. President Vance, President Mike Johnson, President Chuck Grassley, who, by the way, is 92, President Marco Rubio, President Scott Bessent, and President Pete Hegseth. Oh, my God. Yes, you can pick among all of those people. That's just, it's purely theoretical, though, purely theoretical. That's so miserable. Okay.

Oh, my God. Okay. And Article 2 then goes on to talk about the domestic. I know, it's a, it just say the list. I'm just like, okay, it can't get worse and it can't get worse. And it's like, yeah, I think actually Haxeth would be worse. You know, like, oh, my God, okay. But so many things would have to happen for us to have President Pete Haxson

and let us not wish for any of those things happen. Absolutely. Okay, so then class seven of Article 2 contains the domestic emoluments clause. Let's go back to this for a second. The president shall not receive any amolument from the United States or any of them. And this is the plain English of this is the president can't receive any gift from the federal government or any of the state governments. This is similar to the foreign emoluments clause, which can actually be found in Article 1, which says that no person holding any office of profit or trust except any emolument from any king, prince, or foreign state without the consent of Congress. Remember that in Trump's first term, a group of lawsuits were filed alleging that Trump had violated both the foreign and the domestic emoluments clauses.

And the basis of their claims was that Trump's continued stake in his business interests had led to some kind of improper influence. So, for example, if a representative of a foreign government was staying at the Trump International Hotel in Washington, D.C., maybe we could think of that as an improper gift to the president, right? We never, of course, found out whether they were unconstitutional emoluments because after Trump left office in 2021, these lawsuits were declared moot, no longer live, is sure. that a federal court could decide. So we never really got the answer about whether or not these were unconstitutional emoluments. Yeah. And then emoluments after a moment. There's an emolument every hour at this point.

Yeah. Surprisingly, there haven't been any lawsuits that I'm aware of. But again, we don't know the answer. Yeah. Okay. Now, section two of Article 2 specifies the powers of the president. Clause 1 tells us that the president is the commander-in-chief of the military. Right?

So we have talked a bit about the war power and the power. the fact that in our system, the president, who is a civilian, is in charge of the armed forces. And that's a very deliberate choice. So there are some other powers here. But the other thing I want to mention now is that Section 2 of Article 2 includes the pardon power. Article 2 says that the president shall have power to grant reprieves and pardons for offenses against the United States, except in cases of impeachment. So what this means is that the Constitution gives the president, authority to grant pardons. And the only real limits here are that they can only be used for

federal criminal offenses. So you can't use them for state offenses or civil claims of any kind. And it cannot be used in cases of impeachment. And the president's pardon power is so broad that the Supreme Court has said previously that the power of the presidency is not subject to legislative control. And there have been, of course, many controversial pardons in the past. you know, for instance, in 2001, President Clinton pardoned his brother Roger for his conviction on drug offenses, and everyone thought, well, that's just using his influence to help out his family, right? But Trump is a little bit different.

Trump has taken this pardon power much, much further. So, for instance, on December 1st, Trump pardoned former Honduran President Juan Orlando Hernandez. Hernandez, why was he being pardoned? He had been sentenced to 45 years in prison for conspiring to import cocaine, to the United States. Why am I mentioning this? Because this is just months after the administration began to blow up boats in the Caribbean because it claims that these boats are carrying narco-terrorists smuggling drugs into the United States from Venezuela. So a little bit of an inconsistency there. Have they ever spoken to why they did that pardon? Like even their own story of this?

You know, just unfair, witch hunt, too long with sentence, et cetera. And Roger Stone reportedly lobby the president directly on Hernandez's behalf, Stone's a longtime Trump advisor, and apparently it worked. Okay. And on January 20th, as one of Trump's very first acts in a second term, there's a pretty significant use of the pardon power. Trump pardoned nearly all of the 1,600 people charged in connection with the attack on the Capitol on January 6th, 2021. Trump also commuted the sentences of 14 members of the proud boys and the oathkeeper groups. And commutations are also part of the pardon power. These were folks primarily convicted of seditious conspiracy.

As part of his pardon order here, Trump also ordered the Justice Department to dismiss all pending indictments against people who were still facing charges for January 6th. Now, months later, the Justice Department also took the very broad position that criminal cases that were secondary to the January 6 attacks were also covered by the pardon, although some judges, have already rejected these claims. So that's, for instance, they were, after January 6th, let's say investigators were looking

for evidence of your involvement in the attacks on the Capitol, and while they were searching your home, they found illegal firearms or illegal drugs. You know, these folks have said, well, you know, I'm covered by this pardon. And the Justice Department said, well, yeah, sure, because they're somehow related in a very tangential way to investigating your involvement in January 6th, which, of course seems kind of crazy, right? Yeah, for sure. This is a pretty extraordinary use of the pardon power.

I mean, definitely presidents in the past have used a mass pardon power, but this is of a different order altogether. This mass pardon is a political statement by Trump. This was an attempt to shut down a constitutional process on January 6th. And Trump's really saying these acts are not worthy of punishment, not at all. So that seems pretty significant. Is there another example of a mass pardon that was sending a political message? If I'm not mistaken, like, Carter pardoned all the draft daughters. Right, right, right.

Yeah. But, yeah, I mean, for sure, we might say that I'm certain there were people who disagreed with it at the time. But it's not quite the same political statement, isn't it? I mean, I think the same idea of mass political pardons. And, you know, they did in fact violate the law. But here, you know, you might say that the attack on the Capitol was a kind of attack on the very structure of the Democratic. process, right? And Trump's undoing of it, which was well within his power, is a way of saying, this is completely fake. There's nothing that they did wrong. In effect, you know, you could do it all

again. It would be fine. I mean, that's essentially the message of it. Yeah. Yeah. There's no punishment whatsoever. Yeah, but you could say that the, you know, the structure of the armed forces is, you know, relies on the draft and therefore, you know, these people fundamentally undermined that structure and, you know. True. True. That's what, you know, I suppose you could say that. But I think probably the January 6 attack was of a very different magnitude. Totally. Totally different. I'm not saying it's not different. All I'm saying is that you could make a political argument that both of them are undermining the norms of our both political military and governmental system. And it certainly was destabilizing to have people avoid the draft and while that sort of thing. Yeah, true, true. Although I think we still would have had a government that was standing.

Not totally clear to what would happen if an attack had been successful in January 6th. Fair enough. I really would prefer not to think about that. No. And on December 11th, this is another interesting one, Trump pardoned Tina Peters. Peters is a former county clerk in Colorado. She's an election fraud conspiracies. Oh, yeah.

And she was convicted of election interference. Here's the kicker. I'm not sure what to call this. A symbolic pardon, a nonsensical pardon, an outrageous pardon. Because remember, Article 2 gives Trump the authority to pardon someone for an offense against the United States. She was convicted on state charges. It is absolutely a meaningless pardon. He can say whatever he likes. And in fact, I suppose we could say it's not really a pardon at all because it is not permissible for a president to pardon someone on state charges. But these are

the sorts of things that he's doing and everyone says, well, what does that mean? And the answer is it means nothing. If a lawyer was thinking about getting convictions for people who are sympathetic to Trump, usually or used to be that the gold standard for getting a conviction is you bring up federal charges because you have the weight of the federal government to prosecute. And that's really scary when all of a sudden it's like kicked up to the feds. It's a big, big, big deal. Right. But tactically, it makes more sense today to make, you know, some of these things state charges if that's appropriate. Is anyone thinking like that? I don't know if anyone's thinking like that, but that certainly makes sense at the federal level

if you want to avoid federal charges. There's definitely more of a sense that there's a perhaps a pay-to-play system in some aspects of the criminal justice system now, not just only getting a pardon, but maybe you'll have charges that are dropped or charges that are never brought at all. And, of course, that is deeply corrupting

of the criminal justice system. And so, yeah, I assume that the flip side could happen as well. You know, not sure anybody would want to admit to that right now. Structurally, the incentives are certainly there. The incentives are there to use state courts to convict someone. I think so. Right. I think so. Yeah. Although, you know, one example, though, is that if you do that, like if you think about the post-January 6 attempts to prosecute or bring criminal prosecution at the

state level, look what happened, which was harassment, intimidation of the very prosecutors that we saw in Georgia and elsewhere. You know, you can try to bring state charges, but then you have the entire apparatus of the right-wing media and people who the president himself may call you out and threaten you. So there is that. Yeah. So then Article 2 goes next to bring in the Senate. In clause 2, the president can make treaties with the advice and consent of the Senate. So here we now have a partnership with a part of Congress. Now with the advice and consent of the Senate, the president can also appoint ambassadors, Supreme Court justices, and all other officers of the United States. That's why we see televised hearings whenever the president selects new

members of his cabinet. All of the secretaries must be given Senate approval, and same is true, for instance, of federal judges. But there's a more complicated part of this clause, which is called the Appointments Clause. Article 2 refers to the president's ability to appoint officers of the United States, but the Congress may, by law, vest the appointment of such inferior officers as they think proper in the president alone or in the courts of law or in the heads of departments. Now, okay, I got to say pretty dry, very boring part of Article 2, right? Well, it's more confusing than boring. Yes, it's very confusing. Not at all obvious to most people what this means or why it's even important, but it is important. So think of officers as the top people

in the executive branch who don't make up the vast majority of federal employees. Those folks are in the civil service, right? They're not appointed by the president. So the Supreme Court has interpreted this part of Article 2 to mean that there are two kinds of officers of the United States, principal officers and inferior officers. Now, principal officers have to be appointed by the president and confirmed by the Senate. So a member of the president's cabinet has to be appointed by. the president himself and then confirmed by the Senate. Inferior officers can be, but they don't

have to be. They can be appointed by another part of the federal government. So think of the appointments clause as the hiring clause of the Constitution. When can the president hire people himself or when can Congress decide, hey, we want some other part of the government to do the hiring of these top executive officials? Okay. So that's hiring. Pretty important, right? Who gets to run different aspects of the federal government. Sure. Now, here's the other aspect. Hiring implies firing, right?

That's something we think of, well, presidents can do that, right? Well, the problem here is that Article 2 says nothing about when officers can be fired or to use the constitutional language be removed from office. So what we have is a set of practices in the Supreme Court. everyone agrees that the president can certainly fire members of his own cabinet for any reason. The Secretary of Defense, Secretary of State, they can all just be fired because the president just wakes up one day and says, I don't like you. You're fired. That's fine. That's absolutely within the president's power. And our guest for later on in today's episode, Tom Frieden, who was director of the CDC, he held a position that could be fired by the president for any reason, any reason at all. I don't agree with you or I just don't like you personally. Okay. Now, historically, Congress has passed laws to protect some officials in the executive branch from being fired by the president for any reason at all. In other words, they would say, well, this kind of person can only be fired or removed for certain reasons, like they're convicted of a crime or they are obviously incompetent, right? Okay.

So this happens when Congress has decided it would be a good idea for this official to have some independence, to be able to stay in their position, even if the current president disagrees with them. And the constitutional issue is whether that interferes with the president's Article 2 authority. This matters now because the Roberts Court has been chipping away at this idea of protecting these folks and giving the president more control over the executive brand. and disagreeing with Congress providing these folks with some protections. So, for instance, in 2020, the Supreme Court decided that Congress's attempt to protect the director of the Consumer Financial Protection Bureau by restricting the reasons for the president being able to fire them was an unconstitutional interference with the president's authority. So in plain English, after this case, which is called CEL law, the president can fire the CFPB

director for any reason at all. And that's why on February 1st of this year, Trump fired Rohi Chopra, who had been appointed by Biden and confirmed by the Senate. Just don't like you, you're gone. Yeah. Okay. So that's despite what Congress had tried to do, try to protect this person because they should have some independence in, you know, creating the rules and forcing the regulations to help consumers. Right, right. And now the Supreme Court is definitely not done with this issue. This Supreme Court is now considering what is very likely going to be a very important case. It asks, can Trump simply fire a member of the Federal Trade Commission, the FTC, even though Congress has tried, through legislation, to provide some protection for commissioners of the FTC? Now, if the Supreme Court decides to allow Trump to do this, this means trouble not just for the FTC, but the job protections for many other federal commissioners.

and boards that are within the executive branch. These are the agencies meant to protect consumers, workers, the environment, all kinds of things. So what is the argument that Trump can do this, you know, when they were specifically designed to be independent and laws were passed to ensure their independence? Yeah. So in one way, it's not just Trump, right? It's a longstanding conservative movement that was building long before Trump assumed office. But the conservative argument and Trump's argument is that everybody, every single person within

the executive branch should be within the control of the president. Otherwise, they're totally unaccountable. Now, I mean, that's kind of silly, right? Because they're accountable in lots of different ways, but that's the conservative argument. And it's one that the Supreme Court might adopt in this case that I've mentioned. And it's pretty clear that the Supreme Court is very interested in this question, because this is not the only case that they are considering this term. This term, the Supreme Court, will also consider whether Trump can fire a member of the Federal Reserve, Lisa Cook. She had been appointed by Biden for a 14-year term, which is the regular term, right?

But Trump said, I want to fire you, right? Yeah, yeah. So one of the big problems here is that you have a conservative majority on the court. And remember, the Roberts Court has been around now for 20 years, right? The conservative majority on the Roberts Court wants to be protective of a very particular view of presidential power. Let presidents fire agency heads whenever they want and fill them with the choices of whatever they want, right? Yeah. On the other hand, when agencies in a democratic administration issue decisions, they also seem to be targets for the Supreme Court to say, oh, no, no, you're not allowed to do that, right? You've exceeded your powers. So it turns out that agencies can't win either way.

Either they do things that the Supreme Court says, you've exceeded your authority, or when they try to be working within that power, then a Republican president, Trump, will say, well, I don't like these policies, you're fired. So the Supreme Court really just seems to be saying everything is within the control of the president. And the president can dictate everything that happens within the executive branch. Okay. Okay. So we saw this, like, you know, in terms of the agency stuff, we saw this during the height of the pandemic with the court striking down vaccine mandates, the eviction moratorium, even expanded student loan forgiveness was something that really got its start from the inability of borrowers to pay during the worst part of the pandemic. Those are a series of agency actions. Biden, during his administration, wanted these things to happen.

Even they began with Trump too, right? But nope, for the Supreme Court, that was too much for an agency to do. And so agency power seems to be attacked from every single angle under the Roberts Court theory of, you know, how the executive branch should be run. Is there consistency in the decisions, you know, of that set of things of what an agency can do? Or does that seem to be dependent on who the president is? Seems to be strangely dependent on who the president is, right? Because, well, you know, a Republican president tends to roll back regulations. That doesn't seem to be a problem for the Supreme Court.

But in a Democratic administration, an agency that tends to provide more enforcement, more regulation, that always turns out to be a bridge too far. Not always, but often. And, of course, the blame is, well, why are you doing this extreme set of regulation? Congress didn't allow you to do this, or if Congress wanted you to do this, they should be more specific. Of course, Congress made the choice to give these agencies a lot of power. Maybe it wasn't this particular Congress, but it was the institutional body of Congress that said, well, we don't really know what we're doing. let's give the authority to the agency. So you said that there were a set of laws that were passed by Congress to establish kind of

independence and term limits for all these different agencies and to have that kind of control. And through these cases, is the Supreme Court determining that all of those laws are basically unconstitutional and thus far just haven't been tested? Well, not necessarily that the agencies themselves are unlawful, but just that the president has total control over the person at the top of these agencies or, increasingly a form of agency authority that folks had thought were more protected or in less danger were multi-member boards that had staggered terms often with bipartisan membership and that board was supposed to outlast any one particular presidential term well it seems like

even that too is going to be vulnerable in some way if the Supreme Court during this term is going to be cutting away at those protections even further yeah yeah And that just means that, of course, whatever an agency does, you just get whipsawed every time there's a new administration. Right, right. I mean, there has been this notion of building these agencies out to be apolitical bodies in a certain way, to have a certain consistency in mission and execution and follow through and vision that would, you know, maybe be shaped by a president somewhat in the agenda of a president, but wouldn't completely be altered. And, you know, depending on who the president was. And it seems like now the Supreme Court wants all these agencies to basically just be arms of the president and follow the whims of the president, the current president. Well, that's right.

And particularly if you have a president who decides in the case of Trump in a second term that some agencies just shouldn't be agencies. There's not much to argue about if you completely got the agency. You know, there's no argument about this has gone too far. The agency basically is so crippled that it can't do any work. Well, we have to take a quick break, but when we come back, on to Section 3 of Article 2. Section 3 talks about the duties of the president. And, of course, we've talked before in a previous episode about the Take Care Clause. Article 2 says the president.

Can I ask you a quick question? Sure. I've asked you this probably years and years ago. who is the person who decides what the names of the clauses are? You know, like, the take care clause is one thing. Like, I know that it's language brought it out. But, like, you know, like, you could call it the faithfully executed clause. Exactly.

Or, you know, instead of the vested clause, it could be the power clause. Or it could be, you know, like, who's the one who, like, who starts that convention and then who picks it up and determines that that is what you call a clause? That's a great question. I don't know. it just becomes kind of like tribal knowledge of people who work in con law, you know, like everybody, every, every society has its argo, has its lingo, its slang. And like for in constitutional law, that's the slang, right? We know you're not part of the in group. If you don't know, it's called the Take Care Clause. That's the way I'd put it, right. I just wonder who is the, what was the first clause named in the Constitution, you know? Yeah. Not sure, but definitely, you're right. They each have specific names. So this is the Take Care Clause. The president shall take care that the laws be faithfully executed. Interestingly enough, this is not in the part of the powers of the president. It's one of their duties, right?

It's both an emphasis that the executive branch enforces the law. That's the will of Congress. And it's a type of constraint, too, that the president isn't allowed to legislate in any form, right? Now, if you think about the president can't legislate, that's sort of basic high school civic stuff. But what about executive orders? Oh, you've heard of those. Right, right. Yeah, they certainly feel like legislation.

Right, but Article 2 says nothing about executive orders. Wow. And Congress has no general federal statute that says, hey, president, you can issue executive orders. Nevertheless, it's still generally accepted that presidents have the authority to issue some executive orders. Now, usually executive orders are directed at executive officials within the executive branch. So it's kind of like the president telling the members of the executive branch. what to do. So if they're not in here, how are they legal? And why can't the Supreme Court come and just like just completely invalidate every executive order that's ever been given?

Well, who knows at this point? They could do that. But to be legal, a president's executive order either comes from Congress giving the president some power under a federal law, or alternatively, the power can come from the president saying, I'm just using my article two power. So for the first example, in Trump's first term, remember he issued a proclamation called 9-645 that was also known as the Muslim travel man. That was denying entry into the United States of folks from several majority Muslim countries. And the Supreme Court upheld Trump's executive order. And its reason was that Congress, when it passed the Immigration and Nationality Act, gave Trump broad authority about when and whether to suspend the entry of non-citizens.

And of course, Trump was doing just that, maybe for improper, subjectively horrible reasons, but he was simply doing what Congress allowed him to do. So the court says, that's an okay executive order. As for an executive order that is based on constitutional authority, Truman gives us an example. When Truman desegregated the armed forces in 1948, he did so through an executive order.

Yeah. And how did he do that? He said his authority came not just from federal statutes, but from his authority as commander-in-chief. Right, right. That makes the most sense to me. Yeah. Anything within the military makes the most sense to me. Right.

Yeah. Now, a big aspect of Trump's second term is just the sheer number of executive orders that he has issued. So to give you a sense, in his first term, Trump issued 220 executive orders total. So far, it's just December of 2025, in his second term, Trump has issued at least, I think, 218, that was as of October. And, of course, the first year isn't even over yet. And I know there was another one just yesterday. Some of these are just ordinary or they seem to be symbolic.

But others have tried to dramatically change how we understand how the federal government works. So targeting law firms that represent Democrats, ending climate and energy initiatives. freezing foreign aid, and, of course, ending birthright citizenship. Now, just because the present issues an executive order doesn't mean it's legal, of course, and dozens of Trump's executive orders have already been challenged in court. So how can an order be challenged, then? Well, the easiest way is when a later president revokes the executive order. So, like, a succeeding president just says all of that is undone.

And that happens all the time. When Biden became president, he revoked many of Trump's orders from his first term. And then when Trump became president, he revoked a huge number of Biden's orders from his term. Now, in his first two months in office, Trump revoked 91 of Biden's executive orders. That's just a lot comparatively. 67 of Biden's executive orders were revoked in one executive order. He just, like, wanted to wipe out everything that Biden had done. That was the first, actually.

So many in one executive order. Now, Congress can't overturn. If I became president after Trump, not only would I nullify every executive order. I think I would tear down every building he touched. Well, unfortunately, that's going to be a, I'm not sure if it's a harder task or an easier next. Well, Congress can't overturn executive order because it's really something that the president is just doing.

But if the president is claiming that the reason why he can issue an order is because he's implementing a statute, then Congress can simply modify or negate the order by passing another law themselves. So, no, that's not what we meant at all. I see, I see. And, of course, if there's a constitutional problem, lawsuits can be filed alleging that there are legal constitutional problems with the order, right? And we've seen that, again, there are dozens of lawsuits right now. If the power to give executive orders is not in there, how do you begin to argue that he doesn't have the power to do a certain thing?

It just seems like it's all kind of weirdly in the clouds. It is. It is. But, I mean, part of constitutional practice, of course, is always history. And, you know, George Washington had an executive order. So we have lived with something that is arguably constitutional because everyone has always agreed that it's constitutional for the president to do this kind of thing, not the specific versions of them. Wow. But nevertheless, presidents are allowed to do this.

Now, in modern presidencies, unfortunately, it becomes a way for a frustrated president to try to regulate when Congress will not do so. Right, right. But they're always very temporary because the next administration will tend to modify or revoke completely many executive orders. Right. That makes sense. Yeah. So now let's step back for a moment. Article 2 tells us that the president of the United States has some very important powers that are just for the president alone.

The president has the duty to execute federal law. The president commands the armed forces. The president grants pardons, appoints officers of the United States, and negotiates treaties. the Constitution gives this one person in the federal government all of this power. So the question is, how do we ensure that the president, as Hamilton wrote in the federalist papers, is not a feeble executive? How do we make sure that the president isn't hampered too much and can act in the way that Article 2 intended?

Well, in 2024, of course, the Supreme Court's answer was immunity from criminal prosecution, right? So we've done an episode on this previously, but remember that in August of 2023, special counsel, Jack Smith, concluded his investigation, a federal grand jury indicted Trump, who was not president at the time, on a four-count indictment related to what happened after he lost the 2020 election, right? So this includes the fake elector scheme, pressuring state officials, attempting a sham justice department investigation, leaning on vice president Pence to change the election certification on January. six and making public statements about election fraud. So the monumental decision in Trump versus the United States was simply summarized like this. A president cannot be prosecuted for much of this conduct. Specifically for unofficial conduct, the Supreme Court said that's fine. A president can be prosecuted for things that have nothing to do with the office of the presidency. But when it comes to official conduct, the Supreme Court said that the president's official acts can be divided

into two parts. So it'll sort of imagine a circle. At the edge of the circle are official acts that aren't related to a core presidential power. And so there the president enjoys a presumption of immunity from prosecution that the prosecution can overcome in limited circumstances. But that included a lot of conduct, including, according to the Supreme Court, speaking to and on behalf of the American people. And at the time, that was a lot of tweeting, right? I see, I see. Right. And then there's the center of the circle. At the center of the circle, you have official conduct that the Supreme Court called core constitutional functions. What are they?

The powers that we've just talked about. The pardon power. The power to remove or fire officers of the United States. And importantly for the criminal prosecution of Trump, the investigation and prosecution of crimes. So in the Supreme Court's view, even if this was a complete bogus and sham investigation, when Trump directed the Justice Department to say, hey, look into election fraud. well that was core article two conduct therefore it can't be prosecuted even if it's based on bad faith even if it was made up and as for the other conduct that might not have enjoyed total immunity

the outer part of that circle remember the supreme court decision in trump versus the united states came out on july first 24 the court took so long in deciding the case that time ran out Trump was re-elected, and then the case disappeared. But the impact of Trump versus the United States and core Article 2 conduct is just really enormous. You know, we've talked previously about the Trump administration's use of the military for these boat strikes to blow up alleged drug smuggling boats in the Caribbean. Yeah. Well, the administration claims that they're in a war with these drug smugglers, and that's why the boats can be blown up without any process. But, of course, as we've discussed before, this doesn't seem to be a war at all.

And in fact, the decision to kill without arrest or trial has been characterized by many serious legal analysts as murder, just plain simple murder. So what if it is murder? After all, Trump is the commander-in-chief under Article 2. Well, I think the pretty clear answer from the 2024 decision is that as long as Trump is exercising a core Article 2 constitutional power, he himself cannot be criminally prosecuted. even if the evidence suggests that these boat strikes amount to murder. Does that mean everyone around him is immune as well? No, this was only a decision about the president himself. Okay.

Yeah. So everyone around him could go down for murder and he would stand alone as the person was on. I mean, possibly. I mean, of course, the Supreme Court was only deciding the question of president. Yeah. It's just interesting. Yeah. Also, there was that crazy hypothetical from the immunity case. Before the case was actually decided by the Supreme Court, one of the,

the judges on the appeals court panel raised this seal team six hypothetical um seal team six is that elite group of navy seals that carry out um high stakes military missions right um judge florence pan who was on the appeals court in dc asked trump's lawyer could a president order seal team six to assassinate a political rival that's an official act trump's lawyer john sour would not give a direct answer well the washington post reported at the end of november who carried out the boat strikes seal team same six, right? It's just a weird, hypothetical come to real life. Wow. And then there's Section 4 of Article 2. That is impeachment. Section 4 is supposed to be a remedy, right? It tells us that the president, the vice president, and all civil officers of the United States shall be

removed from office on impeachment for and conviction of treason, bribery, or other high crimes and misdemeanors. In 2021, President Trump became the only president in American history to be impeached twice and, in fact, in the same term. The first impeachment trial arose from the call he made to a Ukrainian president, Zelensky, which he was apparently offering to unfreeze military aid if Zelensky would investigate Joe Biden and promote this bogus theory that Russia was not behind the foreign interference in the 2016 election. And the second impeachment trial accused Trump of incitement to insurrection over the January

6th capital attack. In both Senate trials, Trump was, of course, acquitted. So I think the main takeaway here today is that when there's Article 2, there's no question that Trump, as a president, as an ex-president, and now a president again, has left a definitive mark about how we think about Article 2. Yeah. And the Roberts Court has also led to a completely different view of Article 2. That's right. Yeah. Well, this is fascinating stuff.

I'm so glad we went through Article 2 in greater depth. And what great fortune is to have President Trump to guide us through this moment of exploration. We have survived one year. We'll see what happens next year. I mean, I don't even know. I don't even know. Coming up our conversation with former CDC director, Dr. Tom Frieden. Now our conversation with Dr. Tom Frieden, a physician and public health expert.

Today he's the executive director of the global health nonprofit resolved to save lives and author of the recent book, The Formula for Better Health, How to Save Millions of Lives, including your own. He was the 16th director of the Centers for Disease Control and Prevention under President Obama from 2009 to 2017, which makes him the second long. longest serving head in the CDC's history. Before that, Dr. Frieden was the New York City Public Health Commissioner under Mayor Bloomberg from 2002 to 2009, so he has experience at both the city and the federal level. Dr. Frieden, thank you so much for being on the show. Great to join you. So Article 2 establishes the executive branch and assumes that the president will have a

cabinet, but what the drafters of Article 2 did not contemplate is the growth of what we call the administrative state, the many, many agencies in the federal government today that regulate everything from food that is safe to eat and water that is clean to drink, working conditions that are fair, corporate behavior that is honest for consumers. The Centers for Disease Control and Prevention is one of the roughly dozen agencies housed within the Department of Health and Human Services. The origins of the CDC go back to 1942. It's a pretty interesting history. It was a wartime agency called the Office of Malaria Control in war areas, and it became Communicable Disease Center in 1946, and then Centers for Disease Control in 1980.

In part, because of those unusual origins, the CDC acquires its powers from different sources. Congress has directly given the CDC some of its powers, but some of the CDC's powers have been delegated to it from the Secretary of Health and Human Services and from the Surgeon General. For example, the CDC has the power to issue quarantine orders because it has been delegated those powers by the Surgeon General, who in turn was given those powers from the Federal Public Health Service Act of 1944. So it's a long way of talking, giving a little bit of a preamble of where those sort of constitutional powers of the CDC come from. So Dr. Frieden, I'm hoping you can tell us this agency, you know, began as a way to stop malaria from spreading among the military, but it does so much more than that now. Could you describe the objectives of the CDC today? Quite simply, what the CDC has traditionally done is to work 24-7 to protect Americans from threats.

Whether those threats are natural or man-made, whether they are infectious diseases or otherwise, whether they come from the United States or anywhere in the world. That's the bottom line. Healthier, safer people. So the CDC and the entire federal government faced a gigantic health threat in 2020 with the COVID pandemic. And during that first term of the Trump administration, the CDC wasn't insulated from political pressure and there were a lot of criticism, experts criticized, the different sort of calculation of risk. When it comes to this agency, which is within the executive branch and therefore

sort of like under the president, but has its own expertise and its own guidelines and its own thoughts on things, what is the right balance for agency like the CDC to respond to what the president might want versus what is best for public health? I go back. I go back. I go back, to a couple of core concepts here. The analyst and thinker about government, James Q. Wilson and others have talked about what is the definition of a professional? And a professional is someone who has standards that are outside of the line of control, the line of command of their group. So as a physician, if I'm working in an organization and my supervisor says, give this medicine or get this test, and that's inconsistent with my professional responsibility,

I have to say no, or I have to violate my professional responsibility. In the same way, the CDC tries to provide clear, consistent, fact-based information, making clear this is what we know, this is what we don't know, this is how we know what we know. And the second big thing to understand that I think a lot of people have gotten wrong on all sides of the political divide is that the CDC's role is not to set policy. The CDC's role is to inform those who set policy. If you do X, you will get Y. This is really important because, for example, if you talk about something like masks, if everyone wears masks indoors when COVID is spreading, widely, there will be less spread of COVID. That's not saying that everyone should wear masks

indoors all the time, or we should close all the restaurants, or we should close the bars. This is something that we think is best left to communities to decide with a community discussion and elected leaders of that community. So I think the essence of a science-based organization is that it provides valid information based on the best available scientific evidence openly and objectively derived. One of the most visible parts of the CDC is recommendations that come from the agency, and these can be anything from vaccine guidelines to hand hygiene in hospitals and doctors' offices. Is that communication for recommendations one way, or is the recommendation for what the CDC has determined put forward to policymakers and the policymakers? makers go, well, you know, this is possible, this is not possible, this is feasible, this is

not feasible, and then you go, you know, rejigger your models with that in mind and then sort of come up with a sort of thing together? Or is it really just a one-way communication where you present proposals and then they implement it as they see fit? The larger part of the dialogue is with the people who are most familiar with the facts about specific topics to say, you know, what is indicated, what is not indicated? Sometimes it's plain and simple. You know, put your child on their back to sleep if you want to reduce the risk of SIDS.

Straightforward. Other times, the evidence isn't so clear, whether it's about nutrition or physical activity. You know, how important is vigorous physical activity? What's the minimum dose of physical activity? These are complicated topics. So I think when it comes to policy choices or recommendation choices,

the bigger dialogue is both within CDC and among CDC and other parts of the Department of Health and Human Services, other parts of the federal government, academia, advocates, and others to understand what's really the fact here that's going to lead to policy recommendation that will be most effective. In terms of policy implementation, that's kind of a different. science. That may involve Congress allocating money and saying, okay, CDC, give money to states and cities to implement this program if they choose to do so or in the way they choose to do so. Occasionally, you'll get a program that uses those federal dollars to incentivize localities to have healthier policies. And the classic example of that, not part of CDC, but federal government is a road safety where the states were free to take or not take the federal dollars.

But if they took the federal dollars, they needed to reduce the blood alcohol concentration and go to lower speed limits for a while. Yeah. Right. So I think one of the things that is sometimes confusing to the public is, well, maybe I do want to rely on expertise, but who's expertise? So if we turn to the current administration, there's been a complete overturning of ASIP, the committee that advises the CDC on immunization.

All of the former members were removed by HHS Secretary Kennedy, and there are new ones. But if you look at the list, if I'm a member of the public, I think, well, they seem to be well credentialed. So maybe you could explain what is the difference between being well credentialed and actually being able to provide reliable expert advice on something like vaccines? I think we have a challenging situation in this country where the word expert has become a dirty word. And I think part of that is because people don't want someone saying, I'm the expert and I know what you should do. That's very offensive.

So I always start with saying, you are the experts in you. But what science can do is it can tell you if you want to achieve. something health-wise, we can tell you what's proven, what's unproven. And I think when it comes to levels of certainty, it's really important to understand that there are highly specialized areas where there are things that are virtually certain, not such a hard thing. Where there are things where it's no evidence, not so hard. It's in that gray zone where it's so important, even in areas where just to say I'm

I work a huge proportion of my time on one particular health issue. A new article comes out on that. I'm still not the best person to understand whether that article is valid. I know who I can go to, who are people who have worked on this for whole lifetimes. And that's one of the things that CDC is so wonderful about or has been so wonderful about. There are people there. if you opened a medical textbook to any random page, there have been people there who would be able to tell you,

oh, here's what's really important about that topic. And people have asked me, do I miss being CDC director? And what I miss is when an article comes out in the New England Journal of Medicine or some other newspaper or a medical journal, I could call up one of the world's experts in that area and say, you know, what's the real deal here? So that kind of expertise is deep expertise. And, you know, there is something called Brandolini's Law

that it takes infinitely longer to debunk nonsense than to spread it. And I've seen this, for example, with some of the things that RFK Jr. is saying. For example, he recorded a three-minute video when he announced that the U.S. is pulling out of the Global Vaccine Alliance, what's called Gavi. And this is a terrible mistake. This means that lots of kids may die of preventable disease.

The U.S. may be at greater risk if these diseases spread and come here because we can't keep diseases out. Viruses don't need visas. And in this three-minute video, he had multiple falsehoods. And some of them, I understood the issue well enough to understand why it was a falsehood. But there was one that was, you know, really complicated. He said, oh, this vaccine increases the deaths of children. And it took me days to track down the article. He mentioned an article.

And then no one gets promoted in their university for debunking a bad article, right? So this article was in the literature for years. You know, it had been criticized in a kind of gentle way. But it took a couple of days to look carefully and understand, oh, it's got a fundamental methodological flaw. where the unvaccinated girls also had unrecorded deaths. So it looked like not vaccinating these girls resulted in saving their lives. But what it really showed was that the girls were neither accessing health care to get vaccines nor having their deaths recorded.

So sometimes it's very hard to track down the reality amid a blizzard of falsehoods. Yeah. Yeah. It's also not just falsehood, but also like the difference between certainty and uncertainty. Science lives very comfortably in uncertainty. And politics does not. And when you're talking about something, you know, this professional list of principles, you know, I loved hearing them. They are not shared with necessarily a political body. And so when those things have to interact and necessarily they do have to interact, you know, what is the friction of that outcome? I think that's a really important point. And partly it has to do with science education, partly it has to do with encouraging people to embrace nuance in our lives. I was part of a focus group with people who are reluctant to get vaccinated, and several of them kept saying, just tell me the bottom line.

And the bottom line is that it changes over time. And that's why communication is so important, that we are really clear with people what do we know, how do we know it? What do we not know? What are we doing to try to find it out? And based on what we know now, and this may change, this is what we recommend, and to have some degree of certainty in that. There's an interesting paradox when it comes to public health in that sort of step, is

that any appropriate action when it actually prevents something will feel like an overreaction because it has prevented the thing that it was in terms. tending to prevent. How do you get people to believe in a preventative action doing its job when the result is things are going along swimmingly and they don't, you know, like if it's doing, when government is working well and when the CEC is working well, people should not notice its existence, but you need them to notice its existence for it to continue healthfully. Like, what, how do you deal with that? My organization resolved to save lives produces a periodic report called epidemics that didn't happen,

where we highlight the great work of a team of doctors, nurses, public health specialists somewhere in the world that stopped an epidemic that we never heard about. And part of it is emphasizing the progress. It's part of human nature to kind of take for granted the things that aren't problems. And yes, public health generally is not recognized because when we succeed, nothing happens. And when we fail, it's headline news. Now, of course, then there are also epidemics that do happen.

And of course, COVID was kind of that thunderclap, that moment of cataclysm. And one response from the federal government during the pandemic was to put a moratorium or a pause on evictions around the country when many people couldn't work. and this was to prevent homelessness in ways that might spread the virus even further. Now, that moratorium first began in a kind of regular way with Congress approving of the moratorium. But when Congress failed to renew it, it was actually the CDC that used its own authority to issue the moratorium in 2021 because federal law gives the CDC the authority to enforce regulations that are necessary to prevent the spread of communicable diseases.

So the moratorium was ultimately challenged in court, and the Supreme Court put a halt to it the same year that it was issued. Now, this was after your time as director, but we were wondering, when you head an agency like the CDC, when you have to make a really big decision like this, do you think primarily and only about the public health decisions? Or are you also thinking, well, I have kind of a legal framework in my mind, too, to make sure that this, if it is to be challenged, we can have some safe assumptions about it going forward. So I'm not a lawyer. I'm a doctor. I will say that I found some of the regulatory approaches used during COVID, during both the Trump and Biden administrations of CDC not to be appropriate. And I think they were kind of inevitable because Congress didn't act.

I see. So because there was a failure to act on the part of Congress, CDC authorities were used in ways they had never been used before on both eviction moratorium and on some immigration issues that probably haven't stood up to legal review. But your question is a broader one. And I think always public health should consider as broad a set of risk.

and benefits as possible. There's a misconception, I think, that CDC didn't consider, oh, what harm will it be to the economy or to education if there are closures. I wasn't there at the time, but I can tell you that in all of our recommendations, there is explicitly an understanding of the non-direct health-related costs,

whether that's of vaccinations or or other recommendations, and it should be. Now, CDC isn't always privy to what all of those things might be. So to give you an example, during the Ebola epidemic, we wanted to track all incoming travelers, but they were coming into dozens of airports 24-7, and we had no way to do that. I didn't know as CDC director that the transportation,

that the Transportation Department had the authority to mandate that all flights funnel into a limited number of airports. So instead of 32 airports, they could make it just five. And with just five, we could figure out a way to track every incoming passenger from the affected countries. So when you have a cross-government collaboration, you often identify new ways to do something more effective. or costs or benefits or potentials that you didn't know otherwise. So there's been this ongoing debate about whether the president should have the freedom to fire heads of agencies within the executive branch for any reason. The CDC director can be fired for any reason. And in fact, Susan Menares was fired by the Trump administration this past August after only one month on the job.

Do you think that's a good idea for the president to have that kind of latitude? And is there a better model for this? The fact is, and this came up when just recently Congress made the CDC director position one that is Senate confirmed. There are pros and cons of that approach. But fundamentally, if you're a CDC director and the administration doesn't agree with you, you're not going to be able to get your job done. So it doesn't really make sense to keep someone in if they're not part of the team. That's different from a technical agency that may need to make non-political decisions on the economy or something else. But there's a related issue which has to do with what are called national statistical products.

It sounds like a boring term, and it is a boring term. But it's actually quite – Please explain. It's quite an important term. There are certain publications or series that are considered so important that they be not politically tampered with, that they have been national statistical products, including some of the publications from the National Center for Health Statistics, which is part of the CDC. It actually was independent for a while, then it became part of the CDC. And as the CDC director, I was allowed to know what they were going to publish in terms of the title. Like they're going to publish, not even the title, they're going to publish a publication on X.

But I was not permitted legally to see that report before the media saw that report. Interesting. And that also goes for things like the Bureau of Labor Statistics employment data, because you really want people to have confidence in it. Now, in recent months, I learned, really to my astonishment, that that was not a legal or legislative protection. That was the result of a directive from OMB. And if it can be established by OMB, it can be changed by OMB. So I think it is really important for everyone that there is information that is produced by the experts in that. information with transparent methodology and hasn't been meddled with by a politician.

I think that's so important. And one of the things that people may not realize is when an agency like the CDC is producing this kind of very important health data, it's not just for public consumption at large. There's a whole network of researchers outside of the federal government that absolutely depend on this data, can't create or collect it on their own. it's just too expensive to do. And so there's this vast infrastructure that really the CDC and other similar public health agencies are kind of upholding up as, you know, from the bottom. Absolutely.

And this goes also for some of the survey systems. There are surveys that CDC does and the results are anonymized so you could never find who answered what. But researchers, they're goldmines of information. And CDC will do the basic. analysis of them and make them available for researchers to look at more. And that's another essential function of CDC getting back to your first question of, why do we need a CDC.

It establishes the standard for that and then states figure out how to apply that. So if you had a magic wand, what would be at the top of your list for reforming the CDC? Well, CDC is undergoing attacks political and even physical. that are unprecedented. Right. We've had for the first time the firing of a CDC director. About a quarter of CDC staff

have either fired or resigned. Most of the leadership of the agency has left. You have, by last count, a dozen or 15 political appointees basically running the agency that has never happened before. You mentioned the advisory committee on immunization practices,

that's a committee that has used the highest standards of evidence and protection from conflicts of interest for decades. And it's been basically taken over by a group of people who have very limited knowledge of vaccines, most of them, not all of them, and who have made recommendations that are so at variance with basic medical concepts that the professional societies, doctors, nurses, and the insurers have said, we're going to ignore what it says because it doesn't make sense. So this is a very difficult time, and I don't think we're going to go back to the past. I think we're going to have to go forward to a CDC that's faster, that's better at communicating, that has better partnerships and alliances, and that delivers results that people can feel,

that provides tangible benefits for people to understand and live a healthier, safer life. I think one of the things that has to happen more is that CDC needs to be more tightly aligned with state and local governments because I had the benefit of joining CDC as director after having been New York City Health Commissioner. So I had a pretty good sense of what was needed on the front lines, and I felt there was a little too much of a disconnect between folks at the CDC headquarters in Atlanta and folks out there on the front lines. And this is not a political comment about this policy or that it's how fast you need results, how practical recommendations are. And one of the things I did while I was there was I increased the number of CDC staff embedded in state and local health departments, especially early in their career. So people could come in, spend a few years at a city or county or state health department, learn what it looks like on the front lines, and then rotate to CDC where they would be able to provide more practical, helpful guidance. The person who founded CDC, Joseph Mountain, wrote that he thought every CDC officer should have spent at least a year as a county health officer.

Long enough, he wrote, to have proposed a budget and gotten it through. with the city council. Well, this brings up an interesting point that I'm interested in your personal biography. I mean, the mayor of a city, the mayor of the city in New York, you know, has very different powers than the president of the United States. There's also a big difference between, you know, what states and cities can legislate versus what the federal government can do. Still, you know, in terms of public health, you know, well, basically, what were you able to do as NYC health commissioner that you could never propose as the CDC director, I guess is the question I'm asking? Well, I'll tell you, I found it a shock when I got to CDC because the CDC director is way, way, way less powerful than the New York City Health Commissioner. Oh, no.

So as New York City Health Commissioner, I had substantial flexible resources that I could devote to emerging health threats or potential new programs. And the way that worked was if money weren't spent in one area, we could spend it in another area. And inevitably, money gets underspent, and so you can spend it. That's not how the federal government has traditionally worked. If you don't spend the money in the way that Congress allocates it, we were always told you could go to jail because Congress is your board of directors. And so that was called an Anti-Deficiency Act violation. But with this new theory on impoundment, that's a problem. That seems not to be the way the current administration is working.

But that meant that I literally, literally had 20 times more flexible dollars as New York City Health Commissioner that I had as CDC director. Second big difference was that as the CDC director, I had very little control over the different parts of CDC because there are something like 200 budget lines and they all run their own programs, divisions and centers. And the director is kind of, you know, at best conducting an orchestra, but more realistically kind of walking alongside. So when I wanted to start a new program of putting hundreds of staff into state and local health departments, I had no way to do that. I had to go kind of cup in hand to my center and division directors that would you support three or four? Would you support five or six? The other thing that was so very different was actually authority. So as New York City health commissioner, I had a lot of authority.

Like when I was assistant commissioner and I ran the tuberculosis control program, we modernized the detention laws. So if you had tuberculosis and you didn't take your medicines, we could order you detained in a hospital until you were cured. And, you know, if a restaurant is serving food and in unsanitary conditions, we could close it. If there's an environmental hazard in a place, we could order it to be abated.

So there was a huge amount more of authority and power as a city health commissioner, especially New York City, because the city is kind of a hybrid between a state and a city. The New York State has delegated to New York City a lot of things that most cities don't have the authority to do. It has its own health code.

It has its own Board of Health. So I can say that coming from New York City, particularly with Mike Bloomberg, who has a public health school named after him and if it was willing to do public health stuff to the CDC, it was a very frustrating transition because the amount of authority and power was so much less, even though the organization is larger. Yeah, yeah. I mean, would you like to see that power sort of if there was a U.S. health? Commissioner, would that be a better system? I don't think that will ever happen. And we do have a very decentralized, a federal system in the U.S., where we decentralized the states.

What I think would be more effective is a system where there's more alignment between city, county, state, and federal. So that, not that everyone's working in lockstep, but if we're going to try to address the opiate overdose problem or reduce food poisoning or reduce strokes or hard attacks or cancers, we can say, all right, let's do this in a coordinated way that's learned from each other. Maybe we'll try three different approaches and compare them. Right now, there's just too much distance between the different parts of the public health system.

Yeah. Well, what's so interesting about your tenure in New York City is that, you know, what you did there really shows that public health is a thing that, you know, sometimes is wildly unpopular at first and then becomes normalized. But it's exactly the kind of thing that people don't vote. for. Nobody votes for, I want to end smoking in restaurants and bars. But then we decide, oh, this is much better. I can breathe. So that's, I think, the real challenge for public health in a democracy. I tell in the book two stories from the Bloomberg administration. When

Mayor Bloomberg was running for re-election for the first time, I was really enthusiastic about his leadership because he was an excellent manager. He was really focused on public health. We had made a lot of progress. We had banned smoking in bars. We had raised. tobacco tax, we've done new things on HIV care and prevention. And so I asked one of his inner circle, how can I help with his re-election? And she said, I'll tell you how you can help. Let us put you in a closet and put duct tape over your mouth until after the election. And after he won re-election, he called all of the commissioners together.

And he said, you know, look, I financed my own election. don't owe anything to anyone. And our job is to do the hard stuff that nobody else is going to do, like building the new water tunnel for New York City, a multi-billion dollar effort that would take many, many years, and he would never get the credit for. And so it's, it's, Mayor Bloomberg said, it's kind of a mark that we're not doing our job that my approval rating is, you know, in the mid-70s. And if we do our job, the approval rating will come down. And, uh, The head of his communications unit shouted from the back of the room, we're counting on you, Tom.

So, yes, it can be unpopular. But I will say when we made all restaurants and bars smoke-free, it was a huge fight, a huge fight. And, you know, the tabloids had a field day criticizing the mayor and me and everybody else. and by first or second year after, people really appreciated it. And the opposite, people are going to not go to bars and restaurants, the opposite happened.

Oh, there's so much more pleasant. We'll go there, we'll eat, we'll hang out for longer. And I think this is the case with many public health problems. Another example of this, and it's important to see the kind of evolution of social change I discuss in the book is, think of a generation or two, when it was normal for a family to load up the car, drive to a beach, not wearing seatbelts, put on not sunblock, but tanning lotion, have a few beers, hop back into their car without putting on seatbelts, drive to a restaurant, smoke in the restaurant, have a few more drinks, and then not wearing seatbelts again, drive home. I think you might have been spying on my family.

Well, most families, because that was the social norm. That was the social norm. Right. And there's still too much driving under the influence. There's still too much skin cancer. There's still too much exposure to secondhand smoke. But those things are much less common and they're no longer the social norm. And that's the reflection of huge progress, progress that has saved millions of lives.

It's also a social norm to not die of measles. and not being an iron lung. And that has happened for enough decades that people probably, you know, like they're playing footsy with risk that they probably don't understand. How do you make them understand that? I think this has been a real challenge.

First off, there have been anti-vaccination movements ever since the first vaccines. And in the book, I talk about Ben Franklin, whose four-year-old child died from smallpox, and there was misinformation that he had died from the vaccine. And Franklin got on the social. media of his day, which was his gazette that he was putting out, to say, no, the child died from the virus itself. And even a half a century later, when he wrote his autobiography, he very

movingly went back to that episode and he said, you know, basically put yourself in the position of a parent whose child has died. Wouldn't you have rather done everything possible to prevent it? So there are effective ways to find the messaging. We also find that vaccines are. victims of their own success. We don't have any problems getting people in Africa to get vaccinated against meningitis because it's a terrible disease and they see people with terrible meningitis. So, yeah, I want that vaccine. This means that we need to improve communication.

We need to listen carefully to people's concerns. We need to provide objective data. Fortunately, although some of the myths and the falsehoods get a lot of coverage, still, the vast majority of Americans understand that vaccines are life-saving and get their kids vaccinated on schedule. But that's not an assured progress. We're seeing this firehose of falsehoods about vaccines, and it means that our defenses against microbial killers are going to get weaker. Dr. Tom Frieden, thank you so much for taking the time to talk with us, and I really enjoyed talking with you. I enjoyed your book. Thank you. It's been a pleasure speaking with you both.

Thank you so much. Joining us next month, we'll be moving on to Article 3, the Judicial Branch. The 99% Invisible Breakdown of the Constitution is produced by Isabel Angel, edited by committee, music by Swan Real, mixed by Martine Gonzalez. 99% Invisible's executive producer is Kathy 2. Our senior editor is Delaine Hall. Kurt Colstead is the digital director. The rest of the team includes Chris Barube, Jason DeLeon, Emmett Fitzgerald, Christopher Johnson, Vivian Lay, Lashemaddon, Jacob Medina Gleason, Kelly Prime, Joe Rosenberg, Talon and Rain Stradley, and me, Roman Mars. The 99% of visible logo was created by Stefan Lawrence. The art for this series was created by Aaron Nestor. We are part of the series XM

podcast family, now headquartered six blocks north in the Pandora building. In beautiful, Uptown, Oakland, California. You can find us on all the usual social media sites as well as your own Discord server where we have fun discussions about constitutional law, about architecture, movies, and music, all kinds of good stuff. It's where I'm hanging out most these days. You can find the link to the Discord server

as well as every past episode of 99PI at 99PI.org. Thank you.