The health of a nation is ultimately a matter of politics. We can grimace at this fact all we want—or resign ourselves to the belief that clinicians and scientists should never wade into such matters—but the reality is that public health and politics are inextricably linked. The United States embodies the promise and peril of this dynamic. Historical political decisions that have been codified into law or ossified into structures help to perpetuate many of the social inequities that shape our lives today. Political will and courage, however, have resulted in some of the most important population health advances. Whether it is through Medicare and Medicaid, civil rights protection, or the expansion of public education, investing in people has never proven to be a bad idea. And for all our advances in science and technology, the most pressing challenge for countries today is spreading these innovations more effectively and evenly.
This is why the inauguration of Donald Trump poses a serious threat to public health. As the months have passed since the 2016 election, and with each decision and cabinet appointment since, it has become clear that the Trump administration’s policy agenda is fraught with harmful measures that will exacerbate health disparities.
There is the decision, or at least the strong suggestion, to repeal the Patient Protection and Affordable Care Act with no compelling rationale or clear strategy. Even previous bipartisan remedies are no longer considered reasonable. The alternative—or philosophical replacement—appears to be returning to a social condition where almost one in six people are forced to go without health insurance. It could also mean a return to the cruel barriers enforced through “pre-existing conditions”—leaving over a quarter of people under the age of 65 uninsurable due to circumstances we know that neither Republican nor Democrat can predict or control in their lifetime.
To be sure, the Affordable Care Act is no panacea for better health. Its core ideas stem from a conservative think tank, and their initial implementation by a Republican governor allowed the Act’s benefits to reach patients in states led by members of both parties (most of the time). But amid its success in cutting the number of uninsured by nearly half and ensuring that more than 20 million people received access to primary care (many for the first time), the steady rise in deductibles remains a serious problem and one that needs to be addressed head on. As it happens, nearly two-thirds of Americans support a Medicare-for-all system that would prioritize universal coverage. While there will almost inevitably instead be a flurry of proposals pointing to the market for solutions, the Trump administration may soon learn that competition alone is no substitute for compassion or community when it comes to health care delivery.
Public health, when protected, tends to be invisible, and so, is quite often overlooked. Conversely, recognition is the currency of politics. As an example, it may surprise the public to be reminded there is already a vaccine against cancer in our lifetimes: a moonshot in medical achievement against a disease that used to be the leading cause of death from malignancy among American women. Yet because the initial policy discussions regarding the human papillomavirus (HPV) vaccine were mired in politics and misogyny, it never received the acclaim it deserved.
HPV illustrates all too well the paths through which social forces like sexism, racism, and classism can enter the human body and its cells, even changing our DNA to leave us sick. The scale of efforts required to root these pathogenic forces out of our bodies can lead policymakers to lend outsized weight to the promise of precision-medicine to make it all better, shunting spending away from public investments that more drastically shape the health of those around us.
Instead of merely underinvesting in public health, however, Trump’s likely appointment of an outspoken anti-vaccine skeptic to head a vaccine safety panel will skew the balance towards those who seek to shout down science. This mistrust of evidence, or rather, the propagation of “alternative facts”, is the new danger that accompanies Donald Trump to Washington. Such a pivot away from evidence-informed investments might also reverse critical new federal provisions focused on the prevention of chronic illnesses such as diabetes, heart disease, and substance abuse disorders, as well as the responses to global health threats from HIV and tuberculosis to Ebola and Zika.
Dr. Rudolf Virchow, the driving force behind the creation of the world’s first public health insurance system in nineteenth-century Germany, argued that “politics is nothing but medicine on a grand scale.” If this is so, and if he fulfills his promises, President Trump stands at the threshold of committing willful malpractice of unprecedented magnitude, with sequelae that would reverberate for decades to come.
There are already pockets of evidence that help paint what this future might look like. Consider, for instance, what happened in Texas after the Republican legislature in Austin slashed funding for reproductive health and shuttered family planning clinics across the state in 2011. According to a recent analysis, the maternal mortality ratio more than doubled over just two years. Trends like these, the study’s authors wrote, are difficult to explain “in the absence of war, natural disaster, or severe economic upheaval;” withdrawal of essential health services constitutes an unnatural and entirely preventable disaster. Similarly, in the six months following September 11, 2001, pregnant women with names perceived to sound Arabic experienced significant increases in the incidence of low birthweight deliveries compared to all other women; this was thought to be associated with markedly increased rates of hate crimes, workplace discrimination, and verbal harassment targeting Muslim families in the early 2000s.
The state of its democracy—that journey towards equality of opportunity, voice, and vote—has always been one of America’s core vital signs. But the world now watches a country shutting its borders to those in need—which may also jeopardize the recruitment of talent needed for scientific progress—and one beset by more economic inequality than possibly ever. This has also meant a more unequal start for children born to low-income families in the U.S. today. And if that child even makes it to forty years of age, they are granted an unequal finish, as the rich already live a decade or so longer on average. While the burden of disease falls most heavily on communities of color, we have also seen an increase in midlife mortality rates among Americans who identify as white, particularly among those with limited access to public education. No matter one’s race or religion, hope and hard work will only guard against the pathologies of poverty for so long.
Because of this, we believe it is the duty, then, of clinicians and scientists to emphatically remind Donald Trump that he does not, and never will, have the mandate to bankrupt the health of an entire nation. The vows we take as providers of care bind us to stand together not only for health, but also against injustice. This will mean taking up the sort of local activism not usually custom to academic medical centers, and following the lead of our neighbors and our patients. If the President proceeds with his campaign promises to shred the social safety net and to endanger the physical safety of millions of people who call America home, resistance will be both a moral and a public health imperative.
Andrew S. Boozary is a visiting scientist at the Harvard T.H. Chan School of Public Health and resident physician at the University of Toronto. Cameron T. Nutt is a medical student at Harvard Medical School.