The Brooklyn Rail

When I began writing this piece in early January 2025, there was already a lot to say about what a second Donald Trump presidency was likely to mean for public health. Much could be inferred based on the experience of Trump’s first presidency, the ideology reflected in Trump’s campaign (and in Project 2025), and early indications of who his nominees for top government health-related positions might be. But the first few weeks after Trump’s inauguration, marked by multiple presidential executive orders and the actions of the so-called Department of Government Efficiency (DOGE), added a sinister dimension and have created much confusion, chaos, and fear in the public health community about how bad things really could be. The extent to which the executive orders will stand is unknown at the time of this writing, and a performative element intended to distract and overwhelm is certainly a major component of “flooding the zone,” but the brazenness of these initial actions highlights what we are up against. And this, of course, goes way beyond public health, although arguably public health will clearly be impacted in multiple and major ways, as I will discuss.

Well in advance of the inauguration, the anticipation of the second Trump presidency was marked by uncommon attention to public health in the press and to some extent, in political discussions. This was in part due to the experience of the COVID-19 pandemic and the many debates that the public health response triggered, but was also driven by the often bizarre and controversial views of Trump’s nominees for several health-related government positions. For better or for worse, this resulted in unprecedented attention to major health US challenges, chief among them the United States’ dismal performance on life expectancy, which received significantly more press coverage over a few weeks than it had in the past few years, despite the profusion of reports highlighting these issues over the past decade.^1,2 The fact is that the United States has fared remarkably poorly compared to other rich nations in life expectancy in recent decades despite spending a huge proportion of GDP on healthcare, not to speak of the stark differences in life expectancy by race and class. The drivers of this are many (multiple causes of death at multiple ages play a role), and are essentially systemic—that is they are driven by social and economic dynamics and processes well beyond the healthcare system.

One of the most prominent health-related issues that has emerged in the debate on Trump’s nominees is of course the issue of vaccines. Robert F. Kennedy Jr., nominee for Secretary of Health and Human Services (at the time of this writing, he has not yet been confirmed), has a long history as a vaccine denier. It’s remarkable (and a sad comment on our times) that there is a need to justify and defend vaccination. The evidence on the effectiveness of vaccines, and of the utility and need for vaccine mandates, is probably the most robust among all public health interventions and has been so for a long time. The value of vaccines has been demonstrated again and again in clinical trials (often considered the “gold standard” of evidence in medicine because of their experimental and randomized nature) and has been confirmed in practice by the fact that some infectious diseases have even been eradicated or close to eradicated thanks to vaccines, except of course when they are re-emerging, like polio or measles, because of lapses in vaccination.

The COVID-19 pandemic provided yet another stark illustration of the utility of vaccines in protecting individuals, and, most importantly, of their value in protecting the population as a whole. Thus, mass vaccination protects everyone, including those who cannot be vaccinated, and even adds a layer of protection to those who have been vaccinated, given that no vaccine provides complete protection to a vaccinated individual. Of course, no intervention can be guaranteed to be completely free of any risk, although vaccines come close, closer than many other medical interventions that we routinely accept without question. Fringe theories on harmful effects of vaccines (vaccines as a cause of autism being one of the most prominent) have been completely disproven.^3,4 But even more than a concern for adverse effects, at its core much of the questioning of vaccination (and specifically of vaccine mandates), really reflects a questioning of social action (specifically government action) in defense of the public good.

Perhaps because of his attraction to conspiracy theories, RFK Jr.’s questioning of vaccines goes hand in hand with a critique of the food industry. RFK Jr. has especially highlighted the contributions of so-called ultra-processed foods to the obesity epidemic and related “chronic diseases” (non-communicable diseases is a more appropriate term, as infectious diseases can become chronic). In this he is aligned with public health research which points to the role of “obesogenic environments” related to the availability, access to, and advertising of energy dense and otherwise “unhealthy” foods, including ultra-processed foods, as important contributors to obesity and related diseases such as diabetes, hypertension, cardiovascular diseases, and some cancers. The term “ultra-processed foods” was first used by Brazilian nutritional epidemiologist Carlos A Monteiro who identified the increasing consumption of highly processed foods promoted by US food companies as a driver of obesity in lower and middle-income countries like Brazil.⁵ There is debate on what defines ultra-processed foods, and on whether specific ingredients used in ultra-processed foods are the actual culprits. But there is abundant evidence that the promotion of energy-dense, high-sugar, high-salt, high-unhealthy fat and low-fiber foods (for which the label “ultra-processed” may be a pretty good proxy) to the detriment of whole grains and fruits and vegetables is a key contributor to rising rates of obesity and related disorders worldwide.⁵ Revealing a concerning reliance on junk science, RFK Jr. has also made several claims about adverse health effects of seed oils and even pasteurized milk, for which there is no scientific evidence. Indeed, in the case of pasteurization, there is clear evidence of health protection dating back over one hundred years. Mehmet Oz, another Trump nominee to lead a major health care agency, the Centers for Medicare and Medicaid Services, has also repeatedly made unsubstantiated claims regarding health effects of diet and dietary supplements (some of which he may have been benefiting from economically).⁶ All this, of course, raises major concerns about the intentions of these nominees (be they driven by simple lack of judgement or by flagrant economic self-interest) even if by chance, such as when they highlight the role of the food industry in health, they sometimes happen to be right.

We are all subjected to food industry promotion and advertising of unhealthy products; we cannot choose otherwise. The food industry has strong incentives to produce products that sell, and that sell a lot, products that because of their nature (e.g. high sugar, salt, or fat content) are highly palatable and even addictive, and products with a long shelf-life. And all these things result in the development and promotion of food products that are for the most part conducive to excess and unhealthy consumption. Governments can intervene to protect public health, as they have, for example, in restricting tobacco advertising and taxing tobacco products, with great success in reducing disease and death rates. Efforts to regulate the food industry or tax unhealthy food products have had much less success. One example is the taxation of sugar-sweetened beverages, which has shown promise in reducing consumption and generating health benefits^7,8 but has only been implemented in a small number of localities in the US, often meeting with great opposition. Even New York mayor Michael Bloomberg, known as a public health champion, had to scrap his plan to ban large sugary drinks in New York City in 2014. In fact, some lower and middle-income countries, including Mexico with its sugar-sweetened beverage tax and Chile with its comprehensive anti-obesity initiatives,⁹ are well ahead of the US in this regard, and are examples where government, exercising its responsibility to protect the public, has valiantly attempted to rein in the food industry. It will be interesting to see whether RFK Jr.’s critiques of the food industry translate into any meaningful government action to protect public health.

When all else fails, or when challenging the status quo is just not politically or economically desirable, enter the magic bullet: drugs. A new drug, semaglutide, sold under trade names Ozempic and Wegovy, has emerged as the awaited solution to diabetes and obesity.¹⁰ Semaglutide is one among several drugs within a general category called GLP inhibitors that have been recently developed. Reflecting the well-established neurological links between the gut and the brain, semaglutide appears not only to stimulate the production of insulin in the pancreas (the main driver of its effectiveness in treating diabetes) but also to affect the brain, impacting the brain’s reward system, reducing cravings, including cravings for the addictive high energy and ultra-processed foods often promoted by food advertising (it also appears to reduce other addictive behaviors like smoking, alcohol consumption, and possibly drug use).¹¹ In some people with diabetes, the possible benefits of these drugs may overcome risks, although we still have limited knowledge of these risks, as adverse effects can take a long time to emerge. But it is striking to see that in our upside-down world, it appears more feasible to reduce the impact of our obesogenic environment by taking a drug, at great cost and not without side effects, than by changing the obesogenic environment itself. Thus, commercial interests both create the problem (an unhealthy and heavily promoted food supply) and sell us a solution (a drug) which in turn is likely to generate other problems (extraordinary cost as well as the known and unknown side effects of these drugs). In an interesting turn of events, the fast food industry is quite concerned about the possible impact of mass consumption of these drugs on their sales.¹² Will we see the emergence of new semaglutide-resistant ultra-processed foods? The ways in which the food industry has quickly responded to prior efforts to reduce consumption via reformulation of old products and launching of new products suggest that a repositioning of the industry to protect and even continue to expand sales is likely. The food system that we have, largely driven by the interests of huge multinational corporations, is resistant to intervention.

The potential of these drugs for the profitability of the pharmaceutical industry is unprecedented: in 2023 semaglutide was the top drug in expenditures in the US at 38.6 billion dollars (double what it was in 2022),¹³ and some have suggested that as many as half of US adults, about 137 million people, could be eligible for semaglutide treatment.¹⁴ Even the World Health Organization (WHO) has quickly embraced semaglutide-type drugs as a solution to the world’s growing obesity problem.¹⁵ Elon Musk has been a big fan (and apparently user), referring to himself as “Ozempic Santa” on social media. “Nothing would do more to improve the health, lifespan, and quality of life for Americans than making GLP inhibitors super low cost to the public," he posted on X in December 2024. But who knows where all this will land in a second Trump administration: in his rants, RFK Jr. has spoken out not only against vaccines but also against big pharma. ¹⁶

Even more worrying than the unreliable “beliefs” of Trump’s nominees (based more on conspiracy theories and quackery than science, even if some of them, albeit distorted, may hold a grain of truth) or the irresponsible social media postings of Trump-linked billionaires, is what a second Trump administration could mean for the type of government action that is fundamental to protecting the health of the public. Government public health agencies, especially local health departments, struggled valiantly during the COVID-19 pandemic to make evidence-based decisions to protect public health in the face of a new and rapidly evolving health threat and limited information, a chaotic national response (with the sole exception of accelerated vaccine development), growing and often politically motivated misinformation, and a long history of underfunding. Despite this, public health agencies and their leaders have already faced substantial backlash, which is likely to increase even further in a Trump presidency.

The lack of confidence in public health leaders will only be reinforced and increased by persistent underfunding of health departments and other public health agencies.¹⁷ This strategy is not new: first defund government agencies and then critique them as incompetent, leading to even less funding. The defunding of public health will hamper the US’s ability not only to face the next pandemic but also to address other pressing public health issues, including the “chronic disease epidemic” that the “Make America Healthy Again” movement claims to want to address. Funding for public health research under the next Trump administration is also in question. RFK Jr. has argued that we should give infectious disease research at NIH “a break for about eight years,”¹⁸ a truly dangerous proposition given the COVID-19 experience and the persistent threats of other emerging infections. At the time of this writing key public health agencies like CDC are paralyzed by confusing orders and a surreal witch-hunt. Many government agencies and federal contractors are scrambling to eliminate banned words and any evidence of “wokism” in a panic and with little regard for scientific validity or value to the health of the public. Whole sections of the CDC website focused on health equity or the health impacts of racism have been substantially edited or have disappeared, publicly accessible data sets were pulled, and CDC links to important public health resources no longer work.

Protecting public health extends far beyond directly addressing the transmission of infectious diseases or preventing non-communicable disease by promoting healthy behaviors, important as these strategies are. It even extends well beyond the actions of government health departments. Public health is fundamentally impacted by the environments and conditions in which we live and work. And these are two areas in which government regulation can have significant impacts. Given the experience during the first Trump presidency, there is little doubt about the adverse impact that a second Trump presidency could have on the Environmental Protection Agency (EPA). Created in 1970 under Richard Nixon, the EPA has been a model worldwide for evidence-based and responsible environmental regulation to protect public health and the environment. An excellent example is the process the EPA follows to establish air pollution standards as mandated by the Clean Air Act. The actions of the EPA in these areas have contributed to a dramatic reduction in air pollution and have saved hundreds of thousands of lives.¹⁹ In recent years, the EPA has also taken on regulating climate change-inducing pollutants²⁰ and has developed a focus on addressing the stark inequities in environmental exposures by social class and race in the United States.²¹ The first Trump administration cut the EPA’s budget and authority and acted, directly or indirectly, to exclude certain scientists and certain types of scientific evidence from the EPA’s decisions, with the clear goal of reducing the development and enforcement of environmental regulations.²² Although reality has made it increasingly difficult even for Trump supporters to continue to deny man-made climate change, a strategy to dismantle environmental protections similar to or more radical than the one implemented during the first Trump presidency is all but certain. As I write this, major efforts to dismantle the EPA are already underway: Zeldin, the new the EPA administrator, has the support of key polluting industries that have legally challenged the EPA’s authority,²³ and 168 workers at the EPA’s Office of Environmental Justice (which actually has its origin in the Office for Environmental Equity established by George Bush in 1992) have been put on leave,²⁴ with many more likely to follow.

Although even less frequently discussed than environmental factors, occupational hazards are also fundamental drivers of health. This was highlighted during the COVID-19 pandemic, when the risks conferred by work, and the stark inequities in risk of COVID-19 infection by occupation, were made painfully obvious. But in our society the health risks conferred by work span much more than the transmission of infectious diseases. Over 5,000 workers died from occupational injuries in the US in 2023,²⁵ and millions of workers are injured on the job every year, with many injuries likely going unrecorded.²⁶ Exposures at work are linked to many health outcomes including cardiovascular disease and cancer. Abundant research also shows that other aspects of the work environment, including demands and control over the work process, can have effects on the cardiovascular system and mental health.²⁷ Workplace policies like sick leave and family leave also have important health consequences.²⁸ Based on past experiences,²⁹ the second Trump presidency is likely to scale back federal oversight of workplace safety and dismantle efforts to develop new programs or regulations. For example, there have already been indications that the Trump administration is likely to abandon pursuing a recently proposed Occupational Health and Safety (OSHA) Heat Safety rule which would require that employers have plans to protect workers when temperatures rise above a certain level. Many other impacts on programs, enforcement, and staffing are likely.³⁰

Trump has signaled his intent to reduce government action sharply on many fronts and via multiple strategies, including the appointment of Elon Musk to lead DOGE, a new initiative on “government efficiency” aimed at slashing excess regulations. The recent Supreme Court Decision to strike down the Chevron Doctrine has also severely limited the power of federal agencies like the EPA to interpret the laws they administer and opens the door to significant further challenges to regulation in the courts.³¹ All this is in line with intense backlash against government public health intervention after the pandemic, despite, paradoxically, the pandemic demonstrating how critical government intervention really is. It is hard to imagine a more fundamental role for government than protecting people’s health, yet in recent years we have seen increasing abdication of this role. The one saving grace for the US, given its federalism, is the ability of state and local governments to step in.³² But will they, and how many? Post-COVID-19, the movement has actually been in the opposite direction, with many states advancing legislation blocking rather than supporting government intervention to protect public health.³³ In a perverse use of public health law, Trump advisors have been seeking an infectious disease that could be used to justify invoking public health restrictions known as Title 42 to prevent immigrants from entering the US.³⁴ Sadly, in this he is not alone: Biden used Title 42 to turn away thousands of immigrants, despite the fact that its use was not justifiable on public health grounds.³⁵

Important as all these threats to public health are, by far the most important and fundamental threat is the broader social and economic agenda promoted by Trump and his associates. There is little doubt that public health is fundamentally driven by social and economic structures and systems, including inequality and racism. These social drivers of health (sometimes referred to as the “social determinants” of health) operate through many interrelated mechanisms shaping the environments in which people live and work, constraining or creating opportunities, impacting behaviors, and ultimately affecting biology in profound and verifiable ways. These are the forces that really drive the US’s horrible performance on life expectancy and the huge inequities that we see across social groups. Government policy, including federal policy, can certainly influence these forces through things like taxation, government services, and investments. For example, government aid during COVID-19 resulted in dramatic reductions in poverty: the number of people living in poverty fell by 14.5 million between 2019 and 2021 (a whopping 35 percent reduction). But this progress was fully reversed in 2022, when pandemic aid ended.²⁹

Although rarely made visible, many of the fundamental drivers of population health are inextricably linked to our economic system, a system which itself generates ill health and inequities in health. This is not because of greed or unscrupulous business leaders—although there are of course plenty of those! The health consequences are simply a function of how the system works, an “emergent property” of the system, some might say. These effects operate through many different mechanisms including environmental impact and degradation (e.g. air pollution and climate change); workplace hazards for workers (both physical hazards and stressors); production, promotion, and consumption of unhealthy products (e.g. ultra-processed foods and tobacco); and the generation and reinforcement of inequalities in access to the resources (e.g. health care and housing) needed to sustain a healthy life. Government action and regulation can be partly effective in counteracting some of the adverse health consequences of the economic system. It’s clear by now that the Trump administration will fully withdraw from this responsibility. This does not bode well for public health. But a bigger question, that goes well beyond the impact of Trump’s presidency, is whether we are prepared to see fully and someday address the elephant in the room: the need to change the way our economy works so that it generates health and sustainable well-being for all, instead of inequality, disease, and environmental ruin.

The initial actions of the Trump administration have many implications for public health: threats to federal funding of scores of public health-related programs (including services like federally-funded health centers) with very concrete consequences both in the US and globally; elimination of initiatives designed to support the development of the diverse workforce that is needed for public health to be effective; retreat from the rights of immigrants; calls to end so called “gender ideology” and the rights of gender and sexual minorities; elimination of efforts to protect racialized groups from environmental hazards; withdrawal from the World Health Organization; impacts on government-funded public health research, and many more. The real impact of all these orders, whether they will survive legal challenges, and whether they can even be fully implemented, remains to be seen. Perhaps their most important consequence is what they have signaled regarding social norms and values, and the sense of chaos and threat that they have created. In many ways the worst thing they have done is create confusion and paralysis that can lead to inaction, exactly what is needed to advance the radical agenda behind the Trump presidency.

In a sinister twist reminiscent of Orwell’s 1984, federal health agencies and many of their contractors, including institutions presumed to be independent of government influence but heavily dependent on federal funding, are, as I write, scrambling to remove banned or problematic words from their websites and documents: words like gender, equity, diversity, inclusion and even climate. The extreme and bizarre nature of these prohibitions cannot be overstated. They have involved, for example, eliminating questions about gender from standard surveys, questions that have been asked for decades, or avoiding the use of the term “health equity,” which is at the core of public health research and practice. The National Science Foundation purportedly has been screening research proposals for indications that they violate recent Executive Orders using a list of terms that apparently include items like “women” and “people of color,” and even “climate science.”³⁶ NIH Study Sections (committees of scientists that review grant applications to NIH) have apparently been prevented from reviewing grants on certain topics (e.g. impacts of racism on health, or the health of sexual and gender minorities) with no explanation given (grants were pulled from review at the last minute). Proposals submitted by trainees from groups underrepresented in biomedical research were previously scrapped as part of the elimination of DEI efforts. The CDC has ordered scientists to retract scientific publications that use banned terminology or focus on banned subjects, specifically gender, transgender, LGBTQ-related topics.³⁷ Perhaps the most sinister aspect is that the “lists” of banned terms and topics are evolving and hard to pin down; sometimes it is not even clear that any lists actually exist. And the bans implemented by federal mandates are reinforced by intense and pervasive anticipatory self-censoring on the part of individuals and institutions. Some argue that this is just code-switching, that the terms don’t really matter, but I wonder about the path that this puts us on. In his famous essay “Politics and the English Language,” Orwell argued that “thought corrupts language but language can also corrupt thought.” So, it is not only about the words we use but also about the thoughts those words allow us (or do not allow us) to think.

In my role as a senior faculty member at a university I have many junior faculty and students come to me asking for advice. They ask me whether they should pursue the research they think is important and necessary to advance health (including health equity) and to develop and implement policies that protect public health. They are scared and worried that they will be targeted and that their grants will not be funded and their papers not published. They ask if they should cut certain words or sections out of their grant proposals. Having grown up in Argentina during a military dictatorship, when certain terms were considered “subversive” and my parents advised me to be careful what I said in school, I find it hard to believe that I am getting these questions today in the United States. This is alarming, as it signals self-censorship and an understandable fear to express even expert opinions, let alone views, something that was, sadly, accelerated in society at large but especially in US universities over the past year, even before Trump was re-elected. It signals a possible change in social norms and expectations away from the idea of an open society willing to grapple with complicated issues, a retreat from what many of us thought were unalienable principles (including human rights, social justice, the value of knowledge and scientific debate, and even freedom of speech) accepted by all. I tell my colleagues to be smart about how they pursue their research, but to do it still. I tell them their work must continue, that somehow it will. But I also know, and they know, that the challenges are real, that federal funding for certain kinds of work will be suppressed, and, unfortunately, that the funding of grant proposals is probably among the least of our problems.

It’s hard to know how all this will evolve and whether the most bizarre and extreme elements of recent executive orders and other actions taken by the new administration will survive. I know for sure that even in the short time between submission of this piece and its publication many things will have changed. But what is certain is that public health is and will continue to be at the core of the administration’s attack on government action, environmental regulation, promotion of equity and inclusion, and science for public good. As others have argued³⁸ facts and science can be a weapon and a tool for resistance. It’s hard to be optimistic, but, as I also tell the junior faculty and colleagues who ask me, all we can do is keep going, and resistance, which requires a level of optimism, is the only choice.

February 6, 2025