All of this is occurring while Congress remains gridlocked by partisanship, fueling further doubt that public health will be high on the federal agenda. An ideological schism is evident in a recent study by Jonathan Purtle, DrPH, MPH, MSC, assistant professor of health management and policy at Dornsife. Purtle found that Democrats in the U.S. Senate are four times as likely as Republicans to vote for legislation that has been endorsed by the American Public Health Association.
But some resilient professionals in public health take a long view, and warn against despair.
“There have been previous administrations that have taken very deliberate actions to do away with protective regulations and we have survived,” says Jennifer Kolker, MPH, associate dean for public health practice at Dornsife. “We have to remain vigilant about what is going on at the national level, but meanwhile there are a lot of opportunities for public health, especially at the local and state levels.”
The president’s FY2018 draft budget, and the executive orders he has already signed, are windows into the new administration’s priorities. Congress is certain to alter his proposed budget in the coming months, and the courts will likely weigh in on some aspects of his agenda, but a significant impact on public health seems likely.
That thrust is especially apparent in the swift rollback of climate-change initiatives, with their deeply intertwined impact on human and planetary health. Trump initially proposed to cut the Environmental Protection Agency (EPA) budget by 31 percent next year, a draconian reduction that reflects his muchgreater interest in “ investing in defense, and less on the environment, on health and on social services,” says John Rich, MD, MPH, professor of health management and policy at Dornsife. He also has directed the EPA to rescind the Clean Power Plan, intended to reduce carbon emissions from power plants; signed legislation repealing limits on the mining waste that can be dumped into streams; and ordered a review of the Corporate Average Fuel Economy standards, which dictate fuel efficiency for cars and light trucks.
There have been previous administrations that have taken very deliberate actions to do away with protective regulations and we have survived."'
- Jennifer Kolker, MPH, associate dean for public health practice at Dornsife
There are also clear signals that Medicaid coverage is at risk. Reducing any access to health care has a measurable impact on many populations, but does its greatest damage to vulnerable people of color. “When you cut people off from insurance you undermine the fundamental public health ideas of preventing chronic diseases and eliminating health disparities,” says Rich.
Global public health activities are another target. In January, Trump signed a memorandum barring federal funds to any overseas health organization that provides abortions, or even discusses them. As well, his proposed budget eliminates the Fogarty International Center, a tiny line item within the National Institutes of Health that belies its critical role in building global health leadership.
Other political decisions will also weigh on public health. Enforcement action in immigrant communities could discourage undocumented residents from seeking timely medical care. The Trump administration has signaled greater interest in “law and order” than in taking aim at mass incarceration or monitoring troubled police departments, despite the well-documented health benefits of criminal justice reform. Proposed budget cuts at the Department of Transportation would reduce funding for mass-transit projects that help foster vibrant, mixed-use communities.
Skepticism about science itself is another looming threat. “The current disregard for scientific evidence and the scientific process is unprecedented and very concerning,” says Jonathan Patz, MD, MPH, professor of environmental studies and population health sciences at the University of Wisconsin-Madison. “Science is there to inform policy. To shut science out of decision-making is a very dangerous development.”
At the same time, there are glimmers of hope. The FY2018 budget preserves funding for the President’s Emergency Plan for AIDS Relief, the global HIV initiative launched under President George W. Bush, and for Gavi, the global vaccine alliance. The budget also creates a Federal Emergency Response Fund, a dedicated pool of resources designed to be immediately available in the wake of a crisis, such as an infectious disease epidemic.
The scientific community has to be better at talking to decision-makers and aligning our research with imminent, critical policy decisions."
-Franco Montalto, PhD, associate professor in the Department of Civil, Architectural and Environmental Engineering at Drexel
Reassuringly, turning the ship of state is a slow process. “Much of the nuts and bolts of public health work will continue,” says Kolker. “A lot of people are just going about their jobs, keeping their heads down and continuing to maintain the public health status quo.”
Reframing Public Health for Today’s Environment
But in today’s political climate, more upheaval is likely. Researchers and practitioners should respond by becoming advocates, says Franco Montalto, PhD, an associate professor in the Department of Civil, Architectural and Environmental Engineering at Drexel. “The scientific community has to be better at talking to decision-makers and aligning our research with imminent, critical policy decisions.”
Field agrees on the importance of a broader reach. “The academic community needs to be out in front, expressing its opinions in public forums, blogs, white papers, websites and op-eds. The advocacy community needs to be aggressive in terms of outreach to policymakers, legislators, and regulators,” he says. “The two communities need to work together to show the public what it has, and what it stands to lose.”
They can best do that by mastering the art of storytelling, says Alex Ortega, PhD, who chairs Drexel’s Department of Health Management and Policy. “The way we describe our research tends to be so bland. We need a totally different paradigm if we are to be researchers and activists.”
Recasting public health messages to mesh with current federal priorities is one vital approach. For example, job creation is at the top of the Trump agenda. So, the International Monetary Fund’s estimate of a net gain of 2.7 million American jobs from clean-energy investments could resonate.
The administration’s interest in rebuilding the nation’s infrastructure suggests another avenue. “We have been neglecting our public health infrastructure just as we have allowed our roads and bridges to deteriorate,” says Ruth J. Katz, JD, MPH, who heads the Aspen Institute’s Health, Medicine and Society Program. “Let’s remind our leaders that investing in disease surveillance, walkable cities, and community health systems is as important to our economy, and to the health of all Americans, as many other pieces of core infrastructure.”
Countering misleading memes is also important. “We need to be mindful of the language we use. When the Trump administration talks about ‘job-killing regulation,’ what’s forgotten is that regulations are protections,” says Patz. “The Clean Air Act and the Clean Water Act are not there to hold back industry. They were established to mitigate the effects of pollution and protect human health and well-being.”
Linking public health and strong national security may be another way to shift gears. From climate change to infectious diseases, policy decisions related to global issues have significant implications for the safety and well-being of all Americans. “Global health security is a public good,” wrote members of the Commission on a Global Health Risk Framework in the New England Journal of Medicine (January 13, 2016). “Making each of us safer depends on making us all safer; gaps in one community’s defenses are gaps in all our defenses.”
The Work Goes On
Whether or not the current administration ultimately recognizes how public health dovetails with its agenda, research and practice in the field are expected to remain vigorous.
If there is a bright spot, it is the ongoing mobilization of people who realize that without organized voices continually holding their leaders and elected officials accountable, a lot of damage can be done."
- John Rich, MD, MPH, professor of health management and policy at Dornsife
On some issues, there is simply no going back. Shortly after the November 2016 election, Montalto was attending an international meeting on climate change in Marrakesh, Morocco. Participants were anxious to know whether the Obama administration’s commitment to the Paris climate accord, formalized a year earlier, would still be honored. Trump’s tweets, such as the one claiming that the concept of global warming “was created by and for the Chinese in order to make U.S. manufacturing non-competitive” gave them cause for concern.
U.S. corporate representatives at the meeting offered a reassuring perspective: They had already altered their business models to accommodate carbon-emission reductions and would stay the course. “There is only so much that the political shifts in one country are going to be able to push us towards a different model,” Montalto says. “We are moving forward.”
The field’s vitality is also evident in a growing commitment to systems-thinking and cross-disciplinary initiatives. One illustration is the growing recognition that multiple benefits accrue from creative design in the built environment. Whether it is how park land can promote recreation and capture stormwater to prevent sewer overflows; or how green rooftops can provide better building insulation, reduce local air temperatures, provide new habitat for bees, and engage local residents in gardening, “the sky is the limit in terms of innovative thinking,” says Montalto. “The federal government doesn’t get on the drafting board of these projects. The onus is on us as designers to think across domains in everything we build.”
The bulwark of public health has long held back threats, both natural and manmade, and this political season is no exception. “If there is a bright spot, it is the ongoing mobilization of people who realize that without organized voices continually holding their leaders and elected officials accountable, a lot of damage can be done,” says Rich.
Their vigilance is especially important when the evidence base that informs policymaking is challenged, says Patz.
We can’t keep our own supply of air, we can’t avoid contact with people who may have infectious diseases, we can’t live in bubbles. Only communal activities can keep us healthy."
-Robert Field, PhD, MPH, JD professor of health management and policy at the Dornsife School of Public Health at Drexel
“Where science is misrepresented, there needs to be a very quick and clear response about what the science actually says, and what we know and don’t know. Scientists need to make sure that science is not co-opted and interpreted by non-scientists,” he says.
Perhaps the most compelling argument for maintaining the nation’s commitment to public health is at once practical and moral. “It is not every man for himself,” says Field. “We can’t keep our own supply of air, we can’t avoid contact with people who may have infectious diseases, we can’t live in bubbles. Only communal activities can keep us healthy.”
Whither Public Health? We Talked About It!
After the November presidential election, the Dornsife School of Public Health hosted three public gatherings to discuss the challenges facing public health under the new administration. The sessions offered a starting point for renewal of our commitment to protect and promote the health of the public.
December 1, 2016: The 2016 U.S. Presidential Election: Implications for Public Health moderated by Ana V. Diez Roux, MD, PhD, MPH, Dean
March 2, 2017: Public Health Implications of Changes in Environmental and Climate Policies moderated by Jerry Fagliano, PhD, MPH, Associate Clinical Professor and Chair, Environmental and Occupational Health
May 3, 2017: The Future of Health Care Policy moderated by Alex Ortega, PhD, Professor of Health Policy and Chair, Health Management and Policy