Trump presidency threatens global health

The Past As Prologue

A potential displacement of orthodox thought, science, and knowledge may be observed from the candidates for key health positions put forward by the new US administration. Efforts to substitute accepted knowledge and practice for ideologically driven changes and loyalty-assured practices are likely to have profound consequences on health, domestically and globally.

While the regulatory and policy endpoints cannot be known at this time, this group’s distrust of traditional elites and their institutions, knowledge, and policy is well documented. While none of us has a crystal ball to see where this might take us, the ramifications of such an agenda may well subvert or co-opt all the hierarchies that produce today’s orthodox knowledge, particularly scientific and medical knowledge.

There are historical parallels to this kind of delegitimization of orthodox knowledge and the stigmatization of those who produce it, for instance the 1930s’ Europe, when populism and heterodox ideologies were able to dilute democracy, knowledge, and science through seemingly legitimate ways. In short, there is much on record about how such governments, through the displacement of one elite for another, can subvert and rewrite world class science and medicine in order to serve a particular ideological end.

Many lives at stake. Artist Suzanne Brennan Firstenberg walks among flags representing Americans who died of COVID-19. Photo: Patrick Semansky/AP/TT

It might be useful to look at a relatively recent example of when high prestige academic and scientific institutions, policy and thought were captured by an autocratic regime. The development in the post WWII Baltic states may give a better understanding of what the present may have in store.

It is probably not well known to many that a consistent strategy during the Soviet post-WWII occupation of the Baltic states was to dispose of the intellectual elites, rewrite orthodox knowledge, and reinvent these states’ legitimate and well-respected knowledge institutions in its own image. For instance, early modern Baltic ethnology, a prestige science at the time, was one of the first sciences systematically rewritten along Soviet lines. While ethnology and folklore may be perceived as relatively arcane fields, they were primary instruments that declared the uniqueness of the Baltic people, thus their right to be nations. As such, it represented a direct challenge to the Soviet and Slavophile impulses towards Russification and empire.

Following the Soviet occupation and the deportation of those scholars thought most dangerous to the state, the academic landscape was collectivized. All ethnological and folklore efforts were consolidated into State Academies of Science, and publication and fieldwork became possible only through state sanctioned collectives. Further, ethnological research, under the eyes of a new Sovietized elite, was re-focused towards whatever might serve the Soviet state and contributed to creating the new Soviet man.

WHO centers responsible for eradicating polio may have to be shut down. In this picture a child in Pakistan receives an oral vaccine against the disease. Photo: K.M. Chaudary/AP/TT

A Potential US Scenario

With this historical backdrop, imagine what institutions essential for population health may look like in the US under the incoming administration. President Donald Trump has announced the nomination of Robert F Kennedy Jr, a vaccine denier, to head the Department of Health and Human Services. He also has named David Weldon as head of the US Centers for Disease Control and Prevention (CDC), Martin Makary to head the Food and Drug Administration (FDA), and Janette Nesheiwat as Surgeon General.

Weldon is a physician specialized in internal medicine who has served 14 years as a member of the House of Representatives. As a member of Congress, he was skeptical of vaccine safety. Makary is a physician and public policy researcher who also writes for the Washington Post and the Wall Street Journal and is the author of bestselling books. He has criticized the CDC’s response to the COVID-19 pandemic. As head of the FDA, Makary would lead the agency that approves vaccines and medical products and devices. Nesheiwat is a family physician and contributor to Fox News. The Surgeon General leads the communication of health information to the public.

The three nominees have in common, besides a critical attitude to the agencies they are supposed to lead, that they are known to the public and versed in mass media communication. The focus on “controlling the narrative rather than the matter” is further displayed by the fact that, on the second day in office, the new government ordered a freeze on communications from all health agencies despite an ongoing spread of avian influenza in birds and cattle throughout the US.

The WHO and its General Director Tedros Adhanom Ghebreyesus may see its resources cut by 15 percent if the US leaves the organization. Photo: Salvatore Di Nolfi/Keystone via AP/TT

After replacing the top leadership, the new government may continue substituting experienced persons in critical technical roles in the health agencies with similar “demagogues” by reinstating Schedule F, an October 2020 executive order that would have stripped job protections from senior government employees. Thereafter, expert scientists could be replaced with demagogues on the boards that issue recommendations on vaccination practices, e.g. the FDA Vaccines and Related Biological Products Advisory Committee and the CDC Advisory Committee on Immunization Practices.

The new government, in an ambition to “Reform Pharma,” could hereby easily introduce changes in the regulatory oversight of the pharmaceutical industry. For instance, it could petition FDA to reconsider all Emergency Use Authorizations (EUAs) of vaccines and refrain from approving New Drug Applications (NDAs) or Biologics License Applications (BLAs). This could leave large populations vulnerable to emerging and seasonal infectious disease as well as bioterrorist attacks.

Implications for Global Health

The first day in office, President Donald Trump announced that the US would withdraw its financial support and leave the WHO. For the 2022–2023 biennium, the US transferred as the largest contributor USD 1.28 billion to the organization, thereby providing about 15% of the total funding. The immediate effect would be that the WHO Pan American regional office headquartered in Washington, DC, would be forced to close as would more than 20 WHO collaborating centres, including those for polio eradication and global health security. Although the long-term consequences of a US retreat from the WHO, if it becomes manifest, are hard to predict, it will open for countries where human rights are restricted, such as China, to take over leadership position for global health. However, there are also, other, more delicate, ways a degradation of US health institutions would affect global health if positioned “to serve Americans first.”

A health worker attends to an mpox patient at a treatment center in Eastern Congo-Kinshasa, which like many other poor countries does not have any vaccine production capability whatsoever. Photo: Moses Sawasawa/AP/TT

For instance, global immunization coverage has recently seen some recovery from having plateaued in the decade prior to COVID-19. During 2022, about 84% of the 110 million infants worldwide received 3 doses of diphtheria-tetanus-pertussis vaccine. However, these figures obscure significant disparity and risks. Measles, because of its high transmissibility, acts as an early warning system; 22 million children missed their routine first dose of measles vaccine, most of them in low-income countries.

One-hundred ninety-six countries, including the United States, are signatories to the International Health Regulations, a compact intended to reduce the potential for disease outbreaks and pandemics. Maintaining high global vaccination rates worldwide protects not only lower-resourced populations but also international commerce and tourism. Given that, for instance, approximately 70,000 non-Americans fly into the United States daily, consideration must be given worldwide to the risks associated with disease spread not only within countries but also from travelers originating from countries where infections such a measles are common.

The current threat of an avian influenza pandemic calls into question the global capacity for increasing vaccine production to address emerging threats. There is a robust global platform for producing pandemic influenza vaccines based on seasonal influenza vaccine production facilities. However, estimates made in 2019 suggest that doses manufactured in one year could protect only one quarter of the global population against an influenza pandemic. While low-and-middle income countries represent 84% of the global population, 80% of pandemic influenza vaccine production capacity is in high-income countries, with only 19% in upper-middle-income countries, 1% in lower-middle income countries and no production in low-income countries. This implies that any disturbance of vaccine production capacity in the US could have significant consequences for infectious disease outbreaks in more than three quarters of the global population.

US health officials have been muted by the new administration while avian flu is spreading in the country. Photo: CDC/NIAID via AP/TT

Reducing US efforts in global vaccination would not only diminish its global health leadership, it could also compromise the health status of many US trading partners as well as reduce US economic growth. Severe supply chain interruptions during COVID-19 were a stark reminder of the economic interconnectedness of the US and other nations. Global health accords that foster reducing preventable diseases and try to improve the health of the global workforce would be weakened under any sociopolitical strategy that “puts Americans first”.

Final Thoughts

When leaders commit themselves to “world building” based on ideological, not empirical, knowledge, even unwitting populations are under threat. The growing number of countries with populistic leaders supported by oligarchs puts preventive health initiatives at risk globally, with the likelihood of large-scale disease outbreaks within this decade. A half century devoted to building the capabilities and infrastructures needed to combat public health crises could swiftly be erased as these regimes impede the scientific and institutional resources needed to continue reducing premature morbidity and mortality.

Some of today’s populistic leaders represent minor threats to democracies because they do not attempt to reconstruct the societal institutions or reinvent orthodox knowledge. History has shown that democracies with institutions where knowledge is freely produced and used for social progress are not “hedonistic playgrounds” that lead nowhere. Not only is the vaccination agenda worldwide at risk here. Rather, it is but one example of how a milestone in human progress could be undercut and even reversed. Many commentators have warned of the threat that the recent developments pose to the Enlightenment values that sustain today’s democracies. What is worrisome is that few have realized that contained in this is an agenda that at its heart intends to subvert the very institutions, scientific practices and empirical knowledge that drives progress in a democracy and gives its legitimacy.

There is more at stake today than we had imagined.