By David N. Sundwall M.D.
AJPH, April 2018 (published online March 7, 2018)
The election of Donald J. Trump as president of the United States was an unexpected and extraordinary event in the history of our nation. His presidency has resulted in dramatic changes in our politics and our policies and unease in much of our population. Those of us committed to public health and ensuring that government programs devoted to the well-being of our citizens be sustained have been perplexed, confused, and frustrated, to say the least. We are not alone—this situation applies to much of the federal government’s agencies, the federal workforce, organizations representing the public’s interests, and our fellow Americans.
Notwithstanding this uncomfortable uncertainty…regardless of who is in the White House, we (in public health) have important and essential work to do, and we must continue to do it with the budget provided and at the direction of our elected officials. We need to do our work as well as we can with the resources provided and within the scope of the laws authorizing our activities. This does not mean, however, that those of us in public health positions, or for that matter any person or group with an interest in public health, should not advocate to sustain and strengthen our nation’s public health enterprise. An important exception is those federal employees constrained by Hatch Act, which prohibits them from engaging in political activities. (This federal law, which was passed in 1939, limits certain political activities of federal employees, as well as some state, District of Columbia, and local government employees who work in connection with federally funded programs. The law’s purposes are to ensure that federal programs are administered in a nonpartisan fashion, to protect federal employees from political coercion in the workplace, and to ensure that federal employees are advanced on the basis of merit and not on the basis of political affiliation.)
So, accepting that these are difficult times when nothing seems to be done as it previously was, how do we go about advocating public health? The following are just a few of the principles I identified that I think are especially relevant to our current circumstance:
* The importance of being honest, informed, and evidence-based—earnest advocacy will not likely get very far without data and information to support a proposal.
* The importance of not judging a book by its cover—the confirmation process for US Surgeon General C. Everett Koop. Yet, once confirmed, he proved to be an effective leader and champion of public health for all, especially those infected with HIV as this epidemic unfolded during his tenure. Could our new Surgeon General, Jerome Adams, also become an outstanding advocate for public health in this position?
* The importance of building bridges—unlikely allies in working together for reauthorization of the Maternal and Child Health Care Block Grant. The Children’s Defense Fund, a liberal Washington, DC–based organization, came together with a group in South Carolina affiliated with the Southern Baptist Coalition, a staunchly conservative organization, to advocate together for the maternal and child health programs.
* The importance of science-driven policy—the National Organ Transplant Act of 1984: Notwithstanding evidence that some of our elected officials seem to be “anti-science” and do not want to be “confused by the facts,” I contend that a significant majority are not. It is essential that we use current scientific knowledge to bolster our case for new and better public health policies.
* The importance of regulations and rules in addressing policy issues—how to achieve administrative simplification, efficiency, and effectiveness by changing the rules, not the law: The opportunity to achieve policy objectives through modifying existing rules and regulations of public health laws is often overlooked. The Trump Administration is committed to such administrative simplification, deregulation, and therefore is likely to support such proposals for constructive changes.
* The importance of understanding and respecting “who’s in charge” and of nonpartisan advocacy, for public health—cultivating relationships with key elected officials: I think it is fair to generalize that, historically, most advocates for public health have favored a strong federal government role in funding public health initiatives, and have favored regulations holding states and grantees accountable to achieve improved health outcomes. The current Administration and the majority in Congress favor a more limited government role, less spending, and less regulation. The most pressing challenge for public health advocates now is to ensure adequate federal funding for public health programs. So, regardless of personal political views, we must invest time and effort to know those currently in charge—our elected officials and their staffs—to seek compromise in funding levels and regulations to sustain our public health enterprise. Our collective efforts to educate and inform key elected officials will be essential to counter harmful proposals in President Trump’s 2018 budget and also to prevent harmful provisions in the Congress’s budget proposal. We will also need to work together to correct potential problems in the recently passed tax reform legislation.
To successfully advocate sustaining and strengthening our nation’s public health enterprise, I recommend we rely on these six time-proven principles.
Woolhandler and Himmelstein Respond
By Steffie Woolhandler M.D., M.P.H., and David U. Himmelstein M.D.
Who could disagree with Sundwall’s advice to be honest, open-minded, optimistic, and inclusive? But the Trump administration’s authoritarian, antihealth drift demands a stronger response.
Even before Trump, public health was lagging. Funding has been drifting down and death rates creeping up, driven by widening inequality and unrelenting oppression of those at the bottom of the income scale. Although President Obama may be faulted for inadequate responses, his successor has unleashed an all-out assault on the nonrich, non-Christian, nonmale, non-White, non-American—as well as on nature itself. Even George Orwell might flinch at the Centers for Disease Control and Prevention leadership’s ban on words like “science-based,” “evidence-based,” “vulnerable,” “transgender,” and “fetus.”
Yet, the defeat of frontal attacks on the Affordable Care Act (ACA) indicates that health is perilous terrain for Trumpism. The fight against repeal called out legions who packed town hall meetings, disability and other activists who braved arrest, and scholars, journal editors, and journalists who spread the word of mortal and financial consequences from uninsurance. Republicans could only sliver off the Obamacare mandate under cover of a tax bill.
But defensive efforts like those that fended off ACA repeal are not enough. Medicaid—as well as Medicare, SNAP (food stamps [Supplemental Nutrition Assistance Program]), and TANF (welfare [Temporary Assistance for Needy Families])—are also in Congress’s crosshairs. They’ll claim that the ballooning deficits ensured by the new tax law compel cuts.
During the 2016 presidential campaign, Trump’s racist and nativist appeals found fertile ground among beleaguered White working-class voters eager for scapegoats, while the wealthy and powerful needed no dog whistle to understand what Trump could do for them. In response, mainstream Democrats proffered little to ameliorate working-class pain, nor did they threaten to discomfit the wealthy.
The promise—and reality—of sweeping social changes offers the only effective antidote to the president’s reactionary populism. A full turn away from capitalism is not currently on the agenda. Yet experience in other nations—and in ours in the past—shows that redistributing income through taxes and social programs and attending to the environment can do much to improve health, while sustaining, and even spurring, overall prosperity.
Seven decades back, AJPH’s Editor Charles-Edward Winslow called for massive social investments to end the physical and emotional toll exacted “by malnutrition, by slum dwelling, by lack of medical care, by social insecurity” and urged “those who do not agree with me to mend their ways; and those who do agree with me to go forward with hope and courage.”
Such courage is now urgently needed. Public health professionals must put policies to the test of science and raise their voices to decry health-threatening ones. But we must go beyond that, joining others to organize for health-improving reforms and protest harmful initiatives.
As Sundwall notes, for many public employees (including us), politicking for candidates at work and using our employers’ resources, such as computers and e-mail addresses, are verboten. And running for office or soliciting campaign contributions may be off-limits. But while off-duty, we’re free to vote, contribute money, express our views, and protest.
The contrast between our nation’s spectacular wealth and sorry record on health and social indicators gives reason for hope as well as shame. We can readily afford to house, feed, educate, and heal all who are on our soil.
What’s needed is a new New Deal. For medical care, that means single-payer health care, not just defending Obamacare. We can find housing for the 3.5 million homeless in the 18.3 million vacant housing units; food from our abundant harvests can provide for the 41.2 million who suffer food insecurity; and funds can be diverted from the more than $800 billion our governments spend on prisons, policing, and defense to schools, mass transit, and social needs.
Politics, not economics, keeps us from ensuring that our water and air are clean, that carbon is kept from our skies, and that every community enjoys the full measure of prevention in homes, neighborhoods, workplaces, and medical offices. Envisioning what’s possible and fighting for what’s needed are not tangential to public health work. They are our core mission.
By Don McCanne, M.D.
Public health funding in the United States has always been a challenge as have the policy positions of our government leaders. Under the Trump administration the issues are even more difficult because of the anti-spending and anti-regulation ideology which forms a barricade to the public health spending and infrastructure that we need.
The fact that we spend so much on health care yet achieve on average only mediocrity is a sure sign that our government does not have the right policies in place. This applies not only to the health care system directly but to other elements that are essential in maintaining the health of the people. A prime example is that 3.5 million people are homeless when we have 18 million vacant housing units, just as The New York Times this week is reporting on 83 million eviction records. This is not just a failure of our public health system but a failure of our government at large.
The policies that would work are not difficult to understand, but the politics remain a barrier, which is even greater under the current administration. We would already have a single payer, improved Medicare for all if it weren’t for the politics.
David Sundwall I know personally to be a very dedicated, sincere advocate of public health policies. But he represents the all-too-prevalent view that we can do this within the political environment we have, by using his six principles. That approach alone is far too feeble, as our nation’s history demonstrates.
Steffie Woolhandler and David Himmelstein explain why we need much more than that. We need sweeping social change – a new New Deal. We have the resources. It is the politics, not the economics, that keeps us from our goals. We have to fight for what’s needed to make public health work. That must be our core mission.
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