Trump’s Choose-Your-Own-Adventure Health Agenda Is a Wake-Up Call for Cities and States

Donald Trump has taken office with a view on health policy that has left many in the medical field concerned. Despite the rhetoric that his team will take on long-entrenched issues of nutrition and diet-related chronic disease while it “Makes America Healthy Again”, there is no doubt the Trump health orbit—particularly the nomination of Robert F Kennedy, JR. for United States Secretary of Health and Human Services (HHS) and David Weldon to lead the Center for Disease Control and Prevention (CDC)—comes with a strong and dangerous dose of vaccine skepticism, anti-science rhetoric, and a go-it-alone, choose-your-own-adventure mentality to health.

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This new, alarming reality, arriving in the midst of winter respiratory virus season and evinced by Trump’s executive order to withdraw the United States from the World Health Organization, and a freeze on all health communications from federal agencies, sends the message to Americans that you’re on your own. That your health is your business alone, and that the government is no longer in that business.

For those of us who have dedicated our lives to improving health across this nation and beyond, we know this not only won’t work but also makes us less safe. Because health and wellbeing are not simply personal pursuits, but are also shaped by risks and conditions around us that we can only address together. Think about the air we breathe, the food we eat, whether we have a gym or green space nearby that is accessible to exercise, or whether we can see a doctor or afford medications when we need them. These are shaped by policy, and the things we decide to do as a nation—as Americans.

Read More: What Leaving the WHO Means for the U.S. and the World

The federal abdication of health should be a wake-up call for state and local governments to redouble and reimagine their commitments. With significant cuts to the CDC already proposed by House Republicans, and additional saber-rattling about defunding of related public health agencies, states, and cities—like New York City, where I was health commissioner for the last three years—no longer have the assurance that the federal government will step up to combat public health threats, known and unknown. In fact, states will likely operate under significant financial constraints.

A significant portion of the funding for core public health functions in states and cities—think things like disease outbreak investigations and contact tracing, data collection and surveillance, diabetes and chronic disease prevention programs, and more—comes from the federal government. More than 70% of the CDC’s $11 billion budget, for example, directly supports state and local health programs. So when dramatic cuts are proposed—like the House’s 22% reduction in CDC funding for this fiscal year—it is everyday Americans who are most impacted.

This might manifest in slower responses the next time a new infection or threat appears, more women having to navigate pregnancy alone, and less support for new mothers and families in the home after a child is born. This might also mean cutbacks in efforts to slow overdoses, which in cities like New York are responsible for more deaths than auto crashes, homicides, and COVID-19 combined, and which are just beginning to show progress in bending the curve, due to concerted public health attention and investment, much from the federal government.

It will also be harder to continue to mitigate the health impacts of extreme heat and weather caused by climate change, which kills thousands across the country each year and which has accelerated events like the deadly wildfires in Los Angeles which have killed many, to say nothing of their long-term health and mental health impacts on the region. Even funding for food safety and infection control in restaurants, in some jurisdictions, receives federal support, ensuring that Americans can confidently choose where to eat without fear of falling ill.

This is to say nothing of the impact that Trump and his team will have on science and trust, and the challenges for states and localities to combat misinformation coming from the highest levels of government. Vaccine hesitancy and skepticism pushed by HHS Secretary nominee Robert F. Kennedy Jr. has already had deadly consequences around the world, and have contributed to falling childhood immunization and routine vaccination rates here in the U.S. This, in turn, has caused an upsurge in preventable infections, like measles, that we had thought we had relegated to the past.

The American public will have to look to state and local governments to dispel the flurry of misinformation already plaguing health communication. Health officials have a sense of duty to convey responsible, empirical, and scientific communication to the public, and even more so after Trump’s early action to freeze federal agencies from doing the same.

The good news is that most states and localities have spent months planning for these scenarios. They have the benefit of experience from the first Trump term on how to do more with less, and how to protect essential public health functions and messaging in the face of attack. Whether it’s strengthening vaccination policies, locally funding wastewater surveillance, or strengthening data systems, or hiring and retaining public health workers, cities, counties, and states are already getting creative to ensure core services do not lapse in the face of trickle-down budget cuts from Washington.

That said, it’s important that states and cities don’t simply hunker down and protect their essential health work, but that a clear roadmap for the future emerges. And the good news is that, in both red and blue states, there are models designed to keep citizens well in the short term and live longer, healthier lives in the long run—that point the way forward and through this time of uncertainty and tumult.

First, state and local governments should set out a long-term health plan to act as a bulwark to short-term health chaos caused by the Trump administration. In New York City, for example, we set a goal to bring New Yorkers to their highest-ever life expectancy of 83 years by 2030 after a period of unprecedented decline, by reducing preventable and premature deaths from leading causes like chronic diet-related diseases including heart disease, cancer, and diabetes, and addressing mental health in youth, tackling overdoses, and addressing the intersection of severe mental illness and homelessness.

This umbrella strategy, HealthyNYC, was passed into local law and has shown some early progress, while similar plans have been adopted or considered in places like Boston, Chicago, and others. This type of vision and planning creates opportunities for consensus, partnership, and even funding, across sectors and ideologies. Because everyone wants their hometown or home state to be healthier, in the end, because it means they and their kids, or their employees and community, are more likely to be healthy as a result.

Meanwhile, red states like Indiana are proof that public health and healthy longevity can be a unifying issue. The state that Donald Trump won with more than 58% of the vote made a historic commitment to help Hoosiers live longer than the currently expected 74.6 years, by increasing their public health spending a whopping 1,500%, putting counties and localities in control of the spending. Gov. Eric Holcomb recognized that bread-and-butter community health issues like maternal and mental health, HIV and STI services, mental health, and overdose response, among others, were a part of the basic guarantee that the government makes with all constituents, regardless of party or race or location. They will keep them safe and make things better in meaningful, tangible ways that people can see while doing so in a “fiscally responsible” way that reduces back-end treatment in favor of front-end prevention. This is likely to be a winning health strategy that all elected leaders should heed.

If the federal government intends to shrink its health footprint, states, counties, and cities must expand theirs, and do so in smart, strategic ways that are not simply reactive to preserve what we have, but point forward, to a brighter healthier future for us all.

What could be more American than that?

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