America’s Public Health Breakdown Is Just Getting Started

The United States has a health-care system that is terrible and getting worse. It also has a health science system that is the best in the world and about to be dismantled.

The impending return of Donald Trump to the White House seems likely to collapse American health science, with consequences as disastrous for the rest of the world as for the approximately 340 million Americans in the U.S. Canada may be able to soften the impact here, but it will not be easy.

An alarm went out early in December from The Lancet, probably the best medical journal in the world. In a special issue dedicated to U.S. public health under the second Trump administration, one journal article described the impact of American expertise on the rest of the world.

It’s an impressive achievement: victories against yellow fever and polio, HIV-AIDS and malaria, maternal and infant mortality, tuberculosis — not eradicated like smallpox, but greatly reduced.

And American health spending has saved countless lives around the world.

“The U.S.A.’s commitments and leadership have resulted in US$278.1 billion provided by the U.S. government to lower- and middle-income countries for health since 2000,” the report reads. “These investments, which were only 0.3 per cent of U.S. government spending in 2023, were 29.1 per cent of the total development assistance for health provided by all donor countries.”

The article cited a study that found “$1 billion in health aid could be associated with as many as 364,000 fewer child deaths.”

But funding for such projects is likely to shrink dramatically under Trump. And American health care at home — already bad — is likely to get much worse.

One Lancet article illustrated the disparity in health equity across the United States through its lens of “10 Americas,” or 10 mutually exclusive Americas comprising the entire U.S. population.

Through this framework, each of the 10 Americas has its own health traits and life expectancy. The group called “America 10,” which includes “American Indians and Alaska Natives,” has life expectancies over 20 years shorter than the 83 years for “America One,” composed of Asian Americans since the onset of the COVID-19 pandemic.

Other Lancet articles dealt with the burden on the U.S. health-care workforce, the growing threat of opioids called nitazenes (“even worse than fentanyls”), and the burden of diseases in each state, both in the recent past and the near future.

With Trump’s inauguration, a grim shift

Taken together, The Lancet articles present a discouraging future, especially since drug use, obesity, air pollution and smoking are expected to persist. Eliminating them, one article argues, could prevent as many as 12 million premature American deaths between 2022 and 2050.

The journal also offered a “roadmap” for the incoming Trump administration, offering five priority areas for U.S. health strategy: “Improve public health and address health and social inequities; catalyse transformation towards a more effective, equitable health system; address crucial health issues such as climate change; advance artificial intelligence for health and health care; and strengthen responsible science and innovation.”

Given Trump’s statements and recent appointments to health-leadership positions, however, few if any of these subjects will get serious attention. Health equity and climate change will assuredly be non-starters in Trump’s administration.

Robert F. Kennedy Jr., the nominee for Secretary of Health and Human Services, is a famous advocate against vaccines. He has said that on Jan. 20, 2025, the day of Trump’s inauguration, he will fire 600 employees at the National Institutes of Health, and replace them the next day with 600 new people who will shift NIH’s focus from infectious diseases to diseases like obesity.

“We’re going to give infectious disease a break for about eight years,” Kennedy reportedly told an anti-vaccine group.

Vaccine skeptics in public health leadership

The lawyer helping Kennedy with other Health and Human Services nominations is Aaron Siri, who has petitioned the Food and Drug Administration to revoke approval for the polio vaccine and stop distributing 13 other vaccines for diseases such as tetanus, diphtheria and hepatitis A.

Dr. Jay Bhattacharya, named by Trump to lead the National Institutes of Health, signed the Great Barrington Declaration early in the pandemic; the declaration called for protecting only the old and vulnerable, on the assumption that everyone else could catch COVID-19, acquire lifelong immunity, and go right back to work.

Even at the start of the pandemic, most health experts rejected this “let ’er rip” approach, and events have proven them right.

As well, Trump has nominated Dr. Mehmet Oz as administrator of the Centers for Medicare and Medicaid Services. Oz has shifted sharply from “moderate Republican” positions on issues like public health and abortion to reliably Trumpist positions.

Such persons are unlikely even to be aware of the articles in The Lancet, much less eager to implement their recommendations.

Trump’s health nominations triggered a strong negative response among U.S. public health experts and scientists.

Dr. Angela Rasmussen, an American virologist working at the University of Saskatchewan, was quoted as saying, “I don't think that Jay Bhattacharya belongs anywhere near the NIH, much less in the director's office.... That would be absolutely disastrous for the health and well-being of the American public and actually the world.”

Not just a bureaucratic disaster

The disaster would not just be in federal health agencies. In 2021 alone the NIH spent $32.3 billion on medical research carried out in American universities and medical schools in every American state, plus Canadian and other foreign institutions.

Diverting NIH funds from infectious disease research looks especially foolhardy, given the ongoing COVID-19 pandemic and the increasing likelihood that H5N1 avian influenza will learn how to jump efficiently from birds or dairy cattle to humans while keeping its 52 per cent case fatality rate.

Now imagine the consequences when not 600 but scores of thousands of health scientists find their research at the mercy of Trump’s nominees. Think of the graduate students, many from overseas, who will be unable to continue their studies as research funds vanish or move to other fields. What will they do, and where will they go?

Many will start looking to the Government of Canada’s website on how to immigrate, hoping to find jobs in universities or provincial or federal public health. They would be an astounding windfall of talent, with a precedent.

In 1957, the University of British Columbia welcomed the Hungarian Sopron Division of Forestry — 14 faculty members and 200 students, refugees from the 1956 Soviet crackdown on Hungary. We paid their travel costs and provided accommodation, English lessons and financial aid to students and faculty alike, for five years. Many stayed and built careers here.

That kind of ambitious acquisition is likely beyond any modern Canadian university’s (or government’s) ability. But by recruiting individuals and laboratories, universities and health agencies could greatly strengthen their research capabilities, attract new students and research funding, and thereby improve the health of Canadians and other people around the world.

Such recruitment would likely be rejected by Conservative-led governments, because such scientists would be “tainted” in the eyes of anti-vaccine and “medical freedom” groups. They would also arrive amid a flood of disinformation from Trump supporters, plus threats of still more tariffs.

But we could at best help only a fraction of some of the best health scientists in the world, and we would likely be competing for them with nations like Australia, France and the Nordic countries.

Still, some provincial governments might welcome a few top scientists and their students, if only until the 2028 U.S. presidential election (if there is one).

Manitoba is already advertising for U.S. physicians with a tempting invitation: “Practice medicine with stability, predictability, and zero political interference between you and your patients."

We should also plan for the return of Canadian experts who find it difficult to continue work in the U.S. As the American poet Robert Frost once put it, “Home is the place where, when you go there, they have to take you in.”

For the next few years, Canada should be home to as many American scientists and educators as we can squeeze in.