On July 7, Tom Price, MD, secretary of the Department of Health and Human Services (HHS), announced the appointment of Brenda Fitzgerald, MD, as the 17th director of the Centers for Disease Control and Prevention (CDC). To this position, Dr Fitzgerald brings her experience as Commissioner of the Georgia Department of Public Health, a role in which she championed infant health and survival, tobacco control, and obesity prevention. Other significant choices of individuals to head agencies that affect the public’s health include the recent nomination of Jerome Adams, MD, MPH, as surgeon general, and reappointment of Francis Collins, MD, PhD, as National Institutes of Health director.
While such choices appear to bode well for public health, how well these agencies and others will be funded for programs affecting public health both inside and outside the United States matters enormously. What has the Trump administration signaled about its intentions in its proposed budget?
Domestic Public Health and Biomedicine
President Trump’s fiscal-year 2018 budget contains sharp cuts to just about everything in health and biomedicine—from global health, state and local public health, and grassroots community health through to biomedical research. Importantly, the budget calls for a 17 % ($1.2 billion) reduction in funding for the nation’s public health agency, the CDC, and its sister office, the Agency for Toxic Substances and Disease Registry, which investigates environmental health hazards. Former CDC Director Tom Frieden, MD, MPH, characterized the proposed budget cut as “the steepest in 20 years,” undermining CDC’s ability to find, stop, and prevent threats to US health.
Congress may well balk at steep cuts to the nation’s capabilities for public health and biomedicine. And while the CDC has never been a politically favored agency, the NIH maintains robust bipartisan support in the Congress. What seems crystal clear, however, is that the White House views public health as discretionary spending that is a source of budgetary savings, rather than as an essential public good. President Trump similarly wants far less resources devoted to international development assistance for health.
Domestic public health preparedness is more important now than ever, with a rising tide of opioid addiction, an ongoing obesity epidemic, a steady drumbeat of infectious and sexually transmitted diseases (including HIV/AIDS), and the growing prospect of antimicrobial resistance. Mental health services are woefully inadequate and need to be upgraded, not scaled back. Just last summer, the United States experienced a major scare (particularly among women who are pregnant or of childbearing age) as a Zika epidemic in Latin America and the Caribbean (including Puerto Rico) came to our shores. It could happen again.
Among the most worrying proposed budget cuts to the CDC include reductions in funding for domestic HIV/AIDS ($186 million), chronic disease prevention and health promotion ($222 million), and public health preparedness and response ($136 million), mostly for emergency preparedness for states and localities. This would hollow out vital services to prevent and control the nation’s major health threats.
The Senate Republicans’ collapsing health care bill, the Better Care Reconciliation Act of 2017, would have inflicted still deeper pain for the poor and middle class, in the form of loss of health insurance coverage for millions, immediate elimination of the CDC’s Prevention and Public Health Fund, severe cuts to Medicaid, and blocking of Medicaid reimbursements to Planned Parenthood. Overall, the bill would have constituted a major step backwards in our nation’s commitment to its people’s health.
And the White House’s deregulatory agenda could do real harm to the fight against obesity-related diseases. After sustained lobbying from the packaged food and beverage industry, the US Food and Drug Administration indefinitely delayed the launch of changes to Nutrition Facts labels that were intended to help people eat more healthfully. The label changes, championed by former first lady Michelle Obama, would require adding information about “added sugars” and highlighting calorie content in large, bold text. The rollout of the new label had been planned for July 2018 (with an extension of 1 year for smaller companies). The Trump administration also delayed rules requiring calorie counts on restaurant menus and future sodium reductions, while loosening minimum requirements for whole grain in school lunches.
Global Health Assistance
Beyond domestic public health preparedness, the CDC has been the global leader in fighting dangerous infectious diseases, with transformative work on Ebola and Zika outbreaks. Dr Frieden spearheaded an agency focused on global health security, with his signature initiative being the $1.1 billion Global Health Security Agenda (GHSA). In fact, when Secretary Price announced the appointment of Dr Fitzgerald to head the CDC, he referred to “working with Dr. Fitzgerald to achieve President Trump’s goal of “strengthening public health surveillance and ensuring global health security at home and abroad.” Yet, President Trump has proposed drastic cuts in global health assistance. The future of the GHSA is very much in doubt.
These cuts flow from the Trump administration’s “America first” philosophy, captured in the HHS budget outline, titled “Putting America’s Health First.” Given the cuts in domestic public health, that title is a misnomer. It also reflects a stunning failure to appreciate the interconnected nature of global health today—where the health of one nation is linked to the health of all nations—and the centrality of US health leadership to both our nation’s values and global leadership.
The administration’s idea of “America First” also entails drastic cuts to global health, including a $2 billion decrease in the State Department’s global health portfolio and a $225 million reduction for the Global Fund to Fight AIDS, Tuberculosis and Malaria. The Fogarty International Center, a national treasure for global health capacity building, would be entirely eliminated.
Reproductive health services would be particularly hard hit, not only by the proposed cuts, but also by separate administration action. The Trump administration imposed tough new restrictions on US support for aid organizations that provide family planning services. And the White House announced eliminating all contributions to the United Nations Population Fund (UNFPA), the lead international agency promoting family planning and child/maternal health. Overall, the Kaiser Family Foundation predicts a swift rise in HIV, abortions, and maternal and infant mortality—and a sharp turn toward isolationism.
If such draconian budget cuts for foreign health assistance were implemented, it would slow progress, costing untold numbers of lives. Lives in the United States would be at risk, as infectious diseases could not be contained at their source. Cuts in international assistance also undermine our most potent form of “soft” diplomacy. The United States makes friends by investing overseas in health, nutrition, and education—opening markets to US companies, advancing trade, and reducing political and economic instability in fragile states. In other words, forsaking the world’s poor fuels insecurity.
To truly value the idea of “America’s health first,” the nation needs to spend more, not less, on health and biomedicine, both within our borders and well beyond.
About the author: Lawrence O. Gostin, JD, is University Professor and Faculty Director, O’Neill Institute for National and Global Health Law, Georgetown University Law Center, and Director of the World Health Organization Collaborating Center on Public Health Law and Human Rights. His most recent book is Global Health Law (Harvard University Press). (Image: Georgetown University Law Center)
About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.