Ok, Chicken Little. Is the health care sky falling?
Since Secretary Robert F. Kennedy Jr. (RFK Jr) has announced the departure of about 20,000 of the 80,000 U.S. Department of Health and Human Services (HSS) employees, my health professional and policy colleagues are predicting doom and disaster. And it’s not just the HSS employees: hospitals, universities, and medical schools are losing lots of research funding, and many more will be laid off in those places as a result. Everyone is also expecting cuts to Medicaid and perhaps even Medicare. USAID has been shut down. It did some very good public health work around the world, particularly on stopping the spread of HIV and preventing unwanted pregnancies, which will go away. It’s unclear how effective the CDC, which is quietly the world’s infectious disease control organization, will be going forward. I have a very long list of the institutes and centers of excellence that have been gutted.
On the one hand, I have been trying to give RFK Jr. the benefit of the doubt. What he said when he announced all this, that the nation spends twice what the average of the other developed nations in the world spend on health care, but our public health outcomes – life expectancy and infant mortality- are abysmal, is what many of us have been saying for thirty years. It has also been clear for years that the federal health bureaucracy is bloated, too often self-serving, and exists in a bubble of its own creation. I’ve thought for years that healthcare in the US needs leadership and that we have suffered from a lack of focus and organization because no one is in charge. Vaccines work, but the profit motive in vaccine manufacturing makes it hard to trust recommendations, and we have overreached on some of those recommendations and mandates, sometimes urging or even requiring vaccination when its benefits are marginal at best because we can. So, some of what RFK Jr says and thinks is at least partially true.
On the other hand, the magic little secret about public health is that you don’t see it when it is working. You don’t see the epidemics that didn’t happen because we stopped them. You don’t see the people who would have died from cigarettes because they had full and natural lives. You don’t hear about the people who would have died in car accidents because seat belts kept them alive. You don’t hear about 40,000 deaths a year from HIV/AIDS because that number is now less than 8000. And so forth. So I worry that we may lose some of our capacity to prevent disease as we “reorganize” HHS.
And I worry because RFK Jr and some of the people around him seem to be attracted to bad science – Vitamin A and Ivermectin and the very disproven theory that vaccines cause autism and conspiracy theories. This administration seems to have bought into tech bro culture – break things and fail fast and then figure out how to fix them – which runs counter to the precautionary principle in public health – don’t do something until you know it is safe, because human lives are precious – a tech bro culture that seems arrogant and inappropriate for health and health care, where what you “break” are human lives which can never be recovered when lost, and what you lose is trust in government, which is extraordinarily difficult to rebuild. And I don’t think RFK Jr understands how public health actually works, or what actually matters for health, which is one part hospitals, doctors and nurses, and nine parts decent housing, good education, and strong communities, and I fear that our communities will be disrupted and housing and education will be degraded as his boss takes a wrecking ball to the economy, which looks to be in for a rough ride.
So, while I’m glad that RFK Jr has grabbed the bull by the horns and is changing a bloated mess, I’m worried that the bull will gore him and trample us. I think we will lose hospitals around the country, particularly those in densely urban and rural places, and Emergency Room waiting times will increase. I don’t see HHS producing 100,000 new primary care clinicians, which is the number we need tomorrow to pick up the slack from the hospitals that will close and from the public health professionals who will no longer be working at infection control and disease prevention. It is not clear how good we will be at controlling outbreaks and epidemics from now on. It will take a year, I suspect, for the CDC to sort itself out and figure out how to function. So, we may see food and water-borne disease outbreaks in the near term, and epidemics that start in the developing world and move here. I suspect our life expectancy will drop, and our infant and maternal mortality rates will increase. People who live in poor places will suffer most, and too many will be pulled by disease into deeper poverty.
Or not. There’s really no way to predict what will happen.
We are about to find out how much public health matters.
The problem, of course, is that we are experimenting with human lives. Which means we are devaluing human lives.
That’s crazy.
