A sad week for public health in the US

This week is National Public Health Week in the United States and perhaps the saddest one in the 70 years of this celebration. Last week, President Donald Trump’s administration enacted mass firings of staff, or a “reduction in force,” at agencies that form the scaffolding of public health in the US.1 This action continued the attacks on science and health that have quickly become a signature of the new presidency.2

The scope and depth of the cuts to staff are vast, including the Centers for Disease Control and Prevention, the National Institutes of Health, the US Food and Drug Administration (FDA), Health Resources and Services Administration, Substance Abuse and Mental Health Services Administration, Centers for Medicare and Medicaid Services, and many other offices.

Collectively, these cuts impair government functions that are vital to society, including (but not limited to) the ability to ensure the safety of new medications, devices, food, and other products; detect and respond swiftly to new health threats, including outbreaks, epidemics, and pandemics; maintain decades of data for the prevalence of key health conditions across the population; promote positive health behaviours; prevent violence and injury; ensure our living environments are safe from threats such as lead poisoning and poor air quality; investigate harmful conditions at workplaces; improve the quality, safety, and efficiency of healthcare delivery; understand and eliminate health inequalities; run organ donation and transplantation systems; and support children and families in poverty.

These reductions in workforce were not papercuts, they were jugular lacerations. Former FDA commissioner Robert Califf posted online that the “FDA as we've known it is finished, with most of the leaders with institutional knowledge and a deep understanding of product development and safety no longer employed.”3

The consequences of some of these cuts will take years, but others will be felt swiftly because they affect vital services that keep people afloat on a daily basis. The Administration for Community Living, for example, lost 40% to 50% of its staff4; it runs Meals on Wheels, which in the US delivers more than 200 million meals a year to two million older people and people with disabilities.5 The staff cuts at the Administration for Children and Families threaten Head Start, a federally funded early education programme for families living in poverty.6 Both these programmes operate in all 50 states.

Robert F Kennedy Jr, the new secretary of health and human services, has said that he is dedicated to tackling chronic disease.7 However, the National Center for Chronic Disease Prevention and Health Promotion was among the government bodies that were gutted, affecting activities related to Alzheimer’s disease, arthritis, epilepsy, lupus, and chronic disease education and awareness. Across agencies, work on HIV/AIDS, hepatitis, tuberculosis, mental health, cancers, and substance use disorders has been decimated or sharply curtailed.

Kennedy also promised “radical transparency,” but has proceeded to act with opacity during the past few weeks.8 Employees have not known who has been fired or what functions remained, even in their own divisions; the lack of communication about what or who had been the affected meant that people fell to crowdsourcing the information.9 Communication and public outreach departments were hit hard by the reductions in force. Staff in offices dedicated to transparency and accountability under the Freedom of Information Act—the US law that grants the public the right to request access to records from federal agencies—have also been sharply cut, which is likely to lead to illegal delays in public records being shared.8

The firings, led by Elon Musk’s Department of Government Efficiency (DOGE) were chaotic and disorganised.10 Employees found out about their terminations by getting locked out of their offices or email accounts. Some workers needed to be rehired within a few days of losing their job because they had been fired accidentally or the implications of firing them had not been anticipated.11 When critical jobs were axed, no clear process was evident for handing over responsibility or work, and so little was planned or divulged about the purported reorganisations that even the most basic of questions about them remain unanswered.12 The evidence suggests that those responsible neither understand nor care about what these people or offices do, how they function, or why the functions matter sufficiently to improve on them.

This approach is akin to that popularised by Facebook’s Mark Zuckerberg: the notion that scorns careful planning and believes that making mistakes is the cost of innovation. But that method is particularly short sighted, cruel, and ignorant when it relates to programmes that keep people healthy and alive. When a panel falls off a Tesla vehicle, a recall can happen within months of that flaw.13 But what is the parallel recall when over weeks, months, years, and decades, the incidence of diseases soar, injuries increase, hospital practices are under evaluated, older people go hungry, and parents lose jobs because their childcare is gone?

If you ask the average American what the cuts last week mean for them, they may not be able to articulate it. I am sure the same is true for the DOGE employees who applied a red pen to the organisation chart of the Department of Health and Human Services. That is because these agencies and the public servants in them were doing what public health does best: working quietly in the background, keeping Americans safe and healthy.

“Public health saved your life today, and you probably didn’t know it,” begins the description of a popular PBS series.14 We may now find out what happens when public health is so compromised that it cannot continue to save our lives.