Public Health Advocacy in the Tumultuous Times of the Trump Administration

The election of Donald J. Trump as president of the United States was an unexpected and extraordinary event in the history of our nation. His presidency has resulted in dramatic changes in our politics and our policies and unease in much of our population. He promised to “shake things up in Washington,” and whatever one thinks of him and his political views, he has accomplished this to a fare-thee-well. Perhaps the most disconcerting aspect of the president’s performance as the leader of our nation is his eschewing customary ways of functioning in his role, causing widespread uncertainty. Those of us committed to public health and ensuring that government programs devoted to the well-being of our citizens be sustained have been perplexed, confused, and frustrated, to say the least. We are not alone—this situation applies to much of the federal government’s agencies, the federal workforce, organizations representing the public’s interests, and our fellow Americans.

Notwithstanding this uncomfortable uncertainty, as my good friend and colleague Jewel Mullen (then Deputy Assistant for Health under President Obama) reminded me at an Association of State and Territorial Health Officials meeting in 2016, regardless of who is in the White House, we (in public health) have important and essential work to do, and we must continue to do it with the budget provided and at the direction of our elected officials. We need to do our work as well as we can with the resources provided and within the scope of the laws authorizing our activities. This does not mean, however, that those of us in public health positions, or for that matter any person or group with an interest in public health, should not advocate to sustain and strengthen our nation’s public health enterprise. An important exception is those federal employees constrained by Hatch Act, which prohibits them from engaging in political activities.¹ (This federal law, which was passed in 1939, limits certain political activities of federal employees, as well as some state, District of Columbia, and local government employees who work in connection with federally funded programs. The law’s purposes are to ensure that federal programs are administered in a nonpartisan fashion, to protect federal employees from political coercion in the workplace, and to ensure that federal employees are advanced on the basis of merit and not on the basis of political affiliation.)

PRINCIPLES DERIVED FROM NEW POLICIES

So, accepting that these are difficult times when nothing seems to be done as it previously was, how do we go about advocating public health? Last month I was asked to present the first Annual Lectureship on Public Health Policy at the University of Utah School of Medicine. This was an honor, but a daunting responsibility to make a presentation that would be informative and do credit to the importance of public health. I chose to review my now-long career in public health policy and administration in the federal government (in both Legislative and Executive Branches) and in the state of Utah, and to identify principles, each of which were derived from experience addressing specific challenges with new policies. The following are just a few of the principles I identified that I think are especially relevant to our current circumstance:

• The importance of being honest, informed, and evidence-based—earnest advocacy will not likely get very far without data and information to support a proposal.

• The importance of not judging a book by its cover—the confirmation process for US Surgeon General C. Everett Koop: Koop’s nomination for this position was strongly opposed by several women’s groups and lesbian, gay, bisexual, and transgender organizations because of his conservative views, resulting in a protracted series of Senate confirmation hearings. Yet, once confirmed, he proved to be an effective leader and champion of public health for all, especially those infected with HIV as this epidemic unfolded during his tenure. Could our new Surgeon General, Jerome Adams, also become an outstanding advocate for public health in this position?

• The importance of building bridges—unlikely allies in working together for reauthorization of the Maternal and Child Health Care Block Grant: Do not assume that individuals or organizations are going to be opposed to public health initiatives on the basis of previous history until you have made the effort to find common ground. The Children’s Defense Fund, a liberal Washington, DC–based organization, came together with a group in South Carolina affiliated with the Southern Baptist Coalition, a staunchly conservative organization, to advocate together for the maternal and child health programs. They share a strong commitment to the well-being of children, and advocacy from across the political spectrum is always more effective.

• The importance of science-driven policy—the National Organ Transplant Act of 1984: Notwithstanding evidence that some of our elected officials seem to be “anti-science” and do not want to be “confused by the facts,” I contend that a significant majority are not. One landmark example of new scientific knowledge driving policy was when the development of effective antirejection medications enabled successful organ transplantation. This led to the enactment of the National Organ Transplant Act of 1984 legislation that has saved hundreds of thousands of lives.² It is essential that we use current scientific knowledge to bolster our case for new and better public health policies.

• The importance of regulations and rules in addressing policy issues—how to achieve administrative simplification, efficiency, and effectiveness by changing the rules, not the law: The opportunity to achieve policy objectives through modifying existing rules and regulations of public health laws is often overlooked. The Clinical Laboratory Improvement Act is a good example of a common situation in which Congress gives a framework in statute and leaves it up to the responsible agency to fill in the details of how the law is to be implemented.³ In the case of the Clinical Laboratory Improvement Act, this led to very complex regulations that posed costly requirements on clinical laboratories and even laboratories in doctors’ offices. Simplification of such regulations can be achieved by seeking a change in the rules, and if the responsible agency is persuaded that there is merit to such changes, they can publish a Notice for Proposed Rule Making inviting public comment. If consensus on changes within the scope of the law is achieved, they can adopt the proposed changes. This is usually a much more streamlined process than trying to amend the law. In fact, modifying regulations certainly applied to management of the Medicaid program in Utah when I was the executive director of the Utah Department of Health—most of the changes in this program were achieved by amending our rules, not by seeking legislative changes. The Trump Administration is committed to such administrative simplification, deregulation, and therefore is likely to support such proposals for constructive changes.

• The importance of understanding and respecting “who’s in charge” and of nonpartisan advocacy, for public health—cultivating relationships with key elected officials: I think it is fair to generalize that, historically, most advocates for public health have favored a strong federal government role in funding public health initiatives, and have favored regulations holding states and grantees accountable to achieve improved health outcomes. The current Administration and the majority in Congress favor a more limited government role, less spending, and less regulation. The most pressing challenge for public health advocates now is to ensure adequate federal funding for public health programs. So, regardless of personal political views, we must invest time and effort to know those currently in charge—our elected officials and their staffs—to seek compromise in funding levels and regulations to sustain our public health enterprise. Our collective efforts to educate and inform key elected officials will be essential to counter harmful proposals in President Trump’s 2018 budget and also to prevent harmful provisions in the Congress’s budget proposal.⁴ We will also need to work together to correct potential problems in the recently passed tax reform legislation.

TIME-PROVEN PRINCIPLES

To successfully advocate sustaining and strengthening our nation’s public health enterprise, I recommend we rely on these six time-proven principles. As the famous old song says, “The fundamental things [still] apply, as time goes by.”⁵