Woolhandler and Himmelstein Respond

Who could disagree with Sundwall’s (p. 449) advice to be honest, open-minded, optimistic, and inclusive? But the Trump administration’s authoritarian, antihealth drift demands a stronger response.

Even before Trump, public health was lagging. Funding has been drifting down¹ and death rates creeping up, driven by widening inequality and unrelenting oppression of those at the bottom of the income scale. Although President Obama may be faulted for inadequate responses, his successor has unleashed an all-out assault on the nonrich, non-Christian, nonmale, non-White, non-American—as well as on nature itself. Even George Orwell might flinch at the Centers for Disease Control and Prevention leadership’s ban on words like “science-based,” “evidence-based,” “vulnerable,” “transgender,” and “fetus.”

Yet, the defeat of frontal attacks on the Affordable Care Act (ACA) indicates that health is perilous terrain for Trumpism. The fight against repeal called out legions who packed town hall meetings, disability and other activists who braved arrest, and scholars, journal editors, and journalists who spread the word of mortal and financial consequences from uninsurance. Republicans could only sliver off the Obamacare mandate under cover of a tax bill.

But defensive efforts like those that fended off ACA repeal are not enough. Medicaid—as well as Medicare, SNAP (food stamps [Supplemental Nutrition Assistance Program]), and TANF (welfare [Temporary Assistance for Needy Families])—are also in Congress’s crosshairs. They’ll claim that the ballooning deficits ensured by the new tax law compel cuts.

During the 2016 presidential campaign, Trump’s racist and nativist appeals found fertile ground among beleaguered White working-class voters eager for scapegoats, while the wealthy and powerful needed no dog whistle to understand what Trump could do for them. In response, mainstream Democrats proffered little to ameliorate working-class pain, nor did they threaten to discomfit the wealthy.

The promise—and reality—of sweeping social changes offers the only effective antidote to the president’s reactionary populism. A full turn away from capitalism is not currently on the agenda. Yet experience in other nations—and in ours in the past—shows that redistributing income through taxes and social programs and attending to the environment can do much to improve health, while sustaining, and even spurring, overall prosperity.

Seven decades back, AJPH’s Editor Charles-Edward Winslow called for massive social investments to end the physical and emotional toll exacted “by malnutrition, by slum dwelling, by lack of medical care, by social insecurity” and urged “those who do not agree with me to mend their ways; and those who do agree with me to go forward with hope and courage.”^2(p184)

Such courage is now urgently needed. Public health professionals must put policies to the test of science and raise their voices to decry health-threatening ones. But we must go beyond that, joining others to organize for health-improving reforms and protest harmful initiatives.

As Sundwall notes, for many public employees (including us), politicking for candidates at work and using our employers’ resources, such as computers and e-mail addresses, are verboten. And running for office or soliciting campaign contributions may be off-limits. But while off-duty, we’re free to vote, contribute money, express our views, and protest.

The contrast between our nation’s spectacular wealth and sorry record on health and social indicators gives reason for hope as well as shame. We can readily afford to house, feed, educate, and heal all who are on our soil.

What’s needed is a new New Deal. For medical care, that means single-payer health care, not just defending Obamacare. We can find housing for the 3.5 million homeless in the 18.3 million vacant housing units³; food from our abundant harvests can provide for the 41.2 million who suffer food insecurity⁴; and funds can be diverted from the more than $800 billion our governments spend on prisons, policing, and defense to schools, mass transit, and social needs.

Politics, not economics, keeps us from ensuring that our water and air are clean, that carbon is kept from our skies, and that every community enjoys the full measure of prevention in homes, neighborhoods, workplaces, and medical offices. Envisioning what’s possible and fighting for what’s needed are not tangential to public health work. They are our core mission.