Breaking’s Easier Than Making — Health and Communications

If I drop a wine glass to the floor, it will shatter into a million pieces, some smaller even than a grain of sand. And there is simply no way that I or anyone else could ever piece that glass back together into its original form. The same thing, a terrible breaking, is now happening to our public health, our health efforts abroad, and to our once-formidable research efforts.

Surprisingly, physics tells us that there is actually a non-zero chance that the wine glass could spontaneously reassemble itself to the exact condition it had before being dropped. But in the lifetime of every human being who has ever lived, such an entropy-reversal has never occurred, and no one would bet that anything like that could happen to a broken system of healthcare either.

But here’s where the analogy breaks down. Because shattering healthcare doesn’t just destroy a system (a wine glass), it also affects people; people who do the research, people who provide the care, people who directly and indirectly benefit from that care.

THE CUTS

The administration’s drastic cuts to healthcare have been widely reported, but in the firestorm of destructive actions all across the government, the focus on health may have been lost. Here are just a few of those cuts:

USAID
Nearly 19,000 jobs lost in the US, including both USAID employees and its partner organizations, although the number might well be double that. Over 170,000 jobs lost worldwide. Most USAID functions terminated. [1]
HHS
A reduction of 20,000 employees, across HHS, CDC, CMS, FDA, NIH, and other agencies. That figure includes “10,000 employees, on top of 10,000 who had already been fired or left voluntarily.” [2]
State Healthcare
A claw-back of $11 billion in COVID-related emergency funding provided to states. [3]
Research Cuts
NIH is cutting something like $4 billion from the overheard portion of its research grants. [4]
Additional, Potential Cuts
In a new budget, the majority of a proposed $1.5 trillion in spending cuts would fall on programs like SNAP (Supplemental Nutrition Assistance Program) and Medicaid. [5]

This of course is far from a comprehensive list. For example, cuts and regulatory changes to the Environmental Protection Agency and the Department of Agriculture will further erode the nation’s health.

WHAT BREAKS WHEN YOU DROP HEALTHCARE?

Livelihoods and Careers Break
Imagine for a moment that you have special expertise, informed by years of training and experience. Maybe you’re a researcher trying to understand the transmissibility of the viruses that cause hemorrhagic fevers. Maybe you’re a local healthcare worker who’s gained a deep understanding of your community’s hesitancy to vaccinate their children and their distrust of medical staff, but because you know them personally, you’re able to encourage life-saving practices. In any case, you work for the largest employer of your skills. Now imagine that you and many others who do that same work, suddenly lose your jobs and that there’s nowhere else you can be employed to do that same work. Some might be fortunate enough to retire, but for everyone else, what would you do? Could you afford to take four years off and hope to then be rehired? Or would you realize you couldn’t afford to do that and that to help feed and house yourself and your family you’d better find a different job that at best might only be tangentially related to what you used to do and love? Of course you’d make the transition and, sadly, your expertise would no longer be employed. And one more question: After investing yourself for four years doing something else, how likely would you be to return to your old profession? Would you trust that four years after that, you wouldn’t face the same situation all over again?

Knowledge Breaks
People who have knowledge (as a result of years of education, experience, and research) possess a good deal more than simply a collection of facts. If you’re a CDC epidemiologist, facts tell you what you’re seeing; knowledge tells you what and where to look, and most importantly, what it means. Knowledge allows you to predict whether an outbreak will spread, whether it’s likely to reoccur either elsewhere or at a later time, what the immediate and long-term consequences will be. When our medical professionals are fired and dismissed, their knowledge doesn’t disappear (they still know what they know), but it might has well have because if it’s not put to use, it effectively doesn’t exist. So when we lose these professionals, we lose as well the benefit of their knowledge.

Trust Breaks
Healthcare, like democracy itself, is based on trust. Not only do we trust that the people who treat us or watch over our public health are knowledgeable, caring, and apolitical, but we trust that the research and teaching infrastructure in this country is providing them with accurate and up-to-date information. And we also trust that there will be enough of these people to treat us and to safeguard public health. If, for example, there’s no one working at the clinic meant to serve you, then you effectively have no healthcare, you have no one to advise, help, and treat you. And if that trust is broken and none of these people are available and accessible there, then where to you turn? Family lore or the internet of course are poor substitutes and possibly even dangerous.

Lives Break
It’s difficult to say precisely how many more people will contract an illness or die as a result of the funding cuts, but here are some reasoned estimates:
- AIDS – International. PEPFAR (largely implemented through USAID): To date, 30,529 adult deaths, 3,249 deaths of children. [6]
- AIDS – Domestic. HIV-related cuts at CDC, FDA, and NIH: “Up to 75,000 additional HIV infections and 7,500 AIDS-related deaths by 2030 if CDC’s Division of HIV Prevention is cut by 50%. As many as 143,000 new infections and 15,000 deaths with a full elimination of that division. [7]
- Tuberculosis (TB) via USAID: 16,738 additional cases, 13,182 deaths. [8]
- Medicaid, if House cuts are enacted by the Senate: 28,721 additional deaths per year. [9]
And many more. But the point is that even if funding is fully restored and even if government employees are reinstated, and research grantees and public health providers rehired, these deaths can not be undone.

Something Deeper Breaks
The underlying premise of public health is that every individual’s health is protected and strengthened by a collective effort and commitment. We give up some measure of absolute freedom –remarkably small, in reality– in order to all live better lives. We vaccinate to protect ourselves and our children, but also to protect our community. We observe laws of sanitation and public behavior, so that we may all live longer, better, healthier lives. All of that is an important part of a larger social compact that binds us all together as a society, and not just 340 million autonomous individuals. In many ways, public health is a model and a foundation of the compact required of a fully-functioning democratic society.

A STARK AND TROUBLING PREDICITON

Assuming he doesn’t try to seize power and stay in office beyond this term (something he’s already threatening to do), Trump’s behavior will have angered so many people that a Democrat will win the presidency in 2027. But…and this is key…even if he or she spends every moment of their four years in office trying to repair what Trump has broken, too many people will be frustrated with the slow pace of ‘re-normalization,’ resulting in a Trump-like Republican being elected in 2031. It’s going to take a long time (much more than four years) and an extraordinary effort to fix public health in the United States and to reconstitute our contribution to health worldwide. And while many voters may understand this intellectually, their deep sense of anger will have them expecting nothing short of a miraculous turnaround, a spontaneous and impossible reassembly.

CONCLUSION

The old adage “You break it – You own it” is often cited as a warning. But in this case, in this time, with this administration, it would be more appropriate to say “You break it – we still own it and we’ll be the ones to fix it as best we can for whatever long period of time it takes.” Because Trump does not take ownership or responsibility, it will be up to us, not him, to build back what he’s broken. And depending on how damaged our public health, our research, and our global health support are, it may actually be an opportunity, (as unwelcome as it is) to do more than just replace piece for piece, part for part, program for program, and instead to create institutions better than the ones we lost. For an interesting parallel, see this article https://www.healthandcommunications.com/articles/2022/ukraine on reimagining Ukraine’s health Infrastructure.