How a Second Trump Term Could Recast Public Health

The Covid pandemic dominated the last years of Donald Trump’s presidency, and the discontent it caused most likely contributed to his loss in 2020. But on the campaign trail this year, Mr. Trump rarely talks in depth about public health, dwelling instead on immigration, the economy and his grievances.

Still, Project 2025, the blueprint for a new Republican administration shaped by many former Trump staff members, lays out momentous changes to the Food and Drug Administration, the Centers for Disease Control and Prevention, and the National Institutes of Health.

And Mr. Trump’s embrace of Robert F. Kennedy Jr., a vaccine skeptic, and his campaign slogan, “Make America Healthy Again,” suggests there will be significant changes to the nation’s public health priorities should Mr. Trump regain the presidency.

“I’m going to let him go wild on health,” Mr. Trump said of Mr. Kennedy at a rally in New York City on Sunday. “I’m going to let him go wild on the food. I’m going to let him go wild on medicines.”

Republican critics increasingly describe the health agencies as corrupt, riddled with conflicts of interest and staffed by myopic bureaucrats accountable to no one.

Mr. Trump echoed these themes at a rally in Wisconsin: “We’ll take on the corruption at the F.D.A., the C.D.C., World Health Organization and other institutions of public health that have dominated, and really are dominated by corporate power, and dominated really by China.”

In interviews with more than a dozen health experts, including six former Trump administration officials, virtually all foresaw reduced authority for public health agencies should Mr. Trump return to the White House, even as new diseases, like bird flu and mpox, threaten the United States.

Some experts allied with both parties worried about the nation’s response particularly to another potential pandemic in a second Trump presidency.

Handling of the coronavirus pandemic was disastrous, said Dr. Robert Kadlec, who led the Administration for Strategic Preparedness and Response under Mr. Trump: “It didn’t have to be that way.”

Before the pandemic, few presidents had much to say about the C.D.C. beyond appointing its leader. But “the pandemic brought the C.D.C. into the cross hairs,” said Dr. Anne Schuchat, former principal deputy director of the agency, who retired in 2021.

Project 2025 describes the C.D.C. as “perhaps the most incompetent and arrogant agency in the federal government,” and calls for it to be divided into two entities.

One would be responsible only for publishing data gathered from states and other sources. The other would retain a “severely confined ability to make policy recommendations” under the auspices of political leaders.

“He’ll go down the path that he started, which is to fully politicize the C.D.C.,” said Lawrence Gostin, the director of the W.H.O. Collaborating Center on Global Health Law, referring to a second Trump administration.

A complete restructuring of the C.D.C. may not be realistic, several observers noted. It would require approval from Congress and seems unlikely to win the support of Republican moderates.

Yet many Republicans in Congress agree the C.D.C. should be pared down, perhaps focused only on infectious diseases, a view at least partly shared by Dr. Scott Gottlieb, who led the F.D.A. for two years under Mr. Trump.

“There are clearly some C.D.C. functions related to its prevention work that could line up better inside other agencies,” he said in an interview.

Other experts predicted the C.D.C. would most likely lose the authority to enact the few actions it is empowered to use in public emergencies, such as pausing housing evictions, limiting the movements of cruise ships and requiring masks on public transportation.

“There’s a false narrative here that C.D.C. got distracted by these noncore issues and therefore had a bad pandemic, and every part of that narrative is wrong,” said Dr. Thomas Frieden, who led the agency under President Barack Obama and has criticized it for being slow to respond to Covid.

About two-thirds of the agency’s budget goes to state and local health departments, “not building some empire in Atlanta,” where the C.D.C. has its headquarters, he added.

Slashing the C.D.C.’s budget would constrict these state departments, which are already struggling. Last month, Dr. Frieden and seven other former C.D.C. directors warned that shrinking the agency “would cost lives and damage the economy.”

Even without congressional support, Mr. Trump could significantly change the agency’s mission, scope and independence. His administration could suppress data collection for gun violence and gender identity, for example, or expand the agency’s tracking of abortions.

Vaccine requirements are likely to be a particular flashpoint for both the C.D.C. and F.D.A., experts said. Project 2025 inveighs against vaccine and mask mandates, and Mr. Kennedy is perhaps the country’s most high-profile vaccine skeptic.

Mr. Trump is not personally opposed to masks or vaccines, except for some personal qualms about the MMR vaccine, according to officials who worked closely with him. But he has been critical of policies mandating their use.

All 50 states and the District of Columbia require certain vaccinations for schoolchildren, with varying criteria for religious or personal exemptions. Yet at dozens of rallies this year, Mr. Trump has said, “I will not give one penny to any school that has a vaccine mandate or a mask mandate.”

Vaccine policies are set at the state level, not by the federal government. But states look to the F.D.A. to evaluate vaccine safety and to the C.D.C. for guidance on which vaccines should be given and when.

A committee of external advisers to the C.D.C. reviews the evidence for vaccines and recommends which shots people should get and when. An appointed C.D.C. director could reject its advice and reshape the guidance.

The result would be a loss of expertise that doctors and state health officials rely on, some experts said.

“The number of questions that you would have the burden on a clinician to figure it all out, or even on a state body to figure it all out, would be pretty high,” Dr. Schuchat said.

Ending vaccine mandates would put American children at risk of diseases like measles and polio, which have largely been held at bay by the requirements, she said.

The F.D.A. has hardly escaped criticism among conservatives, for its approvals of Covid vaccines and loosening of restrictions regarding medications for abortion and contraception, among other moves.

Project 2025 calls for an end to the “revolving door” between F.D.A. officials and industry, and Mr. Kennedy wants for the agency to stop receiving drug company payments to review their research while seeking approvals.

A diminished role for the National Institutes of Health seems likely, as well.

The N.I.H. has traditionally enjoyed bipartisan support. But Republican lawmakers have set their sights on it in the midst of vociferous criticism of Dr. Anthony Fauci, who led the infectious disease branch.

They have talked about streamlining the N.I.H., eliminating some institutes and merging others. Project 2025 calls for breaking up “the N.I.H. monopoly on directing research” and moving more of its funding to states, as well as instituting term limits for its leaders.

Mr. Kennedy wants more than half of the N.I.H.’s research budget devoted to “preventive, alternative and holistic approaches to health,” including generic drugs and diet.

Even among some former Trump officials, there is hesitation about slashing the budgets of health agencies.

“I have problems with the C.D.C. and the N.I.H, but these are things that you reform,” said Adm. Brett Giroir, a pro-vaccine pediatrician who served as assistant secretary for health under Mr. Trump.

Diminished International Role

In 2020, Mr. Trump announced his intent to withdraw the United States from the World Health Organization and halted funding to it. The W.H.O., an arm of the United Nations, is funded by all of its member countries, but the United States has traditionally been the biggest donor.

President Biden restored ties to the organization on his first day in office. Mr. Trump is likely to withdraw the nation again, experts said.

“It’s run by China, it’s not run by us,” Mr. Trump said of the W.H.O. at a rally last month.

Like all recent Republican presidents, Mr. Trump imposed a rule preventing organizations from receiving funds from the U.S. Agency for International Development if they provide or promote abortion-related services.

He broadened the rule to include nearly all American funds for global health and extended it to organizations that don’t work in reproductive health.

Some global health organizations preemptively ended programs rather than risk angering the administration, and stopped providing contraceptives, H.I.V. testing or screening for cervical cancer.

The Biden administration repealed the Trump-era rule, but some programs are still recovering. “These are health systems that need to be rebuilt,” said Jennifer Sherwood, director of Research and Public Policy at the AIDS charity group AMFAR. “That takes time, and it may never happen.”

Mr. Trump may also permanently shutter Pepfar, perhaps the most successful global health program in history, credited with saving more than 25 million lives by providing H.I.V. treatments.

Republican lawmakers have alleged that the program was promoting abortion services, but they granted the program a reprieve till March 25, 2025. A second Trump administration may close that door.

New Leadership

There has been intense speculation that Mr. Kennedy will be named as the head of an agency or even as secretary of Health and Human Services, a cabinet-level position.

The possibility chills many scientists. But several people who worked closely with Mr. Trump said he was unlikely to hand Mr. Kennedy power to reshape the nation’s public health and may placate him with a more limited role.

“No formal decisions about Cabinet and personnel have been made,” said Karoline Leavitt, a spokeswoman for the Trump campaign.

Seema Verma, former director of the Center for Medicaid and Medicare Services, and Bobby Jindal, who served as assistant secretary of the H.H.S. under President George W. Bush, would be contenders to lead H.H.S., said people involved in the vetting process.

The America First Policy Institute, a conservative think tank that aims to reimagine civil service, may hold some sway over whom Mr. Trump names for key positions.

Employees of health agencies may find their job security is shaky.

Less than two weeks before the 2020 election, Mr. Trump signed an executive order that moved as many as 50,000 civil servants, many in high-level positions, into a new category with little protection from termination.

President Biden rescinded it, but Mr. Trump will almost certainly restore it upon taking office, and could use it to purge anyone opposed to his agenda, several experts said.

But it’s not clear what Mr. Trump would do. Except for the pandemic, he often left senior health leaders alone, according to several former officials in his administration.

“We were not interfered with at all,” Admiral Giroir said.