How the states can protect public health from the federal fringe takeover

If one looks at the past century of back-and-forth changes between Republican and Democratic presidents, one sees a continuous and resounding commitment to scientifically based public health practice.

This commitment has reaped incredible achievements, including the control of infectious diseases, a steep decline in deaths from heart disease and stroke, safer and healthier foods, healthier mothers and babies, family planning, fluoridation of drinking water, recognition of tobacco as a health hazard and the elimination of more than 20 vaccine-preventable diseases.

But with the reelection of President Trump, and the prospect of Robert F. Kennedy Jr. assuming a major role in public health, many in medicine and public health have great concern over looming changes to decades-old practices and programs that protect us.

Never have proponents of fringe public health and scientific claims, including those of the anti-vaccine and closely linked anti-fluoridation movement, had a prominent seat in a presidential administration — a spillover effect of the culture wars that have invaded American politics and degraded expert opinion.

Amid the angst that many feel, it is important to recognize that even if effective public health recommendations are rolled back nationally, such changes will not have immediate effects. The momentum of effective public health action that has been broadly applied for years is long-lasting.

An ideological national public health change, however, means that public health direction will shift to state and local levels, and public health approaches will need to pivot and adapt to new times to protect us.

The federal government, through funding and the U.S. Department of Health and Human Services, the Centers for Disease Control and Prevention and the National Institutes of Health plays a role in developing and implementing public health policy.

Yet public health authority is the domain of the states, granted by the 10th Amendment, which states “The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people.”

During the recent COVID-19 pandemic, which is regrettably being sanitized or forgotten, we saw this principle play out. Although there was guidance from the White House Coronavirus Taskforce, NIH and CDC, and hundreds of billions of federal dollars in support of state public health, individual states developed their own COVID-19 control approaches.

States, not the federal government, regulated whether schools would stay open or closed; states developed their own COVID-19 vaccination policies too.

When looking at local public health responses and recommendations and how states can pivot, we need to consider that the structure of state public health systems varies. In some states, there is a centralized system, where the state department of health supports and directs statewide policies. In other states, counties or other jurisdictions, not the state, determine local public health policies and regulations.

The scope of activities among state and local departments of health varies too. Some departments of health administer school health programs, whereas others do not. Some departments promote childhood vaccination, whereas others are prohibited from doing so.

This lack of uniformity means it is more difficult for some states and jurisdictions to develop and implement new local policies than others. We will also see state and local public health policies influenced by political ideology, like never before, as reflected by roll-backs of school childhood vaccination requirements.

We now move into an unprecedented time when public health at the federal level is influenced by fringe and scientifically unfounded viewpoints. Some of these viewpoints will be from politicians supported by anti-vaccine groups, and some will come from physicians out of the mainstream who serve a political purpose.

Considering the new fringe influence on public health policy, it will not be surprising to see the federal government peel back financial support for established public health programs. We may also see federal guidelines that run counter to established science, medicine and public health practices.

This likelihood will implore state and local health departments to rely on other channels for legitimate information. Peer public health networks and public health organizations will need to convey accurate information.

A major calling of public health is responding to infectious diseases, including those established and new. A huge challenge with the COVID-19 pandemic response was the biology of a new virus, which, unlike many other respiratory viruses, was contagious well before an infected person became ill.

The response to the virus exposed our lack of preparedness at many levels, but also showed how we could rise to respond through the development of new therapeutics and vaccines. Thus, coming out of the recent 100-year pandemic, there was interest in rekindling pandemic planning and a congressionally mandated new office of Pandemic Preparedness and Policy Response was established in the White House by the Biden administration.

However, similar to how a previously established White House pandemic planning team was eliminated by President Trump in 2018, this program may again go away, too. As with information dissemination, public health organizations and academic institutions will need to fill this void.

When Trump was running for office, he threatened to take away funding from schools with vaccine requirements, which is nearly all public schools in the U.S.

In contrast to the views of nearly every doctor and medical organization with expertise in infectious diseases and vaccine science, Robert F. Kennedy Jr. has challenged the need for pediatric vaccination.

Dr. Joseph Ladapo, the current Florida surgeon general being considered for an HHS leadership position, also espouses these views — the only state health officer to do so. Thus, support for federal childhood vaccination programs is threatened.

It is important to consider that the federal Vaccines for Children program has reportedly prevented more than 500 million cases of illness, 32 million hospitalizations, $540 billion in healthcare costs, $2.7 trillion in societal costs, and 1.1 million deaths in the U.S.

Changes in federal ideology related to childhood vaccination guidance and changes in federal support for vaccination programs would shift this need to the states, local insurance and practitioners to support such programs. Rather than having vaccines paid for by the federal government for program-eligible children, which includes about 50 percent of all children in the U.S., vaccine costs would be passed on to state pediatric insurance programs, incurring extra costs for states.

As childhood vaccination rates ebb lower, we will inevitably see localized outbreaks of measles and other diseases in under-vaccinated areas. Departments of health now need to augment their outbreak response teams.

States that fail to make this pivot to protect and promote childhood vaccination will also be faced with the serious toll of illness on children and families, school closures, and community disruption. Fortunately, there are several medical organizations, including the American Academy of Pediatrics, for departments of health, practitioners and the public to call upon for valid information.

Currently, about 145 million people in the U.S. drink fluorinated water, which has proven beneficial in reducing dental caries. Concerns, however, have been raised about adverse effects related to excessive fluoridation. Considering recent public statements by Kennedy Jr., we may see a federal advisory against water fluoridation.

If this sentiment takes hold, here too are options for states, the medical community and the public. Pediatricians can prescribe fluoride tablets, a practice that is routine for children on well water, rather than public water supplies. Pediatric care providers can also apply fluoride varnish to reduce dental caries risk.

In the absence of such measures, increases in dental caries will be seen with an increased economic burden on the state and families. Faced with increased rates of pediatric dental decay, states will need to address ways to pay for and improve the pediatric dental workforce, which is sparse in many regions of the U.S.

After an initial unified approach to the pandemic, we saw a dramatic red-state blue-state divide when it came to COVID-19 control measures. There was an undeniable serious impact of this divide as death rates in red states exceeded those in blue states. Other core public health activities, especially related to children, were similar from coast to coast.

Sadly, we need to ask if we will now see a red-state-blue-state divide when it comes to the health of our children. Will we post red vs. blue state maps of measles and other vaccine-preventable disease outbreaks, like we did with COVID-19?

We can avert this travesty if we reflect on the 10th Amendment and realize that states have not just authority, but the obligation to protect children. No matter where we live, we should ask what our state doing to protect our families against rancorous false cries against basic public health protections.

Scott A. Rivkees, MD is a professor of practice at the Brown School of Public Health. He is a pediatrician and the former state surgeon general and secretary of Health of Florida