Chris Simms: Russian dolls—revealing Trump’s diminution of the common good

Chris_simsA few weeks ago, two of Donald Trump’s top advisers, H R McMaster and Gary Cohn, astonished many in the world community when they wrote in The Wall Street Journal that “The president embarked on his first foreign trip with a clear eyed outlook that the world is not a ‘global community’ but an arena where nations, nongovernmental actors, and businesses engage and compete for advantage.”

This worldview is the antithesis of the values and priorities of the global health community and its search for collaboration and equity across borders. A review of Trump’s policies on a descending scale from global, regional, national, state, community, household, to individual reveals—like the recursion in a set of nesting Russian dolls—a theme of presumed selfishness and competitive struggle. By examining in sequence Trump’s policies, the threat that they pose to people’s health and wellbeing and the communities in which they live becomes clearer.

Firstly, at the global level, Trump has taken several measures to “put America first” at the expense of other nations’ health. His exit from the Paris Climate Accord (on 2 June), described by the Economist as “unconscionable and fatuous,” could, according to physicians and research scientists, lead to a public health disaster—comprised of increased levels of respiratory, heart, and infectious disease and mental health disorders.

Similarly, his cuts to US global health spending by 25% (US$2.2 billion) will have a worldwide impact—notably for women, according to MSF. They include budget cuts of 17% for HIV/AIDS programs in the poorest countries and of 11% for efforts to fight malaria. Funding for family planning and maternal healthcare programs may be eliminated entirely (with proposed budgetary cuts of US$524 million); experts claim that this will lead to 3.3 million more abortions, 15 000 more maternal deaths, eight million more unintended pregnancies, and 26 million fewer women receiving maternal and child healthcare.

Secondly, at the regional level, Trump has been dismissive of collaborative arrangements between nations (including the United Nations, NATO, the North American Free Trade Agreement, and the Trans Pacific Partnership), which seek to promote peace, prosperity, and human development. He has claimed, for example, that the European Union would break up in 10 years and that Europe will be “unrecognizable”; in this context, he is a strong supporter of Brexit—itself a threat to “key aspects of health and healthcare.” A spokesperson for the United Nations secretary general has stated that Trump’s decisions will “make it impossible for the UN to continue all of its essential work.”

Thirdly, at the national level, Trump is cutting spending on social welfare while pursuing his deregulation agenda—both of which will be detrimental to health and healthcare. Massive cuts to the Environmental Protection Agency (EPA) will diminish programs that address occupational health and safety; air, water, and soil quality; and even basic regulations meant to protect children from lead in paint.

Critics of H.R. 1628, the American Health Care Act (Trumpcare), which replaces Obamacare, have focused on how the act jeopardizes coverage for pre-existing conditions such as asthma, diabetes, and heart disease, with its proposal to allow states to waive rules that currently stop insurers from charging new customers more because of their medical history. Trump’s plan, which is predicted to leave 23 million fewer people with healthcare insurance by 2026, has flummoxed even the most hardened observers.

Fourthly, in devolving responsibility for social safety nets to states, Trump sidesteps equity as a core public health principle. According to the Brooking Institute, “historically, equity has been a key justification for federal involvement”—and in the US there is strong reason for adherence to this. Research shows that states with the largest African American populations tend to have the weakest social safety nets. The Office of Minority Health reports that black children are four times more likely to be admitted to hospital for asthma than white children and are 10 times more likely to die from asthma than white children. Coincidentally, the Office of Minority Health is also one of the many targets of Trump’s budgetary cuts.

Fifthly, at the local level, Trump’s policies have a direct impact on community services, such as neighborhood clinics, family planning and maternal healthcare, and chronic disease programs and health promotion. Popular grants that help to revitalize economically distressed communities, including the community services block grant (which normally addresses poverty and its health implications), will be eliminated, as well as billions of dollars for public housing and rental assistance.

Finally, at the individual level, Trump’s policies look to some like “a war against anti-poverty programs”—an injustice perpetuated by the view that individuals are responsible for their own welfare and cannot depend on the state. The secretary of housing and urban development, Dr Ben Carson, underscored this perspective when he recently described poverty as a “state of mind.” Trump is also calling for cuts to meals on wheels and a 25% cut in the food stamp program; when asked about these proposed cuts, an important Republican committee member could not bring himself to state that “people are entitled to eat.”

The assertion by Trump’s advisers that there is no “global community” is similar to Margaret Thatcher’s observation “there is no such thing as society.” Thatcher’s statement—“there are only individual men and women and there are families . . . and people must look after ourselves first”— reads much like Trump’s advisers’ declaration: “An arena where nations, nongovernmental actors, and businesses engage and compete for advantage.” In these circumstances, without a moral code, a sense of the greater good, or a commonweal, the last of the Russian dolls (which in folklore is meant to be a pleasant surprise) is neither surprising nor pleasing.

Dr Chris Simms teaches at Dalhousie University, School of Health Administration, Halifax, Canada; he spent many years living and working in Africa’s health sector.

Competing interests: None declared.

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